Evaluation of Continuous Renal Replacement Therapy and Therapeutic Plasma Exchange, in Severe Sepsis or Septic Shock in Critically Ill Children
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design
2.2. Patient Population and Data Collection
2.3. Catheterisation
2.4. CRRT Protocol
2.5. TPE Protocol
2.6. Statistical Analysis
3. Results
3.1. Cohort Flow
3.2. The Relationship between Severe Sepsis and CRRT Regarding Prognostic Factors in the PICU
3.3. The Relationship between Severe Sepsis and TPE Regarding Prognostic Factors in the PICU
3.4. Comparison of Prognostic Factors for Mortality in Patients with Severe Sepsis
3.5. Logistic Regression Analysis of Risk Factors for Mortality in Patients with Sepsis
3.6. Changes in Serum Liver and Blood Gases in Patients with Severe Sepsis with or without Continuous Haemofiltration
3.7. Survival Data from Kaplan–Meier Survival Analysis
4. Discussion
5. Conclusions
Author Contributions
Funding
Conflicts of Interest
References
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CRRT during Sepsis | p-Value | |||
---|---|---|---|---|
Yes (n = 47), Median (Min–Max) | No (n = 121), Median (Min–Max) | |||
Sex (male) | 24 (51.1%) | 62 (51.2%) | 0.984 | |
Age, years | 2.0 (2 days–17.83 years) | 1.0 (3 days–17.50 years) | 0.022 | |
IMV support | 24 (51.1%) | 57 (47.1%) | 0.541 | |
Inotropic drug use | 34 (72.3%) | 59 (48.8%) | 0.006 | |
Albumin use | 37 (78.7%) | 58 (47.9%) | <0.001 | |
RBC transfusion | 45 (95.7%) | 86 (71.1%) | <0.001 | |
IVIG use | 22 (46.8%) | 38 (31.4%) | 0.133 | |
NIV support | 26 (55.3%) | 59 (48.8%) | 0.445 | |
Mortality | 14 (29.8%) | 11 (9.1%) | <0.001 | |
Duration of stay in PICU | 7.0 (26 h–52 d) | 6.0 (28 h–97 d) | 0.085 | |
PRISM III score | 28 (5–56) | 20 (3–65) | 0.038 | |
Multi-organ failure | 29 (61.7%) | 43 (35.5%) | 0.006 | |
Laboratory findings | Sodium (mmol/L) | 136.0 (118.0–182.0) | 138.0 (119.0–160.0) | 0.750 |
Chlorine (mmol/L) | 99.0 (84.2–150.0) | 102.4 (84.8–121.0) | 0.368 | |
Calcium (mg/dL) | 8.2 (5.6–10.6) | 9.1 (6.4–11.3) | <0.001 | |
Magnesium (mg/dL) | 1.85 (0.90–4.00) | 2.00 (0.89–4.11) | 0.652 | |
ALT (IU/L) | 48 (5–4388) | 20 (4–1620) | 0.008 | |
AST (IU/L) | 72 (19–8620) | 34 (8–1954) | 0.010 | |
PT (s) | 16.8 (11.2–28.3) | 15.6 (1.3–26.6) | 0.300 | |
aPTT (s) | 40.4 (26.2–124.0) | 39.6 (18.8–77.5) | 0.108 | |
INR | 1.46 (0.90–2.40) | 1.40 (0.80–2.20) | 0.325 | |
LDH (IU/L) | 514 (1–6310) | 395 (126–2591) | <0.001 | |
CRP (ml/dL) | 7.8 (0.03–405.9) | 15.9 (0.1–467.0) | 0.935 | |
Leucocyte count (mm3) | 7500 (200–111,800) | 12095 (13–50,180) | 0.528 | |
Uric acid (mg/dL) | 4.2 (0.1–17.8) | 3.7 (0.9–16.2) | 0.323 | |
Haemoglobin (g/dL) | 8.7 (6.1–19.3) | 10.0 (5.6–15.0) | 0.058 | |
Platelet count (103/µL) | 133 (160–441) | 252 (6–899) | <0.001 | |
