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We would like to discuss the publication “High-volume hemofiltration and prone ventilation”.(1) Cornejo et al. reported the use of the combination of these two novel approaches for the management of subarachnoid hemorrhage that is complicated by severe acute respiratory distress syndrome.(1) As Cornejo et al. noted, these two techniques are very challenging and require case by case decision making. There must be consideration of the possible adverse effects of these techniques. A meta-analysis shows that there is “no clear overall beneficial effect” when high-volume hemofiltration is compared to standard volume hemofiltration.(2) Some reports mention the adjustment of cytokine biological processes as the possible responsible factor, whereas other reports do not agree with that hypothesis.(2) In the present case report by Cornejo et al., the reason for the occurrence of septic shock remains unclear. Based on the patient’s available history, it seems that there is no laboratory confirmation of sepsis. Additionally, there is no evidence of cytokine biological process adjustment reported in the present article. In general, due to the uncertainties about the exact biological effect of high-volume hemofiltration, the beneficial effects of this procedure remain unconfirmed in septic shock.(3) Regarding prone positioning, the complication and side effect of the procedure can still be observed.(4) Cardiac arrest immediately after prone positioning is also reported.(5) In the present case report, the use of prone positioning might be valid, and the success of cardiac monitoring is established. Interestingly, 72 hours of prone positioning were required for adjustment of the pressure. This long period might be sufficient for self-adjustment of the patient’s intracranial pressure, due to the neurological improvement after manipulation or other additional procedures for the management of pressure, without the need of a special positioning procedure. The improvement of the patient might be due to the successful control of the neurological problem and might not be related to the use of high-volume hemofiltration plus prone positioning.

revista brasileira de terapia intensiva

To: High-volume hemofiltration and prone ventilation in subarachnoid hemorrhage complicated by severe acute respiratory distress syndrome and refractory septic shock