Prospective evaluation of short-term, high-volume isovolemic hemofiltration on the hemodynamic course and outcome in patients with intractable circulatory failure resulting from septic shock

Objective: To evaluate the effects of short-term, high-volume hemofiltratio n (STHVH) on hemodynamic and metabolic status and 28-day survival in patien ts with refractory septic shock. Design: Prospective, interventional. Setting: Intensive care unit (ICU), tertiary institution. Patients: Twenty patients with intractable cardiocirculatory failure compli cating septic shock, who had failed to respond to conventional therapy. Interventions: STHVH, followed by conventional continuous venovenous hemofi ltration. STHVH consisted of a 4-hr period during which 35 L of ultrafiltra te is removed and neutral fluid balance is maintained. Subsequent conventio nal continuous venovenous hemofiltration continued for at least 4 days. Measurements and Main Results:Cardiac index, systemic vascular resistance, pulmonary vascular resistance, oxygen delivery, mixed venous oxygen saturat ion, arterial pH, and lactate were measured serially. Fluid and inotropic s upport were managed by protocol. Therapeutic endpoints were as follows duri ng STHVH: a) by 2 hrs, a greater than or equal to 50% increase in cardiac i ndex; b) by 2 hrs, a greater than or equal to 25% increase in mixed venous saturation; c) by 4 hrs, an increase in arterial pH to >7.3; d) by 4 hrs, a greater than or equal to 50% reduction in epinephrine dose. Patients who a ttained all four goals (11 of 20) were considered hemodynamic "responders"; patients who did not (4 of 20) were considered hemodynamic "nonresponders. " There were no differences in baseline hemodynamic, metabolic, and Acute P hysiology and Chronic Health Evaluation and Simplified Acute Physiology Sco res between responders and nonresponders. Survival to 28 days was better am ong responders (9 of 11 patients) than among nonresponders (0 of 9). Factor s associated with survival were hemodynamic-metabolic response status, time interval from ICU admission to initiation of STHVH, and body weight. Conclusions:These data suggest that STHVH may he of major therapeutic value in the treatment of intractable cardiocirculatory failure complicating sep tic shock. Early initiation of therapy and adequate dose may improve hemody namic and metabolic responses and 28-day survival.