The Techniques of Blood Purification in the Treatment of Septic Shock
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Mar 26, 2024
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Abstract
In the last few decades, a number of techniques based on different principles of functioning have been developed to remove from the bloodstream of septic shock patients or suffering from other clinical conditions characterized by an exaggerated inflammatory response. Despite Yet, their use is based more on the personal experience than on the results of clinical trials that often-carried contrasting results.
In this review the rationale for the blood purification procedures, their technical features and the findings of clinical trials are exposed and discussed along with the possible rules of engagement.
Article Details
How to Cite
BERLOT, Giorgio; ZARRILLO, Nadia; TOMBOLINI, Ludovica.
The Techniques of Blood Purification in the Treatment of Septic Shock.
Medical Research Archives, [S.l.], v. 12, n. 3, mar. 2024.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/5135>. Date accessed: 22 dec. 2024.
doi: https://doi.org/10.18103/mra.v12i3.5135.
Section
Review Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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2. Clowes GH, George BC, Villee C.t al. Muscle proteolysis induced by a circulating peptide in patients with sepsis or trauma. New Engl J Med. 1983;308: 545-552.
3. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016; 315:801-810.
4. Wiersinga WJ, Leopold SJ, Cranendonk DR, et al. Host innate immune responses to sepsis. Virulence 2014;5: 36-44.
5. Ronco C, Tetta C, Mariano F et al: Interpreting the mechanisms of continuous renal replacement therapy in sepsis: the peak concentration hypothesis. Artif Organs 2003; 27: 792-801.
6. Girardot T, Schneider A, Rimmelé T: Blood Purification Techniques for Sepsis and Septic AKI. Semin Nephrol 2019; 39: 505-514.
7. Lee PA, Matson JR, Pryor RW, Hinshaw LB: Continuous arteriovenous hemofiltration therapy for Staphylococcus aureus-induced septicaemias in immature swine. Crit Care Med 1993; 21: 914-24.
8. Ma S, Xu Q, Deng B., Zheng Y, Tian H, Wang, L et al: Granulocyte and monocyte adsorptive apheresis ameliorates sepsis in rats. Intensive Care Med Exp 2017; 5: 18.
9. Rimmelé T, Kellum JA: Clinical review: blood purification for sepsis. Crit Care 2011; 15: 205.
10. Monard C, Rimmelé T, Ronco C: Extracorporeal Blood Purification Therapies for Sepsis. Blood Purif 2019; 47 Suppl. 3: 1-14.
11. Berlot G, Tomasini A, Zanchi S, Moro E: The Techniques of Blood Purification in the Treatment of Sepsis and Other Hyperinflammatory Conditions. J Clin Med 2023 ;12: 1723.
12. Morgera S, Rocktaschel J, Haase M, et al: Intermittent high permeability hemofiltration in septic patients with acute renal failure. Intensive Care Med 2003; 29: 1989-1995.
13. Rimmelé T, Kellum JA: High-volume hemofiltration in the intensive care unit: a blood purification therapy. Anesthesiology 2012; 116: 1377-1387.
14. Rimmelé T, Hayi-Slayman D, Page M, Rada, H; Monchi M, Allaouchiche B: Cascade hemofiltration: principle, first experimental data. Ann Fr Anesth Reanim 2009; 28: 249-252.
15. Ankawi G, Fan W, Pomarè Montin D, Lorenzin A, Neri M, Caprara C et al: A new series of sorbent devices for multiple clinical purposes: current evidence and future directions. Blood Purif 2019; 47: 94-100.
16. Bauer PR, Ostermann M, Russell L, Robba C, David, S, Ferreyro BL et al: Plasma exchange in the intensive care unit: a narrative review. Intensive Care Med 2022; 48: 1382-1396.
17. Putzu A, Schorer R, Lopez-Delgado JC, Cassina T, Landoni G: Blood Purification and Mortality in Sepsis and Septic Shock: A Systematic Review and Meta-analysis of Randomized Trials. Anesthesiology 2019; 131: 580-593.
18. Chen JJ, Lai PC, Lee TH, Huang YT. Blood purification for adult patients with severe infection or sepsis/septic shock: A Network Meta-Analysis of Randomized Controlled Trials. Crit Care Med 2023; 51: 1777-1789.
