Extracorporeal membrane oxygenation for refractory septic shock in children: one institution's experience.

OBJECTIVE: To report our institutional experience of venoarterial extracorporeal membrane oxygenation (ECMO) in children with septic shock and circulatory collapse. DESIGN: Retrospective case series. SETTING: Intensive care unit of a tertiary pediatric referral center. PATIENTS: Forty-five children with refractory septic shock who received venoarterial ECMO for hemodynamic support. INTERVENTIONS: Venoarterial ECMO. MEASUREMENTS AND MAIN RESULTS: We measured mean arterial pressure and inotropes before cannulation, ventilator settings, oxygenation, site and cause of infection, time on ECMO, complications of ECMO relating to the circuit or anticoagulation, survival to hospital discharge, and functional outcome assessment. Between July 1988 and October 2006, 441 children at our institution received extracorporeal life support for a variety of indications. Forty-five (10%) with septic shock received venoarterial ECMO specifically for hemodynamic support. Eighteen (40%) of these had suffered cardiac arrest and were receiving chest compressions immediately before cannulation. The median time spent on ECMO was 84 hrs (range, 32-135). There were mechanical problems with the ECMO circuit requiring intervention in 17 (38%) patients, such as oxygenator or pump head failure, clots in the circuit, or cannulae malposition. This caused no long-term harm in any but one of the patients, who died during a circuit change. Eleven patients (24%) had clinically apparent episodes of bleeding that required surgical intervention or blood transfusion. Twenty-one (47%) patients survived to hospital discharge. Atrioaortic cannulation through a sternotomy incision was associated with an improvement in survival to hospital discharge (73% of those with central cannulation survived vs. 44% without, p = .05). No survivors had severe disability at long-term follow-up. CONCLUSIONS: Extracorporeal membrane oxygenation can be safely used to resuscitate and support children with sepsis and refractory shock. Sepsis and multiorgan failure should not be considered a contraindication to ECMO. This study adds support to existing guidelines.     

Genetic dilemma: eNOS gene intron 4a/b VNTR polymorphism in sepsis and its clinical features in Turkish children

The role of endothelial nitric oxide synthase gene intron 4 a/b (eNOS4a/b) variable number of tandem repeats (VNTR) polymorphism in various diseases was investigated. We investigated whether this polymorphism is associated with susceptibility to sepsis and its clinical features such as acute respiratory distress syndrome (ARDS), multiorgan dysfunction syndrome (MODS) and shock. eNOS4a/b VNTR polymorphism was determined by the polymerase chain reaction in 100 children with sepsis and in 134 healthy controls. The genotype distribution of eNOS4 was not different between the patients and controls (p=0.44). There was no statistically significant association between genotypes/allele frequency and outcomes like mortality, MODS, ARDS, and shock (p>0.05). This is the first study that evaluates the effect of eNOS4a/b polymorphism in sepsis. We were unable to show a relationship between eNOS gene intron 4 a/b VNTR polymorphism and MODS, ARDS, mortality and shock. Larger studies that do research on the interaction of such genes are needed to clarify the association between eNOS4a/b polymorphism and sepsis.     

205例脓毒症患儿生存分析

目的了解儿童脓毒症的生存情况,探讨影响其预后的相关因素。方法回顾性分析205例脓毒症患儿的临床资料,包括性别、年龄、90 d内生存情况等。结果 90 d生存率78.0%(Life Table法),发病后7～25 d死亡风险最高。死亡患儿并发脓毒性休克(shock)、急性肺损伤(ALI)/呼吸窘迫综合征(ARDS)和多器官功能障碍(MODS)的比例高于存活患儿,差异有统计学意义(P<0.05);死亡患儿的年龄、入PICU时及最危重时的儿童危重病例评分(PCIS)、收缩压(SBP)、舒张压(DBP)、血清白蛋白(ALB)和血小板计数(PLT)均低于存活患儿,而机械通气治疗时间长于存活患儿,差异均有统计学意义(P<0.05)。入选死亡因素多元Cox比例风险回归方程的变量为年龄(RR=0.426)、MODS(RR=4.732)、ALI/ARDS(RR=4.269)、最危重时的PCIS(RR=0.186)、机械通气时间(RR=0.159)和ALB(RR=0.507)。方程的受试者工作特征曲线(ROC)下面积为0.847(95%CI:0.787～0.908),判定死亡的灵敏度91.30%,特异度65.40%,一致率71.22%(Kappa=0.146,P=0.001)。结论儿童脓毒症病死率高,年龄、MODS、ALI/ARDS、最危重时PCIS和ALB是影响其预后的强相关因素。     

