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Original Article
Pulmonary
The effects of direct hemoperfusion with polymyxin B-immobilized fiber in patients with acute exacerbation of interstitial lung disease
Jae Ha Lee, Jin Han Park, Hyo-Jung Kim, Hyun Kuk Kim, Ji Hoon Jang, Yong Kyun Kim, Bong Soo Park, Si Hyung Park, Il Hwan Kim, Se Hun Kim, Woon Heo, Hang-Jea Jang
Acute Crit Care. 2021;36(2):126-132.   Published online April 15, 2021
DOI: https://doi.org/10.4266/acc.2021.00073
  • 5,261 View
  • 186 Download
  • 2 Web of Science
  • 2 Crossref
AbstractAbstract PDF
Background
Acute exacerbation of interstitial lung disease (AE-ILD) causes clinically significant deterioration and has an extremely poor prognosis with high mortality. Recently, several studies reported the effectiveness of direct hemoperfusion with a polymyxin B-immobilized fiber column (PMX-DHP) in patients with AE-ILD as a potential therapy. This study describes the clinical effectiveness and safety of PMX-DHP in patients with AE-ILD.
Methods
We retrospectively reviewed the medical records of 10 patients (11 episodes) with AE-ILD treated with PMX-DHP from January 2018 to June 2019. We compared laboratory and physiologic data of the ratio of partial pressure arterial oxygen to fraction of inspired oxygen (P/F ratio) and level of inflammatory markers before and after implementation of PMX-DHP.
Results
Ten patients were included according to the 2016 revised definition of acute exacerbation of idiopathic pulmonary fibrosis (IPF). Nine patients had IPF and one patient had fibrotic nonspecific interstitial pneumonia. Most patients (90.9%) were treated with a steroid pulse, and four patients (36.4%) were treated with an immunosuppressant. The median number of PMX-DHP cycles was 2, and the median duration of each cycle was 6 hours. After PMX-DHP, the mean P/F ratio improved (86 [range, 63–106] vs. 145 [86–260], P=0.030) and interleukin-6 and c-reactive protein decreased (79 [35–640] vs. 10 [5–25], P=0.018 and 14 [4–21] vs. 5 [2–6], P=0.019, respectively). The 30-day mortality rate was 27.3% and the 90-day mortality rate was 72.7%.
Conclusions
PMX-DHP treatment improved P/F ratio and reduced inflammatory markers in AE-ILD patients.

Citations

Citations to this article as recorded by  
  • Polymyxin B-immobilised fibre column treatment for acute exacerbation of idiopathic pulmonary fibrosis patients with mechanical ventilation: a nationwide observational study
    Nobuyasu Awano, Taisuke Jo, Takehiro Izumo, Minoru Inomata, Yu Ito, Kojiro Morita, Hiroki Matsui, Kiyohide Fushimi, Hirokazu Urushiyama, Takahide Nagase, Hideo Yasunaga
    Journal of Intensive Care.2023;[Epub]     CrossRef
  • Changes in Oxygenation and Serological Markers in Acute Exacerbation of Interstitial Lung Disease Treated with Polymyxin B Hemoperfusion
    Song-I Lee, Chaeuk Chung, Dongil Park, Da Hyun Kang, Jeong Eun Lee
    Journal of Clinical Medicine.2022; 11(9): 2485.     CrossRef
Review Article
Infection
Up-to-date information on polymyxin B-immobilized fiber column direct hemoperfusion for septic shock
Chieko Mitaka, Makio Kusaoi, Izumi Kawagoe, Daizoh Satoh
Acute Crit Care. 2021;36(2):85-91.   Published online April 4, 2021
DOI: https://doi.org/10.4266/acc.2021.00150
  • 6,859 View
  • 324 Download
  • 3 Web of Science
  • 4 Crossref
AbstractAbstract PDF
Endotoxin adsorption therapy by polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP) has been used for the treatment of septic shock patients. Endotoxin, an outer membrane component of Gram-negative bacteria, plays an important role in the pathogenesis of septic shock. Endotoxin triggers a signaling cascade for leukocytes, macrophage, and endothelial cells to secrete various mediators including cytokines and nitric oxide, leading to septic shock and multiple organ dysfunction syndrome. PMX-DHP directly adsorbed not only endotoxin but also monocytes and anandamide. It reduced blood levels of inflammatory cytokines such as interleukin (IL)-1, IL-6, tumor necrosis factor-alpha and IL-17A, adhesion molecules, plasminogen activator inhibitor 1, and high mobility group box-1. As a result, PMX-DHP increased blood pressure and reduced the dose of vasoactive-inotropic agents. PMX-DHP improved monocyte human leukocyte antigen-DR expression in patients with severe sepsis and septic shock. A post hoc analysis of EUPHRATES (Evaluating the Use of Polymyxin B Hemoperfusion in Randomized Controlled Trial of Adults Treated for Endotoxemia and Septic Shock) trial has shown that PMX-DHP significantly reduced 28-day mortality compared with the control group in septic shock patients with endotoxin activity assay level between 0.60 and 0.89. Longer duration of PMX-DHP may be another strategy to bring out the beneficial effects of PMX-DHP. Further studies are needed to confirm the efficacy of PMX-DHP treatment for septic shock.

