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Minerva Anestesiologica 2015 May;81(5):516-25

Copyright © 2015 EDIZIONI MINERVA MEDICA

lingua: Inglese

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%.