thrombocytopenia-associated multiple organ failure and pediatric septic shock: is plasma exchange a...
TRANSCRIPT
![Page 1: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/1.jpg)
Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma
Exchange a Promising Therapy?
James D Fortenberry MD, FCCM, FAAPPediatrician in Chief
Children’s Healthcare of AtlantaProfessor, Pediatric Critical Care
Emory University School of MedicineAtlanta, Georgia
![Page 2: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/2.jpg)
2
Disclosures
No financial disclosures I am an intensivist
• Dumber than smartest nephrologist
• Able to intubate dumbest kidney
![Page 3: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/3.jpg)
3
Respiratory Failure
Cardiovascular Failure
Renal FailureHematologic Failure
Immunologic Failure
The MODS Patient
HIGH MORTALITY
50-90%
-Courtesy of Matt Paden
![Page 4: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/4.jpg)
4
Thrombotic Thrombocytopenic Purpura (TTP)
A thrombotic microangiopathy syndrome Critical defect: deficiency of ADAMTS-13
(< 10%):
A disintegrin and metalloprotease with thrombospondin motifs-13 (formerly vWf cleaving protease)
Ultra-large vWf multimer-platelet thrombi Microthrombotic multi-organ vascular injury:
MOF and autopsy findings
![Page 5: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/5.jpg)
5
Thrombotic Microangiopathy: TTP/TAMOF
IL- 8TNF-IL- 6+R
ADAMTS13 AbIL-6
X
ADAMTS13(vWF-CP)
Endothelium
Endothelium PAI-1
PAI-1
PAI-1
PAI-1
PAI-1 PAI-1
vWF
vWF
PAI-1
TFPI TFPI
PlasminPlasminogen
PAI-1
X
Platelet
Platelet
Platelet
Platelet
Platelet
Platelet
TF TF
Shear stress
Platelet
Platelet
Platelet
ADAMTS13 AbIL-6
ADAMTS13(vWF-CP)
x
IL- 8TNF-
IL- 6+R
![Page 6: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/6.jpg)
6
Thrombocytopenia-Associated Multiple Organ Failure (TAMOF)
A thrombotic microangiopathy described in children (Nguyen, Carcillo 2001)
Similarities to TTP• Deficient ADAMTS-13• Increased ADAMTS-13 inhibitors• Increased vWF antigen• Increased ULvWF multimers• Thrombocytopenia
Primarily secondary to sepsis 3 or greater organ failure High mortality in children
![Page 7: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/7.jpg)
7
ADAMTS-13 Deficiency in Adult Sepsis
-Martin et al., Crit Care Med 2007
![Page 8: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/8.jpg)
8
Adult Sepsis-Survival by ADAMTS-13 Level
ADAMTS-13 above median
Below median
-Martin et al., Crit Care Med 2007
![Page 9: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/9.jpg)
9
ADAMTS-13 Deficiency in Pediatric Sepsis
-Nguyen, Hematologica 2006
![Page 10: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/10.jpg)
10
Refractory Sepsis/MOSF: Desperate Times…
Diseases desperate grownBy desperate appliance are relieved, Or not at all.
