Refractory vasoplegic septic shock after gallbladder perforation: a case report and focused review of oXiris-enhanced CRRT

Authors

• Manal Alghamdi Critical Care Department, King Fahad Military Medical Complex, Dhahran, Saudi Arabia
• Ahmed Abutaleb Critical Care Department, King Fahad Military Medical Complex, Dhahran, Saudi Arabia
• Majid Rashid Critical Care Department, King Fahad Military Medical Complex, Dhahran, Saudi Arabia
• Abdalla Almolhem Critical Care Department, King Fahad Military Medical Complex, Dhahran, Saudi Arabia
• Ahmed Sewify Biomedical Engineering Centre, Institute for Technology and Innovation, Faculty of Engineering, University of Southern Denmark, Odense, Denmark
• Ahmad Elsayed Critical Care Department, King Fahad Military Medical Complex, Dhahran, Saudi Arabia
• Khaled Sewify Critical Care Department, King Fahad Military Medical Complex, Dhahran, Saudi Arabia

drsewafie@hotmail.com

Keywords

Abstract

Introduction: Persistent vasoplegia after source control and guideline-based care remains a major challenge in septic shock. In patients with acute kidney injury requiring continuous renal replacement therapy (CRRT), oXiris combines renal support with endotoxin and cytokine adsorption, but evidence certainty remains low.
Case description: A 70-year-old woman developed septic shock, acute respiratory distress syndrome, coagulopathy, metabolic acidosis and oliguric/anuric acute kidney injury after gallbladder perforation. Urgent surgical drainage, broad-spectrum antimicrobials, corticosteroids, mechanical ventilation, norepinephrine 20–25 µg/min and vasopressin 0.04 U/min did not reverse vasoplegia. oXiris-based continuous veno-venous haemodialysis began on intensive care unit (ICU) day 3, when the Sequential Organ Failure Assessment (SOFA) score was 18. Norepinephrine fell to 3 µg/min by treatment hour 17.75 and was discontinued on ICU day 5; vasopressin stopped on day 9. SOFA fell to 8 within 48–72 hours. CRRT ended after approximately 69 hours, mechanical ventilation was discontinued on day 8, kidney function recovered, and the patient was discharged home on hospital day 36.
Discussion: Early vasopressor de-escalation was the strongest temporally linked signal; however, source control and multimodal care prevent causal attribution. Recent oXiris meta-analyses report favourable cytokine, haemodynamic and inflammatory surrogate signals, but the 2026 Surviving Sepsis Campaign conditionally suggests against blood-purification techniques because patient-important benefits remain uncertain.
Conclusion: Time-limited oXiris-enhanced CRRT may be considered as an adjunct in carefully selected, source-controlled patients with refractory vasoplegia and an independent CRRT indication, but the observation is hypothesis-generating and does not establish efficacy; prospective phenotype-enriched trials are needed.

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