title: Intensive blood and plasma exchange for treatment of coagulopathy in meningococcemia.
abstract: Eight pediatric patients with fulminant meningococcemia, purpura, and disseminated intravascular cogulation who by multiple prognostic scoring systems were anticipated to have a poor outcome underwent intensive plasma exchange (IPE) or whole blood exchange (WBE) in addition to standard medical therapy. IPE/WBE was initiated shortly after admission with a mixture of both fresh frozen plasma and cryoprecipitate as the replacement solution. All IPE procedures were performed using a continuous flow system and a red cell prime. The mean fibrinogen level increased from 62 to 192 mg/dl, the prothrombin time (PT) decreased from a mean of 32.4 seconds to 15.1 seconds, and the mean activated partial thromboplastin time (APTT) decreased from 89.5 seconds to 40.1 seconds following completion of the initial IPE/WBE. There was a corresponding improvement in all coagulation factor levels but only slight improvement in antithrombin III (ATIII) and protein C levels. Seven of eight patients survived (87.5%) their initial presentation with the sole early death attributed to meningitis with cerebral edema. Mean fluid balance after the procedure was +10.8 +/- 5.87 cc/kg. There were no significant bleeding or cardiovascular complications during the procedure. There was no clinical or radiographic evidence of fluid overload after the procedure. This experience demonstrates that IPE/WBE may be conducted safely in critically ill, unstable pediatric patients and is effective in rapidly improving coagulopathy without fluid overload.
authors.affiliation: Multidisciplinary intensive Care Unit, Children's Hospital, Boston, Massachusetts 02115, USA.
authors.forename: K B
authors.initials: KB
authors.lastname: Churchwell
authors.forename: M L
authors.initials: ML
authors.lastname: McManus
authors.forename: P
authors.initials: P
authors.lastname: Kent
authors.forename: J
authors.initials: J
authors.lastname: Gorlin
authors.forename: D
authors.initials: D
authors.lastname: Galacki
authors.forename: D
authors.initials: D
authors.lastname: Humphreys
authors.forename: S V
authors.initials: SV
authors.lastname: Kevy
mesh_terms: D000293:Adolescent; D016470:Bacteremia / Q000209:etiology / Q000628:therapy*; D002675:Child, Preschool; D004211:Disseminated Intravascular Coagulation / Q000150:complications / Q000628:therapy*; D005078:Exchange Transfusion, Whole Blood / Q000009:adverse effects; D006801:Humans; D007223:Infant; D008589:Meningococcal Infections / Q000097:blood* / Q000150:complications / Q000628:therapy; D010951:Plasma Exchange / Q000009:adverse effects; D011693:Purpura / Q000150:complications / Q000628:therapy; D012772:Shock, Septic / Q000209:etiology / Q000628:therapy