Short-term cardiovascular effects of plasmapheresis in norepinephrine-refractory septic shock

Objective: To examine the short-term cardiovascular effects of plasmapheresis in seven patients (six surgical, one medical) with norepinephrine-refractory septic shock. Design and setting: Retrospective observational study in a secondary community hospital. Interventions: Plasmapheresis was performed as follows: blood flow, 120 ml/min; exchange volume, 10 fresh frozen plasma (ca. 2200 ml) at rate of 13 ml/min; anti coagulation, unfractionated heparin 200-300/IU/h. Five patients received one separation and two patients three separations. All patients received norepinephrine intravenously (0.6 +/- 0.7 mug/kg per minute) to achieve a mean arterial pressure of 77 +/- 12 mmHg. All patients received ventilatory support; two had acute oligoanuric renal failure treated by continuous hemodiafiltration. Measurements and results: We recorded heart rate, mean arterial pressure, central venous pressure, catecholamine dose, gas exchange, acid-base status, diuresis, C-reactive protein, white blood cell count, and Simplified Acute Physiological Score II. Except for transitory decreases in central venous pressure no changes were found in any variable. Six of seven patients died 5 3 days after the last plasmapheresis. Conclusions: In patients with norepinephrine-refractory septic shock no directional changes in measured variables were found in the first 24 h after a plasmapheresis. Thus, regarding the cost (ca. 1000 euros per separation) and possible risks the procedure needs rigorous evaluation even as "rescue therapy" in patients with septic shock.