Use of Polymyxin B Hemoperfusion in Heart Transplant Patient for Septic Shock

Abstract

<h3>Introduction</h3> We report the case of a 61-year-old heart transplant patient who developed <i>A. baumannii</i> bilateral pneumonia (MDR-AB) which progressed into septic shock. The patient was treated with antibiotics and Polymyxin B Hemoperfusion resulting in complete resolution of the septic shock. <h3>Case Report</h3> A 61-year-old patient with idiopathic dilatated cardiomyopathy underwent heart transplantation with a regular post-operative course. Post-transplant echocardiogram showed satisfying biventricular contraction (EF 55 %, Tapse 23 mm) and normal pulmonary pressures (PAPs 29 mmHg). On the 15^th day after surgery, he suffered from hyperpyrexia and marked hypotension. The chest X-ray revealed a bilateral pneumonia. He was transferred to the intensive care unit where he was treated with catecholaminergic therapy with IV norepinephrine (0,2 y/kg/min) and antibiotic therapy with meropenem, colistin and ampicillin/sulbactam. In the following 24 hours, we observed a worsening of the respiratory function and oliguria (10 ml/h); therefore, the patient was sedated and intubated and started dialytic treatment. Severe myelosuppression also occurred with a white blood cell count lower than 600 cells/mmc. The scoring systems for the evaluation of critical patients in the ICU were elevated (SOFA score 13; Apache II Score 21; MODS Score 13). The immunosuppressant therapy with tacrolimus was reduced in order to reach a range of serum levels of 5-7 ng/ml. Endotoxemia was 1172 pg/mL (<b>EAA™</b>1 0,63 <b>EAA™</b>2 0,66). A cycle of Polymyxin B Hemoperfusion connected to the dialysis circuit was performed. At the end of two treatments, with a pause of 22 hours in between, we witnessed a significant reduction of endotoxemia: 150 pg/mL (<b>EAA™</b>1 0,11 <b>EAA™</b>2 0,14). In the following days, inflammation indexes decreased (PCT 31 ng/mL→ 1,7 ng/mL), respiratory function recovered (p02 65 → 110), leading to extubation, hemodynamics improved and inotrope support was suspended, white blood cell count increased (WBC 600 cells/mmc → 3300 cells/mmc). <h3>Summary</h3> In our experience, the prompt use of combined IV antibiotic therapy and Polymyxin B Hemoperfusion for septic shock with heart transplant patients has improved the outcome, thus reducing the duration of inotrope and antibiotic therapy and intubation.