[Use of plasmapheresis in a 62-year-old patient with severe infection].

INTRODUCTION: The elimination of cytotoxic substances from blood as part of sepsis treatment has been controversely discussed so far. The following case report demonstrates the advantages and disadvantages of this therapy strategy. CASE REPORT: A 62-year-old male patient developed a paralytic ileus with wound dissection 3 days after elective sigma resection. A few hours after surgical revision he went into severe sepsis. A controlled ventilation was necessary as well as the use of catecholamines to maintain sufficient mean arterial pressure. Body temperature stayed between 39 and 40 degrees C (rectal). The patient's extremities and body showed severe marmorations due to the pathologic vasal alteration. A laparotomy one day after the operation revealed a massive generalized edema of the bowels without any evidence of insufficient anastomosis. The fulminant septic process could not be stopped with conservative treatment including continuous veno-venous hemofiltration. Under further deterioration of the pulmonary function (signs of beginning ARDS) and the generalized capillary leak syndrome we started plasmapheresis 2 days after operation in order to eliminate high-molecular cytokines. The plasmapheresis was done twice the following 2 days. Under this treatment the septic process was stopped. The pulmonary function and the circulation improved. The disturbed peripheral perfusion normalized. A laparotomy confirmed a significant decrease of the intestine wall edema. Unfortunately we could not repeat plasmapheresis. On the following days the patient worsened again and died 20 days later due to multiorgan failure. DISCUSSION: The temporary improvement during plasmapheresis suggests that the patient might have profited from plasmapheresis-related optimized oxygen delivery, controlled diuresis and decrease of oxygen consumption. In addition we hypothesized that elimination of high-molecular cytokines and toxines contributed to the improvement under plasmapheresis. Using plasmapheresis one has to consider the high costs, risk of infection, and the unexplained mode of action to the mediatory process. Therefore we cannot recommend this treatment in general. Further controlled studies should investigate the therapeutic benefits of plasmapheresis in patients with severe sepsis.