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Peer-reviewedCC BY-NC-NDCritical care (London, England)

Consensus recommendations for patient selection and clinical implementation of polymyxin B hemoadsorption in endotoxic septic shock.

  • Lenar Yessayan1
  • Matthieu Legrand2
  • Javier A Neyra3
  • Danielle Davison4
  • Laurence W Busse5
  • William S Bender5
  • Blaithin A McMahon6
  • Jonathan Eaton7
  • Tara Morgan-Gray8
  • Cindy Ramberg8
  • Ashita Tolwani3
8 affiliations
  1. 1Division of Nephrology, Department of Internal Medicine, University of Michigan, 1500 East Medical Center Dr. 5364, Ann Arbor, 48109, MI, USA. [email protected].
  2. 2Department of Anesthesiology, Critical Care and Pain Medicine, University of California San Francisco, San Francisco, CA, USA.
  3. 3Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
  4. 4Department of Anaesthesiology and Critical Care, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
  5. 5Division of Pulmonary and Critical Care Medicine, Emory University School of Medicine, Atlanta, GA, USA.
  6. 6Division of Nephrology and Hypertension, Medical University of South Carolina, Charleston, SC, USA.
  7. 7Division of Pulmonary and Critical Care Medicine, Louisiana State University Health, Shreveport, LA, USA.
  8. 8UCHealth Memorial Central Hospital, Colorado Springs, CO, USA.
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Abstract

Background

Despite long-standing clinical use and emerging evidence, no structured framework exists guiding clinicians in identifying septic shock patients for endotoxemia assessment, interpretation of the Endotoxin Activity Assay (EAA), or practical implementation of polymyxin B hemoadsorption (PMX-HA) therapy.Methods

A modified Delphi consensus process was conducted with ten critical care and nephrology experts, compromising a pre-meeting survey, a one-day in-person consensus conference, and iterative voting on draft statements. Consensus was predefined as ≥ 80% agreement.Results

Consensus was achieved on 20 statements across three domains: (1) operational criteria to prompt endotoxemia assessment in suspected or presumed septic shock, (2) role and interpretation of the EAA, and (3) logistics and clinical implementation of PMX-HA. Key recommendations included standardized criteria to identify eligible patients, EAA thresholds of ≥ 0.60 and < 0.90 to support PMX‑HA consideration, initiation of therapy as early as possible once eligibility is confirmed, with ≤ 36 h from septic shock onset proposed as a pragmatic implementation benchmark, and standardized treatment protocols consisting of two sessions, 24 h apart, targeting 120 min each. A multidisciplinary team model was endorsed for implementation. Identified research priorities were in treatment effect heterogeneity, EAA kinetics, clinical implementation, and healthcare system integration.Conclusions

These consensus recommendations provide a structured, implementation-focused framework for PMX-HA use in suspected endotoxic shock. The framework emphasizes stepwise operational criteria, biomarker-guided decision-making, multidisciplinary team-based implementation, and standardized protocols. It is intended to support institutions currently using PMX-HA and to assist U.S. clinicians and health systems in preparing for potential adoption pending regulatory approval.

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Cite

BibTeXRIS
BibTeX
@article{yessayan2026consensus,
  title = {{Consensus recommendations for patient selection and clinical implementation of polymyxin B hemoadsorption in endotoxic septic shock.}},
  author = {Lenar Yessayan and Matthieu Legrand and Javier A Neyra and Danielle Davison and Laurence W Busse and William S Bender and Blaithin A McMahon and Jonathan Eaton and Tara Morgan-Gray and Cindy Ramberg and Ashita Tolwani},
  journal = {Critical care (London, England)},
  year = {2026},
  month = jul,
  doi = {10.1186/s13054-026-06182-8},
  url = {https://europepmc.org/article/MED/42928302},
  note = {CC BY-NC-ND},
}
RIS
TY  - JOUR
TI  - Consensus recommendations for patient selection and clinical implementation of polymyxin B hemoadsorption in endotoxic septic shock.
AU  - Lenar Yessayan
AU  - Matthieu Legrand
AU  - Javier A Neyra
AU  - Danielle Davison
AU  - Laurence W Busse
AU  - William S Bender
AU  - Blaithin A McMahon
AU  - Jonathan Eaton
AU  - Tara Morgan-Gray
AU  - Cindy Ramberg
AU  - Ashita Tolwani
PY  - 2026
DA  - 2026/07/29
JO  - Critical care (London, England)
DO  - 10.1186/s13054-026-06182-8
UR  - https://europepmc.org/article/MED/42928302
AB  - Background  Despite long-standing clinical use and emerging evidence, no structured framework exists guiding clinicians in identifying septic shock patients for endotoxemia assessment, interpretation of the Endotoxin Activity Assay (EAA), or practical implementation of polymyxin B hemoadsorption (PMX-HA) therapy.Methods  A modified Delphi consensus process was conducted with ten critical care and nephrology experts, compromising a pre-meeting survey, a one-day in-person consensus conference, and iterative voting on draft statements. Consensus was predefined as ≥ 80% agreement.Results  Consensus was achieved on 20 statements across three domains: (1) operational criteria to prompt endotoxemia assessment in suspected or presumed septic shock, (2) role and interpretation of the EAA, and (3) logistics and clinical implementation of PMX-HA. Key recommendations included standardized criteria to identify eligible patients, EAA thresholds of ≥ 0.60 and < 0.90 to support PMX‑HA consideration, initiation of therapy as early as possible once eligibility is confirmed, with ≤ 36 h from septic shock onset proposed as a pragmatic implementation benchmark, and standardized treatment protocols consisting of two sessions, 24 h apart, targeting 120 min each. A multidisciplinary team model was endorsed for implementation. Identified research priorities were in treatment effect heterogeneity, EAA kinetics, clinical implementation, and healthcare system integration.Conclusions  These consensus recommendations provide a structured, implementation-focused framework for PMX-HA use in suspected endotoxic shock. The framework emphasizes stepwise operational criteria, biomarker-guided decision-making, multidisciplinary team-based implementation, and standardized protocols. It is intended to support institutions currently using PMX-HA and to assist U.S. clinicians and health systems in preparing for potential adoption pending regulatory approval.
SN  - 1364-8535
SN  - 1466-609X
ER  -