19. Ronco C, Bellomo R, Homel P, Brendolan A, Dan M, Piccinni P et al: Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet 2000; 356: 26-30.
20. Cole L, Bellomo R, Journois D, Davenport P, Baldwin I, Tipping P: High-volume hemofiltration in human septic shock. Intensive Care Med 2001; 27: 978-986.
21. Rimmelé T, Kellum JA: High-volume hemofiltration in the intensive care unit: a blood purification therapy. Anaesthesiology 2012; 116: 1377-1387.
22. Joannes-Boyau O, Honore PM, Perez P, Bagshaw SM Grand H, Canivet, JL et al: A. High-volume versus standard-volume hemofiltration for septic shock patients with acute kidney injury (IVOIRE) study: a multicentre randomized controlled trial. Intensive Care Med 2013; 39: 1535-1546.
23. Breilh D, Honore PM, De Bels, D, et al: Pharmacokinetics and pharmacodynamics of anti-infective agents during continuous veno-venous hemofiltration in critically ill patients: lessons learned from an ancillary study of the IVOIRE trial. J Transl Int Med 2019; 7: 155-169.
24. Coudroy R, Payen D, Launey Y, et al: Modulation by Polymyxin-B hemoperfusion of inflammatory response related to severe peritonitis. Shock 2017;47: 93-99.
25. Atan R, Virzi GM, Peck Let al: High cut-off hemofiltration versus standard hemofiltration: a pilot assessment of effects on indices of apoptosis. Blood Purif 2014; 37: 296-303.
26. Cruz DN, Antonelli M, Fumagalli R, et al: Early use of polymyxin B hemoperfusion in abdominal septic shock: the EUPHAS randomized controlled trial. JAMA 2009; 301: 2445-52.
27. Payen D, Dupuis C, Deckert Vet al: Endotoxin mass concentration in plasma is associated with mortality in a multicentric cohort of peritonitis-induced shock. Front Med Lausanne 2021; 8: 749405.
28. Dellinger RP, Bagshaw SM, Antonelli M, Foster DM, Klein DJ, Marshall JC et al: Effect of targeted Polymyxin B hemoperfusion on 28-day mortality in patients with septic shock and elevated endotoxin tevel: The EUPHRATES Randomized Clinical Trial. JAMA 2018; 320: 1455-1463.
29. Kogelmann, K, Jarczak D, Scheller M, Drüner M: Hemoadsorption by CytoSorb in septic patients: a case series. Crit Care 2017; 21: 74.
30. Brouwer WP, Duran S, Kuijper M, Ince C: Hemoadsorption with CytoSorb shows a decreased observed versus expected 28-day all-cause mortality in ICU patients with septic shock: a propensity-score-weighted retrospective study. Crit Care 2019; 23: 317.
31. Hawchar F, László I, Öveges N, Trásy D, Ondrik Z, Molnar Z: Extracorporeal cytokine adsorption in septic shock: A proof of concept randomized, controlled pilot study. J Crit Care 2019; 49 :72-178.
32. Schultz P, Schwier E, Eickmeyer C, Henzler D, Köhler T: High-dose CytoSorb hemoadsorption is associated with improved survival in patients with septic shock: A retrospective cohort study. J Crit Care 2021; 64:184-192.
33. Scharf C, Schroeder I, Paal M, et al. Can the cytokine adsorber CytoSorb® help to mitigate cytokine storm and reduce mortality in critically ill patients? A propensity score matching analysis. Ann Intensive Care 2021: 11: 115.
34. Wendel Garcia PD, Hilty MP, Held U, Kleinert EM, Maggiorini M. Cytokine adsorption in severe, refractory septic shock. Intensive Care Med 2021; 47: 1334-1336.
35. Supady A, Brodie D, Wengenmayer T.Extracorporeal haemoadsorption: does the evidence support its routine use in critical care? Lancet Respir Med 2022 ;10: 307-312.
36. Heymann M, Schorer R, Putzu A. The Effect of CytoSorb on Inflammatory Markers in Critically Ill Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Med 2023; 51:1659-1673.
