Indian Journal of Critical Care Medicine Medknow Publications on behalf of the Indian Society of Critical Care Medicine ISSN: 0972-5229 EISSN: 1998-359x Vol. 14, Num. 1, 2010, pp. 39-40

Indian Journal of Critical Care Medicine, Vol. 14, No. 1, January-March, 2010, pp. 39-40

Experts comments

Expert's comments

Mani RK

Director, Critical Care, Pulmonology and Sleep Medicine, Artemis Health Institute, Gurgaon, Haryana Correspondence Address:Director, Critical Care, Pulmonology and Sleep Medicine, Artemis Health Institute, Gurgaon, Haryana rkmjs@vsnl.net

Code Number: cm10008

Following are the comments on the article "Effectiveness of early start of direct hemoperfusion with polymyxin B-immobilized fiber columns judging from stabilization in circulatory dynamics in surgical treatment patients" ^[1] :

1. The article addresses the issue of the role of direct hemoperfusion with polymyxin B-immobilized columns in septic shock. These columns have been shown to adsorb endotoxins and cytokines in previous studies. However, at present there is no clear-cut evidence attesting to benefit of this adjuvant therapy.
2. The study has a few unique features: (a) comparing relative benefits in surgical patients with medical patients, (b) using DHP-PMX columns early, i.e., within 3 hours h of onset of shock, and (c) using two columns consecutively for 2 hours h each.
3. The study shows a clear benefit in terms of 28-day mortality and hemodynamic effects in the case of surgical cases. An earlier, large multicenter study (the EUPHAS ^[2] supports these findings.
4. In contrast, there were no significant positive effects of DHP-PMX in medical patients. Observational impressions from the Japanese experience since 1994 seem to support this view.
5. There are, however, some serious flaws in the study: (a) comparison within the groups with or without PMX columns is not available. In any case the sample size is too small, (b) computation of predicted mortality based on APACHE 2 scores is not reliable, (c) late mortality (>28 days) is not mentioned, (d) secondary end points, such as mechanical ventilator-free days, vasopressor-free days, and ICU days, are not mentioned.

In conclusion, this study supports the possibility that patients of postoperative abdominal sepsis with shock due to endotoxemia may benefit from DHP-PMX adjuvant therapy when treated at a very early stage. It also highlights the need for well-designed studies in this group of patients. The way the columns are used should also be explored in future studies.

References

1.	Sakamoto Y, Mashiko K, Obata T, Matsumoto H, Hara Y, Kutsukata N, et al. Effectiveness of early start of direct hemoperfusion with polymyxin B-immobilized fiber columns judging from stabilization in circulatory dynamics in surgical treatment patients. Indian J Crit Care Med 2010;14:35-9.  Back to cited text no. 1
2.	Cruz DN, Antonelli M, Fumagalli R, Foltran F, Brienza N, Donati A, et al. Early use of polymixin B hemoperfusion in abdominal septic shock: The EUPHAS randomized controlled trial. JAMA 2009;301:2445-52.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]

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