Prognostic utility of the semi-quantitative procalcitonin test, neutrophil count and C-reactive protein in meningococcal infection in children

The aim was to determine whether semi-quantitative procalcitonin (PCT-Q) measurements on admission can identify the severity of meningococcal infection in children. A total of 65 children (mean age 2.4 years) with meningococcal disease were included in a prospective study. All patients were treated with antibiotics, rehydration, inotropic drugs and mechanical ventilation if presenting with shock or respiratory failure. On admission, blood was drawn for routine laboratory analyses including absolute neutrophil count (NC), C-reactive protein (CRP) and PCT-Q (immunochromatographic test). A total of 33 patients presented with septic shock on admission of whom 18 developed multiple organ dysfunction syndrome (MODS) and 9 died. Forty-three patients showed a very high PCT-Q level (10 ng/ml), 12 showed values between 2–9.9 ng/ml and the remaining 10 patients showed PCT-Q levels <2 ng/ml. All patients with a PCT-Q level <10 ng/ml survived, whereas all those who developed MODS or died had PCT-Q levels 10 ng/ml. Receiver operator curve analysis showed that PCT-Q and NC had a high predictive value for MODS and death. PCT-Q showed a sensitivity of 100%, a negative predictive value of 100% and a negative likelihood ratio of 0.0 for MODS and death. Conclusion:semi-quantitative procalcitonin levels under 10 ng/ml predict good outcome of children with meningococcal infection. It is a highly sensitive method to identify patients with an increased risk of multiple organ dysfunction syndrome or death.     

体外膜肺氧合在儿童急性呼吸窘迫综合征中的应用

急性呼吸窘迫综合征（ARDS）患儿常需要呼吸机支持治疗,目前推荐实施肺保护性通气策略。体外膜肺氧合（ECMO）能通过体外循环改善患者氧合和去除二氧化碳,从而部分或完全替代心肺功能,在ARDS应用时具有减少呼吸机相关性肺损伤、改善低氧血症等优势。近年来该技术在儿童ARDS应用的报道逐渐增多。该文就ECMO在儿童ARDS中的应用进行综述。     

Efficacy of three treatment schedules in severe meconium aspiration syndrome

Aim: To compare three different schedules in severe meconium aspiration syndrome (MAS) treatment: standard, bronchoalveolar lavage (BAL) with diluted surfactant, and diluted surfactant BAL plus a single early dexamethasone dose. Methods: Twenty-four full-term newborns with severe MAS (needing mechanical ventilation and with oxygenation index ≥15) were divided into three groups: group I (historical control group; n = 6) treated with standard therapy; group II (n = 7) treated in the first hours of life with one BAL using diluted surfactant (beractant 5 mg/mL) in a volume of 15 mL/kg in four aliquots; and group III (n = 11) treated with one diluted surfactant BAL and a previous single dose of intravenous dexamethasone (0.5 mg/kg) Results: At 12 h, groups II and III showed a significant improvement in oxygenation index (OI) compared with group I (14.7% and 27.0% vs -19.6% respectively; p = 0.012). Group III also showed a significantly lower OI than group I at 24 h (63.6% vs -27.9%) and at 48 h (87.1% vs 49.6%). Group III, in comparison to group I, showed a lower FiO ₂ requirement at 12 h (0.66 vs 1), at 24 h (0.4 vs 0.87) and at 48 h (0.35 vs 0.67), and a decrease in the number of days of inhaled nitric oxide administration, mechanical ventilation, oxygen therapy and hospitalisation period. All patients from groups II and III survived and none developed pneumothorax or respiratory infections.

Conclusion: Diluted surfactant BAL in the first hours of life combined with an intravenous single dose of dexamethasone may be an effective treatment for severe MAS.     