37. Jansen A, Waalders NJB, van Lier DPT, Kox M, Pickkers P. CytoSorb hemoperfusion markedly attenuates circulating cytokine concentrations during systemic inflammation in humans in vivo. Crit Care 2023; 27:117.
38. Hawchar F, Tomescu D, Träger K, et al: Hemoadsorption in the critically ill-Final results of the International CytoSorb Registry. PLoS One 2022, 17: e0274315.
39. Heymann M, Schorer R, Putzu A. Mortality and adverse events of hemoadsorption with CytoSorb® in critically ill patients: A systematic review and meta-analysis of randomized controlled trials. Acta Anaesthesiol Scand 2022; 66:1037-1050.
40. Berlot G, Samola V, Barbaresco I, Tomasini A, di Maso V, Bianco, Fet al: Effects of the timing and intensity of treatment on septic shock patients treated with CytoSorb®: Clinical experience. Int J Artif Organs 2022; 45: 249-253.
41. Bottari G, Confalone V, Cotugno N, et al: Efficacy of CytoSorb in a Pediatric Case of Severe Multisystem Inflammatory Syndrome (MIS-C): A Clinical Case Report. Front Pediatr 2021; 11: 676298.
42. Broman ME, Hansson F, Vincent JL, Bodelsson M: Endotoxin and cytokine reducing properties of the oXiris membrane in patients with septic shock: A randomized crossover double-blind study. PLoS One 2019; 14: e0220444.
43. Turani F, Barchetta R, Falco M, Busatti S, Weltert L: Continuous Renal Replacement Therapy with the Adsorbing Filter oXiris in Septic Patients: A Case Series. Blood Purif 2019: 47 Suppl 3: 1-5.
44. Schwindenhammer V, Girardot T, Chaulier K, et al: oXiris® Use in Septic Shock: Experience of Two French Centres. Blood Purif 2019; 47 Suppl 3: 1-7.
45. Cecchi M, Ulsamer A, Villa G. Oxiris Membrane in Sepsis and Multiple Organ Failure. Contrib Nephrol 2023; 200:55-65.
46. Li Y, Sun P, Chang K, Yang M et al: Effect of Continuous Renal Replacement Therapy with the oXiris Hemofilter on Critically Ill Patients: A Narrative Review. J Clin Med 2022; 11: 6719.
47. Votrico V, Grilli M, Gerini U, Berlot G. Hemoperfusion with high-affinity polyethylene microbeads (Seraph-100®) for the removal of pathogens in chronic critically ill patients: Clinical experience. Int J Artif Organs 2024; 47:115-117.
48. Stewart IJ, McCrea K, Chawla L, Chung KK. Adsorption of Pathogens and Blockade of Sepsis Cascade. Contrib Nephrol 2023; 200:123–132.
49. Eden, G, Schmidt JJ, Büttner S, Kümpers P, Hafer C, Rovas A et al: Safety and efficacy of the Seraph® 100 Microbind® Affinity Blood Filter to remove bacteria from the blood stream: results of the first in human study. Crit Care 2022; 17: 181.
50. Stahl K, Wand P, Seeliger B et al: Clinical and biochemical endpoints and predictors of response to plasma exchange in septic shock: results from a randomized controlled trial. Crit Care 2022; 26: 134.
51. David S, Bode C, Putensen C, Welte T, Stahl K: EXCHANGE study group. Adjuvant therapeutic
plasma exchange in septic shock. Intensive Care Med 2021; 47: 352-354.
52. Garbero E, Livigni S, Ferrari F et al: High dose coupled plasma filtration and adsorption in septic shock patients. Results of the COMPACT-2: a multicentre, adaptive, randomised clinical trial. Intensive Care Med 2021; 47: 1303-1311.
53. Giménez-Esparza C, Portillo-Requena C et al: The premature closure of ROMPA clinical trial: mortality reduction in septic shock by plasma adsorption. BMJ Open 2019; 9: e030139.
54. Snow TAC, Littlewood S, Corredor S, Singer M, Arulkumaran N: Effect of Extracorporeal Blood Purification on Mortality in Sepsis: A Meta-Analysis and Trial Sequential Analysis. Blood Purif 2021; 50: 462-472.
55. Evans L, Rhodes A, Alhazzani W, Antonelli M et al: Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47: 1181-1247.
