Endotoxin Removal Therapy With Polymyxin B Immobilized Fiber Column as a Flowchart Protocol Strategy for Endotoxic Shock

Background: Endotoxin-induced sepsis is a leading cause of ICU mortality. From 1994 to present, Polymyxin B-hemoperfusion (PMX-HP) is available as an adjuvant therapeutic option. PMX-HP is also an immunomodulatory blood purification. The aim of this study was to evaluate the role of diagnostic-therapeutic flowchart for the use of endotoxin neutralization by Polymyxin B Hemoperfusion. Methods: We conducted a prospective, observational web-based database analysis (EUPHAS2 registry), single centre basis, of critically ill patients admitted to the ICU between January 2016 until to May 2021 who were affected by endotoxic shock caused by proved or suspected infection related to Gram negative bacteria and received PMX-HP as per clinical indication of the attending physician. Patients were divided based on the use of diagnostic-therapeutic flowchart in two groups: Pre-Flowchart (Pre-F) and Post-Flowchart (Post-F). Results: 61 patients were treated with PMX-HP out of 531 who received diagnosis of septic shock. The most common source of infection was secondary peritonitis (36.0%) followed by community acquired pneumonia (29.0%). We identified gram negative bacteria in most of the microbiological culture (N=59, 51%), followed by gram positive bacteria in (N=31, 27%), fungi (N=11, 9%) and no growth (N=15,13%). In both groups, SOFA score progressively improved over the next 120h following PMX-HP and it was associated with endotoxin activity levels (EA) decrease. Particularly, in the Post-F Group EA decreased from 0.71 [0.64-0.80] at T0 to 0.56 [0.45-0.66] at T120. Particularly, in Post-F group a lower 28-day mortality [21%], ICU [29%] and lower 90-day mortality [29%] compared to Pre-F group [30%] were observed. Conclusions: In critically ill patients with endotoxic shock, PMX-HP was associated with organ function recovery, hemodynamic improvement and contemporary EA level reduction.