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

Objectives

Devastating toxic strep syndrome has still high mortality race (about 30%) despite all (he therapeutical interventions that have been developped in the last decade. The mortality of the refractory cases lies above 80%. Several descriptions of favorable outcome have been presented using plasmapheresis and intravenous immunoglobin therapy. Amongst the available tools, short lime high volume haemofiltration (ST-HV-SVVH) could be used as therapeutic rescue. We report here a retrospective study of 4 consecutive cases of refractory toxic strep syndrome in terms of haemodynamic course and outcome.

Design

Retrospective study.

Setting

Fifteen bedded, adult polyvalent intensive care unit in a general hospital.

Methods

The four cases were in agreement with the consensus definition of toxic strep syndrome. They were treated with conventional therapy first including high doses of penicillin, surgical debridment when needed and adequate critical care therapy.

Short time high volume haemofiltration was only used after failure of conventional therapy.

Technique

The technique consisted in the use at first of ST-HV-CVVH exchanging 35 l in a 4 h period of time with achieving a neutral balance. A GAMBRO device was used with polyacrylonitrile membrane (1.6 m² of active surface). Bicarbonate was used as buffer. The vascular access was obtained using a 14 french double lumen coaxial catheter allowing blood flow of 450 ml/min. After, the patient was put on low volume haemofiltration (24 l a day).

Results

1) Influence on the haemodynamic and metabolic course

Despite the dramatic improvement, no 'P' value was calculated in view of the small number of cases.

2) Influence on the outcome: Global expected mortality according to the severity scoring (APACHE II and SAPS II) was on admission about 82.5%. Observed mortality at day 28: 25% (no P value was calculated). One responder died at day 18 from nosocomial pneumonia.

Conclusions

Short time high volume haemofiltration using bicarbonate based replacement fluid seems to be a valuable non conventional tool in toxic strep syndrom with severe lactic acidosis after failure of classical treatment. Response to the therapy is associated with higher likelihood of improvement. We need more cases to become statistically significant. We can speculate that the M-Protein and exotoxin A wich play a crucial role in the severity of the disease can be eliminated by the technique regarding their molecular weight.

Table Status on admission:

Table