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Critical Care

Open Access

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

  • PM Honore1,
  • J Jamez2,
  • M Wauthier2 and
  • JP Pelgrim1
Critical Care19982(Suppl 1):P128

Published: 1 March 1998


PolyacrylonitrileConsecutive CaseNosocomial PneumoniaConsensus DefinitionDouble Lumen


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.


Retrospective study.


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


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.


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).


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.


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.

Status on admission:

Haemodynamic status

Mean arterial pressure:

<52 mmHg


Wedge pressure

between 16 and 18 mmHg


Cardiac index

1.95 l/min/m2


Inotropic support


Maximal dosages of dopamine and dobutamine


{norepinephrine (mean)

1.1 μg/kg/min


{epinephrine (mean)

0.61 μg/kg/min


Arterial pH (mean)



Serum lactate (mean)

12.3 mmol/l.

Expected mortality

APACHE II: 34.1 (mean)



SAPS II: 71.5 (mean)



Time after onset of the procedure


T2 (2 hours)

T4 (4 hours)

Mean pH




Serum lactate

12.3 mmol/l

11.4 mmol/l

7.1 mmol/l

Cardiac index

1.95 l/min/m2

3.82 l/min/m2

4.34 l/min/m2

Inotropic support

A = 0.61 μg/kg/min

A = 0.35 μg/kg/min

A = 0.19 μg/kg/min


NA = 1.1 μg/kg/min

NA = 0.79 μg/kg/min

NA = 0.45 μg/kg/min

Authors’ Affiliations

Intensive Care Department, St Pierre Hospital, Ottignies, Belgium
Nephrology Department, St Pierre Hospital, Ottignies, Belgium


© Current Science Ltd 1998