The use of theraputic plasma exchange (TPE) in the setting of refractory burn shock

Introduction: This study examines the physiologic effects of theraputic plasma exchange (TPE) in the setting of refractory burn shock and attempts to identify variables that correlate with the eventual need for TPE. Methods: A retrospective analysis was conducted of 40 patients over 24 months with >20% TBSA burns who experienced complicated resuscitations. TPE was utilized in 21 patients when the patients' total resuscitation volumes exceeded 1.2 times the amount predicted by the modified Baxter formula (3 cm(3) LR/kg/%TBSA). Nineteen matched, contemporaneous patients served as controls. Demographic, injury severity, and acute clinical variables were abstracted for comparison between the two groups. Additionally, the TPE group was analyzed for blood lactate levels, mean arterial pressure (MAP) and urine output (UOP) before and after TPE. Univariate and multivariate statistical analyses were used for comparisons, where appropriate. Results: In response to TPE, MAP increased by 24% (p < 0.0001), UOP increased by >400% (p = < 0.0001), IVF rates were reduced by 25% (p = 0.01), and lactate levels decreased by almost 50% (p = 0.0006). On univariate analysis, admission lactate (p = 0.0006) and %TBSA (p = 0.01) were found to be significantly increased in the TPE group compared to controls, while there was no difference in age, gender, weight, admission HCT, incidence of acute renal failure, or mortality between the groups. However, on multivariate logistic regression analysis, only elevated admission lactate was independently associated with the eventual need for TPE (OR 2.23, 95% CI = 1.30-3.84, p = 0.004). Conclusions: This is the largest study to date examining TPE as an adjunct in burn resuscitation and suggests that TPE may be effective as a salvage intervention for refractory burn shock. Physiologic parameters clearly improved after the use of TPE without any detected adverse consequences. Also, admission lactate may be a useful indicator to determine who will fail standard burn resuscitation and require TPE. (C) 2009 Elsevier Ltd and ISBI. All rights reserved.