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Abstract
Objectives
The use of hemoadsorption (HA) has become popular in the treatment of vasoplegic states associated with massive cytokine release, including septic shock. However, this approach does not seem to be based on robust evidence, and it does not follow international guidelines. To understand the pathophysiological rationale and timing of HA, we conducted a large animal septic shock experiment.
Design
Prospective randomized large-animal peritoneal septic shock experiment.
Setting
Laboratory investigation.
Subjects
Twenty-six anesthetized, mechanically ventilated, and instrumented pigs randomly assigned into (1) sham-operated group with HA (SHAM, n = 5); (2) sepsis animals without HA (SEPSIS, n = 5); (3) sepsis group with HA at norepinephrine initiation (EARLY, n = 8); and (4) sepsis group with HA initiated at norepinephrine rate reaching 0.5 μg/kg/min (LATE, n = 8).
Interventions
Peritoneal sepsis was induced by cultivated autologous feces inoculation. A CytoSorb cartridge (200 g) with a blood flow rate of 200 mL/min and heparin anticoagulation was used to perform HA. The animals received sedation and intensive organ support up to 48 h or until they experienced cardiovascular collapse.
Measurements and main results
Systemic hemodynamics, multiple-organ functions, and immune-inflammatory response were measured at predefined periods. The HA treatment was not associated with any measurable benefit in terms of systemic hemodynamics and organ support. The systemic inflammatory markers were unaffected by any of the treatment timings. In contrast, the HA resulted in higher vasopressor load and decreased 36-h survival (5 animals in SHAM (100%), 4 (80%) in SEPSIS, 4 (57%) in EARLY, and 2 (25%) in LATE; p = 0.041). The HA exposure in healthy animals was associated with hemodynamic deterioration, systemic inflammatory response, and cytopenia.
Conclusions
In this large-animal-controlled fulminant sepsis study, the HA was unable to counteract the disease progression in the early or advanced septic shock phase. However, findings from the HA-exposed sham animals suggest potential safety concerns.
Keypoints
Question: To understand hemoadsorption using CytoSorb device pathophysiological rationale and timing on disease progression in septic subjects.
Findings: In this large-animal-controlled fulminant sepsis study, the CytoSorb hemoadsorption did not counteract the disease progression in the early or advanced septic shock phase. However, findings from the hemoadsorption-exposed sham animals suggest potential safety concerns.
Meaning: Considering the limited evidence, the clinical use of CytoSorb for hemoadsorption in septic patients should be limited to well-designed interventional studies.
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Details

1 Charles University, Laboratory of Experimental Intensive Care Medicine, Biomedical Center, Faculty of Medicine in Pilsen, Pilsen, Czech Republic (GRID:grid.4491.8) (ISNI:0000 0004 1937 116X); Faculty of Medicine in Pilsen, Charles University, Department of Anesthesiology, Resuscitation and Intensive Care, Pilsen, Czech Republic (GRID:grid.4491.8) (ISNI:0000 0004 1937 116X); Faculty Hospital in Pilsen, Department of Anesthesiology, Resuscitation and Intensive Care, Pilsen, Czech Republic (GRID:grid.412694.c) (ISNI:0000 0000 8875 8983)
2 Charles University, Laboratory of Experimental Intensive Care Medicine, Biomedical Center, Faculty of Medicine in Pilsen, Pilsen, Czech Republic (GRID:grid.4491.8) (ISNI:0000 0004 1937 116X); Charles University, Department of Internal Medicine I, Faculty of Medicine in Pilsen, Pilsen, Czech Republic (GRID:grid.4491.8) (ISNI:0000 0004 1937 116X)
3 Charles University, Laboratory of Experimental Intensive Care Medicine, Biomedical Center, Faculty of Medicine in Pilsen, Pilsen, Czech Republic (GRID:grid.4491.8) (ISNI:0000 0004 1937 116X); Charles University, Department of Physiology, Faculty of Medicine in Pilsen, Pilsen, Czech Republic (GRID:grid.4491.8) (ISNI:0000 0004 1937 116X); Faculty of Medicine in Pilsen, Charles University, Laboratory of Experimental Cardiology, Biomedical Center, Pilsen, Czech Republic (GRID:grid.4491.8) (ISNI:0000 0004 1937 116X)
4 Charles University, Department of Physiology, Faculty of Medicine in Pilsen, Pilsen, Czech Republic (GRID:grid.4491.8) (ISNI:0000 0004 1937 116X); Faculty of Medicine in Pilsen, Charles University, Laboratory of Experimental Cardiology, Biomedical Center, Pilsen, Czech Republic (GRID:grid.4491.8) (ISNI:0000 0004 1937 116X)