We report a 49-year-old man, without prior medical history, consulted in the emergency department with a 5 day history of cough, fever, and dysuria. He was admitted to the intensive care unit due to septic shock. Critical care management was initiated, including mechanical ventilation and vasopressors. Endotoxic shock was suspected (endotoxin activity assay [EAA] 0.75), and 2 treatments with Polymyxin B hemoperfusion (Toraymyxin®, Toray Medical Co., Ltd., Tokyo, Japan) were performed in 48 h, alternate with high-volume hemofiltration sessions. Initial blood cultures were positive for Neisseria meningitidis (serogroup B), and a lumbar puncture was deferred because of the coagulopathy and a bleeding risk. The circulatory efficiency significantly improved after the second procedure of hemoperfusion, and the treatment resulted in a marked decrease in the serum endotoxin level (EAA <0.4). However, after 48 h, tachycardia did not improve, left ventricular ejection fraction was 20%, and circulatory insufficiency progressed. Therefore, considering the involvement of septic cardiomyopathy and cardiogenic shock, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was initiated for circulation assistance on day 3 from admission. Continuous cytokine hemoadsorption (Cytosorb®, Cytosorbent Corporation, Monmouth Junction, NJ, USA) was incorporated into a VA-ECMO circuit for 48 h without a considerable improvement. For this reason, a 72-h continuous veno-venous hemodialysis session was started in which a high cutoff filter was used. Tachycardia and myocardial dysfunction improved by day 6, and VA-ECMO was withdrawn on the tenth day. Subsequently, nutrition management and rehabilitation were performed, and the patient was transferred to the department of respiratory medicine on day 80, he was discharged from our hospital on day 113. Sequential extracorporeal therapy may be beneficial when concomitant with circulatory assistance in uncontrollable cases of septic shock using catecholamines and blockers.

1.
Lewis LA, Ram S. Meningococcal disease and the complement system.
Virulence
. 2014 Jan;5(1):98–126.
2.
Nadel S, Ninis N. Invasive Meningococcal Disease in the Vaccine Era.
Front Pediatr
. 2018 Nov;6:321.
3.
Stephens DS, Greenwood B, Brandtzaeg P. Epidemic meningitis, meningococcaemia, and Neisseria meningitidis.
Lancet
. 2007 Jun;369(9580):2196–210.
4.
Doran KS, Fulde M, Gratz N, Kim BJ, Nau R, Prasadarao N, et al. Host-pathogen interactions in bacterial meningitis.
Acta Neuropathol
. 2016 Feb;131(2):185–209.
5.
Rouphael NG, Stephens DS. Neisseria meningitidis: biology, microbiology, and epidemiology.
Methods Mol Biol
. 2012;799:1–20.
6.
Cruz DN, Perazella MA, Bellomo R, de Cal M, Polanco N, Corradi V, et al. Effectiveness of polymyxin B-immobilized fiber column in sepsis: a systematic review.
Crit Care
. 2007;11(2):R47.
7.
Shoji H. Extracorporeal endotoxin removal for the treatment of sepsis: endotoxin adsorption cartridge (Toraymyxin).
Ther Apher Dial
. 2003 Feb;7(1):108–14.
8.
Cruz DN, Antonelli M, Fumagalli R, Foltran F, Brienza N, Donati A, et al. Early use of polymyxin B hemoperfusion in abdominal septic shock: the EUPHAS randomized controlled trial.
JAMA
. 2009 Jun;301(23):2445–52.
9.
Klein DJ, Foster D, Schorr CA, Kazempour K, Walker PM, Dellinger RP. The EUPHRATES trial (Evaluating the Use of Polymyxin B Hemoperfusion in a Randomized controlled trial of Adults Treated for Endotoxemia and Septic shock): study protocol for a randomized controlled trial.
Trials
. 2014 Jun;15(1):218.
10.
Fujii T, Ganeko R, Kataoka Y, Furukawa TA, Featherstone R, Doi K, et al. Polymyxin B-immobilized hemoperfusion and mortality in critically ill adult patients with sepsis/septic shock: a systematic review with meta-analysis and trial sequential analysis.
Intensive Care Med
. 2018 Feb;44(2):167–78.
11.
Payen DM, Guilhot J, Launey Y, Lukaszewicz AC, Kaaki M, Veber B, et al.; ABDOMIX Group. Early use of polymyxin B hemoperfusion in patients with septic shock due to peritonitis: a multicenter randomized control trial.