-Claudius, King of Denmark,Hamlet Act IV Scene 3W. Shakespeare
![Page 11: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/11.jpg)
11
Rationale for Plasma Exchange: TTP
80-90% mortality Plasma Exchange
10% mortality:• Replenishes ADAMTS-
13
• Removes ADAMTS-13 inhibitors
• Removes thrombogenic ULvWf multimers
-Rock, NEJM 1991
![Page 12: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/12.jpg)
12
Plasma Exchange: Rationale In Sepsis
Subset of patients who demonstrate thrombotic microangiopathy similar to TTP
Similar clinical and coagulation factor profile• Deficiency of vWf cleaving protease (ADAMTS-
13)• Platelet/vWf microthrombi• Thrombocytopenia
![Page 13: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/13.jpg)
13
![Page 14: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/14.jpg)
14
CRRT/Plasma Exchange
CRRT/Plasma Exchange
Time
Time
SIRS/CARS
SIRS CARS SIRS CARS
I mmunohomeostasis
I mmunohomeostasis
Pro-inflammatoryMediators
Anti-inflammatoryMediators
IL-1TNF PAF
IL-10
Adapted f rom Ronco et al. Artificial Organs 27(9) 792-801, 2003
Peak Concentration Model of Sepsis
![Page 15: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/15.jpg)
15
Plasmapheresis in Severe Sepsis and Septic Shock
PRCT, Russian adult ICU
106 sepsis patients randomized to:• Standard therapy• Addition of
plasmapheresis (1/2 FFP, 1/2 albumin)
Decreased mortality with plasmapheresis
- Busund et al., Intensive Care Medicine 2002;28:1410
53.8
33.3
0
10
20
30
40
50
60
Standard Plasma
*
*P< .05
![Page 16: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/16.jpg)
16
TAMOF/Plasma Exchange in Children: CHP Trial
28 children with TAMOF• Decreased ADAMTS-13 vs. non-TAMOF• Correlated with outcome
Small RCT (10 patients) 28-day survival
• No PEx: 1/5• PEx: 5/5 (p < .05)
-Nguyen et al., CCM 2008
![Page 17: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/17.jpg)
17
CHP Trial: PELOD Improved with PEx
Pediatric Logistic Organ Dysfunction Score
DAY
0 5 10 15 20 25 30
PE
LOD
0
20
40
60
80
100
Plasma ExchangeNo Plasma Exchange
Figure 3. Pediatric Logistic Organ Dysfunction Score, Mean with standarderror for patients who received plasma exchange therapy (N = 5) and who did not receive plasma exchange therapy (N = 5) for each day x 28 days.
17-Nguyen et al., CCM 2008
PEx
![Page 18: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/18.jpg)
18
Plasma Exchange Replenishes ADAMTS-13
-Nguyen et al., CCM 2008
![Page 19: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/19.jpg)
19
Children’s TAMOF Network
Broader group of Pediatric ICUs Goals:
• Create a study group to perform prospective, observational studies
• Identify TAMOF and evaluate: Clinical and biochemical course Use of specific therapies Associated outcomes
• Inform development of future prospective trials
![Page 20: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/20.jpg)
20
Children’s TAMOF Network
Enrolling centers (site co-I):• Children’s of Atlanta at Egleston: coordinating center
(Fortenberry)• Children’s of Pittsburgh (Raj Aneja/Joe Carcillo)• Cincinnati Children’s (Derek Wheeler)• Nationwide Children’s-Columbus OH (Mark Hall)• Phoenix Children’s Hospital (Sandra Buttram/Heidi
Dalton)• Texas Childrens’ Hospital (Laura Loftis/Trung
Nguyen)• Michigan-Mott Children’s (Yong Han)• Minnesota (Rod Tarrago)• Vanderbilt-Carrell Children’s (Rick Barr/Geoffrey
Fleming)
![Page 21: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/21.jpg)
21
Hypotheses
Children with TAMOF demonstrate decreased ADAMTS-13 levels and increased vWf antigen levels.
Children with TAMOF receiving PEx demonstrate associated improvement of organ dysfunction and survival vs. those receiving standard therapy alone.
