06/2017
Use of CytoSorb in necrotizing fasciitis and severe septic shock

Dr. Yones Salameh, Prof. Dr. Wolfgang Seitz Sana Hospital Hameln-Pyrmont (Germany), Anaesthesiology and Intensive Care Medicine

Summary:

This case study reports on a 57-year-old female patient (known pre-existing diseases: arterial hypertension, poorly adjusted diabetic mellitus type II, peripheral arterial vascular disease), who was admitted to the emergency department with symptoms of sepsis, somnolence, deranged blood glucose of 1000 mg/dl and lactate acidosis.

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Case presentation

  • After initial admission immediate transfer to the intensive care unit
  • Diagnosis of an abscess in the rectogenital region however without initial surgical intervention, immediate start of protocol-based sepsis therapy
  • Long-term medication of the patient: candesartan, simvastatin, hydrochlorothiazid, metformin, insulin
  • Further deterioration on the intensive care unit, on the following day requirement of intubation and controlled ventilation due to increasing respiratory insufficiency
  • Development of multiple organ failure and severe ketoacidosis in the context of her septic disease pattern
  • Surgical focus treatment on the day after initial admission – radical skin and subcutis debridement and excision as well as significant removal of necrotic tissue
  • Intraoperative diagnosis: perianal/gluteal/to retroperitoneal abscess formation in the sense of a Fournier gangrene
  • Postoperative transfer to ICU with further deterioration of her circulatory (norepinephrine 1 mg/h) and metabolic status (lactate 2.9 mmol/l, pH 6.9)
  • Highly elevated inflammation parameters (leukocytes 52.000, CRP 24 mg/dl, PCT 3 ng/ml) and greatly impaired renal function (creatinine 2.1 mg/dl, urea 67 mg/dl, GFR 26 ml/min, anuria)
  • Antibiotic therapy initially with ampicillin/sulbactam and later metronidazol, 2 days later escalated to meronem, gentamycin, metronidazol
  • Due to her acute renal insufficiency as well as the hemodynamic instability and the increased inflammation markers the decision was made to initiate CytoSorb as adjunctive therapy together with a CVVHD

Treatment

  • Two consecutive treatments with CytoSorb for 24 hours each
  • CytoSorb was used in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) performed in CVVHD mode
  • Blood flow rate: 180 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Demand for catecholamines
  • Renal function (creatinine, urea, GFR, excretion)
  • Inflammatory parameters (CRP, PCT, leucocytes)
  • Metabolic variables: lactate, pH

Results

  • Hemodynamic stabilization with a significant reduction in catecholamine doses – norepinephrine from initially 1 mg/h to 0.5 mg/h within the first 24 hours, after 48 hours to 0.25 mg/h, patient was free from catecholamines 6 days after completion of the last CytoSorb treatment
  • Moderate reduction in inflammatory parameters under CytoSorb therapy (CRP 20 mg/l,  leucocytes 30,000/µl,  PCT 2,5 ng/ml)
  • Clear improvement in renal function during the two treatment cycles: normalization of creatine and urea values, GFR from 26 to 90 ml/min, recovery of quantitative excretion (1,6 l/24 h)
  • Significant improvement of ketoacidosis, lactate decreased to 1.7 mmol/l, normalization of pH

Patient Follow-Up

  • Daily surgical wound care, disinfection, removal of necrotic tissue
  • Termination of renal replacement therapy 1 day after CytoSorb application with complete recovery of kidney function
  • Weaning and extubation successful 6 days after CytoSorb application
  • In the days post extubation, the patient presented as clinically stable
  • Development of delirium, which normalized within the next 2 weeks
  • Surgical installation of a sigmoidostoma and a sliding flap
  • 26 days after the use of CytoSorb the patient was discharged to the normal ward

CONCLUSIONS

  • Treatment with CytoSorb was accompanied by an unexpectedly rapid and significant stabilization in vital functions (renal function, hemodynamics) as well as declining catecholamine doses within the two treatment cycles
  • The installation of the absorber into the CVVH circuit as well as the application of CytoSorb itself was simple and safe