24/2017
Use of CytoSorb in a patient with para-pneumonic ARDS and severe septic shock 6 days after cardiac surgery

Dr. L.-U. Kühne, Prof. Dr. F.-C. Rieß, Dipl-Ing. R. Binczyk | Cardio-surgical Intensive Care Unit, Cardiovascular Centre, Albertinen Hospital, Hamburg, Germany

Summary:

This case study reports on a 73-year-old male patient who was admitted to hospital due to dyspnoea, malaise, reduced daily function and lack of appetite.

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Case presentation

  • Medical history included an aortic valve replacement in 2005
  • Additional diagnosis showed coronary heart disease, which was treated using a drug-coated stent
  • In addition, high-grade dysfunction of the aortic valve replacement as well as high degree of mitral and tricuspid valve leakage was found
  • Furthermore, congestive pneumonia was evident which was treated with antibiotics (ceftriaxone, ampicillin/sulbactam, clarithromycin)
  • Due to recurrent decompensation of cardiac insufficiency during hospitalization, an emergency cardio-surgical procedure was performed including revision of the aortic valve as well as mitral and tricuspid valve reconstruction
  • Upon postoperative transfer to ICU the patient was already in septic shock
  • Significantly impaired gas exchange (FiO2 1.0, PEEP 12).
  • Escalation of antibiotic therapy (meropenem/levofloxacin)
  • Stabilization due to volume substitution and the above mentioned therapy with extubation on the third postoperative day
  • On the sixth postoperative day the patient developed a fever of up to 39.5°C and respiratory exhaustion followed by intubation, escalation of anti-infective therapy (meropenem, linezolid and voriconazole)
  • Diagnosis of para-pneumonic Acute Respitatory Distress Syndrome (ARDS) (FiO2 1.0), prone positioning for 12 hours, severe septic shock with extremely high catecholamine doses (norepinephrine 34 μg/min, vasopressin 0.05 IU/min), and development of acute renal failure with initiation of continuous renal replacement therapy (CRRT) 17 hours after intubation (2 cycles at 72 hours)
  • With the rationale to reduce the high-dose vasopressor therapy, to improve the ventilator situation and ultimately as a last resort, the decision was made to install CytoSorb into the CRRT circuit

Treatment

  • One treatment with CytoSorb for 48 hours
  • CytoSorb was used in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) performed in CVVHD mode
  • Blood flow rate: 120 ml/min
  • Dialysate flow 2200 ml/h, ultrafiltration 50-200 ml/h
  • Anticoagulation: systemically with unfractionated heparin (1.280 I.E./h unter aPTT control)
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Hemodynamics and demand for catecholamines
  • Inflammatory parameters
  • Respiratory status
  • Renal function

Results

  • Impressive improvement of the hemodynamic situation, accompanied by a rapid reduction of norepinephrine dosages
  • Significant mitigation of inflammation with decreasing inflammatory markers
  • Clear improvement of the respiratory situation

Patient Follow-Up

  • Tracheotomy on the 10th postoperative day
  • Successful CVVHD termination
  • Postoperative delirium, clinically CiP/CiM
  • Transfer to an external clinic for weaning on the 21st postoperative day, tracheotomized, ventilated in CPAP-ASB mode, FiO2 0.5; without vasopressor therapy
  • Awake, tracheotomized, spontaneously breathing, neurologically uneventful

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CONCLUSIONS

  • In this case, the use of CytoSorb resulted in a clear and steady improvement in the patient‘s critical situation, mainly due to stabilization in hemodynamics and dampening of the inflammatory reaction
  • According to the medical team, the use of CytoSorb decisively influenced the outcome for this patient
  • CytoSorb was easy to use in this setting and there was an overall positive adsorber experience