儿童脓毒症休克与体外膜肺氧合治疗

儿童难治性脓毒症休克可很快进展为多器官功能衰竭,病死率高。体外膜肺氧合(extracorporeal membrane oxygenation, ECMO)技术作为液体复苏无效和血管活性药物抵抗的难治性脓毒症休克的挽救性治疗正越来越受到重视和应用。但目前对于难治性脓毒症休克时ECMO救治的确切疗效、应用时机以及模式、置管方式等方面仍不明确。该文就ECMO治疗此类患儿的应用原理、发展历史、争议焦点和ECMO运行期间应关注问题进行探讨,以期更为合理、规范地应用ECMO技术治疗难治性脓毒症休克患儿,提高生存率。     

Enteroviral myocarditis in neonates

Enteroviruses are a leading cause of viral infections in children. While most enteroviral infections are mild and self‐limiting, severe disease such as a viral sepsis syndrome, myocarditis, hepatitis and meningoencephalitis may occur. We present two cases of neonatal enteroviral myocarditis. Cardiorespiratory failure occurred in both cases, and severe shock refractory to conventional treatment required support with extracorporeal membrane oxygenation (ECMO). One child with coxsackievirus B3 myocarditis failed to recover and died after 3 weeks on ECMO, while one child could be decannulated successfully after 9 days of ECMO and recovered completely subsequently. In conclusion, neonatal myocarditis has a very high mortality, and ECMO should be considered early in neonates with rapid clinical and echocardiographic deterioration despite adequate inotropic support.     

Urological complications and copper replacement therapy in childhood Menkes syndrome

Background: Urological complications are frequent in Menkes syndrome, a very rare X-linked recessive disorder of copper (Cu) metabolism. Aim: To evaluate the role of Cu therapy in preventing the progression of urological complications. Subjects and methods: We retrospectively enrolled 57 patients with Menkes syndrome (55 published case reports and two of our own unpublished cases) and investigated the reported urological complications, distinguishing the patients with or without Cu replacement therapy and evaluating the efficacy of this therapy in the prevention of urological complications. Results: The most frequent urological complication was bladder diverticulum (38.6% of the total patients); obstruction bladder outflow and rupture of the kidney were less frequent (both 1.8% of the total). The number of congenital urological complications increased progressively by age category; in fact, 77.8% of patients did not report urological complications at the age of 0.4±0.2 y, and 28.6% of them displayed ≥ two congenital urological complications at the age of 9.3±2.6 y. The percentage of urological complications found in younger patients not on Cu therapy did not differ from that of older patients treated with Cu therapy. A comparison between patients of the same age interval, who were or were not treated with Cu, showed that treated children had fewer urological complications than untreated children.

Conclusion: Our investigation suggests that Cu therapy in patients with Menkes syndrome does not prevent the progression of urological complications; however, it might delay their worsening.     

Extrakorporale Membranoxygenierung (ECMO)

Children who require mechanical ventilation represent a high risk population with high morbidity and mortality. Experienced handling of conventional therapies, including high frequency oscillation ventilation and initiation of newer treatment options, such as therapy with surfactant or nitric oxide has led to some improvements. Nevertheless, extracorporeal membrane oxygenation (ECMO) is a life-saving technology for patients with respiratory failure refractory to maximum medical therapy. This article demonstrates the clinical management and selection criteria for ECMO in childhood contributing to the incidence and of acquired or inborn diseases which may lead to acute respiratory distress syndrome (ARDS).     

Abnormalities in plasma fatty acid composition in human immunodeficiency virus-infected children treated with protease inhibitors

Aim: To study plasma fatty acid composition in human immunodeficiency virus-infected children treated with protease inhibitors and its relation with other components of the metabolic syndrome observed after this therapy. Design: Cross-sectional study from collected clinical database. Subjects: 17 children with HIV infection treated with protease inhibitors. Nine patients received ritonavir (20-30 mg/kg/d) and the remaining eight received nelfinavir (60-90 mg/kg/d). Duration of protease inhibitors treatment was 711±208 d. As controls, we used 112 matched blood samples from apparently healthy children admitted for minor surgical procedures. Methods: Plasma fatty acids were determined using a Hewlett Packard GC 5890 gas chromatograph. Results: Plasma levels of cholesterol and triglycerides and insulin-like growth factor 1 (IGF-1) tended to be high in protease inhibitor-treated patients. Plasma content of ω6 long-chain polyunsaturated fatty acids and, in particular, of the highly unsaturated 22:4ω6 and 22:5ω6, was significantly increased. Also, infected children had increased Δ6 and Δ4 desaturase activities and decreased Δ5 desaturase activity. Significant correlations were present between plasma IGF-1 level and plasma triglycerides, plasminogen activator inhibitor-1 activity and Δ6 desaturase activity.

Conclusion: HIV-infected, protease inhibitor-treated children exhibit a metabolic syndrome which is associated with significant changes in plasma fatty acid composition. These changes are similar to those observed in situations of insulin resistance and are linked to variations in plasma IGF-1 concentration.     

