Abstract
Burn centers routinely treat a complex mix of patients with soft tissue injuries, including burn injuries, necrotizing soft tissue infections, and dermatologic conditions such as toxic epidermal necrolysis (TEN). In each of these conditions, fluid resuscitation, surgical interventions, and advances in critical care have improved survival significantly; however, there remains a subset of patients who do not respond to conventional means. It is because of these patients that we continue to seek means to “rescue” patients who are failing to respond to conventional care. Therapeutic plasma exchange (TPE) is an uncommon and underutilized treatment modality that has been used as a form of treatment “rescue.” We provide a review of the literature describing the use of TPE in TEN, burn shock, and sepsis. Our review of the literature over the past 30 years demonstrates persistent clinical benefits and reduced morbidity and mortality with use of TPE in TEN, burn shock, and sepsis. Many studies demonstrate significant improvement in morbidity and mortality with TPE in patients suffering from these conditions. However, future well-designed studies of the role of TPE in conditions commonly encountered in burn units are indicated. Improved awareness of TPE may lead to increased use of this uncommonly utilized modality and allow for potential future collaboration in a prospective, randomized, controlled trial with a larger number of subjects.
CONCLUSIONS
Significant burn injury, sepsis, and TEN all lead to large and sometimes excessive amounts of proinflammatory factors such as complement activation and cytokines, contributing to hemodynamic abnormalities and multiorgan dysfunction syndrome. The question remains as to whether modalities such as TPE or hemofiltration might lead to attenuation of the inflammatory response and shock by clearing proinflammatory mediators either in patients with established acute renal dysfunction or if applied at an early stage before renal shutdown. As our advances in critical care and surgical management of the wound have improved dramatically, in turn increasing the ability of patients to survive the acute systemic inflammatory response, the ability of TPE to improve survival and temper the acute systemic inflammatory response is of significant importance and deserves further study. Collaboration between centers to study further the use of plasma exchange in these three settings common to burn units would allow for larger sample sizes and more definitive answers regarding the potential benefits of TPE.
ARYAN'S BLOG 