Reversal of intractable circulatory failure complicating septic shock with short time high volume haemofiltration (ST-HV-CVVH) after failure of conventional therapy: a prospective evaluation

Objectives

According to our previous retrospective study, shorttime high volume haemofiltration may have beneficial effects on the haemodynamic course and outcome of patients with refractory septic shock. Therefore, a prospective study was performed to confirm (or not) these preliminary results.

Design

Prospective open study over 20 consecutive patients.

Setting

Fifteen bedded adult polyvalent intensive care unit in a general hospital with more than 45% of the admissions coming through the emergency department.

Methods

Twenty patients with septic shock were included according to entry criteria including haemodynamic status, acid-base balance, septic status, respiratory support and renal status.

Technique

It consisted in an exchange of 35 l in a 4 h period of time, achieving a neutral balance. A Gambro device was used with polyacrylonitrile membranes and bicarbonate was used as buffer. After, the patient was put on low volume haemofiltration exchanging 24 l a day.

Results

1) Influence on the haemodynamic course: data were analysed using non parametric statistical methods. A responder was defined using 4 criterias as shown by the following table (criteria: C). 2) Influence on the outcome : 9 patients out of 11 responders survived at day 28. Both groups (survivors N = 9 and non survivors - N = 11) were similar on admission in terms of APACHE II score (31.1 vs 32.3 P > 0.05), SAPS II score (69 vs 68.5 P > 0.05) but were significantly different regarding the time of intervention (6.1 h vs 14.2 h P < 0.01). The global expected mortality was 79.1% and the observed mortality was 55%. Using the angular transformation as statistical test, the difference was significant with a P value below 0.05.

Conclusions

Our prospective open study is confirming our preliminary results by suggesting that ST-HV-CVVH is able to reverse intractable circulatory failure complicating septic shock and to improve survival. Early intervention is related with a better outcome. Outcome is well predicted by the early haemodynamic response and not by conventional scoring systems. In our institution, at the present time, this therapy is restricted to cases unresponsive to conventional therapy.

Table 1 Inclusion criteria:

Table 2