1. Haemofiltration In Sepsis
Tom Owen
Mar 2006

2. Overview Rationale for CVVH use in sepsis Evidence of effectiveness
Newer therapies
Summary

3. Pathophysiology of Sepsis

4. Pathophysiology of Sepsis
Complicated!!
Release of over 100 mediators
Pro- and anti-inflammatory
Overlapping functions
‘Specific’ therapies ineffective

5. CVVH

6. CVVH – Why Might It Work? Convection versus diffusion
Better clearance of ‘middle molecules’
Adsorption onto membrane
Non-specific

7. What Ultrafiltration Rate?
Ronco et al, Lancet, 2000
‘Landmark Study’
20ml/kg/hr – 41% survival (25% in Sepsis)
35ml/kg/hr – 57% survival (19% in Sepsis)
45ml/kg/hr – 58% survival (47% in Sepsis)

8. High Volume Haemofiltration
Theoretical advantage in the septic patient
Peak Concentration Hypothesis – degree of insult depends on the peak concentration of cytokines
Lack of evidence that concentrations are decreased

9. HVHF –The Evidence
Infusion of ‘septic’ ultrafiltrate into healthy pigs causes sepsis
Numerous animal studies show improved haemodynamics with HVHF
Oudemans et al, Int Care Med 1999
Cohort analysis, 306 patients
Better than predicted mortality

10. HVHF – The Evidence (3) Honore et al, Crit Care Med 2000
35l in 4hrs then conventional CVVH
9/11 survivors in responders
0/9 survivors in non-responders
Cole, Bellomo et al, Int Care Med 2001
1l/hr vs 6l/hr CVVH
Decreased norad requirements and cytokine levels in HVHF

11. HVHF – The Evidence (4) Ratanarat et al 2005 Piccinni et al, 2006
PHVHF – 85ml/kg/hr for 6-8hrs then 35ml/kg/hr
Improved haemodynamics that were maintained
??improved survival
Piccinni et al, 2006
Early 45ml/kg/hr CVVH for 6 hrs
Improved gas exchange, MAP, weaning, 28 day survival and shorter ICU stay

12. HVHF - Limitations Cost Increased workload
Potential for fluid/electrolyte imbalance
? Interaction with APC

13. Future Directions Continuous haemoperfusion
Continuous plasmafiltration coupled with adsorption

14. Summary High Volume Haemofiltration appears promising
The earlier the better
Pulse – HVHF helps to avoid some of its limitations
Haemoperfusion may well have a role
RCT’s needed!!

15. And Relax………