Extracorporeal membrane oxygenation after stage I reconstruction for hypoplastic left heart syndrome.

OBJECTIVE: Although extracorporeal membrane oxygenation (ECMO) is an acceptable strategy for children with refractory cardiac dysfunction after cardiac surgery, its role after stage I reconstruction for hypoplastic left heart syndrome and its variants is controversial. Our objective is to describe the outcome of "nonelective" ECMO after stage I reconstruction. DESIGN: Retrospective case series. SETTING: Pediatric cardiac intensive care unit. PATIENTS: Infants placed on ECMO after stage I reconstruction from January 1998 to May 2005. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 382 infants who underwent stage I reconstruction during the study period, 36 (9.4%) required ECMO in the postoperative period. There were 22 infants with hypoplastic left heart syndrome. Indications for ECMO included inability to separate from cardiopulmonary bypass in 14 and cardiac arrest in 22. Fourteen infants (38.8%) survived to hospital discharge. Nonsurvivors had longer cardiopulmonary bypass time (150.1 +/- 70.0 mins vs. 103.9 +/- 30.0 mins, p =. 01). 9/14 infants (64%) supported with ECMO> than 24 hrs after stage I reconstruction survived while only 5/22 infants (22%) requiring ECMO< 24 hrs of stage I reconstruction survived (p =. 02). Of note, all five infants diagnosed with an acute shunt thrombosis were early survivors. Mean duration of ECMO was 50.1 +/- 12.5 hrs for survivors and 125.2 +/- 25.0 for nonsurvivors (p =. 01). 7/14 early survivors are alive at a median follow-up of 20 months (2-78 months). CONCLUSIONS: In our experience, ECMO after stage I reconstruction can be life saving in about a third of infants with otherwise fatal conditions. It is particularly useful in potentially reversible conditions such as acute shunt thrombosis and transient depression of ventricular function.     

Diagnosis-related criteria in the consideration of extracorporeal membrane oxygenation in neonates previously treated with high-frequency jet ventilation.

High-frequency jet ventilation (HFJV) is one of several high-frequency techniques that are particularly valuable for treating the neonate with lung disease refractory to conventional ventilation or with pulmonary air leak. Extracorporeal membrane oxygenation (ECMO) has also emerged as a valuable rescue therapy for neonates of more than 2000 g birth weight and 34 weeks' gestation with intractable respiratory failure. With the concurrent introduction of HFJV and ECMO, the authors sought to evaluate the role of HFJV prior to the institution of ECMO therapy. The data base for 2856 neonates receiving mechanical ventilation in one unit was used to identify 73 (of 298 total) neonates treated with HFJV, who were eligible by age and weight criteria for ECMO. Patients were grouped by diagnosis, and the oxygenation index (OI) was calculated during therapy. Outcome was evaluated for mortality, and the sensitivity of the OI for predicting mortality was calculated. Neonates who survived with HFJV alone presented with an OI of 0.30 +/- 0.03 (SEM), significantly less than nonsurvivors (0.42 +/- 0.04, P = .016). Survivors responded to HFJV with a rapid decrease in OI at 1 hour (0.19 +/- 0.02, P less than .001) and 6 hours (0.15 +/- 0.01, P less than .001). Nonsurvivors did not respond significantly at 1 hour (OI = 0.33 +/- 0.04, P = not significant [NS]) or at 6 hours (OI = 0.40 +/- 0.06, P = NS). By diagnosis, neonates with respiratory distress syndrome survived more often with HFJV (28/34, 82%) than neonates with meconium aspiration (10/26, 38%) or diaphragmatic hernia (3/9, 33%). Neonates with respiratory distress syndrome seldom presented with high OI values, but the majority of those who did survived (5/7 survived with initial OI greater than or equal to 0.40).(ABSTRACT TRUNCATED AT 250 WORDS)     

Low serum cortisol in combination with high adrenocorticotrophic hormone concentrations are associated with poor outcome in children with severe meningococcal disease

