Abstract

A 76-year-old man was transferred to our department because of high fever with chills. According to the Tokyo Guidelines 2018, he was diagnosed with sepsis due to Grade III (severe) acute cholangitis. Fluid resuscitation, noradrenaline administration, antibiotic therapy, and an emergency endoscopic retrograde biliary drainage were
performed. Due to these treatments, his general condition improved initially; however, on the 5th hospital day, he eventually became persistently hypotensive despite adequate fluid resuscitation while on a vasopressor. Under the diagnosis of septic shock, intensive care including endotracheal intubation followed by mechanical ventilation, thoracic drainage, administration of vasopressors, strict antibiotic therapy, and total parenteral nutrition, was promptly initiated; however, he remained in shock. We judged his condition as refractory septic shock that was resistant to conventional treatments. Therefore, endotoxin adsorption therapy with polymyxin B hemoperfusion (PMX-DHP) was attempted on the 7th hospital day, and two sessions of PMX-DHP were carried out 24 h apart. Following this procedure, he successfully recovered from septic shock, and was discharged on the 84th hospital day.
We propose that PMX-DHP might be considered for the treatment of refractory septic shock due to acute cholangitis that is resistant to appropriate conventional treatments, especially when the presence of endotoxemia has been confirmed.

Keywords: Septic shock; Acute cholangitis; Polymyxin B hemoperfusion