Sepsis and Septic Shock: Does Plasma Exchange Improve Survival?


The Efficacy and Safety of Plasma Exchange in Patients With Sepsis and Septic Shock: A Systematic Review and Meta-analysis

Rimmer E, Houston BL, Kumar A, et al

Plasma Exchange in Sepsis

Sepsis is a common medical condition and the most common cause of death among critically ill patients.[1,2] Plasma exchange separates plasma from whole blood and exchanges the plasma with normal saline, albumin, or fresh frozen plasma. Plasma exchange thus could improve sepsis outcomes through removal of harmful substances or by replacement of depleted blood components.

Rimmer and colleagues sought to determine whether plasma exchange was associated with improved outcomes by conducting a systematic review of the literature (MEDLINE, EMBASE, CENTRAL, Scopus, reference lists of relevant articles, etc) focusing on randomized trials of patients receiving plasma exchange as part of therapy for septic shock. They found 1957 studies but only four unique trials enrolling a total of 194 patients (one enrolled adults only, two enrolled children only, and one enrolled adults and children).

The use of plasma exchange was associated with a significant reduction in all-cause mortality in adults (risk ratio [RR], 0.63; 95% confidence interval [CI], 0.42-0.96) but not in children (RR, 0.96; 95% CI, 0.28-3.38). None of the trials reported length of intensive care unit or hospital stay. Only one trial reported adverse events associated with plasma exchange, including six episodes of hypotension and one allergic reaction to fresh frozen plasma. The study authors concluded that there is insufficient evidence about plasma exchange for patients with sepsis or septic shock, and randomized controlled trials are required.

This study is very helpful in providing an evidence-based synthesis of data for the effect of plasma exchange as adjunctive therapy in the management of sepsis or septic shock. Not surprisingly, it is difficult to draw definitive conclusions from only four studies (two of which were strictly pediatric trials).[3-6]
However, the data suggest that there could be a benefit to plasma exchange in adults with septic shock, and companies and individual investigators are working to test this further. Given the pathogenesis of sepsis, with increased understanding of the damage resulting from both severe inflammation and anti-inflammation, strategies to modulate the immune response may confer real benefits for these patients, for whom morbidity and mortality remain high. However, whether this strategy is most effectively delivered by plasma exchange or by pharmacologic manipulation of the immune response remains to be seen.

References

  1. Angus DC, van der Poll T. Severe sepsis and septic shock. N Engl J Med. 2013;369:840-851. Abstract
  2. Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med. 2003;348:1546-1554. Abstract
  3. Reeves JH, Butt WW, Shann F, et al. Continuous plasmafiltration in sepsis syndrome. Plasmafiltration in Sepsis Study Group. Crit Care Med. 1999;27:2096-2104. Abstract
  4. Busund R, Koukline V, Utrobin U, Nedashkovsky E. Plasmapheresis in severe sepsis and septic shock: a prospective, randomised, controlled trial. Intensive Care Med. 2002;28:1434–-439. Abstract
  5. Nguyen TC, Han YY, Kiss JE, et al. Intensive plasma exchange increases a disintegrin and metalloprotease with thrombospondin motifs-13 activity and reverses organ dysfunction in children with thrombocytopenia associated multiple organ failure. Crit Care Med. 2008;36:2878-2887. Abstract
  6. Long EJ, Shann F, Pearson G, Buckley D, Butt W. A randomised controlled trial of plasma filtration in severe paediatric sepsis. Crit Care Resusc. 2013;15:198-204. Abstract

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