Polymyxin B Hemoperfusion in Pediatric Septic Shock: Single-Center Observational Case Series

Abstract

OBJECTIVES: To evaluate the use of direct hemoperfusion with polymyxin B-immobilized fiber (PMX-DHP) as adjunctive therapy during pediatric patients with septic shock. DESIGN: Prospective observational study. SETTING: Nine-bed PICUs at university referral hospital. PATIENTS: Children (30 d to 15 yr) with septic shock and Pediatric Logistic Organ Dysfunction (PELOD)-2 score greater than or equal to 10 or Pediatric Risk of Mortality (PRISM) 3 score greater than or equal to 15, who were also receiving at least one inotrope. INTERVENTION: Patients received 2–4 hour treatment with PMX-DHP 20R column on 2 consecutive days. MEASUREMENTS AND MAIN RESULTS: We enrolled six children aged 21–167 months old (median, 99-mo old), with a body weight of 10–50 kg (median, 28 kg). All six patients had both PELOD-2 greater than or equal to 10 and PRISM-3 greater than or equal to 15, required invasive mechanical ventilation, and received standard treatment for septic shock before enrollment. We observed significant improvement in PELOD-2 score from baseline to 72 hours after the start of PMX-DHP (mean [95% CI] from 14.3 [12.2–16.5] to 6.0 [0.3–11.7]; p = 0.006). The vasoactive inotropic score (VIS) and lactate concentration also significantly decreased from baseline to 72 hours (VIS, 60 mmol/L [25–95 mmol/L] to 4.0 mmol/L [44.1–12 mmol/L]; p = 0.003; lactate, 2.4 mmol/L [1.0–3.8 mmol/L] to 1.0 mmol/L [0.5–1.5 mmol/L]; p = 0.01). Five of six patients survived. There was no device-related adverse event in these patients. CONCLUSIONS: In this case series of treatment with PMX-DHP as adjunctive therapy in children with refractory septic shock and high baseline severity, we have shown that patient recruitment is feasible. We have also found that clinical hemodynamic and severity of illness scores at 72 hours may be potential end points for testing in future randomized controlled trials.

Practical points of hemoperfusion in the intensive care unit

“…Hemoperfusion can be performed in severe COVID-19 patients with cytokine release syndrome, particularly when contemplating ECMO support. Some case studies have reported swift reductions in vasopressor demand, rapid hemodynamic stabilization, decreases in IL-6 levels, enhancements in chest X-rays, and improvements in acute kidney injury outcomes [39]. However, as mentioned earlier in the randomized study [36], the use of Cytosorb® hemoperfusion during ECMO support did not result in reduced IL-6 concentrations.…”

“…Notably, a recent prospective observational case series explored the use of adjunctive polymyxin B hemoperfusion in children with refractory septic shock. After undergoing two hemoper- fusion sessions, clinical hemodynamics improved significantly, along with reductions in severity of illness scores, and importantly, no device-related adverse events were recorded [39].…”

Impact of CytoSorb and CKRT on hemodynamics in pediatric patients with septic shock: the PedCyto study

“…Polymyxin-B hemoadsorption with PMX-05 cartridges was applied in 15 children with septic shock; the authors reported a trend towards an improvement in hemodynamics after two sessions of therapy, although inotropic agent requirements did not change over time ( 32 ). More recently, Saetang et al described the use of PMX-20R (a modified polymyxin-B cartridge circuit for pediatric use) in 6 children and reported a significant reduction in PELOD-2 and VIS scores after two sessions of therapy ( 33 ). Clinical experiences are also reported on application of the Selective Cytopheretic Device (SCD) in critically ill children with AKI and multiorgan dysfunction showing promising results in terms of safety and efficacy ( 34 ).…”

A Thai guideline summary in management of pediatric septic shock

“…Potential benefits of RRT in sepsis include the treatment of fluid overload and metabolic disturbances unresponsive to medications, but RRT is not associated with other PICU outcomes [37]. The potential benefits of blood purification in sepsis encompass the reduction of various pro-inflammatory cytokines levels (IL-1β, IL-6, IL-8, and TNF-α), a decreased vasopressor-inotropic score (VIS), a lowered Pediatric Logistic Organ Dysfunction (PELOD-2) score at 72 hours, a shortened ICU length of stay, and a reduced mechanical ventilator day [38][39][40][41][42]. Different adsorptive columns exhibit varying reported benefits, though specific details for each adsorptive column are not fully described for simplicity of recommendation.…”