title: Use of therapeutic plasma exchange as a rescue therapy in 2009 pH1N1 influenza A--an associated respiratory failure and hemodynamic shock.
abstract: OBJECTIVE
  Acute pneumonitis with acute lung injury is a cause of significant mortality related to the 2009 pH1N1 influenza A virus. Widespread lung inflammation and increased pulmonary vascular permeability has been noted on autopsy. Also, many of these patients present with significant hemodynamic compromise suggesting systemic cytokine release. Therefore, attenuating circulating cytokines, and other mediators, by blood purification techniques is a theoretically attractive strategy. We report the use therapeutic plasma exchange in three children with 2009 H1N1 related acute lung injury with severe hemodynamic compromise that had failed conventional therapeutic interventions.
  
  
  METHODS
  Case series.
  
  
  METHODS
  Pediatric intensive care unit in a university children's hospital.
  
  
  METHODS
  Three children, aged 8, 11, and 17 yrs, with acute respiratory distress syndrome and hemodynamic compromise related to the 2009 pH1N1 influenza A virus documented by polymerase chair reaction. All patients were on mechanical ventilation and inhaled nitric oxide, and one patient was on extracorporeal membrane oxygenation. Therapeutic plasma exchange was used as a rescue strategy.
  
  
  METHODS
  Each patient received three exchanges of 35-40 mL/kg on consecutive days.
  
  
  METHODS
  All three patients had dramatic reduction in pediatric logistic organ dysfunction scores, oxygen requirements, and vasopressor requirements after two exchanges. All survived with good functional recovery.
  
  
  RESULTS
  In this small series of patients with H1N1/acute respiratory distress syndrome and hemodynamic compromise, therapeutic plasma exchange appeared to benefit as a method of mitigating the associated cytokine storm. The procedure was well tolerated with no reported side effects. All three patients survived, defying the predicted mortality. Because these procedures used the filtration exchange method, it was performed in a timely fashion by intensive care unit personnel and on equipment already available in the intensive care unit for renal support.
  
  
  CONCLUSIONS
  This very limited case series suggest there may be a role for therapeutic plasma exchange as a rescue therapy in severe shock and acute lung injury related to pH1N1 that has not responded to traditional therapy.
authors.affiliation: Critical Care Medicine Division, Department of Pediatrics and Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA.
authors.forename: Pritesh
authors.initials: P
authors.lastname: Patel
authors.forename: Veena
authors.initials: V
authors.lastname: Nandwani
authors.forename: John
authors.initials: J
authors.lastname: Vanchiere
authors.forename: Steven A
authors.initials: SA
authors.lastname: Conrad
authors.forename: L Keith
authors.initials: LK
authors.lastname: Scott
mesh_terms: D000293:Adolescent; D002648:Child; D015897:Comorbidity; D016207:Cytokines / Q000097:blood; D006439:Hemodynamics / Q000502:physiology*; D006801:Humans; D053118:Influenza A Virus, H1N1 Subtype / Q000302:isolation & purification*; D007251:Influenza, Human / Q000150:complications*; D015278:Intensive Care Units, Pediatric; D010951:Plasma Exchange; D012128:Respiratory Distress Syndrome / Q000209:etiology* / Q000503:physiopathology; D012769:Shock / Q000209:etiology*; D016896:Treatment Outcome
chemical_list: D016207:Cytokines
references.citation: J Pediatr Hematol Oncol. 2003 Oct;25(10):801-5
references.pmid: 14528104
references.citation: Semin Pediatr Infect Dis. 2006 Apr;17(2):72-9
references.pmid: 16822469
references.citation: Cytokine. 2009 Jul;47(1):65-8
references.pmid: 19497758
references.citation: N Engl J Med. 2009 Aug 13;361(7):680-9
references.pmid: 19564631
references.citation: Scand J Infect Dis. 1993;25(6):757-61
references.pmid: 8052817
references.citation: Blood Purif. 2008;26(2):145-50
references.pmid: 18212497
references.citation: Blood Purif. 2008;26(1):30-5
references.pmid: 18182792
references.citation: Crit Care Med. 2003 Jun;31(6):1730-6
references.pmid: 12794412
references.citation: Chest. 2009 Dec;136(6):1631-1643
references.pmid: 19801579
references.citation: Int J Artif Organs. 2008 Oct;31(10):882-90
references.pmid: 19009506
references.citation: Crit Care Med. 2008 Oct;36(10):2878-87
references.pmid: 18828196
references.citation: Intensive Care Med. 2002 Oct;28(10):1434-9
references.pmid: 12373468
references.citation: Am J Med Sci. 2001 Feb;321(2):124-8
references.pmid: 11217814
references.citation: Blood Purif. 2002;20(3):282-8
references.pmid: 11867876