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The efficacy and safety of plasma exchange in patients with sepsis and septic shock: a systematic review and meta-analysis.
Crit Care. 2014 Dec 20; 18(6):699.CC

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, I(2) 60%). In adults, plasma exchange was associated with reduced mortality (RR 0.63, 95% CI 0.42 to 0.96; I(2) 0%), but was not in children (RR 0.96, 95% CI 0.28 to 3.38; I(2) 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.

Authors+Show Affiliations

Department of Internal Medicine, University of Manitoba, GC425-820 Sherbrook Street, HSC, Winnipeg, R3A 1R9, Canada. emily.rimmer@cancercare.mb.ca. Department of Haematology and Medical Oncology, CancerCare Manitoba, 675 McDermot Ave, Winnipeg, R3E 0V9, Canada. emily.rimmer@cancercare.mb.ca.Faculty of Medicine, University of Manitoba, 250 Brodie Centre, 727 McDermot Ave, Winnipeg, R3E 3P5, Canada. umhoustb@cc.umanitoba.ca.Department of Internal Medicine, University of Manitoba, GC425-820 Sherbrook Street, HSC, Winnipeg, R3A 1R9, Canada. akumar61@yahoo.com.George & Fay Yee Center for Healthcare Innovation, University of Manitoba/Winnipeg Regional Health Authority, GE706-820 Sherbrook Street, HSC, Winnipeg, R3A 1R9, Canada. abousetta_md@hotmail.com.Neil John Maclean Health Sciences Library, University of Manitoba, Brodie Centre, 727 McDermot Ave, Winnipeg, R3E 3P5, Canada. carol_friesen@umanitoba.ca.Section of Critical Care Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, M5B 1W8, Canada. marshallj@smh.toronto.on.ca.Ottawa Hospital, 501 Smyth Road, Ottawa, K1H 8L6, Canada. gailrock1@hotmail.com.Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine and Population Health and Optimal Health Practices Unit, CHU de Québec Research Center, Université Laval, 1401-18th Street, Québec, G1J 1Z4, Canada. alexis.turgeon@fmed.ulaval.ca.Department of Medicine, McMaster University, Hamilton, L8S 4K1, Canada. debcook@mcmaster.ca. Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street, West, Hamilton, Canada. debcook@mcmaster.ca.Department of Internal Medicine, University of Manitoba, GC425-820 Sherbrook Street, HSC, Winnipeg, R3A 1R9, Canada. houston@cc.umanitoba.ca. Department of Haematology and Medical Oncology, CancerCare Manitoba, 675 McDermot Ave, Winnipeg, R3E 0V9, Canada. houston@cc.umanitoba.ca.Department of Internal Medicine, University of Manitoba, GC425-820 Sherbrook Street, HSC, Winnipeg, R3A 1R9, Canada. rzarychanski@cancercare.mb.ca. Department of Haematology and Medical Oncology, CancerCare Manitoba, 675 McDermot Ave, Winnipeg, R3E 0V9, Canada. rzarychanski@cancercare.mb.ca. George & Fay Yee Center for Healthcare Innovation, University of Manitoba/Winnipeg Regional Health Authority, GE706-820 Sherbrook Street, HSC, Winnipeg, R3A 1R9, Canada. rzarychanski@cancercare.mb.ca.

Pub Type(s)

Journal Article
Meta-Analysis
Review
Systematic Review

Language

eng

PubMed ID

25527094

Citation

Rimmer, Emily, et al. "The Efficacy and Safety of Plasma Exchange in Patients With Sepsis and Septic Shock: a Systematic Review and Meta-analysis." Critical Care (London, England), vol. 18, no. 6, 2014, p. 699.
Rimmer E, Houston BL, Kumar A, et al. The efficacy and safety of plasma exchange in patients with sepsis and septic shock: a systematic review and meta-analysis. Crit Care. 2014;18(6):699.
Rimmer, E., Houston, B. L., Kumar, A., Abou-Setta, A. M., Friesen, C., Marshall, J. C., Rock, G., Turgeon, A. F., Cook, D. J., Houston, D. S., & Zarychanski, R. (2014). The efficacy and safety of plasma exchange in patients with sepsis and septic shock: a systematic review and meta-analysis. Critical Care (London, England), 18(6), 699. https://doi.org/10.1186/s13054-014-0699-2
Rimmer E, et al. The Efficacy and Safety of Plasma Exchange in Patients With Sepsis and Septic Shock: a Systematic Review and Meta-analysis. Crit Care. 2014 Dec 20;18(6):699. PubMed PMID: 25527094.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - The efficacy and safety of plasma exchange in patients with sepsis and septic shock: a systematic review and meta-analysis. AU - Rimmer,Emily, AU - Houston,Brett L, AU - Kumar,Anand, AU - Abou-Setta,Ahmed M, AU - Friesen,Carol, AU - Marshall,John C, AU - Rock,Gail, AU - Turgeon,Alexis F, AU - Cook,Deborah J, AU - Houston,Donald S, AU - Zarychanski,Ryan, Y1 - 2014/12/20/ PY - 2014/09/08/received PY - 2014/11/27/accepted PY - 2014/12/21/entrez PY - 2014/12/21/pubmed PY - 2015/10/20/medline SP - 699 EP - 699 JF - Critical care (London, England) JO - Crit Care VL - 18 IS - 6 N2 - 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, I(2) 60%). In adults, plasma exchange was associated with reduced mortality (RR 0.63, 95% CI 0.42 to 0.96; I(2) 0%), but was not in children (RR 0.96, 95% CI 0.28 to 3.38; I(2) 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. SN - 1466-609X UR - https://www.unboundmedicine.com/medline/citation/25527094/The_efficacy_and_safety_of_plasma_exchange_in_patients_with_sepsis_and_septic_shock:_a_systematic_review_and_meta_analysis_ L2 - https://ccforum.biomedcentral.com/articles/10.1186/s13054-014-0699-2 DB - PRIME DP - Unbound Medicine ER -