Multi-center research of small-sized
polymyxin B hemoperfusion
Naohiro Wada
Department of Pediatric Nephrology
Shizuoka Children’s Hospital
Shizuoka, JAPAN
polymyxin B immobilized fiber column
Polystyrene/polypropylene (9/1) conjugated fiber
Covalent linkage
Polymyxin B
Polymyxin B
Lipid A
LPS =Endotoxin
Polysaccharide
Lipid A
+ Anandamide
2-arachidonylglycerol
(endocannabinoids)
Gram –positive bacterial infection
also effective
Crus DN et al (Crit Care 2007;11:R47)
“Effectiveness of polymixin B immobilized fiber column
in sepsis: a systematic review”
Review : meta-analysis
Favorable effect : MAP, dopamine use, PaO2/FiO2 ratio, mortality
Consideration : publication bias, lack of blinding
Cruz DN et al (JAMA 2009;301:2445-2452)
“Early Use of Polymyxin B Hemoperfusion in Abdominal
Septic Shock. The EUPHAS Randomized Controlled Trial.”
PMX 20R
PMX 05R
Priming volume
135 ml
Length
225 mm
135 mm
63 mm
55 mm
Diameter
40 ml
PURPOSE
The effectiveness and safety of small-sized polymyxin B
hemoperfusion in the severe septic shock children.
Retrospective analysis in three units.
Complete count survey in the units.
Units: pICU, Nagano Children’s Hosp.
Neonatal section, Kurashiki Central Hosp.
Nephrology section, Shizuoka Children’s Hosp.
PATIENS
Septic shock
Definitions for sepsis and organ dysfunction in pediatrics
(Pediatr Crit Care Med 2005;6:2-8)
Cases : 36
Age
(male 24, female 12)
: 1.6±2.6 y (0m-10y : median 0.32 y)
Weight : 6.5±5.5kg (1.2kg~28kg : median 5.0kg）
Data (at the time of treatment)
sBP (mmHg)
77±24
HR ( /min)
144 ±33
WBC (103/mm3) 8.3±6.9
Plt (104/mm3)
8.6±8.3
BUN (mg/dl)
19.0 ±17.1
Cr (mg/dl)
0.80 ±0.67
PELOD : 35 ±11 (predictive mortality : 94.6%)
Frequency : once 11
twice 25
Bacterial culture
detected 22
E.coli
Klebsiella
Pseudomonas
Serratia
MSSA
MRSA
GBS
Streptococcus
2
2
3
1
5
4
3
2
( blood 2)
( blood 1、ascites 1)
( blood 2、urine 1)
( blood)
( blood 5)
( blood 2、 sputum 2)
( blood 3）
( blood 2）
Endotoxin （before treatment）
detected
not detected
not done
11 (1-714： mean 150.6土227.4；median 49.9)
9
16
Qb
28.3 ± 15.0 ml/min (5－80)
6.2±4.0 ml/min/kg (0.97～16.2：median 5.7)
Anticoagrant
Nafamostat mesilate : 36 (100%)
0.40±0.18 mg/kg/hr, (0.1～1.0, median 0.41)
Priming
Blood ＋Albumin/FFP
albumin
saline
34
1 （2y:9.9kg)
2 （7y:26kg, 14y:18kg)
Concurrent therapy（overlapped）
CH(D)F
ECMO
36 (100%)
4 ( 11%)
Blood access
(excluded ECMO route access)
20
10
2
Catheter size （DL)
(excluded ECMO route access)
17G
16G
15G
6 Fr
6.5Fr
7 Fr
8 Fr
10 Fr
1
2
2
8
1
4
13
1
10
Catheter size（Fr)
jugular v.
femoral v.
subclavian v.
9
8
7
6
5
4
0
5
10
15
20
25
boby weight(kg)
※17G=4.5Fr, 16G=5Fr, 15G=5.5Fr
30
Changes in blood pressure before and end of treatment
(before therapy = 1)
1.6
1.5
>1：30/52 (57%)
1.4
1.3
1.2
1.09±0.23
1.1
1
0.9
0.8
0.7
0.6
pre
post
Changes in blood pressure
( before therapy = 1)
2
1.8
1.6
1.4
1.2
1
0.8
0.6
pre
just after
Tx
pre 2nd Tx
just after
2nd Tx
24hrs after 48hrs after
Tx
Tx
Changes in HR
(before therapy = 1)
1.6
1.4
1.2
1
0.8
0.6
0.4
pre
just after
Tx
pre 2nd Tx
just after
2nd Tx
24hrs after 48hrs after
Tx
Tx
Change in WBC and platelet
before and 24hrs after treatment (before therapy = 1)
3.5
7
WBC
3
6
2.5
5
2
4
1.5
3
1
2
0.5
1
0
0
pre
post
Platelet
pre
post
PROGNOSIS
Death : 18/36 (mortality rate 50%)
< 7 days
14 (39%)
8～28 days
2
29 days<
2
PELOD 40< : 19 cases
Death : 9 /19 （47％）
(predicted mortality rate: 99% and more）
Comparison of death group and living group
Death
Living
number
18
18
ns
Age (y)
1.5±2.6
1.7±2.8
ns
Weight (kg)
6.1±4.9
6.8±6.3
ns
Systolic BP (mmHg)
73±24
81±24
ns
HR (/min)
139±34
149±32
ns
PELOD
35.9±7.9
33.8±13.3
ns
7.2±6.5
9.2±7.2
ns
(104/mm3)
8.6±8.6
8.7±8.3
ns
BUN
(mg/dl)
19.0±17.6
19.0±17.3
ns
Cr
(mg/dl)
0.89±0.71
0.72±0.63
ns
WBC
Plt
(103/mm3)
Conclusion
Polymyxin B hemoperfusion treatment was possible to be
effective to the septic shock children safely even at low body
weight and contributed to the prognosis improvement.
However, other therapies effect to the mortality, randomized
control trial and definite indication are necessary for the
effectiveness of polymyxin B hemoperfusion itself.
CHDF + PMX-DHP
PMX－DHP
Double lumen
CHDF
CH(D)F + PMX-DHP
QB1
CH(D)F
CH(D)F + PMX-DHP
QB1
QB2
CH(D)F
PMX-05R
QB1>QB2
CH(D)F + PMX-DHP
QB1
CH(D)F