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01.12.2014 | Research | Ausgabe 6/2014 Open Access

Critical Care 6/2014

The efficacy and safety of plasma exchange in patients with sepsis and septic shock: a systematic review and meta-analysis

Zeitschrift:
Critical Care > Ausgabe 6/2014
Autoren:
Emily Rimmer, Brett L Houston, Anand Kumar, Ahmed M Abou-Setta, Carol Friesen, John C Marshall, Gail Rock, Alexis F Turgeon, Deborah J Cook, Donald S Houston, Ryan Zarychanski
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​s13054-014-0699-2) contains supplementary material, which is available to authorized users.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

ER and RZ conceived and designed the study. ER, AMA-S, CF and RZ designed the search strategy. ER and BLH collected the data. ER, RZ and AMA-S performed statistical analyses. ER drafted the manuscript. AK, AFT, DJC, and DSH made substantial contributions to the design of the study. BLH, AK, AMA-S, JCM, CF, GR, AFT, DJC, DSH and RZ revised the manuscript critically for important intellectual content. All authors read and approved the final manuscript.

Abstract

Introduction

Sepsis and septic shock are leading causes of intensive care unit (ICU) mortality. They are characterized by excessive inflammation, upregulation of procoagulant proteins and depletion of natural anticoagulants. Plasma exchange has the potential to improve survival in sepsis by removing inflammatory cytokines and restoring deficient plasma proteins. The objective of this study is to evaluate the efficacy and safety of plasma exchange in patients with sepsis.

Methods

We searched MEDLINE, EMBASE, CENTRAL, Scopus, reference lists of relevant articles, and grey literature for relevant citations. We included randomized controlled trials comparing plasma exchange or plasma filtration with usual care in critically ill patients with sepsis or septic shock. Two reviewers independently identified trials, extracted trial-level data and performed risk of bias assessments using the Cochrane Risk of Bias tool. The primary outcome was all-cause mortality reported at longest follow-up. Meta-analysis was performed using a random-effects model.

Results

Of 1,957 records identified, we included four unique trials enrolling a total of 194 patients (one enrolling adults only, two enrolling children only, one enrolling adults and children). The mean age of adult patients ranged from 38 to 53 years (n = 128) and the mean age of children ranged from 0.9 to 18 years (n = 66). All trials were at unclear to high risk of bias. The use of plasma exchange was not associated with a significant reduction in all-cause mortality (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.45 to 1.52, I2 60%). In adults, plasma exchange was associated with reduced mortality (RR 0.63, 95% CI 0.42 to 0.96; I2 0%), but was not in children (RR 0.96, 95% CI 0.28 to 3.38; I2 60%). None of the trials reported ICU or hospital lengths of stay. Only one trial reported adverse events associated with plasma exchange including six episodes of hypotension and one allergic reaction to fresh frozen plasma.

Conclusions

Insufficient evidence exists to recommend plasma exchange as an adjunctive therapy for patients with sepsis or septic shock. Rigorous randomized controlled trials evaluating clinically relevant patient-centered outcomes are required to evaluate the impact of plasma exchange in this condition.
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