Adsorptive therapies in sepsis and inflammation: description of the various adsorptive techniques and their failure to improve outcomes.

Blood purification as an adjunctive therapy has been studied for several decades. In this review, we will focus on the most recent studies, particularly on adsorption techniques. These include hemofilters with adsorptive membranes, both endotoxin-specific and non-specific. In addition, we will discuss sorbents that target endotoxins, as well as devices that non-selectively capture viruses and bacteria. For each technique, we will also explore the reasons why blood purification methods have thus far failed to improve survival. Conventionally, reasons for the lack of success in blood purification techniques have been attributed to the need for better patient stratification through bedside measurements of interleukins and endotoxins. The choice of assay is also crucial, with endotoxin activity assays being preferable to other forms of limulus amoebocyte lysate assays. Another critical factor is timing, as administering blood purification at the wrong moment can potentially harm the patient. Mechanistic studies are still lacking for most devices, leaving us to treat patients blindly, except in endotoxin cases. In the context of viruses, especially COVID-19, we require a deeper understanding of the complexities involved in viral replication, as this could significantly impact the efficacy of blood purification techniques. The failures highlighted for each device should be viewed as potential areas for improvement. Despite the challenges, we remain hopeful that these techniques will eventually succeed and prove beneficial in the future.

Sedation for adult ICU patients: A narrative review including a retrospective study of our own data.

The optimization of patients' treatment in the intensive care unit (ICU) needs a lot of information and literature analysis. Many changes have been made in the last years to help evaluate sedated patients by scores to help take care of them. Patients were completely sedated and had continuous intravenous analgesia and neuromuscular blockades. These three drug classes were the main drugs used for intubated patients in the ICU. During these last 20 years, ICU management went from fully sedated to awake, calm, and nonagitated patients, using less sedatives and choosing other drugs to decrease the risks of delirium during or after the ICU stay. Thus, the usefulness of these three drug classes has been challenged. The analgesic drugs used were primarily opioids but the use of other drugs instead is increasing to lessen or wean the use of opioids. In severe acute respiratory distress syndrome patients, neuromuscular blocking agents have been used frequently to block spontaneous respiration for 48 hours or more; however, this has recently been abolished. Optimizing a patient's comfort during hemodynamic or respiratory extracorporeal support is essential to reduce toxicity and secondary complications.

Anticoagulation Prophylaxis in Extracorporeal Adsorption Techniques.

In this chapter, anticoagulation treatments for adsorption techniques in continuous renal replacement therapy (CKRT) will be reviewed. Anticoagulation used with adsorption techniques is quite different than anticoagulation in classical CKRT with nonadsorptive therapies. Regional citrate anticoagulation (RCA) and unfractionated heparin (UFH) are the most common anticoagulation modalities for both nonselective adsorptive membranes - such as surface-treated acrylonitrile 69 membranes (AN69ST) and polymethylmethacrylate membranes - and selective adsorptive membranes such as AN69-oXiris. For these techniques, the efficacy of RCA seems to be superior to UFH. Regardless of the lack of large comparative studies in comparison to ones conducted for adsorptive filter techniques in CKRT, RCA and UFH will also be discussed for nonselective adsorptive sorbents like CytoSorb and Jafron HA. For selective adsorptive sorbents, such as polymyxin-B hemoperfusion, UFH and RCA seems to be the appropriate techniques; however, randomized controlled trials confirming this are yet to be conducted. Lastly, anticoagulation prophylaxis for more specific techniques like coupled plasma filtration adsorption and double plasma molecular adsorption system will be discussed.