De Rosa Silvia, Zanella Monica, Samoni Sara, Ronco Claudio
Department of Anesthesiology and Intensive Care, San Bortolo Hospital, Vicenza, Italy.
International Renal Research Institute of Vicenza, Vicenza, Italy.
Front Nephrol. 2022 Aug 3;2:847305. doi: 10.3389/fneph.2022.847305. eCollection 2022.
Endotoxin -induced sepsis is a leading cause of ICU mortality. From 1994 to the present, PMX-HP has been available as an adjuvant therapy for endotoxin removal and immunomodulation. The efficacy and usefulness of this therapy have been demonstrated for more than a quarter of a century and are partially supported by clinical studies. However, it appears that selected subgroups of patients with endotoxic shock and with appropriate timing could benefit. Endotoxemia may be involved in the pathophysiology of COVID-19, based on enterocyte dysfunction and malabsorptive syndrome. Due to the characteristics of the microbiota, Gram-negative bacteria or their fragments (i.e., endotoxin) may translocate into the systemic circulation leading to inflammatory activation, immune dysfunction, and sepsis. In addition, patients with severe forms of COVID-19 are at risk of superimposed infections. Endotoxemia can arise due to the translocation of Gram-negative bacteria or their fragments from the gut barrier. According to the most updated evidence available from large randomized trials, septic shock patients with MODS > 9 and EA levels ranging from 0.6 to 0.9 are those who may benefit the most from PMX-HP treatment in terms of improvement of survival. As shown in a previous publication, we believe that similarly to the source control, microbiological cultures, and antibiotics administration, EA evaluation at regular intervals, and the targeted use of PMX-HP could be lifesaving and adequate within the golden hour for the diagnosis and treatment of endotoxic shock. In our center, we applied a diagnostic-clinical flowchart also for endotoxic shock related to COVID-19.
内毒素诱导的脓毒症是重症监护病房（ICU）死亡的主要原因。从1994年至今，PMX-HP一直作为一种辅助治疗手段用于去除内毒素和调节免疫。这种治疗的有效性和实用性已在超过四分之一世纪的时间里得到证实，并且得到了临床研究的部分支持。然而，似乎内毒素休克的特定亚组患者以及在适当的时机可能会从中受益。基于肠上皮细胞功能障碍和吸收不良综合征，内毒素血症可能参与了COVID-19的病理生理过程。由于微生物群的特性，革兰氏阴性菌或其片段（即内毒素）可能会转移到体循环中，导致炎症激活、免疫功能障碍和脓毒症。此外，重症COVID-19患者有发生叠加感染的风险。内毒素血症可能由于革兰氏阴性菌或其片段从肠道屏障转移而产生。根据大型随机试验的最新证据，多器官功能障碍评分（MODS）>9且内毒素活性（EA）水平在0.6至0.9之间的脓毒症休克患者，在改善生存率方面可能是最能从PMX-HP治疗中获益的人群。正如之前发表的文章所示，我们认为，与源头控制、微生物培养和抗生素使用类似，定期进行EA评估以及有针对性地使用PMX-HP在诊断和治疗内毒素休克的黄金时间内可能是挽救生命且恰当的。在我们中心，我们还针对与COVID-19相关的内毒素休克应用了诊断临床流程图。
