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Rivista di Anestesia, Rianimazione, Terapia Antalgica e Terapia Intensiva
Minerva Anestesiologica 2015 May;81(5):516-25
Rescue therapy with polymyxin B hemoperfusion in high-dose vasopressor therapy refractory septic shock
Monti G. 1, Terzi V. 1, Calini A. 1, Di Marco F. 2, Cruz D. 3, Pulici M. 1, Brioschi P. 1, Vesconi S. 1, Fumagalli R. 4, Casella G. 1 ✉
1 Unità di Terapia Intensiva “Bozza”, I Servizio di Anestesia e Rianimazione, Azienda Ospedaliera Niguarda Ca’ Granda, Milano, Italia;
2 Dipartimento di di Scienze della Salute, Università degli Studi di Milano, Ospedale San Paolo, Milano, Italia;
3 Division of Nephrology-Hypertension, University of California San Diego, San Diego, CA, USA;
4 Dipartimento di Scienze della Salute, Università Milano Bicocca, Azienda Ospedaliera Niguarda Ca’ Granda, Milano, Italia
BACKGROUND: Refractory septic shock (RSS) requiring major vasopressor support is associated with high mortality, especially in Gram-negative infections. The study aim was to describe hemodynamics, organ failure, and clinical outcomes in high-dose vasopressor therapy (HDVT) RSS patients treated with Polymyxin B hemoperfusion (PMX-HP) as rescue therapy.
METHODS: We retrospectively analyzed 52 patients, unresponsive to conventional therapy, treated with two sessions of PMX-HP requiring HDVT (norepinephrine and/or epinephrine requirement (NEP+EP) ≥0.5 µg/kg/min), ≥2 organ failures, and suspected/confirmed Gram-negative infection from any source.
RESULTS: At baseline, mean arterial pressure (MAP) was 80±13 mmHg and NEP+EP requirement was 1.11±0.56 µg/kg/min. After two PMX-HP sessions, at 72 h, MAP significantly increased and NEP+EP requirement decreased respectively by 12% and 76%. Pulmonary and renal function also improved significantly. Thirty patients (58%) showed a ≥50% reduction in NEP+EP dose within only 24 h after the first PMX-HP session (early responders), and 22 did not or died from irreversible shock in the same time frame (early non-responders). The 30-day hospital mortality was 29%; it was 16% in early responders and 45% in early non-responders. On multivariate analysis, SAPS II score, vasopressin, and central venous pressure significantly affected 30-day hospital mortality.
CONCLUSION: This is the first study describing the use of PMX-HP as a rescue therapy in RSS patients with HDVT and MOF. Our results suggest a possible role for PMX-HP in improving hemodynamics, organ function, and mortality in RSS, with a 30-day survival of up to 70%.