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Therapeutic Plasma Exchange in Critically Ill Children Requiring Intensive Care
Gerard Cortina1,2, Rosemary McRae1, Roberto Chiletti1
1Paediatric Intensive Care Unit, Royal Children's Hospital Melbourne, Australia.
Insights
Therapeutic plasma exchange (TPE) is safe for critically ill children, with excellent outcomes when used alone. Survival decreases when TPE is combined with other life support like continuous renal replacement therapy or extracorporeal membrane oxygenation.
Area of Science:
- Pediatric critical care medicine
- Extracorporeal therapies
Background:
- Critically ill children often require advanced life support.
- Therapeutic plasma exchange (TPE) is an extracorporeal therapy used in various pediatric conditions.
- Understanding the safety and efficacy of TPE in this population is crucial.
Purpose of the Study:
- To evaluate the clinical indications for therapeutic plasma exchange (TPE) in critically ill children.
- To assess the procedural safety and patient outcomes associated with TPE.
- To identify factors influencing survival in children undergoing TPE.
Main Methods:
- Retrospective observational study utilizing a prospective registry.
- Analysis of data from 48 critically ill children who underwent TPE over an 8-year period.
- Inclusion of TPE performed alone or in conjunction with continuous renal replacement therapy (CRRT) and extracorporeal membrane oxygenation (ECMO).
Main Results:
- A total of 244 TPE sessions were analyzed.
- Common indications included hematologic, neurologic, and rheumatologic disorders, and solid organ transplantation.
- Complications occurred in 21.2% of sessions; overall ICU survival was 82%.
- Survival rates were 97% for TPE alone, 69% with CRRT, and 50% with ECMO.
- Factors associated with mortality included lower Pediatric Index of Mortality 2 score, mechanical ventilation, organ failure, and longer ICU stay.
Conclusions:
- Therapeutic plasma exchange can be safely administered to critically ill children in specialized centers.
- TPE alone is associated with excellent outcomes in pediatric patients.
- Concomitant use of CRRT and ECMO with TPE is associated with decreased survival rates, highlighting the severity of illness in these patients.
Objective:
To characterize the clinical indications, procedural safety, and outcome of critically ill children requiring therapeutic plasma exchange.
Design:
Retrospective observational study based on a prospective registry.
Setting:
Tertiary and quaternary referral 30-bed PICU.
Patients:
Forty-eight critically ill children who received therapeutic plasma exchange during an 8-year period (2007-2014) were included in the study.
Interventions:
Therapeutic plasma exchange.
Measurements And Main Results:
A total of 48 patients underwent 244 therapeutic plasma exchange sessions. Of those, therapeutic plasma exchange was performed as sole procedure in 193 (79%), in combination with continuous renal replacement therapy in 40 (16.4%) and additional extracorporeal membrane oxygenation in 11 (4.6%) sessions. The most common admission diagnoses were hematologic disorders (30%), solid organ transplantation (20%), neurologic disorders (20%), and rheumatologic disorders (15%). Complications associated with the procedure occurred in 50 (21.2%) therapeutic plasma exchange sessions. Overall, patient survival from ICU was 82%. Although patients requiring therapeutic plasma exchange alone (n = 31; 64%) had a survival rate of 97%, those with additional continuous renal replacement therapy (n = 13; 27%) and extracorporeal membrane oxygenation (n = 4; 8%) had survival rates of 69% and 50%, respectively. Factors associated with increased mortality were lower Pediatric Index of Mortality 2 score, need for mechanical ventilation, higher number of failed organs, and longer ICU stay.
Conclusion:
Our results indicate that, in specialized centers, therapeutic plasma exchange can be performed relatively safely in critically ill children, alone or in combination with continuous renal replacement therapy and extracorporeal membrane oxygenation. Outcome in children requiring therapeutic plasma exchange alone is excellent. However, survival decreases with the number of failed organs and the need for continuous renal replacement therapy and extracorporeal membrane oxygenation.
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