13/2017
Use of CytoSorb in complex therapy of generalized meningococcal infection, septic shock and MOF in a pediatric patient – case report

Dr. Konstantin V. Serednyakov Head of ICU and CRRT Unit, FMBA Children Infections Scientific Research Center, St.Petersburg, Russia

Summary:

This case study reports on a 8-month old, 10 kg female infant who was admitted to the emergency department with a temperature of 38.6°C and signs of systemic inflammation.

button_EN

Case presentation

  • The day before whilst at home the temperature was already 38.6°C, the doctor had diagnosed an acute respiratory viral infection (ARVI), and prescribed an antifebrile drug, drotaverin and corvalol.
  • Over night the temperature further rose to 39.9°C, and at the time of diaper change the mother noticed a rash on the infants thighs and stomach so an ambulance took the infant to the emergency department
  • On admission, dexamethasone was administered i.v., the infant was breathing spontaneously, and no venous access was required
  • Patient was transferred to the ICU on the same day in a critical condition and had to be intubated and ventilated
  • Hemodynamic support by inotropes (dobutamine 5-10 mcg/kg/min) and vasopressors (noradrenaline 0.5 mcg/kg/min)
  • Patient was in a critical condition suffering from meningococcal meningitis, accompanied by severe meningococcal sepsis, refractory septic shock and multiple organ failure (central nervous system, respiratory failure from multiple causes, circulatory, renal, coagulation, metabolic) with a SOFA score of 13
  • Complex anti-shock therapy was initiated including ventilation in pressure control mode, inotrope and vasopressor support, volume restriction strategy and fluid management, antibaсterial therapy (Ceftriaxone 100 mg/kg/day), immunosupportive therapy (Pentaglobin 5 ml/kg № 3), nutritional supplementation, coagulation factors deficit compensation (FFP transfusion – total dose 110 ml/kg), Anemia correction (filtered erythrocyte suspension transfusion), patient was nursed supine with head at 30°; diuretic drugs, symptomatic therapy (hemostatics, probiotics), neurometabolic therapy (Cytoflavin)
  • Two hours after admission CVVH was initiated and five hours after admission cytokine adsorption therapy was started using CytoSorb installed into CVVH circuit.

Treatment

  • One treatment with CytoSorb for 11 hours
  • CytoSorb was used in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) performed in CVVHDF mode
  • Blood flow rate: 80 ml/min
  • Anticoagulation: heparin
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Hemodynamics
  • Inflammatory parameters (CRP, PCT, IL-6, IL-10)
  • Renal function (creatinine, urea)
  • PaO2: FiO2 ratio

Results

  • During the first 24 hours after the start of cytokine adsorption, vasopressor need decreased drastically
  • Significant reduction of inflammatory parameters (i.e. IL-6, IL-10, PCT) during the treatment
  • Improvement of the ventilation parameters (i.e. PaO2: FiO2 ratio)

tabelle_E

Patient Follow-Up

  • CVVH could be stopped 17 hours after initiation
  • Septic shock resolved within 72 hours with no further signs of systemic inflammation development thereafter
  • ARDS threat did not materialize and the patient was extubated on day 4 after admission
  • Gastric tube was extracted on day 5 and the patient received feeding per mouth with good digestion afterwards

CONCLUSIONS

  • Rapid hemodynamic stabilisation, which was a result of complex anti-shock therapy and extracorporeal hemo-correction. The laboratory values confirmed that with the start of cytokine adsorption the deleterious process was quickly under control and could be rapidly stopped
  • It was possible to lower vasopressor dosages just 6 hours after therapy start
  • Quick improvement in the patient condition, due to, in large part, cytokine adsorption procedure using CytoSorb
  • Despite the fact that the clinical role of cytokine adsorption is to be determined, this initial use is promising and justifies further study