Survival Benefits of Therapeutic Plasma Exchange in Severe Sepsis and Septic Shock: A Systematic Review and Meta-analysis.

OBJECTIVES: To summarize the role of therapeutic plasma exchange (TPE) in critically ill adults and children with severe sepsis. DATA COLLECTION: A systematic search was performed using the following databases: Medline, EMBASE, CINAHL, and Cochrane from January 1990 till December 2022. Comparative studies of TPE in severe sepsis were selected. Adult and pediatric data were analyzed separately. DATA SYNTHESIS: Eight randomized control trials and 6 observational studies (n = 50,142 patients) were included. Centrifugal TPE was the most common modality (209/280, 74.6% adults and 952/1026, 92.7% children). Every TPE study utilized different volume exchanges. Most TPE sessions (1173/1306, 89.8%) employed fresh frozen plasma (FFP) as replacement fluid and heparin as anticoagulant. Adults with severe sepsis supported with TPE using FFP had lower mortality (risk ratio, RR: 0.64 [95% confidence interval, CI: 0.49, 0.84]) compared to those who did not. In contrast, TPE was associated with increased mortality in septic children without thrombocytopenia-associated multiorgan failure (RR: 2.23, 95% CI: 1.93, 2.57). There was no difference in outcomes in patients supported with centrifugal and membrane TPE. In both populations, patients supported on TPE as a continuous regime had poorer outcome. CONCLUSION: Current evidence indicates that TPE is a potential adjunct therapy in adults with severe sepsis but not in children.

Fluid management in children with severe dengue: a narrative review.

Dengue is a mosquito-borne arboviral infection of increasing public health importance. Globally, children account for a significant proportion of infections. No pathogen-specific treatment currently exists, and the current approach to reducing disease burden is focused on preventative strategies such as vector control, epidemiological interventions, and vaccination in selected populations. Once infected, the mainstay of treatment is supportive, of which appropriate fluid management is a cornerstone. The timely provision of fluid boluses has historically been central to the management of septic shock. However, in patients with dengue shock, particular emphasis is placed on judicious fluid administration. Certain colloids such as hydroxyethyl starches and dextran, despite no longer being used routinely in intensive care units due to concerns of acute kidney injury and impairment of coagulation, are still commonly used in dengue shock syndrome. Current guidelines recommend initial crystalloid therapy, with consideration of colloids for severe or recalcitrant shock in patients with dengue. In this review, we discuss the pathophysiology of septic shock, and consider whether any differences in dengue exist that may warrant a separate approach to fluid therapy. We critically review the available evidence for fluid management in dengue, including the role of colloids. In dengue, there is increasing recognition of the importance of tailoring fluid therapy to phases of disease, with attention to the need for fluid "deresuscitation" once the critical phase of vascular leak passes.

Fluid overload in children with pediatric acute respiratory distress syndrome: A retrospective cohort study.

OBJECTIVES: To assess the association of cumulative fluid overload (FO) up to 14 days from the diagnosis of pediatric acute respiratory syndrome (PARDS) with pediatric intensive care unit (PICU) mortality, 28-day mechanical ventilation free days (VFD), and 28-day intensive care unit free days (IFD). We hypothesized that fluid overload, even beyond the acute period, would be associated with increased morbidity and mortality. METHODS: We conducted a retrospective cohort study of PARDS patients admitted to PICU from 2009 to 2015. For repeated admissions, we considered the admission with the highest oxygenation index (OI). Daily FO (%) was calculated as (intake - output)/weight at PICU admission × 100. Peak cumulative FO (CFO) was the highest CFO from the diagnosis of PARDS to Day 14 or to PICU discharge or mortality, whichever was earliest. Rate to peak CFO was the peak CFO divided by the number of days to reach that highest CFO. The association of FO with mortality, VFD and IFD were analyzed with logistic and linear regression models, with the following covariates: Pediatric Index of Mortality 2 score, PARDS severity, and the presence of acute kidney injury (AKI). RESULTS: There were 165 patients included in this study, with a mortality rate of 45.5% (75/165), median age 3.2 years (interquartile range [IQR] 0.7-9.9) and OI 15.8 (IQR 9.5-27.9). Seventy-three (44.2%) patients had severe PARDS and 64 (38.8%) had AKI. AKI (aOR [adjusted odds ratio] 3.19, 95% CI [confidence interval] 1.43-7.09, p = 0.004) and rate to peak cumulative FO (aOR 1.23, 95% CI 1.07-1.42, p = 0.004) were associated with mortality. AKI and peak cumulative FO were associated with decreased VFD and IFD. CONCLUSION: The rate to peak CFO over the first 14 days of PARDS was associated with mortality and peak CFO was associated with decreased VFD and IFD.