01/2017
Use of CytoSorb in severe septic shock

Dr. med. Volkmar Hanisch, Dr. med. Andreas Graf, Prof. Dr. med. Sebastian M. Schellong Municipal Hospital Dresden, Location Friedrichstadt, II. Medical Clinic, Center for Internal Intensive Care Medicine and Emergency Therapy

Summary:

This case study reports on an 83-year-old female patient (pre-existing diseases: coronary heart disease, condition post LIMA on RIVA, long-QT-syndrome, intermittent atrial fibrillation, arterial hypertension, post hysterectomy and cholecystectomy), who was found at home by the emergency services after she had fallen and sustained a scalp laceration and multiple bleeding abrasions after a recent history of nausea, ‘slimy’ vomit, and weakness over the previous weeks.

button_EN

Case presentation

  • When found at home, the patient had a heart rate of 90/min and a blood pressure of 77/40 mmHg
  • Immediate on-site administration of 500 mls of crystalloids i.v. and subsequent transfer and presentation to the Emergency Room
  • On admission, the patient was cool and pale, hypotonic, slow to respond, with a respiratory rate of 33/min, pH 7.27 and lactate 9.5 mmol/l
  • Administration of 1500 mls of crystalloids i.v., wound care and withdrawal of 2 blood cultures as well as start of antibiotic therapy with piperacillin/tazobactam
  • Chest X-ray showed minor signs of emphysema, cranial CT was negative, and CT abdomen showed evidence of intra-hepatic cholestasis without clear cause, as well as sigmoid diverticulosis
  • Laboratory values at this time: hemoglobin 7.3 mmol/l, leukocytes 18 Gpt/l, platelets 199 Gpt/l, PCT 12 ng/ml, Quick 60, bilirubin (total) 128 mmol/l, bilirubin (direct) 110 mmol/l, aspartate aminotransferase (AST) 2.89 mmol/l, alanine aminotransferase (ALT) 2.49 mmol/l,  gamma-glutamyltransferase (GGT) 12.82 mmol/l, alkaline phosphatase 5.13 mml/l, glomerular filtration rate (GFR) 28.9 ml/l
  • Admission to Intermediate Care (IMC) and initiation of arterial pressure measurement and placement of a femoral central venous catheter (CVC)
  • Despite volume replacement, rapidly increasing need for vasopressor therapy and persistant high lactate
  • After a further 4 hours, transfer to the internal intensive care unit with diagnosis of septic shock (suspected abdominal focus) with an APACHE II score of 27, acute anuric kidney failure, early stage liver failure and suspected septic encephalopathy
  • With further increases in volume requirements and ongoing anuria, initiation of renal replacement therapy (CVVHDF) and administration of dobutamine and levofloxacin
  • On the following day suspicion of cholangitis so initiation of an emergency endoscopic retrograde cholangio-pancreaticography (ERCP) with papillotomy (EPT) and insertion of a stent in the draining bile duct (DHC)
  • Postoperatively elevated plasma levels of IL-6 (> 5000 pg/ml) and PCT (88 ng/ml)
  • Initiation of advanced hemodynamic monitoring (PiCCO)
  • Due to the presence of septic shock as well as acute renal failure, CytoSorb was added to the CRRT circuit 20 h after the initial ambulatory emergency treatment

Treatment

  • One treatment with CytoSorb over a total treatment period of 24 hours
  • Cytosorb® was applied in conjunction with CRRT (Prismaflex, Firma Gambro) run in CVVHDF mode
  • Blood flow: 120 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: post-hemofilter

Measurements

  • Demand of catecholamines
  • IL-6 and PCT
  • Lactate
  • Bilirubin

Results

  • Hemodynamic stabilization with a clear reduction of norepinephrine doses from 0.4 μg/kg/min to 0.04 μg/kg/min and a complete cessation of catecholamines 24 hours later
  • Clear reduction in inflammation-relevant parameters (IL-6 from >5000 to 268 pg/ml, PCT from 88 to 26 ng/ml) during the course of the treatment
  • Normalization of the lactate plasma levels
  • Significant reduction in plasma bilirubin levels from 128 to 28 μmol/l

Patient Follow-Up

  • Ongoing abdominal pain associated with an increase in creatine kinase levels, clinical suspicion of colitis
  • Colonoscopy showing sigma diverticulosis, mucosal bleeding in the ascending colon, ulcerative lesions in the rectum
  • On the 3rd day proof of E. coli in the blood culture followed by deescalation of antibiotic therapy to Rocephin
  • On day 4 successful extubation and another day with non-invasive ventilation
  • On day 5 termination of CVVHDF as well as start of enteral nutrition via a nasogastric tube and transition to a normal diet
  • Day 6-10: Polyuric phase, delirium, detection of critical-illness polyneuropathy followed by referral for rehabilitation
  • Day 11: Normalization of retention parameters
  • Day 12: Transfer of the patient to the normal ward for another 10 days where she was able to take some initial steps on the walking bench
  • After 43 days the patient was able to be discharged from the rehabilitation clinic to her home environment without any deficits

CONCLUSIONS

  • Clear stabilization and consolidation of hemodynamics and reduction of inflammatory mediators under CytoSorb within 24 hours in addition to standard therapy
  • Regain of control of septic shock and decrease of plasma bilirubin levels within a short period of time
  • The early start of CytoSorb therapy was possibly decisive for the good clinical course of the patient
  • The application of CytoSorb therapy was simple, safe and without problems installing the adsorber in a post-hemofilter position