Nakamura Kensuke, Okazaki Tetsuya, Tampo Akihito, Mochizuki Katsunori, Kanda Naoki, Ono Takahiro, Yanagita Kunio, Shimomura Taro, Murase Taichi, Saito Ken, Hirayama Takahiro, Ito Tomoaki, Ogawa Koji, Nakamura Mizuki, Oda Tomohiro, Morishima Takeshi, Fukushima Takuma, Yasui Hiroharu, Akashi Naoki, Oshima Kojiro, Kawarazaki Hiroo, Akiba Tsukasa, Uemura Susumu, Honma Yuhei, Nitta Kenichi, Okamoto Koji, Takaki Shunsuke, Takeda Hirotaka, Yamashita Chizuru
Department of Critical Care Medicine, Yokohama City University Hospital, Yokohama, Kanagawa, Japan.
Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Ibaraki, Japan.
Artif Organs. 2025 Feb;49(2):218-228. doi: 10.1111/aor.14865. Epub 2024 Sep 18.
Polymyxin-B direct hemoperfusion (PMX-DHP) is an endotoxin adsorption column-based blood purification therapy. Since one of the most potent effects of PMX-DHP is blood pressure elevations, it may be the most effective when it is introduced at the time when the need for vasopressors is the greatest, which, in turn, may reduce mortality.
A multicenter retrospective study was conducted at 24 ICUs in Japan. In each ICU, the 20 most recent consecutive cases of septic shock treated with PMX-DHP were analyzed. The duration between the time of the peak vasopressive agent dose, expressed as the noradrenaline equivalent dose (NEq), and the time of PMX initiation was evaluated. The primary outcome was 28-day mortality, and a multivariable analysis was performed to investigate factors associated with mortality.
A total of 480 septic shock patients were included in the analysis. Among all patients, the 28-day mortality group was older, more severely ill, and had a higher body mass index. The NEq peak and NEq on PMX-DHP initiation were both higher in deceased patients. Regarding the timing of PMX-DHP initiation from the NEq peak, -4 << 4 h had more survivors (229/304, 75.3%) than ≤-4 h (50/75, 66.7%) and ≥4 h (66/101, 65.4%) (p = 0.085). When -4 << 4 h was assigned as a reference, the timing of PMX-DHP initiation from the NEq peak of ≤-4 h had an odds ratio of 1.96 (1.07-3.58), p = 0.029, while ≥4 h had an odds ratio of 1.64 (0.94-2.87), p = 0.082 for 28-day mortality, in the multivariable regression analysis. A spline curve of the relationship between the probability of death and the timing of PMX-DHP initiation from the NEq peak showed a downward convex curve with a nadir at timing = 0. The odds ratios of the timing of PMX-DHP initiation other than -4 << 4 h were significantly higher in an older age, male sex, lower BMI, more severe illness, and higher oxygenation.
The induction of PMX-DHP at the time of the peak vasopressor dose correlated with lower mortality. PMX-DHP is one of the options available for elevating blood pressure in septic shock, and its initiation either too early or late for shock peak may not improve the outcome.
多粘菌素B直接血液灌流（PMX-DHP）是一种基于内毒素吸附柱的血液净化疗法。由于PMX-DHP最显著的作用之一是升高血压，因此在血管升压药需求最大的时候进行该治疗可能最为有效，进而可能降低死亡率。
在日本的24个重症监护病房进行了一项多中心回顾性研究。在每个重症监护病房，分析了最近连续20例接受PMX-DHP治疗的感染性休克病例。评估了以去甲肾上腺素等效剂量（NEq）表示的血管升压药剂量峰值时间与开始PMX治疗时间之间的间隔。主要结局是28天死亡率，并进行多变量分析以研究与死亡率相关的因素。
共有480例感染性休克患者纳入分析。在所有患者中，28天死亡组年龄更大、病情更严重且体重指数更高。死亡患者的NEq峰值和开始PMX-DHP治疗时的NEq均更高。关于从NEq峰值开始PMX-DHP治疗的时机，-4＜＜4小时的幸存者（229/304，75.3%）比≤-4小时（50/75，6/101，65.4%）更多（p = 0.085）。在多变量回归分析中，以-4＜＜4小时为参照，从NEq峰值开始PMX-DHP治疗的时机≤-4小时的28天死亡率比值比为1.96（1.07 - 3.58），p = 0.029，而≥4小时的比值比为1.64（0.94 - 2.87），p = 0.082。死亡概率与从NEq峰值开始PMX-DHP治疗时机之间的样条曲线显示为向下凸的曲线，最低点在时间=0处。除-4＜＜4小时外，PMX-DHP治疗时机的比值比在年龄较大、男性、体重指数较低、病情更严重和氧合较高的情况下显著更高。
在血管升压药剂量峰值时进行PMX-DHP治疗与较低的死亡率相关。PMX-DHP是感染性休克中升高血压的可用选择之一，在休克峰值时过早或过晚开始治疗可能无法改善结局。