Citations

Citations to this article as recorded by  
  • Methods of Extracorporeal Hemocorrection in Sepsis (Review)
    V. A. Kovzel, L. A. Davydova, A. V. Karzin, S. V. Tsarenko, V. Yu. Baturova, A. A. Polupan, A. I. Gutnikov
    General Reanimatology.2023; 19(2): 68.     CrossRef
  • Modifications of peripheral perfusion in patients with vasopressor-dependent septic shock treated with polymyxin B-direct hemoperfusion
    Motohiro Sekino, Yu Murakami, Shuntaro Sato, Ryosuke Shintani, Shohei Kaneko, Naoya Iwasaki, Hiroshi Araki, Taiga Ichinomiya, Ushio Higashijima, Tetsuya Hara
    Scientific Reports.2023;[Epub]     CrossRef
  • Rhabdomyolysis secondary to hypervirulent Klebsiella pneumoniae infection: A case report
    Naoko Niimi, Keiko Taga, Taiju Miyagami, Toshio Naito, Chieko Mitaka
    Clinical Case Reports.2022;[Epub]     CrossRef
  • Endotoxin Activity in Patients With Extracorporeal Membrane Oxygenation Life Support: An Observational Pilot Study
    Chen-Tse Lee, Chih-Hsien Wang, Wing-Sum Chan, Yun-Yi Tsai, Tzu-Jung Wei, Chien-Heng Lai, Ming-Jiuh Wang, Yih-Sharng Chen, Yu-Chang Yeh
    Frontiers in Medicine.2021;[Epub]     CrossRef
Case Reports
Pulmonary
Direct hemoperfusion with polymyxin B-immobilized fiber column in a patient with acute exacerbation of idiopathic pulmonary fibrosis
Shin Young Kim, Jin Han Park, Hyo Jung Kim, Hang Jea Jang, Hyun Kuk Kim, Seung Hoon Kim, Jae Ha Lee
Acute Crit Care. 2020;35(4):302-306.   Published online April 13, 2020
DOI: https://doi.org/10.4266/acc.2020.00038
  • 9,282 View
  • 212 Download
AbstractAbstract PDF
Idiopathic pulmonary fibrosis (IPF) is a progressive fibrosing interstitial lung disease characterized by dyspnea and a worsening of the lung function. Acute exacerbations of idiopathic pulmonary fibrosis (AE-IPF) are defined by a clinically significant respiratory deterioration, that typically develops in less than 1 month, accompanied by new radiologic abnormalities on high-resolution computed tomography, including diffused and bilateral ground-glass opacification, along with an absence of other obvious clinical etiologies. Recently, AE-IPF has gained significant importance as a major cause of mortality and morbidity. However, despite the extremely poor prognosis of the condition, no well-validated therapeutic interventions are currently available. Therefore, novel treatment modalities are being investigated and applied in addition to conventional treatments. Among them, several studies have reported that a direct hemoperfusion with a polymyxin B-immobilized fiber column (PMX-DHP), developed for endotoxin removal in septic shock, has an effect on AE-IPF. We describe two cases of PMX-DHP treatment with conflicting results. One patient successfully recovered via a PMX-DHP in severe AE-IPF that required extracorporeal membrane oxygenation (ECMO). PMX-DHP subsequently improved oxygenation (PaO2/FiO2 ratio) and decreased the levels of inflammatory markers (interleukin-6, C-reactive protein, and white blood cells). The patient dramatically recovered without the need for ECMO. PMX-DHP may be considered an alternative therapy in AE-IPF patients requiring mechanical ventilation or ECMO.
Infection
A successful application of adult polymyxin B-immobilized fiber column hemoperfusion to a neonate with septic shock
Young A Kim, Hyungtae Kim, Yu-Mi Kim, Su Eun Park
Acute Crit Care. 2019;34(4):284-288.   Published online November 6, 2018
DOI: https://doi.org/10.4266/acc.2017.00528
Correction in: Acute Crit Care 2023;38(4):515
  • 11,504 View
  • 181 Download
  • 6 Web of Science
  • 5 Crossref
AbstractAbstract PDF
Direct hemoperfusion therapy with a polymyxin B-immobilized fiber column (PMX-HP) has been introduced as a therapeutic option for gram negative bacterial septic shock in adults. However, its use in neonates and children has not yet been established. We successfully performed hemoperfusion therapy using an adult polymyxin B-immobilized fiber column in a neonate with carbapenem resistant Acinetobacter baumannii septic shock. The application was technically feasible because the neonate was on extracorporeal membrane oxygenation (ECMO). Although it did not rescue the patient, there was significant short-lasting improvement in pulmonary oxygenation and hemodynamics, leading to wean the patient from ECMO. PMX-HP could be used as an adjunctive treatment for selected neonatal and pediatric patients with gram negative bacterial septic shock.

