Hemodynamic changes during hemofiltration in meningococcal septicemia

1. Hemodynamic changes during hemofiltration in meningococcal septicemia Dr Rajiv Chhabra Dr Prabhat Maheshwari Dr Claudine De Munter

2. Meningococcal sepsis • Incidence: • One of the most common infectious cause of death in children outside neonatal period

3. Meningococcal sepsis (MS) at St Mary’s hospital • Tertiary care center • Research on meningococcal disease in Prof Michael Levin’s lab • PICU: 8 bedded unit Over 900 cases of MS since 1993

4. Meningococcal sepsis (MS): patient population at St Mary’s Hospital PICU • endotracheally intubated: 100% • fluid volume: > 100 ml/Kg first 24 hours: 70% > 200 ml/Kg first 24 hours: 20% • inotropes: 90%; adrenaline and/or noradrenaline • haemofiltration: since 1996 for renal failure 5%

5. Retrospective Study:Objective • BASIS: Observation of rapid clinical improvements in hemodynamics after initiation of CRRT despite the rapid clinical deterioration prior to and leading to CRRT compared to the rate of improvement in the less sick non-haemofiltered cases. • AIM: To review the clinical improvements in hemodynamics after initiation of CRRT in MS

6. Methods • Retrospective review of notes • Parameters: inotropic requirement, base excess, fluid requirement, blood lactate • Recorded: - 12 hours before starting haemofiltration, - time of starting, - 6, 12, 24 & 48 hours after initiating CRRT • statistics used ANOVA

7. CRRT • Hygeia+ (Kimal) • Filters : polysulfones • Heparin infusion • High flows: Flows used 80-120 ml/kg/hour choice: highest flows tolerated within this range

8. Results • 27 patients (5% of MS cases) • Age: 6 months to 16 years (median 5.5 years) • 3 died, within 8 hours of admission: excluded • mean PRISM score among the 24 survivors: 64.7(3.4 – 96).

9. Controls • 21 severely ill controls chosen on the basis of their inotropic requirement: adrenaline > 0.1mcg/kg/min and noradrenaline > 0.1mcg/Kg/min • Age: 8m-14 years (median: 6 years) • PRISM score: 7.1-84.7 (median:45.8)

11. Adrenaline infusion CRRT controls

12. Noradrenaline infusion CRRT controls CRRT

13. Base excess CRRT controls

14. Lactate levels CRRT controls

15. Continuous veno-venous hemofiltration improves hemodynamics in septic shock with acute renal failure without modifying TNFalpha and IL6 plasma concentrations.J Nephrol. 2002 Mar-Apr;15(2):150-7. • In patients with septic shock and ARF, CVVH improves mean arterial pressure and SVR.

16. Early filtration and mortality in meningococcal septic shock?Arch Dis Child. 2000 Dec;83(6):508-9 • Following the introduction of a policy of early therapeutic filtration for presumed meningococcal septicaemic shock, the overallmortality hasdecreased.

17. Pulse high-volume haemofiltration for treatment of severe sepsis: effects on hemodynamics and survival Critical Care 2005, 9:R294-R302  High-volume hemofiltration in septic shock.Crit Care. 2005 Aug;9(4):329-30 • high-volume haemofiltration (HVHF) has exhibited beneficial effects in severe sepsis, improving haemodynamics.

18. Pulse High-Volume Hemofiltration in Critically Ill Patients: A New Approach for Patients with Septic ShockSemin Dial. 2006 Jan-Feb;19(1):69-74. • PHVHF applied in patients with septic shock/severe sepsis: beneficial effects on vasopressor requirements. • PHVHF: may represent a beneficial adjuvant treatment for severe sepsis/septic shock in terms of patient survival.

19. Limitations and comments • Observational study • Small number of patients -but all patients have the same disease process • Controls are not matched • Data confirms results of existing studies

20. Conclusion • Hemodynamic status of patients with extremely severe meningococcal sepsis improved rapidly after initiation of CRRT. This allowed rapid reduction of dose of vasoconstrictors that were initially required and avoid potential deleterious effects.