Refractory Septic Shock Treated with Nephrectomy under the Support of Extracorporeal Membrane Oxygenation
Korean Journal of Critical Care Medicine
Conventional medical therapies have not been very successful in treating adults with refractory septic shock. The effects of direct hemoperfusion using polymyxin B and veno-arterial extracorporeal membrane oxygenation (ECMO) for refractory septic shock remain uncertain. A 66-year-old man was admitted to the emergency department and suffered from sepsis-induced hemodynamic collapse. For hemodynamic improvement, we performed direct hemoperfusion using polymyxin B. Computed tomography scan of this
... graphy scan of this patient revealed emphysematous pyelonephritis (EPN), for which he underwent emergent nephrectomy with veno-arterial ECMO support. To the best of our knowledge, this is the first report of successful treatment of EPN with refractory septic shock using polymyxin B hemoperfusion and nephrectomy under the support of ECMO. It is difficult to treat adults with septic shock, which is refractory to adequate intravascular volume and infusion of very highdose catecholamines. Endotoxin plays an important role in the pathogenesis of septic shock. Polymyxin B hemoperfusion aims to remove circulating endotoxin by adsorption, theoretically preventing the progression of the biological cascade of sepsis. In a systematic review, we found that when direct hemoperfusion with the polymyxin B (PMX-DHP) was carried out, there were significant improvements in the hemodynamics, pulmonary oxygenation, and mortality of patients with septic shock. However, we do not have sufficient evidence to prove that PMX-DHP was applied while conducting rescue therapy on patients with refractory septic shock. To treat neonates and children with refractory septic shock , the American College of Critical Care Medicine has recommended extracorporeal membrane oxygenation (ECMO) as a viable therapy.  Several studies have reported the use of ECMO in the treatment of adult patients with refractory septic shock. However, its efficacy remains controversial.    In this report, we describe how a patient with emphysematous pyelonephritis (EPN) and refractory septic shock was successfully treated with PMX-DHP and nephrectomy under the support of ECMO. Case Report A 66-year-old man was admitted to our emergency department as he complained of severe fever and chills for the past two days. He was a diabetic and hypertensive patient who received regular medication. cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.