56. Friesecke S, Stecher SS, Gross S, Felix SB, Nierhaus A. Extracorporeal cytokine elimination as rescue therapy in refractory septic shock: a prospective single-center study. J Artif Organs 2017; 20 :252-259.
57. Berlot G, Di Bella S, Tomasini A, Roman-Pognuz E: The Effects of Hemoadsorption on the Kinetics of Antibacterial and Antifungal Agents. Antibiotics (Basel) 2022;11:180.
2. Clowes GH, George BC, Villee C.t al. Muscle proteolysis induced by a circulating peptide in patients with sepsis or trauma. New Engl J Med. 1983;308: 545-552.
3. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016; 315:801-810.
4. Wiersinga WJ, Leopold SJ, Cranendonk DR, et al. Host innate immune responses to sepsis. Virulence 2014;5: 36-44.
5. Ronco C, Tetta C, Mariano F et al: Interpreting the mechanisms of continuous renal replacement therapy in sepsis: the peak concentration hypothesis. Artif Organs 2003; 27: 792-801.
6. Girardot T, Schneider A, Rimmelé T: Blood Purification Techniques for Sepsis and Septic AKI. Semin Nephrol 2019; 39: 505-514.
7. Lee PA, Matson JR, Pryor RW, Hinshaw LB: Continuous arteriovenous hemofiltration therapy for Staphylococcus aureus-induced septicaemias in immature swine. Crit Care Med 1993; 21: 914-24.
8. Ma S, Xu Q, Deng B., Zheng Y, Tian H, Wang, L et al: Granulocyte and monocyte adsorptive apheresis ameliorates sepsis in rats. Intensive Care Med Exp 2017; 5: 18.
9. Rimmelé T, Kellum JA: Clinical review: blood purification for sepsis. Crit Care 2011; 15: 205.
10. Monard C, Rimmelé T, Ronco C: Extracorporeal Blood Purification Therapies for Sepsis. Blood Purif 2019; 47 Suppl. 3: 1-14.
11. Berlot G, Tomasini A, Zanchi S, Moro E: The Techniques of Blood Purification in the Treatment of Sepsis and Other Hyperinflammatory Conditions. J Clin Med 2023 ;12: 1723.
12. Morgera S, Rocktaschel J, Haase M, et al: Intermittent high permeability hemofiltration in septic patients with acute renal failure. Intensive Care Med 2003; 29: 1989-1995.
13. Rimmelé T, Kellum JA: High-volume hemofiltration in the intensive care unit: a blood purification therapy. Anesthesiology 2012; 116: 1377-1387.
14. Rimmelé T, Hayi-Slayman D, Page M, Rada, H; Monchi M, Allaouchiche B: Cascade hemofiltration: principle, first experimental data. Ann Fr Anesth Reanim 2009; 28: 249-252.
15. Ankawi G, Fan W, Pomarè Montin D, Lorenzin A, Neri M, Caprara C et al: A new series of sorbent devices for multiple clinical purposes: current evidence and future directions. Blood Purif 2019; 47: 94-100.
16. Bauer PR, Ostermann M, Russell L, Robba C, David, S, Ferreyro BL et al: Plasma exchange in the intensive care unit: a narrative review. Intensive Care Med 2022; 48: 1382-1396.
17. Putzu A, Schorer R, Lopez-Delgado JC, Cassina T, Landoni G: Blood Purification and Mortality in Sepsis and Septic Shock: A Systematic Review and Meta-analysis of Randomized Trials. Anesthesiology 2019; 131: 580-593.
18. Chen JJ, Lai PC, Lee TH, Huang YT. Blood purification for adult patients with severe infection or sepsis/septic shock: A Network Meta-Analysis of Randomized Controlled Trials. Crit Care Med 2023; 51: 1777-1789.
19. Ronco C, Bellomo R, Homel P, Brendolan A, Dan M, Piccinni P et al: Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet 2000; 356: 26-30.
20. Cole L, Bellomo R, Journois D, Davenport P, Baldwin I, Tipping P: High-volume hemofiltration in human septic shock. Intensive Care Med 2001; 27: 978-986.
21. Rimmelé T, Kellum JA: High-volume hemofiltration in the intensive care unit: a blood purification therapy. Anaesthesiology 2012; 116: 1377-1387.