![Page 22: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/22.jpg)
22
Methods
Prospective, observational, nonrandomized cohort study
Enrolled patients 1 month-21 years of age meeting TAMOF criteria:• Sepsis, transplant, chemotherapy• Platelet count < 100,000/mm3
• Organ failure index (OFI) > 2 Data collected via web-based registry
![Page 23: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/23.jpg)
23
Methods
Blood obtained for:• ADAMTS-13• vWf antigen levels• Studies performed at Baylor College of Medicine
(Trung Nguyen MD) Therapy, and use of PEx at attending/center
discretion• Typical: centrifugation approach• Suggested protocol:
FFP: 1.5x plasma volume day 1 1x plasma volume daily exchanges x 4 days
• Duration at MD discretion
![Page 24: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/24.jpg)
24
Results: Demographics
Overall No PEx (21) PEx (60)
Mean age (yr) 8.6 + 6.2 6.7 + 6.3 9.2 + 6.4
Mean weight (kg)
35.2 + 27.9 29.8 + 27.6 37.2 + 28.5
Race: White (%) 65.4 63.6 66.1
Race: A-A 19.8 22.7 18.6
Diagnosis-Sepsis
79/81 20/21 59/60
Ever on ECMO 30/81 (37%) 4/21 (13) 26/60 (43.3)
Ever on CRRT 46/81 (56.8%) 8/21 (41.1) 38/60 (63.3)
-No differences between groups
- 81 patients enrolled and met criteria
![Page 25: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/25.jpg)
25
Results: Severity of Ilness
Overall No PEx (21) PEx (60) P value
Baseline PELOD
20.2 + 12.1 15.8 + 10.1 21.9 + 12.4 .04
Baseline PRISM 18.2 + 6.8 16.9 + 5.5 18.7 + 7.2 0.28
Baseline OFI 4.5 + 1.2 4.2 + 1.0 4.6 + 1.2 0.21
Baseline Platelet Count (x 1000)
62.2 + 42.1 55.9 + 35 64.6 + 44.7 0.42
Baseline ADAMTS-13 (%)
52.9 + 27.8 63.7 + 26 49.9 + 28 0.22
Baseline vWF Ag (%)
161 + 66.3 217 + 73 146 + 56.4 0.005
![Page 26: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/26.jpg)
26
Results: Therapies
Treatment:• No PEx: 21 patients• PEx: 60 patients
Use of CVVH: 46 patients (57%)• No PEx 8 (41%)• PEx 38 (63%) p = 0.07
Use of ECMO: 30 patients (37%)• No PEx: 4 (13%)• PEx: 26 (44%) p = 0.07
![Page 27: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/27.jpg)
27
TAMOF Network Results: 28 Day Survival
No PEx: 61.9%
PEx: 68.3%
P = 0.5
![Page 28: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/28.jpg)
-PELOD scores decreased more rapidly in patients receiving PEx (p < .05)
*
![Page 29: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/29.jpg)
- PEx associated with increase in ADAMTS-13 in first 4 days
![Page 30: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/30.jpg)
30
Multivariable Risk Factors for Death: PELOD and Plasma Exchange
Variable
Descriptive StatisticsNo. (%) / Mean (SD)
Estimate Standard Error
Odds Ratio
95% CI P-value
ECMO 30/81 (37.0%)0.4676
0.6167 1.596 0.48-5.4 0.45
CVVH 45/81 (55.6%)0.7484
0.6215 2.114 0.63-7.2 0.23
Baseline PELOD(per 5 pt increase)
21.2 (11.4)0.1100
0.0321 1.734
1.27-2.4
0.0006
MRSA Infection
12/81 (14.8%)0.8618
1.2200 2.367
0.51-10.9
0.27
Plasma Exchange
60/81 (74.1%) -1.3213 0.6801 0.267 0.07-1.01
0.05
![Page 31: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/31.jpg)
31
Risk Factors
For every 5 unit increase in PELOD score at baseline (day 1 on study) mortality risk increases 1.73 times (p=0.0006)
PEx reduced risk of death by 73.3% = odds of survival 3.75 times higher with PEx (p = 0.05)
![Page 32: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/32.jpg)
32
Conclusions
TAMOF patients demonstrated:• Decreased ADAMTS-13, increased vWf
antigen, consistent with TTP profile Use of PEx vs. standard therapy was
associated with: Greater improvement in organ dysfunction Better survival (adjusted for severity, risk
factors) Cannot conclude outcome benefit
![Page 33: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/33.jpg)
33
Next Steps
These results could inform a randomized trial to determine contribution of PEx to TAMOF outcome
Need to better define subgroups; use biomarkers• ADAMTS-13 real-time
Submitted a U34 Planning Grant: Rare Thrombotic and Hemostatic Disorders
![Page 34: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/34.jpg)
34
Alexis- A Success Story
![Page 35: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/35.jpg)
35
Why Not Plasma Infusion Alone?
