03/2017
Use of CytoSorb in septic shock after colon perforation and 4-quadrant peritonitis

Dr. med. Wojciech Palinkiewicz, PD Dr. med. Thorsten Krause | Hospital Reinbek St. Adolf-Stift GmbH (Germany), Anesthesiology, Intensive Care Medicine, Pain Therapy and palliative care

Summary:

This case study reports on a 60-year-old female patient, who was hospitalized for elective debulking surgery after diagnosis of ovarian carcinoma (FIGO IV).

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Case presentation

  • Postoperative transfer to intensive care unit and 3 days later transfer to normal ward
  • Deterioration in her general condition with development of an acute abdomen and relaparotomy 2 days later
  • After relaparotomy re-admission to the intensive care unit with septic shock after colon perforation and 4-quadrant peritonitis
  • At the time of admission, the patient had an APACHE 2 score of 30, severe septic shock with acute renal failure
  • Despite antibiotic therapy (initially meropenem and then after 24h changed to piperacillin/ tazobactam according to antibiogram) as well as protocol-based volume therapy, the patient developed a highly catecholamine-dependent cardiac insufficiency with norepinephrine dosages of up to 38 μg/min
  • Due to anuria despite sufficiently positive volume balance, CVVHDF therapy was initiated in conjunction with Cytosorb

Treatment

  • Two treatments with CytoSorb for a total duration of 48 hours (24 hours each)
  • Cytosorb was applied in conjunction with CRRT (Prismaflex, Gambro Hospal GmbH)  run in CVVHDF mode
  • Blood flow: 100-150 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: post-hemofilter

Measurements

  • Demand of catecholamines
  • Parameters of infection (leucocytes, CRP, PCT)
  • Creatinine
  • SAPS 2
  • Lactate

Results

  • Shock-reversal after a total of 2 treatment cycles to <25% of the initial norepinephrine dose; – further maintenance of norepinephrine infusion was necessary most probably due to the ongoing need for analogosedation.  From day 5 the patient was catecholamine-free
  • Significant reduction in inflammatory parameters with CytoSorb therapy
  • Stabilization of lactate acidosis, after 3 days normalization of the plasma lactate values
  • Dose adjustment of the antibiotic therapy was not necessary

EN

Patient Follow-Up

  • Completion of renal replacement therapy 30 hours after cessation of CytoSorb treatment with normal renal clearance parameters
  • During hospitalization, the patient developed a delirious syndrome, resulting in prolonged weaning
  • During hospitalization the patient had to be tracheotomized
  • During the recovery phases, the patient showed a left-sided hemiparesis. A CCT examination revealed the suspicion of meningeal suspensions in the context of metastases with brain swelling. However, the cerebrospinal fluid showed no malignant cells.
  • Tracheal decannulation 28 days after the last application of Cytosorb
  • Transfer to normal ward 30 days after the last Cytosorb treatment with normal renal values
  • Discharge to geriatric rehabilitation 69 days after the last Cytosorb adsorber application

CONCLUSIONS

  • Clear stabilization and consolidation of hemodynamics and inflammatory parameters under CytoSorb therapy within 48 hours
  • The application of CytoSorb therapy was simple, safe and the installation of the adsorbers was possible without problems