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Hello and welcome everyone to our latest presentation on blood purification in covet 19. as we all know the infection in the covenant 19 starts in the nasal cavity and then goes into affect the lungs and the alveoli it is primarily mediated by the as2 receptors whereby it increases the cytokine production and causes a cytokine storm now the covalent 19 has a
Typical signature which is associated with reduction in the t cell levels and elevation in the antibodies and the cytokines now the phases of infection is there is an initial infection of the local tissues with initiation of a local innate immune response finally a systemic impact now it is this systemic impact which is associated with the respiratory symptoms
That is the cytokine storm and the production of ards and ultimately may lead to a fatal outcome now what we are trying basically in this is to try to clear these cytokines from the blood thereby reducing the systemic impact of the disease and preventing the fatal outcome in patients who develop a cytokine storm now the blood purification therapy can attenuate
The organ damage and the immune paralysis it can do it by two ways which are proposed mechanism by which the blood purification may work that is by reducing the peak concentration of the cytokines thereby reducing their effects the other is the cytokinetic model in the cytokinetic model the basic idea is by blood purification systems we are reducing the level of
Cytokine in the blood thereby causing a gradient from the tissue into the blood and thereby removing the cytokines from the local tissue and also enhancing the entry of these cells into the local tissue thereby resulting in removal of the infection needles now the approaches that are present for reducing this cytokine are direct hemoperfusion and the second
Is plasma absorption third crt is hollow fiber filters with absorptive properties and the last is high dose crrt with medium cutoff or high cut off membranes now apart from these the other extra corporeal therapies that can be incorporated in reducing the impact is the use of ecor ecmo renal replacement therapies apart from that we can also have mars for liver
Support so coming first to cytosol this is basically absorber beads which absorb the cytokines into them so these cartridges contain biocompatible polystyrene diagonal benzene copolymer beads and so once the blood is flowing through them they absorb the cytokines and reduce their levels in the blood now it is recommended to use it for three days and you have
To change the filter every 24 hours the minimum float is 100 and the maximum 700 but the optimal that is recommended is 150 to 500. the contraindications include low platelets any other contraindication to extracorporeal therapy allergies heparin indus thrombocytopenia sickle cell crisis more breedly obese patients patients who already have a life expectancy
Less than one month pregnancy and someone in a clinically futile state so let’s analyze the data that is present till now of use of these devices in kovid 19. this is a case series which is published of 50 patients in this the mortality rate is around 30 percent and if you see the sofa score and the apache are quite high so this was a very sick group of patient
With severe to moderate ards and as you can see the urine output and the norad requirement is quite high apart from that the levels of cytokines is also very high so if we divide these patients in terms of survivor versus non survivor if you look closely then all the parameters that are related with cytokine are showing a reduction in survivors while in the
Non-survivors most of these parameters are elevated in spite of therapy so this could be one of the reasons why they did not develop and if you look in terms of clinical outcomes the sofa score the pf score all have improved post the use of these devices while in the non-survivors it was not found to be reduced now this is one of the large studies which is
Ongoing right now which is being done in critically ill patients undergoing the covert 19 for cytokine storm and the results may add more to the available data till now apart from that we have a lot of pilot studies and case series like this blood purification therapy with hemody filtration with enhanced absorptive properties and in this they find that after
The use of the absorptive crrt there was a reduction in the il-6 levels and so far scores as well so overall showing benefit of use of these therapies now hemoperfusion in copen 191 again with cytokine storm a case series in this they find that most of the patients had a reduction in after treatment parameters in terms of both the clinical outcomes as well as
The lab outcomes this is the old study and the post hoc analysis it shows that in patients who are having septic shock there is a benefit of using this polymex in b hemoperfusion therapy so though the overall study was negative in the specific subgroup of endotoxin septic shock they did find some benefit of using the therapy so this is again a registry study in
This they analyzed 12 patients with a mean age of 59 and this organ affected and the apache scorings were quite significant here they found reduction in the sofa scores improvement in map decrease in lactate and decrease in the lung injury scores overall all the parameters showing again improvement in outcome then there was this study which was a randomized
Trial published in landsat they include 34 patients but in this they found significantly worse outcomes with cytokine absorption compared to patients who did not receive any therapy so they have concluded that early initiation of cytokine absorption with severe covalent 19 and vb ecmo did not reduce the il-6 levels and had a negative impact on survival now as
You can see there is a lot of organ crosstalk especially between the lungs and the kidney and this usually results in a multi-organ dysfunction if it is not treated in an appropriate manner so that is a role of reducing the co2 levels and thereby improving the renal outcome so this is one of such trials in this they found that using the extra corporal carbon
Tax at removal there was improvement in the kidney parameters as well however this is a metanalysis which has been done of all the patients of covalent 19 and these therapies till now and in this there is a lot of variation with both positive as well as negative results so we are not yet sure about the utility of these devices so the study population is very
Very small as of now now we need to find out which patients are more likely to benefit from this disease as we know that cobit 19 per se is not very similar to any of the known cytokine storms that we know till now that is the ards or sepsis or the cart induced crs however we must also need to know that this is just the initial part of covert 19. kobit 19 can
Of the course progress from this stage into this like a severe aids where you have all these parameters also elevated so we need to understand at which point and in which patient we need to intervene with these therapies to have a better outcome so to summarize regarding covalent 19 there are three major problems the first is the release of cytokine which can
Be because of mostly that is cytokine release syndrome but it can also be augmented by the use of mechanical ventilation use of ecmo crt circuits and the hemos phagocytic syndrome in terms of organ crosstalk there can be a organ crosstalk with heart resulting in cardiorenal syndrome the as we have already discussed the organ crosstalk between lungs and kidney
The high peak pressures as we have seen as well as rhabdomyolysis in terms of systemic there is an impact of the positive fluid balance that may there in the patient the endothelial damage and third space loss hypotension use of nephrotoxic agents metabolic acidosis and hyperkalemia so to deal with the cytokine part we can use the cytokine removal therapies to
Reduce the effect apart from that for crosstalk we have therapies like lvad for the lung part we can use the e core or ecmo for abdominylysis we have to use the crt and here for fluid management and the electrolyte and the acidosis management we can use crrt as a method of reducing the impact so the take home message for use of these devices is whenever user
Using these devices it is recommended to use a jugular double lumen catheter for adequate size flow do not put it anywhere else because the flows are not adequate and we want a very good flow in these patients and so putting it in a jugular catheter is the best especially the right jugular in case of unfractioned heparin start with 10 international units per kg
Per hour but in some patients you have to go with higher doses up to 15 to 20 to ensure the patency of the circuit blood flows above 150 and the use of diffusive therapy with minimal filtration fraction helps in avoiding circuit clotting so do not attempt flows less than 150 and it is better to use the diffusive therapies finally cytokine removal strategy should
Be reserved in patients with high circulating levels of cytokines high sofa score with a clinical association with high vasopressor requirements and immune dysregulation however the cutoffs and the clinical parameters which could be used are not yet well established these are especially the areas of the research and even which blood purification therapy we can
Use to reduce the impact of covet 19 is still to be determined because there is a lot of organs which are affected and a lot of organ can be supported by extracorporeal therapies so thank you for your patience and check our website for further
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Blood Purification in COVID 19: Experience till now By CCM Academics