22. Joannes-Boyau O, Honore PM, Perez P, Bagshaw SM Grand H, Canivet, JL et al: A. High-volume versus standard-volume hemofiltration for septic shock patients with acute kidney injury (IVOIRE) study: a multicentre randomized controlled trial. Intensive Care Med 2013; 39: 1535-1546.
23. Breilh D, Honore PM, De Bels, D, et al: Pharmacokinetics and pharmacodynamics of anti-infective agents during continuous veno-venous hemofiltration in critically ill patients: lessons learned from an ancillary study of the IVOIRE trial. J Transl Int Med 2019; 7: 155-169.
24. Coudroy R, Payen D, Launey Y, et al: Modulation by Polymyxin-B hemoperfusion of inflammatory response related to severe peritonitis. Shock 2017;47: 93-99.
25. Atan R, Virzi GM, Peck Let al: High cut-off hemofiltration versus standard hemofiltration: a pilot assessment of effects on indices of apoptosis. Blood Purif 2014; 37: 296-303.
26. Cruz DN, Antonelli M, Fumagalli R, et al: Early use of polymyxin B hemoperfusion in abdominal septic shock: the EUPHAS randomized controlled trial. JAMA 2009; 301: 2445-52.
27. Payen D, Dupuis C, Deckert Vet al: Endotoxin mass concentration in plasma is associated with mortality in a multicentric cohort of peritonitis-induced shock. Front Med Lausanne 2021; 8: 749405.
28. Dellinger RP, Bagshaw SM, Antonelli M, Foster DM, Klein DJ, Marshall JC et al: Effect of targeted Polymyxin B hemoperfusion on 28-day mortality in patients with septic shock and elevated endotoxin tevel: The EUPHRATES Randomized Clinical Trial. JAMA 2018; 320: 1455-1463.
29. Kogelmann, K, Jarczak D, Scheller M, Drüner M: Hemoadsorption by CytoSorb in septic patients: a case series. Crit Care 2017; 21: 74.
30. Brouwer WP, Duran S, Kuijper M, Ince C: Hemoadsorption with CytoSorb shows a decreased observed versus expected 28-day all-cause mortality in ICU patients with septic shock: a propensity-score-weighted retrospective study. Crit Care 2019; 23: 317.
31. Hawchar F, László I, Öveges N, Trásy D, Ondrik Z, Molnar Z: Extracorporeal cytokine adsorption in septic shock: A proof of concept randomized, controlled pilot study. J Crit Care 2019; 49 :72-178.
32. Schultz P, Schwier E, Eickmeyer C, Henzler D, Köhler T: High-dose CytoSorb hemoadsorption is associated with improved survival in patients with septic shock: A retrospective cohort study. J Crit Care 2021; 64:184-192.
33. Scharf C, Schroeder I, Paal M, et al. Can the cytokine adsorber CytoSorb® help to mitigate cytokine storm and reduce mortality in critically ill patients? A propensity score matching analysis. Ann Intensive Care 2021: 11: 115.
34. Wendel Garcia PD, Hilty MP, Held U, Kleinert EM, Maggiorini M. Cytokine adsorption in severe, refractory septic shock. Intensive Care Med 2021; 47: 1334-1336.
35. Supady A, Brodie D, Wengenmayer T.Extracorporeal haemoadsorption: does the evidence support its routine use in critical care? Lancet Respir Med 2022 ;10: 307-312.
36. Heymann M, Schorer R, Putzu A. The Effect of CytoSorb on Inflammatory Markers in Critically Ill Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Med 2023; 51:1659-1673.
37. Jansen A, Waalders NJB, van Lier DPT, Kox M, Pickkers P. CytoSorb hemoperfusion markedly attenuates circulating cytokine concentrations during systemic inflammation in humans in vivo. Crit Care 2023; 27:117.
38. Hawchar F, Tomescu D, Träger K, et al: Hemoadsorption in the critically ill-Final results of the International CytoSorb Registry. PLoS One 2022, 17: e0274315.
39. Heymann M, Schorer R, Putzu A. Mortality and adverse events of hemoadsorption with CytoSorb® in critically ill patients: A systematic review and meta-analysis of randomized controlled trials. Acta Anaesthesiol Scand 2022; 66:1037-1050.
