Role of early continuous venovenous hemodiafiltration in septic shock and multiorgan failure

Introduction

To evaluate early continuous venovenous hemodiafiltration (CVVHDF) in patients with refractory septic shock and multiorgan failure upon mortality and morbidity in the ICU.

Methods

Forty patients were prospectively studied and randomly treated with either conventional treatment (20 patients; group II) or with early CVVHDF (less than 6 hours of maximal hemodynamic support) in addition to the conventional treatment (20 patients; group I). Metabolic acidosis, serum lactate and serum procalcitonin level (PCT) before and 5 days after CVVHDF were monitored to evaluate the outcome. APACHE II and ΔSOFA scoring systems were used before and 5 days after CVVHDF.

Results

Compared with group II, patients of group I had lower mortality (55% vs 70%) with an insignificant P value (P = 0.54). Group I patients showed a nonsignificant ΔSOFA (5.95 ± 4.39 vs 6.2 ± 3.3 in groups I and II, respectively, P = 0.66); regarding APACHE II scores, group I also showed statistically nonsignificant lower figures than group II (on admission APACHE II scores were 39.35 ± 10.65 vs 41.85 ± 10 in groups I and II, respectively, P = 0.45, while on day 5 APACHE II scores were 34.8 ± 10.6 vs 36.1 ± 10.9 in groups I and II, respectively, P = 0.41). Group I patients showed lower PCT on admission and day 5 than group II patients (on admission PCT level was 0.64 ± 0.18 vs 0.68 ± 0.17 in groups I and II, respectively, P = 0.5) while the day 5 PCT level was (0.51 ± 0.15 vs 0.52 ± 0.17 in groups I and II, respectively, P = 0.83). Indicators of improvement showed a statistically significant difference between survivors and nonsurvivors in group I regarding serum lactate level at day 5 (P < 0.001), while other indicators as fever, renal profile, WBC count, metabolic acidosis, serum lactate level on admission and platelet count were statistically insignificant (on admission P = 0.2, 0.55, 0.45, 0.41, 0.65, 0.55, respectively, and on day 5 P = 0.37, 0.94, 0.71, 0.5, <0.001, 0.88, respectively). There was a significant statistical difference between survivors and nonsurvivors in group I considering the number of organ failures as less than or equal to three organs involved in comparison with more than three organs involved (P = 0.008).

Conclusions

Early CVVHDF may improve the prognosis of sepsis-related multiple organ failure. Continuous rising of the serum lactate level despite CVVHDF is associated with an increased mortality rate. Of all scoring systems used, SOFA maximum, ΔSOFA and day 5 APACHE II were the most accurate prognostic indicators for mortality.