Citations

Citations to this article as recorded by  
  • Polymyxin B Hemoperfusion in Pediatric Septic Shock: Single-Center Observational Case Series
    Patcharin Saetang, Rujipat Samransamruajkit, Kanokwan Singjam, Tawatchai Deekajorndech
    Pediatric Critical Care Medicine.2022; 23(8): e386.     CrossRef
  • Controlling an Outbreak of Multidrug-resistant Acinetobacter baumannii in a Pediatric Intensive Care Unit: a Retrospective Analysis
    Joung-Hee Byun, Su Eun Park, Minhae Seo, Jeungmi Jang, Mi Sun Hwang, Ju Yeoun Song, Chulhun L. Chang, Young A Kim
    Journal of Korean Medical Science.2021;[Epub]     CrossRef
  • Effects of continuous renal replacement therapy with the AN69ST membrane for septic shock and sepsis-induced AKI in an infant: a case report with literature review of cytokine/mediator removal therapy in children
    Naoto Nishizaki, Riko Ueno, Yuki Nagayama, Hanako Abe, Akina Matsuda, Akira Mizutani, Kaoru Obinata, Tadaharu Okazaki, Toshiaki Shimizu
    Renal Replacement Therapy.2020;[Epub]     CrossRef
  • Suggestions and tips regarding polymyxin B-immobilized fiber column direct hemoperfusion of neonates with sepsis
    Naoto Nishizaki
    Acute and Critical Care.2020; 35(3): 226.     CrossRef
  • Case Report: Successful Use of Extracorporeal Therapies After ECMO Resuscitation in a Pediatric Kidney Transplant Recipient
    Andrey Rybalko, Anna Pytal, Mikhail Kaabak, Nadejda Rappoport, Anuar Bidzhiev, Vasilii Lastovka
    Frontiers in Pediatrics.2020;[Epub]     CrossRef
Cardiology
Use of Polymyxin B Hemoperfusion in a Patient with Septic Shock and Septic Cardiomyopathy Who Was Placed on Extracorporeal Membrane Oxygen Support
Sun Hye Shin, Hyun Lee, Aeng Ja Choi, Kylie Hae Jin Chang, Gee Young Suh, Chi Ryang Chung
Korean J Crit Care Med. 2016;31(2):123-128.   Published online May 31, 2016
DOI: https://doi.org/10.4266/kjccm.2016.31.2.123
  • 19,742 View
  • 174 Download
AbstractAbstract PDF
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.
Infection/Surgery
Refractory Septic Shock Treated with Nephrectomy under the Support of Extracorporeal Membrane Oxygenation
Young Kun Lee, Jeong Am Ryu, Jeong Hoon Yang, Chi-Min Park, Gee Young Suh, Kyeongman Jeon, Chi Ryang Chung
Korean J Crit Care Med. 2015;30(3):176-179.   Published online August 31, 2015
DOI: https://doi.org/10.4266/kjccm.2015.30.3.176
  • 4,525 View
  • 69 Download
AbstractAbstract PDF
Conventional medical therapies have not been very successful in treating adults with refractory septic shock. The effects of direct hemoperfusion using polymyxin B and veno-arterial extracorporeal membrane oxygenation (ECMO) for refractory septic shock remain uncertain. A 66-year-old man was admitted to the emergency department and suffered from sepsis-induced hemodynamic collapse. For hemodynamic improvement, we performed direct hemoperfusion using polymyxin B. Computed tomography scan of this patient revealed emphysematous pyelonephritis (EPN), for which he underwent emergent nephrectomy with veno-arterial ECMO support. To the best of our knowledge, this is the first report of successful treatment of EPN with refractory septic shock using polymyxin B hemoperfusion and nephrectomy under the support of ECMO.