40. Berlot G, Samola V, Barbaresco I, Tomasini A, di Maso V, Bianco, Fet al: Effects of the timing and intensity of treatment on septic shock patients treated with CytoSorb®: Clinical experience. Int J Artif Organs 2022; 45: 249-253.
41. Bottari G, Confalone V, Cotugno N, et al: Efficacy of CytoSorb in a Pediatric Case of Severe Multisystem Inflammatory Syndrome (MIS-C): A Clinical Case Report. Front Pediatr 2021; 11: 676298.
42. Broman ME, Hansson F, Vincent JL, Bodelsson M: Endotoxin and cytokine reducing properties of the oXiris membrane in patients with septic shock: A randomized crossover double-blind study. PLoS One 2019; 14: e0220444.
43. Turani F, Barchetta R, Falco M, Busatti S, Weltert L: Continuous Renal Replacement Therapy with the Adsorbing Filter oXiris in Septic Patients: A Case Series. Blood Purif 2019: 47 Suppl 3: 1-5.
44. Schwindenhammer V, Girardot T, Chaulier K, et al: oXiris® Use in Septic Shock: Experience of Two French Centres. Blood Purif 2019; 47 Suppl 3: 1-7.
45. Cecchi M, Ulsamer A, Villa G. Oxiris Membrane in Sepsis and Multiple Organ Failure. Contrib Nephrol 2023; 200:55-65.
46. Li Y, Sun P, Chang K, Yang M et al: Effect of Continuous Renal Replacement Therapy with the oXiris Hemofilter on Critically Ill Patients: A Narrative Review. J Clin Med 2022; 11: 6719.
47. Votrico V, Grilli M, Gerini U, Berlot G. Hemoperfusion with high-affinity polyethylene microbeads (Seraph-100®) for the removal of pathogens in chronic critically ill patients: Clinical experience. Int J Artif Organs 2024; 47:115-117.
48. Stewart IJ, McCrea K, Chawla L, Chung KK. Adsorption of Pathogens and Blockade of Sepsis Cascade. Contrib Nephrol 2023; 200:123–132.
49. Eden, G, Schmidt JJ, Büttner S, Kümpers P, Hafer C, Rovas A et al: Safety and efficacy of the Seraph® 100 Microbind® Affinity Blood Filter to remove bacteria from the blood stream: results of the first in human study. Crit Care 2022; 17: 181.
50. Stahl K, Wand P, Seeliger B et al: Clinical and biochemical endpoints and predictors of response to plasma exchange in septic shock: results from a randomized controlled trial. Crit Care 2022; 26: 134.
51. David S, Bode C, Putensen C, Welte T, Stahl K: EXCHANGE study group. Adjuvant therapeutic
plasma exchange in septic shock. Intensive Care Med 2021; 47: 352-354.
52. Garbero E, Livigni S, Ferrari F et al: High dose coupled plasma filtration and adsorption in septic shock patients. Results of the COMPACT-2: a multicentre, adaptive, randomised clinical trial. Intensive Care Med 2021; 47: 1303-1311.
53. Giménez-Esparza C, Portillo-Requena C et al: The premature closure of ROMPA clinical trial: mortality reduction in septic shock by plasma adsorption. BMJ Open 2019; 9: e030139.
54. Snow TAC, Littlewood S, Corredor S, Singer M, Arulkumaran N: Effect of Extracorporeal Blood Purification on Mortality in Sepsis: A Meta-Analysis and Trial Sequential Analysis. Blood Purif 2021; 50: 462-472.
55. Evans L, Rhodes A, Alhazzani W, Antonelli M et al: Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47: 1181-1247.
56. Friesecke S, Stecher SS, Gross S, Felix SB, Nierhaus A. Extracorporeal cytokine elimination as rescue therapy in refractory septic shock: a prospective single-center study. J Artif Organs 2017; 20 :252-259.
57. Berlot G, Di Bella S, Tomasini A, Roman-Pognuz E: The Effects of Hemoadsorption on the Kinetics of Antibacterial and Antifungal Agents. Antibiotics (Basel) 2022;11:180.