21/2017 CytoSorb in distributive shock with multi-organ failure in the context of acute, severe exudative pancreatitis
Dr. Bernd Yuen, Frau Dr. Pamela Dreessen, Frau Dr. Barbara Lienhardt Nobbe Interdisciplinary Intensive Care Unit, Spital Bülach, Switzerland
This case study reports on a 67-year-old male patient, who was admitted to the Emergency Department with diffuse abdominal pain and recurrent vomiting for 24 hours.
Rapid transfer to the interdisciplinary intensive care unit (ICU) with the diagnosis of acute severe pancreatitis with pronounced lactic acidosis and encephalopathy
Medical history revealed laparoscopic appendectomy in 2007 for an acute appendicitis, a laparotomy in 2007 because of a gangrenous cholecystitis as well as an idiopathic edematous pancreatitis in 2008. In addition, he had arterial hypertension managed with perindopril.
On admission to the ICU, the patient was disoriented and encephalopathic, with a blood pressure of 130/80/65 mmHg, a sinus tachycardia of 125/min, an SpO2 of 91% with 3 liters of O2 nasal and a temperature of 37.5 ° C
The initial blood gas analysis showed a lactic acidosis with a pH of 7.28 (BE -6.1 mmol/L, lactate 10.7 mmol/L)
He had signs of marked volume deficiency with hemoconcentration (hemoglobin of 21.0 g/dl, hematocrit 64%) and a completely collapsed inferior vena cava on sonography
Furthermore, he had an activated coagulation with an INR of 2.4, as well as a thrombocytopenia of 122,000/μl
CRP was 212 mg/l and procalcitonin was 9.1 ng/ml
Despite aggressive volume resuscitation, the patient deteriorated continuously over the next 12 hours
Hemodynamically, the patient became catecholamine-dependent, because of progressive respiratory failure he was intubated and mechanicaly ventilated, due to decreased urinary output to less than 0.5 ml/kgKG/h as well as persistent severe lactic acidosis CRRT was initiated
He also had a paralytic ileus with increasing intra-abdominal hypertension up to a maximum bladder pressure of
22 mmHg, and a septic cardiomyopathy with positive cardiac biomarkers and a diffuse severely impaired systolic pump function (EF 25%) as well as low cardiac index of 2.0 l/min/m2
Due to the catecholamine- and volume-refractory shock, continuing vasoactive and volume therapy was guided by using advanced hemodynamic monitoring with the PiCCO system
To maintain a MAP of at least 60 mmHg, norepinephrine doses of up to 55 μg/min were required
Due to the low cardiac index, dobutamine up to 200 μg/min and also levosimendan were given
In addition, hydrocortisone was used as an adjunctive therapy at a dose of 4×50 mg/d
At this time, the physicians decided to add an additional treatment using CytoSorb due to the severe distributive and cardiogenic shock with severe capillary leak
Two consecutive treatments with CytoSorb for a total treatment time of 36 hours (1st treatment for 12 hours, 2nd treatment for 24 hours)
CytoSorb was used in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) performed in CVVHD mode
Blood flow rate: 110 ml/min
CytoSorb adsorber position: pre-hemofilter
Hemodynamic parameters and demand for catecholamines
Inflammatory parameters (leucocytes, CRP, PCT)
Hemodynamically, impressive stabilization was noted, so that norepinephrine therapy could be reduced from 55 μg/min to 10 μg/min within 24 hours and consecutively stopped after 48 h. At the same time, lactate levels normalized accompanied by a reduction in volume requirements
After the patient had a total balance of +13 liters in the first 36 hours, the balance could be reduced to +1.5 liters over the next 24 hours. Negative balance could already be achieved from the third day onwards.
The course of the inflammatory parameters was as follows: CRP showed a peak at 432 mg/l after 48 hours and continued to decrease thereafter. PCT showed its highest value of 9.1 ng/ml at the first day and declined thereafter
Minimal diuresis was always maintained during CRRT and improved continuously so that CRRT could be stopped after 50 hours and diuresis could be stimulated by furosemide.
Percutaneous tracheostomy had to be performed on day 8 because of a protracted wake-up response due to multifactorial, metabolic-inflammatory encephalopathy and prolonged weaning
Due to the abdominal hypertension, the patient was on parenteral nutrition in the first days. After stabilization he was successfully converted to enteral nutrition.
Finally, the patient could be de-cannulated on day 21 and was transferred hemodynamically stable and neurologically aware to the peripheral ward
While still in the hospital, his condition improved so impressively that he was able to walk on his own and was able to feed himself independently.
CytoSorb treatment resulted in rapid hemodynamic stabilization with shock-reversal within less than 48 hours
The capillary leak also improved while volume requirements decreased significantly and the patient could be in negative balance from the third day onwards. This also had a positive impact on the course of the grade III abdominal hypertension.
Application of CytoSorb therapy was simple and without complications