Infection
Polymyxin B Hemoperfusion in Pneumonic Septic Shock Caused by Gram-Negative Bacteria
Jung-Wan Yoo, Su Yeon Park, Jin Jeon, Jin Won Huh, Chae-Man Lim, Younsuck Koh, Sang-Bum Hong
Korean J Crit Care Med. 2015;30(3):171-175.   Published online August 31, 2015
DOI: https://doi.org/10.4266/kjccm.2015.30.3.171
  • 4,712 View
  • 84 Download
AbstractAbstract PDF
Severe sepsis and septic shock are the main causes of death in critically ill patients. Early detection and appropriate treatment according to guidelines are crucial for achieving favorable outcomes. Endotoxin is considered to be a main element in the pathogenic induction of gram-negative bacterial sepsis. Polymyxin B hemoperfusion can remove endotoxin and is reported to improve clinical outcomes in patients with intra-abdominal septic shock, but its clinical efficacy for pneumonic septic shock remains unclear. Here, we report a case of a 51-year-old man with pneumonic septic shock caused by Pseudomonas aeruginosa, who recovered through polymyxin B hemoperfusion.
Infection
Polymyxin B Immobilized Fiber Hemoperfusion in Refractory Intra-abdominal Septic Shock
Hae Wone Chang, Young-Jae Cho, Sang-Hyun Park, Moonsuk Kim
Korean J Crit Care Med. 2015;30(2):95-102.   Published online May 30, 2015
DOI: https://doi.org/10.4266/kjccm.2015.30.2.95
  • 5,592 View
  • 65 Download
AbstractAbstract PDF
The effects of direct hemoperfusion with polymyxin B immobilized fiber (PMX) treatment for septic shock have been recently reported. However, little evidence of a true benefit on clinical outcomes, including mortality, is available. Herein, we report three cases of intra-abdominal infection associated with refractory septic shock Case 1 was Escherichia coli peritonitis after a colectomy. PMX treatment improved the hemodynamic parameters and lactic acid levels of the patient. In case 2, secondary peritonitis was associated with septic or cardiogenic shock. Septic cardiomyopathy was assumed to be the cause of shock. 24 hours after the use of PMX, cardiac contractility assessed by echocardiography returned to baseline. In case 3, a patient with Burkitt’s lymphoma and neutropenia was found to be gastroenteritis and Klebsiella pneumoniae bacteremia. Intravenous meropenem was administered for 3 days. Hemodynamic parameters improve after the twice use of PMXOverall, the change of serial sequential organ failure assessment score (SOFA) was more significant in surgical cases as compared to the medical case at 72 hours after PMX administration. All patients were discharged from the hospital. In addition to early resuscitation efforts and infection source control, PMX treatment may be beneficial to patients with refractory intra-abdominal infection associated with septic shock.

ACC : Acute and Critical Care