OBJECTIVES: To study the correlation between serum concentrations of adrenocorticotrophic hormone (ACTH) and cortisol in relation to severity of disease in children with meningococcal sepsis. METHODS: Subjects were children with meningococcal sepsis, admitted to the pediatric intensive care unit. Clinical data, laboratory values and blood samples were selected. Arterial cortisol, ACTH, interleukin 6 and tumor necrosis factor alpha concentrations were measured on admission and studied for their relation to severity of disease (sepsis, septic shock/survivors, septic shock/nonsurvivors). RESULTS: Seventy-two patients fulfilled the criteria for meningococcal sepsis. Sixty-two of these children with positive blood cultures of Neisseria meningitidis, who were not treated with corticosteroids before admission, were included. Fifty of the 62 patients had septic shock. Twelve of those children (24%) died. The median age of the subjects was 2.6 years (range, 0.3 to 16.1 years). Cortisol values were significantly lower in non-survivors (median, 654 nmol/l) than in survivors (median, 2184 nmol/l) (P < 0.01). ACTH values were significantly higher in children who died (median, 1271 ng/l) than in survivors (85 ng/l) (P < 0.01). The median cortisol:ACTH ratio decreased significantly depending on the disease severity categories. CONCLUSIONS: Low serum cortisol concentrations in combination with high ACTH concentrations are associated with poor outcome in children with severe meningococcal disease.     

Neonatal extracorporeal membrane oxygenation: practice patterns and predictors of outcome in the UK

OBJECTIVE: To review the UK neonatal extracorporeal membrane oxygenation (ECMO) service and identify predictors of outcome. DESIGN: Retrospective review of the national cohort. Patients and interventions: 718 neonates received ECMO for respiratory failure between 1993 and 2005. Measurements and results: Diagnoses were: 48.0% meconium aspiration syndrome (97.1% survivors), 15.9% congenital diaphragmatic hernia (CDH; 57.9% survivors), 15.9% sepsis (62.3% survivors), 9.5% persistent pulmonary hypertension (79.4% survivors), 5.6% respiratory distress syndrome (92.5% survivors) and 5.1% congenital lung abnormalities (24.3% survivors). The overall survival rate of 79.7% compared favourably with the worldwide Extracorporeal Life Support Organization (ELSO) Registry. Over the period of review, pre-ECMO use of advanced respiratory therapies increased (p<0.001), but ECMO initiation was not delayed (p = 0.61). The use of veno-venous (VV) ECMO increased (p<0.001) and average run time fell (p = 0.004). Patients treated with VV ECMO had a survival rate of 87.7% compared with 73.4% in the veno-arterial (VA) ECMO group; only 42.4% of those needing conversion from VV to VA ECMO survived. In non-CDH neonates, lower birth weight, lower gestational age, older age at ECMO and higher oxygenation index (OI) were associated with increased risk of death. In CDH neonates, lower birth weight and younger age at ECMO were identified as risk factors for death. CONCLUSION: The UK neonatal ECMO service achieves good outcomes and with overall survival rate reaching 80% compares favourably with international results. Advanced respiratory therapies are used widely in UK ECMO patients. Identification of higher OI and older age at ECMO as risk factors in non-CDH neonates reinforces the importance of timely referral for ECMO.     

内生吗啡对儿童脓毒症的诊断价值

目的 检测脓毒症患儿血浆内生吗啡浓度,探讨内生吗啡对脓毒症患儿发生休克、死亡及多器官功能障碍（MODS）的预测价值。方法 符合诊断标准的脓毒症患儿（n=31）,根据是否伴有休克分为脓毒症非休克组（n=19）和休克组（n=12）;根据结局分为存活组（n=22）和死亡组（n=9）;根据是否伴有MODS分为非MODS组（n=13）和MODS组（n=18）。另设普通感染患儿（n=16）和行健康体检儿童（n=31）作为对照。用高效液相质谱串联法检测各组血浆内生吗啡浓度。用受试者工作特征曲线（ROC）评估内生吗啡对脓毒症患儿发生休克、死亡及MODS的预测价值。结果 健康对照组儿童血浆未检测到内生吗啡,普通感染组仅3例患儿血浆检测到内生吗啡;脓毒症患儿血浆中均检测到内生吗啡。休克组患儿血浆内生吗啡浓度高于非休克组（P < 0.05）;死亡患儿血浆内生吗啡浓度高于存活患儿（P < 0.05）;MODS患儿血浆内生吗啡浓度高于非MODS患儿（P < 0.05）。ROC结果显示内生吗啡对脓毒症患儿休克、死亡和MODS均有预测价值（P < 0.05）。结论 脓毒症患儿血浆内生吗啡浓度明显升高,其对脓毒症患儿休克、死亡、MODS风险的发生有较好的预测价值。     

