Polymyxin B Hemoperfusion in Septic Shock Management

Septic shock remains a leading cause of mortality in critical care, driven in part by circulating endotoxin from Gram-negative bacteria. Polymyxin B hemoperfusion (PMX-HP) employs an extracorporeal cartridge coated with Polymyxin B to bind and remove endotoxin, attenuating the cascade of inflammatory mediators that drive vasoplegia, capillary leak and organ failure. Early mechanistic studies demonstrated rapid endotoxin clearance and downstream reductions in pro-inflammatory cytokines, with associated improvements in blood pressure, oxygenation and renal function. Subsequent clinical investigations have yielded mixed results on mortality, prompting a focus on patient selection, timing of intervention and biomarker-driven approaches. Registry data suggest benefit when PMX-HP is initiated within a narrow window after shock onset and in patients with moderate organ dysfunction. A theragnostic paradigm utilising an endotoxin activity assay to identify high-risk subjects has been proposed to maximise efficacy. While pivotal randomised trials are ongoing, real-world experience across Europe and Asia indicates that PMX-HP can shorten vasopressor dependence and reduce Sequential Organ Failure Assessment (SOFA) scores in appropriately selected patients. Integration of hemoperfusion into sepsis treatment bundles offers a promising adjunct to antimicrobial therapy and supportive care, with the potential to improve outcomes in diverse healthcare settings worldwide.

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Technical terms

Endotoxin: Lipopolysaccharide component of Gram-negative bacterial outer membranes that triggers systemic inflammation.

Polymyxin B Hemoperfusion (PMX-HP): Extracorporeal blood purification using a Polymyxin B-coated cartridge to adsorb circulating endotoxin.

Endotoxin Activity Assay (EAA): Whole-blood test measuring neutrophil-dependent chemiluminescence to quantify endotoxin burden.

Sequential Organ Failure Assessment (SOFA) Score: Composite index quantifying the degree of organ dysfunction in six systems to predict outcomes in critical illness.

References

1. The role of endotoxin in septic shock. Critical Care (2023).
2. Polymyxin B hemoperfusion: a mechanistic perspective. Critical Care (2014).
3. Effects of enhanced adsorption haemofiltration versus haemoadsorption in severe, refractory septic shock with high levels of endotoxemia: the ENDoX bicentric, randomized, controlled trial. Annals of Intensive Care (2023).
4. Polymyxin-B hemoperfusion in septic patients: analysis of a multicenter registry. Annals of Intensive Care (2016).
5. The EUPHRATES trial (Evaluating the Use of Polymyxin B Hemoperfusion in a Randomized controlled trial of Adults Treated for Endotoxemia and Septic shock): study protocol for a randomized controlled trial. Trials (2014).
6. Measurement of endotoxin activity in critically ill patients using whole blood neutrophil dependent chemiluminescence. Critical Care (2002).
7. Effectiveness of polymyxin B hemoperfusion for sepsis depends on the baseline SOFA score: a nationwide observational study. Annals of Intensive Care (2021).