Best choice of acute blood purification therapy based on the severity score and blood lactic acid values in septic shock patients

Introduction

Septic shock is a condition associated with diffuse coagulopathy and multiple organ failure, and frequently leads to death. Direct hemoperfusion using a polymyxin B-immobilized fiber column (DHP-PMX) has been used for the treatment of septic shock [1]. On the other hand, there is another kind of acute blood purification therapy, but the optimal column of continuous veno-venous hemodiafiltration (CVVHDF) is still controversial.

Methods

We treated 88 septic shock patients by DHP-PMX. The patients were divided into two groups based on the survival outcome and on the improvement in the circulatory dynamics immediately after DHP-PMX (Group A: increase of systolic blood pressure (SBP) by more than 30 mmHg (44 cases); Group B: increase of SBP by 30 mmHg or less (44 cases)). In another study conducted to review the best choice of acute blood purification therapy after DHP-PMX, the patients were divided into three groups: groups undergoing CVVHDF using a polymethylmethacrylate membrane hemofilter (PMMA) (28 cases), CVVHDF using a polyacrylonitrile membrane hemofilter (26 cases), and no CVVHDF after DHP-PMX (34 cases).

Results

There were 48 survival cases and 40 expired cases. The overall survival rate was 54.5% (good outcome judging from the APACHE II score), and outcome significantly related to APACHE II score, Sepsis-Related Organ Failure Assessment score and blood lactic acid value before treatment (P < 0.0001). The improvement rates of the blood pressure (increased by more than 30 mmHg) were 50.0% and significantly low blood lactic acid level in Group A. For another examination, only the PMMA CVVHDF group showed a better outcome (survival rate of 78.6%) compared with the other groups (P = 0.0190). In addition, only the PMMA CVVHDF group showed significant improvements of the blood lactic acid on day 3 (P = 0.0011).

Conclusion

Our study suggests that DHP-PMX treatment was effective in the early phase of septic shock before critical increase of the blood lactic acid levels. The optimal column for CVVHDF, as determined by improvement of the blood lactic acid levels, following DHP-PMX treatment is the PMMA column.