Inflicted traumatic brain injury (ITBI) or shaken baby syndrome (SBS) in Estonia

Background: Inflicted traumatic brain injury (ITBI) or shaken baby syndrome (SBS) is recognized as a major cause of disability and death in the paediatric population. Aim: To find out the incidence of ITBI in Estonia. Methods: 26 cases of ITBI were recognized: four children died, 22 survived. Results: Of 26 children, 20 (77%) were boys and six (23%) were girls. Median age at admission to hospital was 3.9 mo, and the boys were younger than the girls. Conclusion: The overall incidence of ITBI was 28.7 per 100 000 infants. In the prospective group the incidence was 40.5 per 100 000, and in retrospective group 13.5 per 100 000. ITBI is not rare but not always a recognized form of child abuse. Healthcare professionals should be more aware of this condition.     

体外膜肺氧合在儿童急性呼吸窘迫综合征中的应用#br#

急性呼吸窘迫综合征（acute respiratory distress syndrom,ARDS）是临床常见的急危重症,发生率及病死率较高,是重症患儿入住儿童重症监护病房及住院患儿的主要死亡原因。体外膜肺氧合（extracorporeal membrane oxygenation,ECMO）部分或全部替代患儿心肺功能,可对传统治疗无效的严重心肺衰竭患儿提供较长时间心肺支持。目前,对儿童ARDS的ECMO介入时机和模式选择等方面的临床应用仍存在较多争议。较多成人临床实践推荐将静脉-静脉ECMO（VV-ECMO）模式作为ARDS的首选方案。近年来,ECMO技术有了较大的进步,ECMO临床应用对改善重度肺内外源性ARDS的预后可能有一定作用。     

Extracorporeal membrane oxygenation and early-onset group B streptococcal sepsis.

Recently, extracorporeal membrane oxygenation (ECMO) has been used as rescue therapy for newborns with overwhelming early-onset group B streptococcal sepsis. To determine which clinical factors best predict mortality and to evaluate the outcome of this therapy, a retrospective examination of the clinical course and outcome of ECMO-eligible newborns with early-onset group B streptococcal sepsis was undertaken. The study period was divided into two phases based on when ECMO was initially used at Kosair Children's Hospital as therapy for septic neonates. Phase 1 (pre-ECMO) was the period from January 1, 1982, through June 15, 1986, and phase 2 (ECMO) from June 16, 1986, through December 31, 1989. Newborns with gestational age greater than or equal to 34 weeks, birth weight greater than or equal to 2000 g, and evidence of early-onset group B streptococcal sepsis were eligible for study. Only newborns who received mechanical ventilation were evaluated. Sixteen patients from phase 1 met the above criteria. Of those, 10 exhibited no sign of hypotension and all survived. Of the 6 patients with hypotension, 3 died. Forty patients were identified from phase 2. Seven patients remained normotensive and all survived. Thirty-three patients were hypotensive, of which 15 received ECMO and 13 survived. Of the 18 who did not receive ECMO, 7 died. Regarding all hypotensive newborns, those who did not receive ECMO had a trend toward lower survival (P less than .06) and were more likely to die if they were of lower birth weight, manifested a persistent acidosis (pH less than or equal to 7.25), and had an absolute neutrophil count less than 500 cells/mm3.(ABSTRACT TRUNCATED AT 250 WORDS)     

Extracorporeal therapies in the treatment of sepsis: experience and promise

Desire to restore the balance of body elements has enamored physicians since the ancient practice of bloodletting. More recently, extracorporeal techniques have been employed in both adults and children in treating sepsis. Extracorporeal therapies include continuous renal replacement (CRRT), plasma-based removal techniques, and extracorporeal membrane oxygenation (ECMO). These treatments could theoretically 1) provide immunohomeostasis of pro- and anti-inflammatory cytokines and other sepsis mediators, 2) decrease organ microthrombosis through removal of pro-coagulant factors and modulating the impaired septic coagulation response in sepsis, and 3) provide mechanical support of organ perfusion during the acute septic episode to allow time for response to traditional sepsis therapies and antimicrobials. CRRT is beneficial in managing fluid overload and acute renal failure in sepsis. Removal of sepsis mediators through the technique is variable, and the outcome impact of CRRT on sepsis has not been definitively determined. High-flow CRRT has demonstrated benefit in septic adults. Intriguing early results suggest that plasma exchange could improve outcomes in both adults and children. Based on experience, ECMO is recommended for refractory septic shock in neonates and should be considered for use in children. Ongoing trials may help determine whether the promise of extracorporeal therapies translates into outcome improvement in septic children.