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Critical Care

Open Access

Endotoxin activity assay and polymyxin B hemoperfusion use in a cohort of critically ill patients

  • SL Cutuli1,
  • G De Pascale1,
  • V Alicino1,
  • S Cicconi1,
  • V Di Gravio1,
  • D Silvestri1,
  • D Giacobelli1,
  • E Gasperin1,
  • S Marsili1,
  • MS Vallecoccia1 and
  • M Antonelli1
Critical Care201418(Suppl 1):P408

Published: 17 March 2014


Endotoxin plays a crucial role in the pathogenesis of severe sepsis and septic shock (SS&SSh) [1]. The aim of this study is to analyze the impact of extracorporeal endotoxin removal with polymyxin B hemoperfusion (PMX-DHP) (Toraymyxin®).


All patients admitted to our ICU between 1 April 2011 and 30 June 2013 who developed SS&SSh and underwent endotoxin activity assay (EAA) measurement were retrospectively evaluated.


During the study period, EAA was dosed in 100 patients. Eighty- one patients were affected by septic shock. The source of infection was identified in 70.4% of cases (45% abdominal) and the percentage of microbiologically confirmed episodes was 77% (81% Gram-negatives). The mortality rate was 49%. The mean EAA level was 0.66 ± 0.2, and in 66% of patients the value was higher than 0.6. No significant differences were found in terms of SAPS II (P = 0.32) and SOFA score (P = 0.67), according to EAA level (>/≤0.6). Patients with levels >0.6 presented a higher percentage of microbiologically confirmed infections (84% vs. 66%; P = 0.09). Thirty-two of 66 patients with EAA >0.6 were treated with Toraymyxin®. No complications leading to treatment interruption were recorded and a relevant decrease of cardiovascular SOFA score and lactate levels were observed 72 hours after treatment (P = 0.05 and P = 0.06, respectively). Source control and Toraymyxin® treatment resulted as the only modifiable factors improving the ICU survival rate (Table 1).
Table 1

Multivariate analysis for ICU mortality risk factors


P value

OR (95% CI)

SAPS II score


1.1 (1.01 to 1.1;

Septic shock


10.4 (1.5 to 71)



0.2 (0.1 to 0.9)

Source control


0.1 (0.03 to 0.5)


EAA is a rapid and reliable method to identify patients who may be treated with polymyxin B hemoperfusion. Source control and extracorporeal endotoxin removal have appeared as two effective interventions that should be implemented in the early management of patients with SS&SSh.

Authors’ Affiliations

Sacro Cuore Catholic University, Rome, Italy


  1. Cruz DN, Antonelli M, et al.: Early use of polymyxin B hemoperfusion in abdominal septic shock. The EUPHAS randomized controlled trial. JAMA 2009, 301: 2445-2452. 10.1001/jama.2009.856View ArticlePubMedGoogle Scholar


© Cutuli et al.; licensee BioMed Central Ltd. 2014

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.