Extracorporeal Blood Purification Techniques in Septic Shock: Operating Principles, Supporting Evidence and Clinical Applications

Several extracorporeal blood purification techniques are used to treat septic shock and other conditions characterized by the release of inflammatory mediators and bacterial toxins, notably lipopolysaccharide (endotoxin), which account for the cardiovascular, coagulation and metabolic derangements. Each technique has advantages and drawbacks, including, for most devices, the need for circuit anticoagulation and the possible removal of antibiotics. High-quality randomized trials remain scarce, and their heterogeneity in populations, techniques, dose and timing, together with the enrollment of biologically unselected patients, limits firm conclusions. In this narrative review, we describe the available techniques, critically appraise the clinical evidence for each modality against the 2026 Surviving Sepsis Campaign guidelines, and outline the phenotype-guided direction of ongoing research. The 2026 Surviving Sepsis Campaign guidelines suggest against the use of blood purification techniques in adults with sepsis or septic shock (conditional recommendation, very low certainty of evidence) and, specifically, against polymyxin-B hemoperfusion (conditional recommendation, low certainty of evidence). In the phenotype-enriched Tigris trial, polymyxin-B hemoadsorption showed a high posterior probability of mortality benefit in endotoxic septic shock; given the small sample, the imprecise primary estimate and the informative prior, this promising finding requires independent confirmation. Outside clinical trials, routine blood purification is not supported.