HCO3 (mmol/L) | 15.0 (9.0–29.5) | 20.2 (3.5–37.0) | <0.001 | |
Lactate (mmol/L) | 4.4 (0.5–16.0) | 2.0 (0.5–29.0) | 0.014 | |
CRRT indications | Progressive metabolic acidosis | 35 (74.5%) | ||
Volume overload-oliguria | 24 (51.1%) | - | - | |
Severe electrolyte abnormalities | 9 (19.1%) |
TPE Use during Sepsis | p-Value | |||
---|---|---|---|---|
Yes (n = 29), Median (Min–Max) | No (n = 139), Median (Min–Max) | |||
Sex (male) | 13 (44.8%) | 73 (52.5%) | 0.451 | |
Age, years | 5.0 (5 months–17.83 years) | 3.0 (2 days–17.58 years) | 0.761 | |
IMV support | 14 (48.3%) | 67 (48.2%) | 0.942 | |
Inotropic drug use | 21 (72.4%) | 72 (51.8%) | 0.042 | |
Albumin use | 23 (79.3%) | 72 (51.9%) | 0.008 | |
RBC transfusion | 28 (96.6%) | 103 (74.1%) | <0.001 | |
IVIG use | 13 (44.8%) | 47 (33.8%) | 0.260 | |
NIV support | 13 (44.8%) | 72 (51.8%) | 0.495 | |
Mortality | 7 (24.1%) | 18 (12.9%) | 0.124 | |
Duration of stay in PICU | 6.0 (27 h–48 d) | 7.0 (26 h–97 d) | 0.761 | |
PRISM III score | 28 (6–55) | 21 (3–65) | 0.195 | |
Multi-organ failure | 15 (51.7%) | 57 (41.0%) | 0.289 | |
Laboratory findings | Sodium (mmol/L) | 136.0 (119.0–182.0) | 138.0 (119.0–161.0) | 0.399 |
Chlorine (mmol/L) | 99.9 (84.2–150.0) | 102.0 (84.8–121.0) | 0.937 | |
Calcium (mg/dL) | 8.0 (5.6–10.6) | 9.0 (6.4–11.3) | <0.001 | |
Magnesium (mg/dL) | 1.64 (1.10–4.11) | 2.00 (0.89–4.00) | 0.507 | |
ALT (IU/L) | 43 (7–4388) | 20 (4–1620) | <0.001 | |
AST (IU/L) | 51 (19–8620) | 36 (8–1954) | <0.001 | |
PT (s) | 16.8 (11.2–28.3) | 15.6 (1.3–26.6) | 0.318 | |
aPTT (s) | 41.6 (27.7–124.0) | 39.1 (18.8–124.0) | 0.226 | |
INR | 1.42 (0.90–2.40) | 1.40 (0.80–2.20) | 0.455 | |
LDH (IU/L) | 539 (1–6310) | 393 (126–2591) | <0.001 | |
CRP (mL/dL) | 8.1 (0.74–405.9) | 11.6 (0.3–467.0) | 0.408 | |
Leucocyte count (mm3) | 7100 (200–54,600) | 12095 (13–111,800) | 0.216 | |
Uric acid (mg/dL) | 5.7 (1.0–17.8) | 3.5 (1.0–16.2) | 0.004 | |
Haemoglobin (g/dL) | 8.0 (6.1–11.2) | 9.6 (5.6–19.3) | 0.007 | |
Platelet count (103/µL) | 84 (24–410) | 228 (6–899) | <0.001 | |
HCO3 (mmol/L) | 13.9 (9.0–35.3) | 19.2 (3.5–37.0) | 0.150 | |
Lactate (mmol/L) | 4.5 (0.5–16.0) | 2.5 (0.5–29.0) | 0.160 |
Mortality | p-Value | ||
---|---|---|---|
Yes (n = 25), Median (Min–Max) | No (n = 143), Median (Min–Max) | ||
Sex (male) | 12 (48.0%) | 74 (51.7%) | 0.729 |
Age, years | 1.0 (2 months–17.58 years) | 1.1 (2 days–17.83 years) | 0.799 |
Invasive mechanical ventilation support | 22 (88.0%) | 64 (44.8%) | <0.001 |
Inotropic drug use | 24 (96.0%) | 69 (48.3%) | <0.001 |
Albumin use | 17 (68.0%) | 78 (54.5%) | 0.211 |
Red blood cell transfusion | 22 (88.8%) | 109 (76.2%) | 0.190 |
Intravenous immunoglobulin use | 10 (40.0%) | 50 (35.0%) | 0.628 |
