Hemadsorption as rescue therapy for patients with multisystem organ failure in pediatric intensive care—Report of two cases reports and review of the literature

Abstract

Hemadsorption via the cytokine-adsorber CytoSorb (CytoSorbents Europe, Berlin, Germany) has successfully been used as an adjunctive method in adults, mainly for the purpose of immunomodulation under acute inflammatory conditions such as sepsis and cardiac surgery. In recent years, there has been growing interest in its use in pediatric intensive care to improve outcomes in patients with multiple organ failure following an inflammatory illness. Literature on the application of CytoSorb in neonatal and pediatric patients is scarce, though the implication is that it could be an effective last-resort treatment option in critically ill pediatric patients. Herein we present the clinical cases of two pediatric patients successfully treated with a combination of the CytoSorb hemadsorber, continuous renal replacement therapy, and extracorporeal membrane oxygenation due to multiple organ failure following different underlying medical conditions. Patient 1 was a 7-month-old male child with Down's syndrome admitted to the Pediatric Intensive Care Unit (PICU) after congenital heart surgery, who developed antimicrobial-resistant septic shock and severe acute respiratory distress syndrome. Patient 2 was a 2-year-old male child admitted to the PICU with influenza A-associated acute liver failure resulting in hyperammonemia, lactate acidosis, hemodynamic instability, and acute kidney failure. In both patients, hemadsorption with CytoSorb was initiated as an adjunctive rescue therapy to treat refractory multisystem organ failure. Improvement of laboratory and clinical parameters was observed within hours of treatment initiation. The application of the hemadsorber-developed for use in adults-proved simple and safe for use in both of our low-weight pediatric patients.

Application of Adsorptive Blood Purification Techniques during Cardiopulmonary Bypass in Cardiac Surgery

“…At present, there are very limited scientific data on adsorptive BPTs in the pediatric population and even more scarce data in pediatric CPB. Although some case reports and observational studies provide positive evidence for the use of absorptive BPTs in children [ 92 , 93 , 98 – 100 ], the quality of these evidences is low.…”

“…What is more, these devices are designed for adults, so there are certain challenges when it comes to children. For example, optimal blood flow in low-weight patients, length of treatment, and plasma level surveillance of certain drugs and physiologic agents remain to be determined [ 98 ]. Selection of the filter in relation to weight, blood heating, patient connection, and dialytrauma are also technical challenges [ 101 ].…”

Use of CytoSorb© Hemoadsorption in Patients on Veno-Venous ECMO Support for Severe Acute Respiratory Distress Syndrome: A Systematic Review

“…After excluding irrelevant articles (i.e., reviews, meta-analyses, protocols, letters), 60 studies were retrieved ( Figure 2 ). Of these, 22 were excluded due to their focus on veno-arterial ECMO (V-A ECMO) or extracorporeal cardiopulmonary resuscitation (ECPR) [ 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 ]. Fourteen studies were excluded for lack or scarcity of data on CytoSorb© use [ 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 ], four because of the lack of specific data for the ECMO subgroup [ 67 , 68 , 69 , 70 ], four because CytoSorb© was not used concomitantly with ECMO therapy [ 71 , 72 , 73 , 74 ], two because outcomes of interest for the simultaneous use of CytoSorb© and ECMO were not reported [ 75 , 76 ], and one because it focused on a different device [ 77 ].…”

Hemoadsorption for severe MIS-C in critically ill children, should we consider it as a therapeutic opportunity?

“…Sparing ECMO in critically ill children with severe myocardial dysfunction due MIS-C is a stimulating therapeutic opportunity considering morbidity and mortality ECMO-related in these patients. 1,5,16,17 Indeed blood purification is for technical reasons less invasive and allow the use of regional anticoagulation with citrate. On the other hand, these preliminary experiences should be confirmed with more evidences.…”