Polymyxin B Hemoperfusion for Patients With Septic Shock Requiring High-Dose Norepinephrine: A Multicenter Prospective Cohort Study

IMPORTANCE: Polymyxin B hemoperfusion (PMX-HP) is a potential therapeutic option for sepsis; however, its clinical effects remain unclear. OBJECTIVE: We explored the association between PMX-HP and clinical outcomes in patients in ICUs. DESIGN, SETTING, AND PARTICIPANTS: This is a multicenter prospective cohort study conducted in 20 ICUs in Japan between 2020 and 2022. Patients with septic shock requiring high-dose norepinephrine (≥ 0.2 µg/kg/min) were included. MAIN OUTCOMES AND MEASURES: We compared patient characteristics and outcomes between those who received PMX-HP (PMX group) and those who did not (non-PMX group). A primary outcome was 28-day mortality, with secondary outcomes including changes in mean arterial pressure (MAP) and vasoactive-inotropic score over time in the initial 48 hours, 28-day vasopressor-free days, and 90-day mortality rate. RESULTS: Among 309 patients, 175 (56.6%) were males, with a median age of 72 years and an Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 26. Overall, 82 patients underwent PMX-HP. The PMX and non-PMX groups had similar median ages (71 vs. 73 yr) and APACHE II scores (26 vs. 27). The median PMX-HP duration was 1016 minutes. The 28-day mortality was similar between the groups (PMX group: 17.1%, non-PMX group: 18.9%, p = 0.71), with an adjusted hazard ratio of 0.88 (95% CI, 0.46–1.68). MAP was maintained at a higher level with low-dose vasopressor from 8 to 32 hours following admission in the PMX group. The PMX group had fewer 28-day ICU-free days (16 vs. 18, p = 0.026). The 90-day mortality rate was similar between the groups (PMX group, 23.5%; non-PMX group, 27.1%; p = 0.62). CONCLUSIONS AND RELEVANCE: PMX-HP was not associated with the 28-day mortality improvement but was associated with higher MAP and lower vasopressor use for 8–32 hours of admission. Our findings suggested that PMX-HP requires careful adaptation.