Research

Effectiveness of polymyxin B-immobilized fiber column in sepsis: a systematic review

Dinna N Cruz^1,2 , Mark A Perazella³ , Rinaldo Bellomo⁴ , Massimo de Cal¹ , Natalia Polanco¹ , Valentina Corradi¹ , Paolo Lentini¹ , Federico Nalesso¹ , Takuya Ueno⁵ , V Marco Ranieri⁶ and Claudio Ronco¹

¹Department of Nephrology, Ospedale San Bortolo, Viale Rodolfi 37, 36100 Vicenza, Italy

²Section of Nephrology, Department of Medicine, St. Luke's Medical Center, 279 E Rodriguez Sr Boulevard, Quezon City 1102, Philippines

³Section of Nephrology, Department of Medicine, Yale University School of Medicine, 333 Cedar Street FMP 107, New Haven, CT 06520, USA

⁴Department of Intensive Care and Department of Medicine, Austin & Repatriation Medical Centre, Studley Road, Heidelberg, Victoria 3084, Australia

⁵Transplantation Unit, Surgical Services, Massachusetts General Hospital, 55 Fruit Street White 506, Boston, MA 02114, USA

⁶Department of Anesthesia and Intensive Care, Ospedale San Giovanni Battista, Corso Bramante 88, 10126 Torino, Italy

author email corresponding author email

Critical Care 2007, 11:R47doi:10.1186/cc5780

Published:	20 April 2007

See related commentary by Kellum, http://ccforum.com/content/11/3/137

Abstract

Introduction

Severe sepsis and septic shock are common problems in the intensive care unit and carry a high mortality. Endotoxin, one of the principal components on the outer membrane of gram-negative bacteria, is considered important to their pathogenesis. Polymyxin B bound and immobilized to polystyrene fibers (PMX-F) is a medical device that aims to remove circulating endotoxin by adsorption, theoretically preventing the progression of the biological cascade of sepsis. We performed a systematic review to describe the effect in septic patients of direct hemoperfusion with PMX-F on outcomes of blood pressure, use of vasoactive drugs, oxygenation, and mortality reported in published studies.

Methods

We searched PubMed, the Cochrane Collaboration Database, and bibliographies of retrieved articles and consulted with experts to identify relevant studies. Prospective and retrospective observational studies, pre- and post-intervention design, and randomized controlled trials were included. Three authors reviewed all citations. We identified a total of 28 publications – 9 randomized controlled trials, 7 non-randomized parallel studies, and 12 pre-post design studies – that reported at least one of the specified outcome measures (pooled sample size, 1,425 patients: 978 PMX-F and 447 conventional medical therapy).

Results

Overall, mean arterial pressure (MAP) increased by 19 mm Hg (95% confidence interval [CI], 15 to 22 mm Hg; p < 0.001), representing a 26% mean increase in MAP (range, 14% to 42%), whereas dopamine/dobutamine dose decreased by 1.8 μg/kg per minute (95% CI, 0.4 to 3.3 μg/kg per minute; p = 0.01) after PMX-F. There was significant intertrial heterogeneity for these outcomes (p < 0.001), which became non-significant when analysis was stratified for baseline MAP. The mean arterial partial pressure of oxygen/fraction of inspired oxygen (PaO₂/FiO₂) ratio increased by 32 units (95% CI, 23 to 41 units; p < 0.001). PMX-F therapy was associated with significantly lower mortality risk (risk ratio, 0.53; 95% CI, 0.43 to 0.65). The trials assessed had suboptimal method quality.

Conclusion

Based on this critical review of the published literature, direct hemoperfusion with PMX-F appears to have favorable effects on MAP, dopamine use, PaO₂/FiO₂ ratio, and mortality. However, publication bias and lack of blinding need to be considered. These findings support the need for further rigorous study of this therapy.