Korean J Crit Care Med.  2016 May;31(2):123-128. 10.4266/kjccm.2016.31.2.123.

Use of Polymyxin B Hemoperfusion in a Patient with Septic Shock and Septic Cardiomyopathy Who Was Placed on Extracorporeal Membrane Oxygen Support

• Shin SH
• Lee H
• Choi AJ
• Chang KH
• Suh GY
• Chung CR

• KMID: 2350919
• DOI: http://doi.org/10.4266/kjccm.2016.31.2.123

Abstract

Although shock in sepsis is usually managed successfully by conventional medical treatment, a subset of cases do not respond and may require salvage therapies such as veno-arterial extracorporeal membrane oxygenation (VA ECMO) support as well as an attempt to remove endotoxins. However, there are limited reports of attempts to remove endotoxins in patients with septic shock on VA ECMO support. We recently experienced a case of septic shock with severe myocardial injury whose hemodynamic improvement was unsatisfactory despite extracorporeal membrane oxygenation (ECMO) support. Since the cause of sepsis was acute pyelonephritis and blood cultures grew gram-negative bacilli, we additionally applied polymyxin B direct hemoperfusion (PMX-DHP) to the ECMO circuit and were able to successfully taper off vasopressors and wean off ECMO support. To the best of our knowledge, this is the first adult case in which PMX-DHP in addition to ECMO support was successfully utilized in a patient with septic shock. This case indicates that additional PMX-DHP therapy may be beneficial and technically feasible in patients with septic shock with severe myocardial injury refractory to ECMO support.

Keyword

extracorporeal membrane oxygenation; hemoperfusion; polymyxin B; myocardia diseases; septic shock

MeSH Terms

Adult
Cardiomyopathies*
Endotoxins
Extracorporeal Membrane Oxygenation
Hemodynamics
Hemoperfusion*
Humans
Membranes*
Oxygen*
Polymyxin B*
Polymyxins*
Pyelonephritis
Salvage Therapy
Sepsis
Shock
Shock, Septic*
Endotoxins
Oxygen
Polymyxin B
Polymyxins

Figure

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  Fig. 1. Computed tomography of abdomen. (A) Multifocal perfusion decreased area and hydronephroureterosis of right kidney. (B) About 0.7 cm sized stone (white arrow) in right distal ureter which can be distinguished from calcification of adjacent vessels.

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  Fig. 2. Schematic diagram for simultaneous connection of ECMO, CRRT, and HP device. VA-ECMO was performed using the left femoral artery and right femoral vein. The access line and return line of CRRT and HP device were connected to the arterial line and venous line of ECMO circuit via three-way connector, respectively. ECMO: extracorporeal membrane oxygenation; CRRT: continuous renal replacement therapy; HP: hemoperfusion; VAECMO: veno-arterial extracorporeal membrane oxygenation.

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  Fig. 3. Pictures showing the connection between devices. (A) A polymyxin B hemoperfusion device (white arrow) and CRRT (white arrow head) were connected to the ECMO circuit (white circle). (B) The access line of HP (black arrow) and CRRT (white arrow) were connected to the arterial line of ECMO (white arrow head). (C) The return line of HP (black arrow) and CRRT (white arrow) were connected to the venous line of ECMO (white arrow head). CRRT: continuous renal replacement therapy; ECMO: extracorporeal membrane oxygenation; HP: hemoperfusion.

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  Fig. 4. Graphs show serial changes in vital signs, laboratory findings and vasopressor infusion rate. (A) Trend of MAP, HR and vasopressor infusion rate. (B) Trend of WBC count, lactic acid level and cTnI level. T1: ICU admission, T2: before ECMO support, T3: 1 hour after ECMO support, T4: before PMX-DHP and 14 hours after ECMO, T5: 6 hours after PMX-DHP, T6: 24 hours after PMX-DHP, T7: ECMO removal. MAP: mean arterial pressure; HR: heart rate; WBC: white blood cell; cTnI: cardiac troponin I; ICU: intensive care unit; ECMO: extracorporeal membrane oxygenation, PMX-DHP: polymyxin B directed hemoperfusion; NE: norepinephrine, VA-ECMO: veno-arterial extracorporeal membrane oxygenation.

• 

  Fig. 5. The brief course of events. EGDT: early goal directed therapy; PCN: percutaneous nephrostomy; CRRT: continuous renal replacement therapy; VA-ECMO: veno-arterial extracorporeal membrane oxygenation; PMX-DHP: polymyxin B directed hemoperfusion; CABG: coronary artery bypass graft surgery; NSTEMI: non-ST segment elevation. myocardial infarction.

Reference

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