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Postoperative Polymyxin B Hemoperfusion and Mortality in Patients With Abdominal Septic Shock: A Propensity-Matched Analysis*

Iwagami, Masao MD, MPH1; Yasunaga, Hideo MD, PhD2; Doi, Kent MD, PhD3; Horiguchi, Hiromasa PhD4; Fushimi, Kiyohide MD, PhD5; Matsubara, Takehiro MD, PhD3; Yahagi, Naoki MD, PhD3; Noiri, Eisei MD, PhD1

doi: 10.1097/CCM.0000000000000150
Clinical Investigations

Objectives: To examine the effect of postoperative polymyxin B hemoperfusion on mortality in patients with abdominal septic shock triggered by lower gastrointestinal tract perforation, identifying subpopulations of patients who may benefit from this treatment.

Design: Propensity-matched analysis.

Setting: We used a nationwide inpatient database in Japan.

Patients: We included patients who are 18 years old or older hospitalized during a period of 34 months between July 2007 and October 2011, who had open abdominal surgery on the day of admission (day 0) for perforation of lower gastrointestinal tract, and who required noradrenaline and/or dopamine. We excluded patients who died on day 0 or 1 and patients starting polymyxin B hemoperfusion on day 2 or later.

Measurements and Main Results: The main outcome was 28-day mortality. Of 2,925 eligible patients, 642 received one or two polymyxin B hemoperfusion sessions, starting the first one on day 0 or 1. Propensity score matching created a matched cohort of 1,180 patients (590 pairs with and without polymyxin B hemoperfusion). The 28-day mortality was 17.1% (101 of 590) in the polymyxin B hemoperfusion group and 16.3% (96 of 590) in the control group (p = 0.696). Subgroup analyses by number of polymyxin B hemoperfusion sessions (one or two), timing of polymyxin B hemoperfusion initiation (day 0 or 1), the use of noradrenaline, and number of dysfunctional organs (one to six) did not show any significant difference in 28-day mortality between the groups. Multiple logistic did not show a significant association between the use of polymyxin B hemoperfusion and 28-day mortality (adjusted odds ratio, 1.10; 95% CI, 0.80–1.51; p = 0.569). Age, end-stage renal disease requiring maintenance hemodialysis, the use of noradrenaline, and number of dysfunctional organs were positively associated with 28-day mortality.

Conclusions: In this retrospective study, postoperative polymyxin B hemoperfusion did not show any survival benefit for the overall study population or any of the studied subgroups of patients with abdominal septic shock. A large multicentered prospective randomized trial is warranted to identify the true role of polymyxin B hemoperfusion in sepsis caused by Gram-negative bacteria.

1Department of Hemodialysis and Apheresis, The University of Tokyo Hospital, Tokyo, Japan.

2Department of Health Economics and Epidemiology Research, School of Public Health, The University of Tokyo, Tokyo, Japan.

3Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan.

4Department of Clinical Data Management and Research, Clinical Research Center, National Hospital Organization Headquarters, Tokyo, Japan.

5Department of Health Informatics and Policy, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan.

* See also p. 1309.

Drs. Iwagami and Yasunaga had full access to all the study data and take responsibility for the integrity of the data and accuracy of the data analysis. All the authors directly participated in the planning, execution, or analysis of the study and read and approved the final submitted version of this article.

Supported, in part, by grants H22-Policy-031 (Research on Policy Planning and Evaluation) from the Ministry of Health, Labour and Welfare, Japan; 22390131 (Scientific Research B) from Ministry of Education, Culture, Sports, Science and Technology, Japan; and 0301002001001(Funding Program for World-Leading Innovative R&D on Science and Technology, FIRST program) from the Council for Science and Technology Policy, Japan. The funders had no role in the execution of this study or interpretation of results.

Drs. Yasunaga and Fushimi’s institutions received grant support from the Japanese government. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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© 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins