SP PP SP PP Crs, ml/cmH2O 52 ± 15 65 ± 6 54 ± 9 67 ± 12 PaO2/FO2 154 ± 33 277 ± 45* 171 ± 21 290 ± 18* VretPEEP, ml 383 ± 34 399 ± 45 671 ± 56 694 ± 26 Vdalv*ml 267 ± 19 194 ± 32 * 311 ± 13 201 ± 23* * P< 0.01
P125
Cytokine removal from plasma of patients with SIRS by the Biologic-DTPF™
H Levy1, SR Ash2,3, J Steczko3, DJ Carr3
1
Department of Internal Medicine, University of New Mexico, 2211 Lomas Blvd NE, Albuquerque, New Mexico 87131, USA;2Purdue University and St
Elizabeth Medical Center, West Lafayette, Indiana, USA;3HemoCleanse, Inc.,
West Lafayette, Indiana, USA Critical Care1998,2(Suppl 1):P125
The BioLogic-DTPF System™uses a single lumen 10F venous catheter and combines a hemodiabsorption system using 2 l of sorbent suspension, flowing through the dialysate side of a parallel plate cellulosic dialyzer with whole blood perfusion on the blood side (the BioLogic-DT™System), in series with a push-pull pheresis system (BioLogic-PF System™). Bidirectional plasma flow (80–100 ml/min) across the 0.5 micron PF membranes provide direct contact between plasma protein and powdered sorbent suspension of either charcoal or charcoal and silica.In vitrotests using whole blood have demonstrated that the BioLogic-DTPF clears cytokines (TNF-a, IL-lb, and IL-6) at a rate of 15–25 ml/min, without evidence of saturation of sorbent during 90 min run times. Systemic Inflammatory Response Syndrome (SIRS) is the most common manifestation of cyrokine mediated disease in ICU patients. A Food and Drug Administration-approved Investiganonal Device Exemption permits a phase I preliminary safety and efficacy study of a single 6 h BioLogic-DTPF treatment of 8 patients with SIRS and organ failure due to sepsis.
Results:In treatment of 4 patients with charcoal, no adverse events occurred, hemodynamics were stabilized and less pressor agent was required. Cytokine levels decreased during treatment and remained significantly lower the next day.
The broad and nonspecific cytokine binding by the BioLogic-DTPF may quench both the proinflammatory and anti-inflammatory responses of SIRS and prove beneficial in treatment of patients.
P126
Immunological effects of CWHD in critically ill patients
D Kehler, E Tonnesen, P Toft
Department of Anaesthesia and Intensive Care, Aarhus University Hospital, 8000 Aarhus C, Denmark
Critical Care1998,2(Suppl 1):P126
Acute renal failure as part of the multi-organ dysfunction syndrome (MODS) is a severe complication in critically ill patients. Hemodynamic instability is common in these patients and exacerbated by hemodialysis (HD). Therefore, continuous veno-venous hemodiafiltration (CVVHD) is used as an alternative to conventional HD. The aim of the study was to test the hypothesis that initiation of CVVHD elicits an acute activation of the immune system followed by immunosuppression.
Patient and methods:Fifteen consecutive, septic patients with acute renal failure were treated with CVVHD in the ICU. The study was approved by the Regional Ethical Committee on Human Research and informed consent was obtained from the patients or a close relative. The cellular response was measured as the distribution of the CD3+, CD4+ and CD8+lymphocytes (flow cytometry), and the leukocyte adhesion
molecules CD1la, CD11b, CD16, CD18, CD44 and CD42 (flow cytometry). The humoral response was estimated as plasma cortisol (RIA), the proinflammatory cytokines TNFaand IL-8 and the anti-inflammatory cytokine IL-10 (ELISA), and the complement split products C3d and C4d (RIE).
Results: Ten men and five women were included. Eleven patients developed MODS after abdominal surgery, 4 patients suffered from medical diseases. Mean age was 59 years (range 25–75 years). Mean APACHE II score before CVVHD was 19 (range 8–27). Nine patients (60%) died in septic shock. Mean duration of CVVHD treatment was 9 days (1–21 days). TNFaand IL-8 were detectable in all patients, while IL-10 was detectable only in a few patients. Low cytokine concentrations were measured in the ultra-filtrate. Big intra- and interindividual variations were demonstrated for all the immunological parameters. In summary, no
significant changes were demonstrated in any of the immunological variables.
Conclusions:The hypothesis that CVVHD induces an acute activation of the immune system followed by immunosupression was not confirmed in the present study. The heterogenic patient material with different underlying diseases and various duration of illness before start of CVVHD may contribute to the large variation in the measured immunological markers.
P127
Reversal of intractable circulatory failure complicating septic shock with short time high volume haemofiltration (ST-HV-CVVH) after failure of conventional therapy: a prospective evaluation
PM Honore1, J Jamez2, M Wauthier2, T Dugernier1
1Intensive Care Department, St Pierre Hospital, 1340 Ottiguies, Belgium; 2Nephrology Department, St Pierre Hospital, 1340 Ottignies, Belgium
Critical Care1998,2(Suppl 1):P127
Objectives:According to our previous retrospective study, shorttime high volume haemofiltration may have beneficial effects on the haemodynamic course and outcome of patients with refractory septic shock. Therefore, a prospective study was performed to confirm (or not) these preliminary results.
Design:Prospective open study over 20 consecutive patients.
Setting:Fifteen bedded adult polyvalent intensive care unit in a general hospital with more than 45% of the admissions coming through the emergency department.
Methods:Twenty patients with septic shock were included according to entry criteria including haemodynamic status, acid-base balance, septic status, respiratory support and renal status.
Technique:It consisted in an exchange of 35 l in a 4 h period of time, achieving a neutral balance. A Gambro device was used with
polyacrylonitrile membranes and bicarbonate was used as buffer. After, the patient was put on low volume haemofiltration exchanging 24 l a day.
Results:1) Influence on the haemodynamic course: data were analysed using non parametric statistical methods. A responder was defined using 4 criterias as shown by the following table (criteria: C). 2) Influence on the outcome : 9 patients out of 11 responders survived at day 28. Both groups (survivors N = 9 and non survivors - N = 11) were similar on admission in terms of APACHE II score (31.1 vs 32.3P> 0.05), SAPS II score (69 vs 68.5
P> 0.05) but were significantly different regarding the time of intervention (6.1 h vs 14.2 hP< 0.01). The global expected mortality was 79.1% and the observed mortality was 55%. Using the angular transformation as statistical test, the difference was significant with aPvalue below 0.05.
Conclusions:Our prospective open study is confirming our preliminary results by suggesting that ST-HV-CVVH is able to reverse intractable circulatory failure complicating septic shock and to improve survival. Early intervention is related with a better outcome. Outcome is well predicted by the early haemodynamic response and not by conventional scoring systems. In our institution, at the present time, this therapy is restricted to cases unresponsive to conventional therapy.
P128
Successful treatment of refractory toxic streptococcal syndrome associated with severe lactic acidosis using a combined haemofiltration technique with a bicarbonate based replacement fluid: report of 4 consecutive cases
PM Honore1, J Jamez2, M Wauthier2, JP Pelgrim1
1Intensive Care Department, St Pierre Hospital, 1340 Ottignies, Belgium; 2Nephrology Department, St Pierre Hospital, 1340 Ottignies, Belgium
Critical Care1998,2(Suppl 1):P128
Objectives:Devastating toxic strep syndrome has still high mortality race (about 30%) despite all (he therapeutical interventions that have been