Plasma Infusion• Restores procoagulant
factors• Restores anticoagulant
factors (protein C, AT III, TFP-I)
• Restores prostacyclin• Restores tPA• Restores ADAMTS-13
Plasma Exchange• Restores factor
homeostasis like plasma infusion
In addition:• Removes ADAMTS-13
inhibitors• Removes ultra-large
vWF multimers• Removes tissue factor• Removes excess PAI-1• Maintains fluid balance
during procedure vs. infusion
![Page 36: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/36.jpg)
36
Course of Organ Dysfunction and TMA: Plasma Infusion vs. Plasma Exchange
36 adult TMA patients Decreased mortality with
plasma exchange Plasma infusion group
• received larger volumes
• had larger weight gain
- Darmon et al., Crit Care Med, 2006
31.8
0
0
5
10
15
20
25
30
35
Plasma
Infusion
Plasma
Exchange
*
![Page 37: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/37.jpg)
37
Days of Plasma Exchange
Non-survivors(n = 19)
Survivors(n = 40)
No. / Total (%)
Total Days on PEx Therapy 1 6/19 (31.6%) 0/40 (0%)
2 4/19 (21.1%) 1/40 (2.5%)
3 1/19 (5.3%) 7/40 (17.5%)
4 1/19 (5.3%) 1/40 (2.5%)
5 2/19 (10.5%) 14/40 (35.0%)
6 1/19 (5.3%) 6/40 (15.0%)
7 1/19 (5.3%) 9/40 (22.5%)
8 2/19 (10.5%) 0/40 (0%)
10 0/19 (0%) 2/40 (5.0%)
14 1/19 (5.3%) 0/40 (0%)
![Page 38: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/38.jpg)
38
Results: Site Enrollment
Non-Plasma Exchange Group(n = 21)
Plasma Exchange Group(n = 60)
Deaths by Site
CHOA-Egleston 0/1 (0%) 10/22 (45.5%)
Pittsburgh - 0/6 (0%)
Columbus 3/5 (60.0%) -
Cincinnati 0/2 (0%) -
Texas Children’s 3/5 (60.0%) 1/2 (50.0%)
Minnesota 0/1 (0%) 3/13 (23.1%)
Vanderbilt 1/6 (16.7%) 2/4 (50.0%)
Michigan - 1/9 (11.1%)
Phoenix 1/2 (50.0%) 2/3 (66.7%)
All sites 8/21 (36.4%) 19/60 (32.2%)
![Page 39: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/39.jpg)
39
Results: TAMOF Patients
Overall survival 54/81 (67%) • No PEx: 13/21 (61.9%)• PEx: 41/60 (68.3%) NS
Survival: PELOD > 21 (47)• No PEx 50 %• PEx 56.4 %
Survival: PELOD < 21 (34)• No PEx 77.8 %• PEx 90.5 %
![Page 40: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/40.jpg)
40
Everything will be all right in the end. So if it is not all right, then it is not yet the end.
![Page 41: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/41.jpg)
41
Desperate but Reasonable?
![Page 42: Thrombocytopenia-Associated Multiple Organ Failure and Pediatric Septic Shock: Is Plasma Exchange a Promising Therapy? James D Fortenberry MD, FCCM, FAAP](https://reader038.vdocument.in/reader038/viewer/2022103122/56649cec5503460f949b8205/html5/thumbnails/42.jpg)
42
Plasma Therapies in Sepsis-Why Use Them?
General: exchange “transfer factors” Specific: control thrombotic microangiopathy
(TMA) Slow progression of TMA-induced organ
failure Treat coagulation abnormalities