1. Hemodynamic changes during hemofiltration in meningococcal septicemia Dr Rajiv Chhabra Dr Prabhat Maheshwari Dr Claudine De Munter

2. Meningococcal sepsis Incidence: One of the most common infectious cause of death in children outside neonatal period

3. Meningococcal sepsis (MS) at St Mary’s hospital Tertiary care center Research on meningococcal disease in Prof Michael Levin’s lab PICU: 8 bedded unit Over 900 cases of MS since 1993

4. Meningococcal sepsis (MS): patient population at St Mary’s Hospital PICU endotracheally intubated: 100% fluid volume: > 100 ml/Kg first 24 hours: 70% > 200 ml/Kg first 24 hours: 20% inotropes: 90%; adrenaline and/or noradrenaline haemofiltration: since 1996 for renal failure 5%

5. Retrospective Study: Objective BASIS: Observation of rapid clinical improvements in hemodynamics after initiation of CRRT despite the rapid clinical deterioration prior to and leading to CRRT compared to the rate of improvement in the less sick non-haemofiltered cases. AIM: To review the clinical improvements in hemodynamics after initiation of CRRT in MS

6. Methods Retrospective review of notes Parameters: inotropic requirement, base excess, fluid requirement, blood lactate Recorded: - 12 hours before starting haemofiltration, - time of starting, - 6, 12, 24 & 48 hours after initiating CRRT statistics used ANOVA

7. CRRT Hygeia+ (Kimal) Filters : polysulfones Heparin infusion High flows: Flows used 80-120 ml/kg/hour choice: highest flows tolerated within this range

8. Results 27 patients (5% of MS cases) Age: 6 months to 16 years (median 5.5 years) 3 died, within 8 hours of admission: excluded mean PRISM score among the 24 survivors: 64.7(3.4 – 96).

9. Controls 21 severely ill controls chosen on the basis of their inotropic requirement: adrenaline > 0.1mcg/kg/min and noradrenaline > 0.1mcg/Kg/min Age: 8m-14 years (median: 6 years) PRISM score: 7.1-84.7 (median:45.8)

10. Hemofiltered (n= 27) Controls (n= 21) Mortality30 Age6 m-16 years (median 5.5 yrs) 8 m- 14 years (median 6 years) Prism score (median) 64.745.8 Adrenaline (median) 2.5 mcg/kg/min1 mcg/kg/min Noradrenaline (median) 1.12 mcg/kg/min0.6 mcg/kg/min Worst lactate:63.7

11. Adrenaline infusion CRRT controls

12. Noradrenaline infusion CRRT controls

13. Base excess CRRT controls

14. Lactate levels CRRT controls

15. Continuous veno-venous hemofiltration improves hemodynamics in septic shock with acute renal failure without modifying TNFalpha and IL6 plasma concentrations. J Nephrol. 2002 Mar-Apr;15(2):150-7. In patients with septic shock and ARF, CVVH improves mean arterial pressure and SVR.

16. Early filtration and mortality in meningococcal septic shock? Arch Dis Child. 2000 Dec;83(6):508-9 Following the introduction of a policy of early therapeutic filtration for presumed meningococcal septicaemic shock, the overall mortality has decreased.

17. Pulse high-volume haemofiltration for treatment of severe sepsis: effects on hemodynamics and survival Critical Care 2005, 9:R294-R302 High-volume hemofiltration in septic shock. Crit Care. 2005 Aug;9(4):329-30 high-volume haemofiltration (HVHF) has exhibited beneficial effects in severe sepsis, improving haemodynamics.

18. Pulse High-Volume Hemofiltration in Critically Ill Patients: A New Approach for Patients with Septic Shock Semin Dial. 2006 Jan-Feb;19(1):69-74. PHVHF applied in patients with septic shock/severe sepsis: beneficial effects on vasopressor requirements. PHVHF: may represent a beneficial adjuvant treatment for severe sepsis/septic shock in terms of patient survival.

19. Limitations and comments Observational study Small number of patients -but all patients have the same disease process Controls are not matched Data confirms results of existing studies

20. Conclusion Hemodynamic status of patients with extremely severe meningococcal sepsis improved rapidly after initiation of CRRT. This allowed rapid reduction of dose of vasoconstrictors that were initially required and avoid potential deleterious effects.