Acute kidney injury | 22 (88.0%) | 65 (45.5%) | <0.001 |
Continuous renal replacement therapy | 14 (56.0%) | 33 (23.1%) | <0.001 |
Therapeutic plasma exchange | 7 (28.0%) | 22 (15.4%) | 0.124 |
PRISM III score | 31 (12–65) | 20.5 (3–55) | <0.001 |
Duration of stay in PICU | 3.0 (26 h–97 d) | 7.0 (27 h–41 d) | 0.029 |
HCO3 (mmol/L) | 16.9 (9.0–37.0) | 19.1 (6.3–35.3) | 0.254 |
Lactate (mmol/L) | 4.4 (0.6–17.0) | 2.4 (0.5–11.0) | 0.002 |
ALT (IU/L) | 11.0 (−234–134) | 11.0 (−1762–45) | 0.716 |
AST (IU/L) | 2.0 (−640–234) | 1.0 (−4523–234) | 0.698 |
Risk factors | p-Value | Odds Ratio | 95% Confidence Interval |
---|---|---|---|
Acute kidney injury | 0.155 | 1.952 | 0.664–13.131 |
Continuous renal replacement therapy | 0.032 | 3.996 | 1.126–14.186 |
Invasive mechanical ventilation | 0.008 | 7.287 | 1.666–31.887 |
Therapeutic plasma exchange | 0.738 | 0.797 | 0.211–3.008 |
Inotropic drug use | 0.005 | 10.638 | 1.180–95.906 |
Blood component transfusions | 0.750 | 1.325 | 0.234–7.490 |
Intravenous immunoglobulin | 0.338 | 0.557 | 0.168–1.842 |
Albumin use | 0.189 | 0.376 | 0.088–1.619 |
CRRT (n = 23) Median (Min–Max) | CRRT+TPE (n = 24) Median (Min–Max) | Without CRRT or TPE (n = 116) Median (Min–Max) | p-Value | ||
---|---|---|---|---|---|
Underlying disease before the sepsis on admission | |||||
Healthy before the admission | 9 (39.1%) | 10 (41.7%) | 56 (48.3%) | 0.065 | |
Metabolic diseases | 8 (34.8%) | 2 (8.3%) | 13 (11.2%) | ||
Neurologic | 1 (4.3%) | 3 (12.5%) | 16 (13.8%) | ||
Haematology-oncology | 2 (8.7%) | 2 (8.3%) | 6 (5.2%) | ||
Congenital heart diseases | 1 (4.3%) | 0 | 8 (6.9%) | ||
Others | 2 (8.7%) | 7 (29.2%) | 17 (14.7%) | ||
Sex (male) | 11 (47.8%) | 11 (45.8%) | 63 (54.3%) | 0.679 | |
Age, years | 1.0 (2 days–17.58 years) | 7.0 (5 months–17.83 years) | 1.0 (2 days–17.50 years) | <0.001 | |
Prognostic factors | |||||
IMV support | 14 (60.9%) | 10 (41.7%) | 57 (49.1%) | 0.124 | |
Inotropic drug use | 17 (73.9%) | 17 (70.8%) | 58 (50.0%) | 0.107 | |
RBC transfusion | 22 (95.7%) | 23 (95.8%) | 83 (71.6%) | 0.003 | |
IVIG use | 11 (47.8%) | 11 (45.8%) | 38 (32.8%) | 0.239 | |
NIV support | 15 (65.2%) | 11 (45.8%) | 58 (50.0%) | 0.254 | |
PRISM-III score | 24 (5–56) | 29 (6–55) | 20 (3–65) | 0.117 | |
Duration of stay in PICU | 9.0 (48 h–52 d) | 6.0 (26 h–48 d) | 7.0 (28 h–97 d) | 0.153 | |
Multi-organ failure | 17 (73.9%) | 12 (50.0%) | 43 (37.1%) | 0.017 | |
Mortality | 7 (30.4%) | 7 (29.2%) | 11 (9.5%) | 0.026 | |
Catheters’ diameters | |||||
6.5 and 7 Fr | 8 (34.8%) | 1 (4.2%) | - | 0.065 | |
8 Fr | 8 (34.8%) | 11 (45.8%) | |||
10 Fr | 1 (4.3%) | 2 (8.3%) | |||
11.5 and 12 Fr | 6 (26.1%) | 10 (41.7%) | |||
Hemodialysis filter | |||||
0.2 m2 | 6 (26.1%) | 0 | - | 0.024 | |
0.6 m2 | 11 (47.8%) | 13 (54.2%) | |||
