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

Dinna N Cruz, Mark A Perazella, Rinaldo Bellomo, Massimo de Cal, Natalia Polanco, Valentina Corradi, Paolo Lentini, Federico Nalesso, Takuya Ueno, V Marco Ranieri, Claudio Ronco, Dinna N Cruz, Mark A Perazella, Rinaldo Bellomo, Massimo de Cal, Natalia Polanco, Valentina Corradi, Paolo Lentini, Federico Nalesso, Takuya Ueno, V Marco Ranieri, Claudio Ronco

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 microg/kg per minute (95% CI, 0.4 to 3.3 microg/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.

Figures

Figure 1
Figure 1
Details of included and excluded trials. MAP, mean arterial pressure; PaO2/FiO2, arterial partial pressure of oxygen/fraction of inspired oxygen.
Figure 2
Figure 2
(a) Change in MAP after PMX-F (275 participants included). (b) Change in dopamine/dobutamine dose after PMX-F (96 participants included). CI, confidence interval; MAP, mean arterial pressure.
Figure 3
Figure 3
Risk ratio (RR) for death after polymyxin B-immobilized fiber column (PMX-F) treatment (920 participants included in meta-analysis). CI, confidence interval.
Figure 4
Figure 4
Funnel plots. (a) Mean arterial pressure (MAP). (b) Mortality. Solid line represents line of neutral effect. Dashed line represents point estimate of analysis. RR, risk ratio; SE, standard error.

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