The place of plasmapheresis in septic patients complicated with disseminated intravascular coagulation

Sepsis, complicated with disseminated intravascular coagulation (DIC), is the most frequent cause of mortality in the ICU despite improvements in patient care [1]. Plasmapheresis is a tool to remove endotoxins and inflammatory mediators responsible for pathophysiology. We design a study in a small group of septic patients complicated with DIC to evaluate the changes on coagulation parameters, severity of sepsis and outcome of plasmapheresis.

After ethical approval for the trial and written informed consent was obtained, patients were prepared for plasmapheresis. The criteria for entry to the trial were sepsis as described by Bone [2], and DIC [3] as described by Bick. The exclusion criteria were uncontrolled hemorrhagia, recent (< 48 hours) cardiac surgery, recent(< 48 hours) resuscitation, platelets < 20,000/mm³, positive human immunodeficiency virus serology, morbid obesity and pregnancy. After obtaining the laboratory data and scores first, plasmapheresis was performed using fresh frozen plasma as a 1:1 ratio for the calculated plasma volume for each patient. The second plasmapheresis was performed after 48 hours. The severity of illness and mortality rates was calculated using the APACHE II scale and the severity of DIC was calculated by the DIC score. The outcomes at 28 days were recorded. Statistical analysis was performed with SPSS version 11.0 for Windows (Chicago, IL, USA), values are expressed as mean ± SD and P < 0.05 considered statistically significant.

Thirteen patients were treated in the ICU with plasmapheresis from 2002 to 2003. The difference between the calculated mortality rate based on initial APACHE II scores (59.6 ± 21.3), and 28-day mortality of all patients (20%), was significant (P < 0.05). The decrease in prothrombin time and activated partial thromboplastic time, based on initial results, were significant in 24, 48 and 72 hours (P < 0.05). The enhancement of the DIC score (from 6.2 ± 0.6 to 3.7 ± 0.9) between the baseline and the end of the procedure was statistically significant (P < 0.01). The level of D-dimer before the first plasmapheresis (1333 ± 972) was decreased (638.6 ± 252.9) significantly at the end of the procedure (P < 0.007). The increase in biological markers of sepsis (antithrombin, protein C and protein S activity) was statistically significant (P < 0.01). It was also found that the protein C activity was controversially correlated with 28-day survival (P < 0.02).

We thought that repeated plasmapheresis in the early stages of sepsis may be considered a therapeutic method even during progressive sepsis that is complicated with DIC.