Intensive Care Med
. 2015 Jun;41(6):975–84.
12.
Dellinger P. EUPHRATES: evaluating the use of polymyxin B hemoperfusion in a randomized controlled trial of adults treated for endotoxemia and septic shock. Toronto: Canadian Critical Care Forum; 2016.
13.
De Rosa S, Villa G, Ronco C. The golden hour of polymyxin B hemoperfusion in endotoxic shock: the basis for sequential extracorporeal therapy in sepsis.
Artif Organs
. 2019, Epub ahead of print.
14.
Borthwick EM, Hill CJ, Rabindranath KS, Maxwell AP, McAuley DF, Blackwood B. High-volume haemofiltration for sepsis in adults.
Cochrane Database Syst Rev
. 2017 Jan 31;1:CD008075.
15.
Vieillard-Baron A, Cecconi M. Understanding cardiac failure in sepsis.
Intensive Care Med
. 2014 Oct;40(10):1560–3.
16.
Bloch A, Berger D, Takala J. Understanding circulatory failure in sepsis.
Intensive Care Med
. 2016 Dec;42(12):2077–9.
17.
Kellum JA, Mehta RL, Angus DC, Palevsky P, Ronco C; ADQI Workgroup. The first international consensus conference on continuous renal replacement therapy.
Kidney Int
. 2002 Nov;62(5):1855–63.
18.
Clark E, Molnar AO, Joannes-Boyau O, Honoré PM, Sikora L, Bagshaw SM. High-volume hemofiltration for septic acute kidney injury: a systematic review and meta-analysis.
Crit Care
. 2014 Jan;18(1):R7.
19.
Ankawi G, Neri M, Zhang J, Breglia A, Ricci Z, Ronco C. Extracorporeal techniques for the treatment of critically ill patients with sepsis beyond conventional blood purification therapy: the promises and the pitfalls.
Crit Care
. 2018 Oct;22(1):262.
20.
De Vriese AS, Vanholder RC, Pascual M, Lameire NH, Colardyn FA. Can inflammatory cytokines be removed efficiently by continuous renal replacement therapies?
Intensive Care Med
. 1999 Sep;25(9):903–10.
21.
Parker MM, Shelhamer JH, Bacharach SL, Green MV, Natanson C, Frederick TM, et al. Profound but reversible myocardial depression in patients with septic shock.
Ann Intern Med
. 1984 Apr;100(4):483–90.
22.
Nemeth E, Szigeti S, Varga T, Daroczi L, Barati Z, Merkely B, et al. Continuous cytokine haemoadsorption incorporated into a venoarterial ECMO circuit for the management of postcardiotomy cardiogenic and septic shock – a case report.
Perfusion
. 2018 Oct;33(7):593–6.
23.
Dogan G, Hanke J, Puntigam J, Haverich A, Schmitto JD. Hemoadsorption in cardiac shock with bi ventricular failure and giant-cell myocarditis: A case report.
Int J Artif Organs
. 2018 Aug;41(8):474–9.
24.
Muller G, Flecher E, Lebreton G, Luyt CE, Trouillet JL, Bréchot N, et al. The ENCOURAGE mortality risk score and analysis of long-term outcomes after VA-ECMO for acute myocardial infarction with cardiogenic shock. Intensive Care Med. 2016 Mar;42(3):370–8.
25.
Poli EC, Rimmelé T, Schneider AG. Hemoadsorption with CytoSorb®.
Intensive Care Med
. 2019 Feb;45(2):236–9.
26.
Bonavia A, Groff A, Karamchandani K, Singbartl K. Clinical Utility of Extracorporeal Cytokine Hemoadsorption Therapy: A Literature Review. Blood Purif. 2018;46(4):337–49.
27.
Morgera S, Slowinski T, Melzer C, Sobottke V, Vargas-Hein O, Volk T, et al. Renal -replacement therapy with high-cutoff hemofilters: impact of convection and diffusion on cytokine clearances and protein status. Am J Kidney Dis. 2004 Mar;43(3):444–53.
28.
Villa G, Chelazzi C, Morettini E, Zamidei L, Valente S, Caldini AL, et al. Organ dysfunction during continuous veno-venous high cut-off hemodialysis in patients with septic acute kidney injury: A prospective observational study.
PLoS One
. 2017 Feb;12(2):e0172039.
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