Extracorporeal blood purification therapies (EBPTs) use extracorporeal circuits to remove or modulate circulating substances for organ support and detoxification. These therapies include renal replacement therapy, ultrafiltration, haemoadsorption, and plasma therapies. Recent advances in technology have expanded EBPTs from single-organ to multiple-organ support in critically ill patients.
Despite their potential, particularly in septic shock, the effectiveness of EBPTs remains controversial due to limited high-quality evidence and a lack of standardised guidelines. This issue is especially pronounced in paediatric intensive care, where technical challenges and limited paediatric-specific devices create variability in practice.
To address these concerns, the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) conducted an expert opinion study. A panel of 15 paediatric intensivists developed a consensus statement on EBPT use in PICUs through a modified Delphi-based model (2022–2024). The core team created an initial questionnaire addressing indications, discontinuation, and outcome measures. Panellists ranked responses, with consensus strength determined by percentage agreement (>90% for strong consensus, <49% for no consensus).
A total of 116 survey responses were collected from panellists across eight European countries. Strong consensus was reached on six of 24 questions, with consensus (75%-90% agreement) on 18 questions. Panellists identified continuous renal replacement therapy with standard or enhanced adsorption haemofilters and plasma exchange as the most commonly used EBPTs.
Panellists identified EBPTs as a potential adjuvant therapy for refractory septic shock, MODS, and cytokine storm syndrome. In paediatric liver failure, detoxification and ammonia reduction were key therapeutic goals. Limited evidence supports EBPT use in paediatric cardiopulmonary bypass and rhabdomyolysis, though interest is growing. Despite increasing application, haemoadsorption remains underutilised in PICUs.
No consensus exists on using advanced biomarkers for EBPT initiation, likely due to their limited bedside availability. However, there is broad agreement on haemodynamic stability and bleeding risk as key safety parameters. Standard CRRT, enhanced adsorption haemofilters, and plasma exchange are the most commonly used EBPTs.
Challenges to EBPT implementation in PICUs include assessing effectiveness, managing complications, and the lack of paediatric-specific technology. Future research should focus on establishing criteria for treatment efficacy, discontinuation, and futility, as well as developing paediatric-adapted EBPT technologies.
This consensus statement aims to support paediatric intensivists in bedside decision-making and guide future EBPT research in PICUs, given the lack of high-quality evidence for formal guidelines. Strong panel agreement on EBPT indications suggests the need for further studies. Successful implementation across European PICUs requires targeted research to develop reliable assessment parameters and paediatric-specific technologies before high-quality clinical trials. Future investigations could include a global PICU survey to enhance EBPT safety and effectiveness.
Source: JAMA
Image Credit: iStock
