Direct hemoperfusion with a polymyxin B-immobilized cartridge in intestinal warm ischemia reperfusion

Polymyxin B hemoperfusion as a feasible therapy after source control in abdominal septic shock

BACKGROUND

Polymyxin B hemoperfusion (PMX-HP) has been used as a treatment for intra-abdominal septic shock by absorbing and removing endotoxins of gram-negative bacilli.

AIM

To investigate the clinical efficacy of PMX-HP in patients with gram-negative septic shock who underwent abdominal surgery.

METHODS

From January 2012 to December 2018, patients who had septic shock secondary to peritonitis were enrolled. They were classified into PMX-HP treated and control groups based on postopreative intervention using PMX-HP. The clinical outcomes were compared using 1:1 propensity score matching methods to balance the overall distribution between the two groups.

RESULTS

After propensity score matching, 40 patients were analyzed (20 patients in the PMX group and 20 patients in the control group). The scores of total Sequential Organ Failure Assessment (SOFA) score, renal SOFA and coagulation SOFA were significantly improved in the PMX group but not in the control group. (from 11.2 ± 5.8 to 4.7 ± 3.5 in PMX group vs 10.0 ± 4.0 to 8.7 ± 7.3 in control group, P = 0.047 from 2.6 ± 1.0 to 0.7 ± 1.0 in PMX group vs 2.6 ± 1.5 to 2.8 ± 1.6 in control group, P = 0.000, from 1.6 ± 1.5 to 1.3 ± 1.3 in PMX group vs 1.2 ± 1.2 to 2.8 ± 1.8 in control group, P = 0.014, respectively). Further, the length of intensive care unit (ICU) stay was significantly shorter in PMX group. However, no statistically significant difference was found in ICU mortality (50% in PMX group vs 50% in control group).

CONCLUSION

PMX-HP is a feasible adjunct treatment for peritonitis in ICU patients with peritonitis for improved organ impairment and to stabilize hemodynamics. It would be helpful to enhance clinical outcomes especially in patients with complete elimination of the source of gram-negative bacilli infection by surgical procedure accompanied with conventional treatment of sepsis.

Clinical outcomes and prognostic factors after surgery for non-occlusive mesenteric ischemia: a multicenter study

BACKGROUND

To date, no large-scale study has been undertaken to understand the clinical features of non-occlusive mesenteric ischemia (NOMI) after surgery. We thus performed a multicenter investigation to clarify the clinical outcomes and prognostic factors of NOMI.

PATIENTS AND METHODS

Clinical databases from 22 Japanese facilities were reviewed for evaluation of patients who received surgery for NOMI between 2004 and 2012. NOMI patients (n = 51) were divided into two groups: group I (n = 28) consisted of patients who survived, and group II (n = 23) consisted of patients who did not survived. Prognostic factors were compared between the two groups.

RESULTS

NOMI surgery represented 0.04% of the total number of operations performed in this time period. The overall mortality rate for NOMI surgery was 45%. Hemodialysis was a significant negative prognostic factor (p = 0.027). Preoperative elevation of transaminases, potassium, and white blood cell count, as well as metabolic acidosis and colon ischemia was poor prognostic factors. The mean Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) score of group I versus group II was 54.5 ± 3.6 and 85.2 ± 4.1, respectively (p < 0.001).

CONCLUSIONS

Currently, NOMI surgery has a 45% mortality rate. POSSUM scores can be used to predict the clinical outcome of patients who receive NOMI surgery.

The effect of nicorandil on small intestinal ischemia-reperfusion injury in a canine model

BACKGROUND

It has been shown that nicorandil, which has both ATP-sensitive K+ (KATP) channel opener-like and nitrate-like properties, has an organ-protective effect in ischemia-reperfusion injury in several experimental animal models.

AIMS

We evaluate the effectiveness of nicorandil on warm ischemia-reperfusion injury of the small intestine in a canine model.

METHODS

Eighteen beagle dogs were divided into three groups: the control group (n=6); the nicorandil group (n=6), to which nicorandil was injected intravenously before the ischemia; and the glibenclamide group (n=6), to which glibenclamide, which closes the KATP channel and does not suppress the nitrate effect of nicorandil, was orally administered, and then nicorandil was injected in the same manner as in the nicorandil group. Both the superior mesenteric artery and vein were clamped for 2 h. Superior mesenteric artery blood flow, small intestinal mucosal tissue blood flow, intramucosal pH, and histopathological analyses were compared among the three groups.

RESULTS

Superior mesenteric artery blood flow, mucosal tissue blood flow and pHi after reperfusion were significantly maintained in the nicorandil in comparison with the control and the glibenclamide groups. The histopathological findings showed less severe mucosal damage after reperfusion in the nicorandil group compared with the other two groups. Between the control group and the glibenclamide group, no significant differences were observed in all those parameters.

CONCLUSION

This study suggests that nicorandil has a protective effect on small intestinal IR injury, and activation of KATP channels plays an important role in inhibiting small intestinal IR injury.

Targeting endotoxin in the treatment of sepsis

The role of endotoxin in the genesis of sepsis has long been recognized and multiple treatments aimed at neutralizing it have been studied. Endotoxin can be bound by antibodies (whose role as a therapeutic agent is unlikely), binding proteins such as BPI or human lactoferrin (effectiveness debated and promising respectively) and phospholipid emulsion (which has not improved outcomes in a recent study). Alternatively, the action of endotoxin could be blocked by lipid A analogs (initial study showed no overall benefit and another large trial is near completion targeting a subpopulation of that study). Finally, endotoxin can be bound by polymyxin B embedded in hemoperfusion cartridges. The later treatment has been used for more than a decade in Japan. Since both pre-clinical rationale and studies support the targeting of endotoxin to ameliorate the pro-inflammatory and pro-coagulation response of severe sepsis, this therapeutic intervention is being pursued.

Hemoperfusion with polymyxin B-immobilized fiber column improves liver function after ischemia-reperfusion injury

AIM: To investigate the usefulness of direct hemoperfusion with a polymyxin B-immobilized fiber column (DHP-PMX therapy) for warm hepatic ischemia-reperfusion (I/R) injury after total hepatic vascular exclusion (THVE) using a porcine model.

METHODS: Eleven Mexican hairless pigs weighing 22-38 kg were subjected to THVE for 120 min and then observed for 360 min. The animals were divided into two groups randomly: the DHP-PMX group (n = 5) underwent DHP-PMX at a flow rate of 80 mL/min for 120 min (beginning 10 min before reperfusion), while the control group did not (n = 6). The rate pressure product (RPP): heart rate × end-systolic arterial blood pressure, hepatic tissue blood flow (HTBF), portal vein blood flow (PVBF), and serum aspartate aminotransferase (AST) levels were compared between the two groups.

RESULTS: RPP and HTBF were significantly (P < 0.05) higher in the DHP-PMX group than in the control group 240 and 360 min after reperfusion. PVBF in the DHP-PMX group was maintained at about 70% of the flow before ischemia and differed significantly (P < 0.05) compared to the control group 360 min after reperfusion. The serum AST increased gradually after reperfusion in both groups, but the AST was significantly (P < 0.05) lower in the DHP-PMX group 360 min after reperfusion.

CONCLUSION: DHP-PMX therapy reduced the hepatic warm I/R injury caused by THVE in a porcine model.