Adjunctive use of plasmapheresis and intravenous immunoglobulin therapy in sepsis: a case report.

In the United States, approximately 750 000 cases of severe sepsis occur each year, and more than 210000 cases result in death. Although the prevalence of sepsis continues to increase, the mortality rate of 28% to 50% remains unchanged. Sepsis causes disturbances of homeostasis that lead to excessive coagulation, systemic inflammation, and impaired fibrinolysis. In addition, blood flow to organs can be reduced despite adequate cardiac output because an imbalance occurs between coagulation and fibrinolysis, resulting in impaired tissue perfusion. Traditional treatment of sepsis includes control of the source of infection, intravenous antibiotic therapy, aggressive replacement of fluids, inotrope and/or vasopressor therapy, as well as supportive therapies such as mechanical ventilation, strict glycemic control, and measures to prevent infection. Survival in patients with sepsis depends on recovery at a microcirculatory level that allows impaired organs to function normally again. Experimental therapies such as treatment with anti-inflammatory agents, antiendotoxins, and anticytokine medications have resulted in little improvement in survival. A newer therapy, administration of drotrecogin alfa (activated), treats the pathophysiological consequences of severe sepsis: inflammation, coagulation, and impaired fibrinolysis. Drotrecogin alfa (activated) has been effective in patients with evidence of a systemic inflammatory response and organ dysfunction, but use of the agent increases the risk of bleeding and so its appropriateness must be determined on an individual basis. Plasmapheresis has been available for decades and is most commonly used in treatment of systemic lupus erythematosus, myasthenia gravis, sickle cell crisis, and oncological disorders such as lymphoma and multiple myeloma. More recently, plasmapheresis has been used in the treatment of sepsis associated with necrotizing soft tissue infections (NSTI) caused by both aerobic and anaerobic organisms. According to Harborview Medical Center’s institutional guidelines (Table 1), patients with NSTI caused by proven clostridial, streptococcal, or staphylococcal infections with or without toxic shock syndrome may receive plasmapheresis. However, plasmapheresis should not replace aggressive surgical debridement, which should be the primary therapy before plasmapheresis is considered. Plasmapheresis removes harmful substances produced by the infecting organism and/or the excessive inflammatory response. Two methods are used to separate plasma from blood cells: membrane filtration and extracorporeal centrifugation. Both techniques are designed to remove large molecular weight substances from the plasma. Examples of these substances include plasma proteins such as albumin and immunoglobulins, pathogenic autoantibodies, clotting factors, endotoxins, and proinflammatory cytokines.