20/2017
Use of CytoSorb in a case of severe septic shock and MOF due to urosepsis

Heike Keller, Dr. med. M. Schmidt, Dipl.-Med. Dirk Weiland - Werner Forßmann Hospital Eberswalde, Intensive Care Unit of the Department for Anesthesiology and Intensive Care Medicine, Germany

Summary:

This case study reports on a 55-year-old severely obese female patient (BMI 50 kg/m2), who presented at the Emergency Center with abdominal symptoms and signs of a generalized infection (tachycardia, hypotonia, tachypnea and hypercapnia).

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Case presentation

  • Immediately after admission laboratory diagnostics (blood and urine culture) and CT abdomen were done
  • On the basis of proven urinary congestion left, decision taken to implant a bilateral ureteral splint and the patient was operated on after another hour
  • In the course of intubation, the patient had to be resuscitated (1 cycle, 1 mg adrenaline)
  • After surgery, the patient was transferred to the intensive care unit – intubated, ventilated, hemodynamically unstable and catecholamine-dependent
  • Initiation of calculated antibiotic therapy with ciprofloxacin and piperacillin/tazobactam, after the detection of E. coli in the urine culture with de-escalation to piperacillin/tazobactam
  • On the 1st postoperative day, development of anuria with a sharp increase in retention parameters (creatinine 554 μmol/l, urea 23.9 mmol/l, GFR 7.2 ml/min) and inflammatory parameters (CRP> 500 mg/l, PCT 350 ng/ml, leukocytes 22.7 GPT/l)
  • Progressing hemodynamic instability with increasing doses of norepinephrine (0.3 μg/kg/min) and lactic acidosis (11.8 mmol/l), PICCO: CI 3,73 l/min/m2; EVLWI 12,5ml/m2; ITBVI 1715 ml/m2
  • Due to acute renal failure and septic shock with massively increased inflammatory parameters, renal replacement therapy was started in combination with CytoSorb therapy
  • Final diagnosis: urosepsis with multiple organ failure (cardiovascular, kidney, lung)

Treatment

  • Four consecutive treatments with CytoSorb for a total treatment time of 96 hours
  • CytoSorb was used in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) performed in CVVHD mode
  • Blood flow rate: 150 ml/min
  • Anticoagulation: initially none, later heparin
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Advanced hemodynamic monitoring (PiCCO)
  • Renal function
  • Inflammatory parameters (CRP, PCT, leucocytes)
  • Lactate

Results

  • Hemodynamic stabilization with significant reduction in catecholamine dosages – norepinephrine could be reduced from 0.3 μg/kg/min initially to 0.13 μg/kg/min within the first 3 days of treatment
  • Significant improvement in renal function
  • Within the first 3 days, reduction in leukocytes to 17.2 Gpt/l, CRP to 431 mg l and PCT to 147 ng/ml
  • Lactate decreased from 11.8 mmol/l initially to 3.8 mmol/l within the first 3 days of treatment and normalized after 10 days

Patient Follow-Up

  • Tracheotomy on the 8th postoperative day and weaning from mechanical ventilation on the 13th postoperative day
  • Termination of renal replacement therapy on the 13th postoperative day, however, further necessity for intermittent dialysis
  • In the further course, development of a Critical Illness Myopathy (CIM) and Critical Illness Polyneuropathy (CIP)
  • 27 days after CytoSorb the patient was discharged straight to rehabilitation

CONCLUSIONS

  • The surgical and intensive care treatment of urosepsis (focus eradication, antibiotic therapy, other sepsis therapies) and the early application of CytoSorb in combination with renal replacement therapy was accompanied by a rapid and significant stabilization of hemodynamics and declining catecholamine dosages as well as a reduction in inflammatory parameters
  • According to the medical team, its early use proved to be useful and effective considering the severity of the disease including multi-organ failure
  • Safe and easy application of CytoSorb