title: Rescue therapy with polymyxin B hemoperfusion in high-dose vasopressor therapy refractory septic shock.
abstract: 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.
  
  
  CONCLUSIONS
  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%.
authors.affiliation: Unità di Terapia Intensiva "Bozza", I Servizio di Anestesia e Rianimazione, Azienda Ospedaliera Niguarda Ca' Granda, Milano, Italia - gianpaola.monti@ospedaleniguarda.it.
authors.forename: G
authors.initials: G
authors.lastname: Monti
authors.forename: V
authors.initials: V
authors.lastname: Terzi
authors.forename: A
authors.initials: A
authors.lastname: Calini
authors.forename: F
authors.initials: F
authors.lastname: Di Marco
authors.forename: D
authors.initials: D
authors.lastname: Cruz
authors.forename: M
authors.initials: M
authors.lastname: Pulici
authors.forename: P
authors.initials: P
authors.lastname: Brioschi
authors.forename: S
authors.initials: S
authors.lastname: Vesconi
authors.forename: R
authors.initials: R
authors.lastname: Fumagalli
authors.forename: G
authors.initials: G
authors.lastname: Casella
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D004351:Drug Resistance; D004837:Epinephrine / Q000008:administration & dosage / Q000627:therapeutic use; D005260:Female; D006464:Hemoperfusion; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000209:etiology / Q000401:mortality; D009638:Norepinephrine / Q000008:administration & dosage / Q000627:therapeutic use; D011112:Polymyxin B / Q000008:administration & dosage / Q000627:therapeutic use*; D012189:Retrospective Studies; D012772:Shock, Septic / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D014662:Vasoconstrictor Agents / Q000008:administration & dosage / Q000627:therapeutic use*
chemical_list: D000900:Anti-Bacterial Agents; D014662:Vasoconstrictor Agents; D011112:Polymyxin B; D009638:Norepinephrine; D004837:Epinephrine