Igm-enriched-immunoglobulins associated with EMiC2 filter in the treatment of early septic shock after cardiac surgery

Introduction The occurrence of septic shock after cardiac surgery is a rare event with a reported prevalence between 0.39% and 2.5% (1). However patients who develop severe sepsis after cardiac procedures have a high mortality, varying from 65% to 79%. They also require a prolonged mechanical ventilation in intensive care unit and hospital length of stay. Reducing the time to diagnosis and early extracorporeal treatment is believed to be crucial factor for reducing mortality from multiple organ dysfunction is sepsis (1). We assessed the effectiveness of IgM enriched immunoglobulins (Pentaglobin Biotest Germany) 5mg/kg/3 days associated with 72 hours of chronic renal replacement therapy with Emic2 using citrate anticoagulation in septic shock after cardiac surgery. Methods Our retrospective study was performed in the Department of Cardiovascular Anesthesia and Intensive Care San Carlo Hospital between 01/01/2018 and 01/01/2019. Patients developed septic shock after elective cardiac surgery with the use extracorporeal circulation were included. Septic shock were diagnosed according to Sepsis Surviving Campaign criteria. We tested the serum concentration of IL-6, procalcitonin (PCT), white blood cell count (WBC) and Endotoxin Activity Assay (EAA) before treatment (T0) and at 24 (T1), 48 (T2) and 72 hours (T3) after treatment. We evaluated the dynamic changes in the serum concentrations and activity of these molecules and techniques. Results Finally, 11 patients (4 males) were included. The average age was 64.5±7.1 with EUROSCORE value of 13.5±2.3. Nine patients (90.0%) had concomitant renal insufficiency and 5 (45.5%)had chronic obstructive pulmonary disease. The serum concentration of IL-6 ranged from 313.4±111.1 µg/dl before the treatment to 446.1±117.5 µg/dl after 24 hours, 121.3±97.6 µg/dl after 48 hours and 67.6±36.7 µg/dl at 72 hours. At the same time the serum concentration of PCT decreased respectively from 7.3±2.3 mg/dl to 6.1±1.2 mg/dl; 4.5±2.1 mg/dl; and 2.1±1.9 mg/dl. Similarly the EAA decreased from 1.21±0.60 before the treatment to 0.35±0.14 at the end of the treatment. Discussion Our small study confirm that Pentaglobin associated with Emic2 treatment in early septic shock after cardiac surgery is safe and can reduce concentration of major cytokines of endotoxin activity. Further studies needed to assess the clinical efficacy of this promising treatment technique.