Impact of Early Peri-operative Use of Polymyxin-B Hemoperfusion in Septic Patients Undergoing Emergent Abdominal Surgery

Impact of Early Per-operative Use of Polymyxin-B Hemoperfusion in Septic Patients Undergoing Emergent Abdominal Surgery

Septic shock of intra-abdominal origin is likely due to Gram-negative bacteria or mixed pathogens and associated with high levels of endotoxin. The injury to the endothelium results in an increase of endothelial permeability, interstitial edema and release of nitric oxide (NO) that is a very potent vasodilatator. [6] Polymyxins obtained from the Gram-positive bacterium Bacillus polymyxa are antibiotics known for their ability to bind LPS in the outer membrane of the Gram-negative bacterial cell wall as well as free endotoxins with high affinity. Polymyxin-B has been shown to block the activation of cells by a wide variety of LPS. Studies converged to show an improvement in the treatment of septic shock by removing circulating endotoxin.Starting Polymyxin-B hemoperfusion during the operative time is to block the initiation of various deleterious biological cascades induced by endotoxemia such as systemic inflammation, disseminated coagulation disorders, and shock, leading to organ dysfunction and death.

Inclusion Criteria:

• Adults > 18 years
• Severe sepsis*or septic shock as define by the ACCCP/SCCM consensus conference, of abdominal origin
• Need for emergent abdominal surgery procedure under general anesthesia with expected duration of ≥ 120 min (in and out patients) for bowel perforation, ileus or peritonitis

Exclusion Criteria:

• Patients younger than 18 years
• Organ transplantation in the last year
• Terminally ill patients: do-not-resuscitate order, perceived to die within 48 hrs of admission
• Known pregnancy or diagnosed by US or Ct-scan (>14 weeks)
• History of sensitivity to polymyxin-B or to anticoagulant ( heparin)
• Uncontrolled hemorrhage within the last 24h
• Severe granulocytopenia ( leukocyte count of < 500/µL)
• Severe thrombocytopenia ( platelets count of < 30'000/µL)
• Need for CPR pre-operatively