0.9 m2 or bigger | 6 (26.1%) | 8 (33.3%) | |||
oXiris® | 0 | 3 (12.5%) | |||
Localisation of the haemodialysis catheters | |||||
Internal jugular | 15 (65.2%) | 18 (75.0%) | - | 0.188 | |
Femoral | 5 (21.7%) | 6 (25.0%) | |||
Subclavian | 3 (13.0%) | 0 | |||
Initial settings for CRRT | |||||
Blood flow rate (mL/min) | 56.5 (36–150) | 75.0 (40–150) | - | 0.177 | |
Dialysate rate (mL/1.73m2/h) | 2090 (825–8355) | 2054 (1750–4550) | - | 0.843 | |
Replacement rate (mL/kg/h) | 37.0 (29–61) | 36.0 (28–53) | - | 0.164 | |
Duration of CRRT (hours) | 34.0 (8–189) | 45.0 (12–228) | - | 0.286 | |
CRRT starting time | |||||
0–12. h | 19 (82.6%) | 22 (91.7%) | - | 0.497 | |
12–24. h | 3 (13.0%) | 2 (8.3%) | |||
>24. h | 1 (4.3%) | 0 | |||
TPE sessions | - | 3.0 (1–7) | - | - | |
ALT (IU/L) | 0 h | 34.0 (5–534) | 48.0 (7–4388) | 20 (4–1620) | <0.001 |
24 h | 44.0 (7–301) | 37.0 (8–2626) | 31.0 (2–922) | <0.001 | |
0–24 h change | +10.5 (−234, 101) | −10.0 (−1762, 23) | +12.0 (−698, 134) | <0.001 | |
AST (IU/L) | 0 h | 68.0 (19–1070) | 98 (19–8620) | 35.5 (8–1954) | 0.002 |
24 h | 61.5 (10–730) | 89.0 (20–5747) | 39.0 (1–1235) | <0.001 | |
0–24 h change | −8.5 (−343, 145) | −6.0 (−4523, 21) | 2.0 (−765, 234) | 0.003 | |
HCO3 (mmol/L) | 0 h | 16.9 (9–26.5) | 13.7 (9–35.3) | 20.1 (3.5–37) | 0.113 |
24 h | 23.1 (7–29.5) | 23.9 (6.2–32.3) | 22.8 (8.4–29.0) | 0.351 | |
0–24 h change | 5.0 (−10, 13) | 6.0 (−8, 22) | 3.0 (−11, 15) | 0.773 | |
Lactate (mmol/L) | 0 h | 4.5 (0.5–12) | 3.0 (0.5–16) | 2.25 (0.5–17) | 0.005 |
24 h | 2.1 (0.9–11.6) | 2.3 (1–9.7) | 2.0 (0.1–14) | 0.167 | |
0–24 h change | −2.5 (−9.15, 7.0) | 0.5 (−6.7, 6.3) | −0.2 (−5.4, 9.2) | 0.114 |
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Aygün, F.; Varol, F.; Durak, C.; Talip Petmezci, M.; Kacar, A.; Dursun, H.; Irdem, A.; Çokuğraş, H.; Camcıoğlu, Y.; Çam, H. Evaluation of Continuous Renal Replacement Therapy and Therapeutic Plasma Exchange, in Severe Sepsis or Septic Shock in Critically Ill Children. Medicina 2019, 55, 350. https://doi.org/10.3390/medicina55070350
Aygün F, Varol F, Durak C, Talip Petmezci M, Kacar A, Dursun H, Irdem A, Çokuğraş H, Camcıoğlu Y, Çam H. Evaluation of Continuous Renal Replacement Therapy and Therapeutic Plasma Exchange, in Severe Sepsis or Septic Shock in Critically Ill Children. Medicina. 2019; 55(7):350. https://doi.org/10.3390/medicina55070350
Chicago/Turabian StyleAygün, Fatih, Fatih Varol, Cansu Durak, Mey Talip Petmezci, Alper Kacar, Hasan Dursun, Ahmet Irdem, Haluk Çokuğraş, Yıldız Camcıoğlu, and Halit Çam. 2019. "Evaluation of Continuous Renal Replacement Therapy and Therapeutic Plasma Exchange, in Severe Sepsis or Septic Shock in Critically Ill Children" Medicina 55, no. 7: 350. https://doi.org/10.3390/medicina55070350