21/2016
Case report of a patient with multiorgan failure due to severe SIRS in cardiac failure additionally treated with CytoSorbents haemadsorption as an adjunctive therapy

Klaus Kogelmann, Matthias Drüner, Dominik Jarczak, Department of Anaesthesiology and Intensive Care Medicine, Hospital Emden

Summary:

This case study reports on a female patient who was admitted to hospital after she collapsed several times at home

 

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Case presentation

  • Patients medical history included peripheral arterial obstructive disease, arterial hypertension and a previous minor stroke
  • Glasgow Coma scale was 11, heart rate 20 bpm, hypothermia 30 °C, metabolic acidosis with pH 7.2, no measurable blood pressure
  • After immediate resuscitation the patient developed severe SIRS and multiple organ failure with cardiogenic shock due to refractory cardiac arrhythmia • Initial ultrasound of heart function showed diffuse hypokinesia and an ejection fraction (EF) of around 45 %, with a heart rate of 36 bpm
  • 24 hours of conventional treatment (differentiated catecholamine therapy with combined norepinephrine and adrenaline, ultrasound guided volume therapy, lung-protective ventilation, temporary cardiac pacemaker)
  • Following this, ultrasound showed diffuse dysfunction and hypokinesia with an EF of 50 %
  • Laboratory tests and electrocardiography on admission showed neither myocardial infarction nor evidence of infection but highly elevated liver enzymes and creatinine
  • Due to high and stable catecholamine support associated with persistent renal failure, CytoSorb therapy and CRRT were initiated

Treatment

  • Duration of therapy with CytoSorb was 72 hours
  • Three CytoSorb treatment sessions for 24 hours each
  • CytoSorb was used in conjunction with citrate dialysis (Multifiltrate; Fresenius Medical Care) in CVVHD mode
  • Blood flow rate: 100 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Before, during and after treatment
    o SAPS II-Score, SOFA-Score
    o Mean Arterial Pressure
    o Requirement for norepinephrine
    o Blood lactate level
  • During therapy
    o Demand of norepinephrine (µg/h vs. mmHg MAP)

Results

  • During CytoSorb therapy the authors observed a decrease in catecholamine demand of more than 95 %, and 72 h after therapy the patient was free of catecholamines
  • SOFA Score did not change; SAPS II-Score decreased to 50 % of its initial value
  • Blood lactate decreased from 46.9 to 21.4 mg/dl
  • Liver function tests improved, AST decreased from 5355 U/L to 431 U/L 3 days later; ALT decreased from 4858 U/L to 888 U/L and LDH decreased from 6859 to 242 U/L

Patient Follow-Up

  • 12 days after treatment the liver enzymes had returned to normal values
  • Chest X-ray 10 days after admission showed only slight effusions, 6 days later she could be weaned from ventilation, the patient was alert, vigilant and stable clinically without the requirement for catecholamines
  • During therapy, blood natriuretic peptide level showed a tenfold increase to 1.959 pg/ml as a marker of left ventricular dysfunction
  • Coronary angiography showed three vessel coronary artery disease with ischemic cardiomyopathy as the reason for the patients cardiac arrhythmia which had led to pump failure and the severe SIRS

Conclusions

  • Treatment using CytoSorb adsorption in this patient with severe cardiac failure due to ischemic cardiomyopathy was associated with significant clinical improvement, was safe and without apparent side effects
  • The authors note that CytoSorb therapy was helpful even in a patient with marked cardiac failure leading to severe SIRS