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

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.

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.

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.

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.