22/2017
Use of CytoSorb in suspected cholangitis with E. coli sepsis and endotoxin shock

Dr. Bodo Albrecht, Dr. Peter Wolf Department for Anesthesiology and Intensive Care Medicine, Zeisigwald Clinics Bethanien Chemnitz

Summary:

This case study reports an 81-year-old female patient (pre-existing diseases: suspected chronic pancreatitis due to lithiasis, pulmonary fibrosis, polyarthritis with multiple joint replacements, morbid obesity – BMI 33), who was found collapsed at home by the rescue service and was brought to the emergency department in a coma-like, hyperglycemic state (33 mmol/l).

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Case presentation

  • Prior medical history showed only dysenteric complaints and multiple arthroses (especially hip and shoulder)
  • Admission to Intermediate Medical Care on the same day and further transfer to the intensive care unit the following day due to respiratory insufficiency
  • Initiation of antibiotic therapy with moxifloxacin due to the suspicion of pneumonia
  • After therapy for hyperglycemia and volume depletion, rapid development of sepsis and later septic shock (PCT 73.1 μg/l, leukocytes 15,000/μl) accompanied by metabolic acidosis (lactate 7 mmol/l, pH 7.22, base process -20)
  • Immediately after ICU admission – intubation, mechanical ventilation, and start of a high-dose vasopressor (norepinephrine 4 mg/h) and volume therapy (6 liters/12 hours) plus hydrocortisone (200 mg/day)
  • Complementary antibiotic therapy with cefotaxime, as gram-negative rods were detected in the blood culture
  • Subsequently further focused investigations: biopsy of the hip joint (E.coli, with blood smearing, later found to be sterile), chest x-ray, ultrasound examination of the gall bladder showed a solitary stone
  • Diagnosis of a transient cholestasis in the context of her known stone ailments (ASAT 15.5 μkat/l, ALAT 6.05 μkat/l, GGT 1.02 μkat/l, alkaline phosphatase 5.1 μkat/l), only slightly increased bilirubin levels on admission, later marked thickening of the gall-bladder wall in control sonography – later found to be regressive
  • Due to anuria, multiple organ failure and refractory septic shock, continuous renal replacement therapy was commenced in combination with CytoSorb
  • Meanwhile diagnosis of bladder carcinoma due to macrohaematuria and subsequent cytoscopy diagnostics
  • Final diagnosis: acute septic cholangitis with E.coli sepsis

Treatment

  • Two treatments with CytoSorb for a total treatment period of 43 hours (1st treatment for 24 hours, 2nd treatment for 15 hours, separated by a 4 hour pause)
  • CytoSorb was used in conjunction with CRRT (BM11/BM14, Baxter) performed in CVVHDF mode
  • Blood flow rate: 130 ml/min
  • Anticoagulation: heparin
  • CytoSorb adsorber position: post-hemofilter

Measurements

  • Demand for catecholamines
  • Renal function (diuresis)
  • Liver function (bilirubin, transaminases)
  • Inflammatory parameters (PCT, leucocytes)
  • Metabolics (Lactate, base excess, pH)

Results

  • Moderate hemodynamic stabilization with initial reduction in catecholamines but a later rebound – norepinephrine after 24 hours of treatment 2 mg/h – thereafter an increased to 5 mg/h was noticed, this was however in the context of a developing tachyarrhythmia
  • After 24 hours of treatment, diuresis started (10-20 ml/hour). During simultaneous discontinuation of CVVHDF/CytoSorb the patient became polyuric – creatinine levels did not rise above 150 μmol/l at any time after completion of both procedures
  • Clear improvement in liver function with reduction of relevant parameters during the course of the two treatment cycles: ASAT to 7.7 µkat/l, ALAT to 4.4 µkat/l, alkaline phosphatase to 4.07 µkat/l
  • Inflammatory parameters: PCT dropped to 20 ng/ml, leucocyte levels were slightly higher after treatment at 20,000/µl
  • Lactate after treatment at 2.4 mmol/l, base excess at -0.5, pH back to a normal level (7.44)
  • No relevant organ insufficiencies

Patient Follow-Up

  • Termination of renal replacement simultaneously with CytoSorb treatment while polyuria started
  • Development of peripheral pulmonary embolism and severe critical illness neuropathy
  • Tracheotomy 7 days after the last CytoSorb treatment
  • Subsequent discharge to rehabilitation for final respiratory weaning

CONCLUSIONS

  • The early use of CVVHDF and CytoSorb attenuated the septic shock in this patients and lead to the rapid stabilization of the organ functions
  • The temporary increase in catecholamine demand was most likely explained by an emerging septic cardiomyopathy with tachyarrhythmia
  • Metabolic acidosis improved, liver dysfunction parameters and PCT declined during the combined CRRT/CytoSorb therapy. As a result, the patient’s status stabilized quickly.
  • According to the medical team, the patient would probably not have survived her epicrisis without the use of CytoSorb
  • Safe and easy application of CytoSorb