27/2016
Improvement of hemodynamic and inflammatory parameters by combined hemoadsorption and hemodiafiltration in septic shock

Steffen R. Mitzner, Martin Gloger, Jörg Henschel, Sebastian Koball, Divisions of Nephrology and Pulmonology and Internal Intensive Care, Department of Internal Medicine, University of Rostock, Germany

Summary:

This case study reports on a 80-year-old male patient stable on chronic hemodialysis for more than 12 months who was admitted to emergency department after he collapsed at the end of a regular dialysis session.

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Case presentation

  • Past history included coronary artery disease with a myocardial infarction 14 months ago, end-stage renal disease due to nephrosclerosis, arterial hypertension and diabetes mellitus type II
  • On examination, patient had fever (39.2°C), moist rales in bilateral lungs, O2-saturation 79%, BP 126/60 mmHg, HR 130 beats/min, lactic acidosis with pH 7.1, APACHE II 33, SAPS II 48
  • Later blood cultures remained negative, however, bronchoalveolar lavage was positive for Staph aureus
  • Upon further deterioration of the circulatory situation, patient was diagnosed of having pneumogenic septic shock
  • Intubation for mechanical ventilation and admission to ICU
  • Immediate start on Ceftriaxone and Clarithromycin and 0.2 µg/kg/min noradrenaline
  • On day 3 of the ICU stay the patient was in clinical need for renal replacement therapy
  • Interleukin (IL) 6 level was elevated to 665 pg/m
  • Due to clinical need for renal replacement therapy, a sharp increase of inflammatory markers, high need for catecholamines and septic shock with multiple organ failure CytoSorb was additionally installed into the CRRT circuit

Treatment

  • One CytoSorb treatment session for 24 hours
  • CytoSorb was used in conjunction with citrate dialysis (Multifiltrate; Fresenius Medical Care) in CVVHD mode
  • Anticoagulation: citrate
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Demand for catecholamines
  • Inflammatory parameters (IL-6, PCT, CRP, leucocytes)
  • Renal function (creatinine)

Results

  • Noradrenaline could be reduced from a maximum of 3.0 to 0.4 µg/kg/min while MAP remained stable
  • Values of IL-6, CRP, creatinine, procalcitonin, and leukocytes decreased during treatment
  • Antibiotic therapy was perforemd without necessity to adjust doses at any time during CytoSorb treatment

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Patient Follow-Up

  • Values of inflammatory markers continued to decrease in the following days

Conclusions

  • Clear stabilization and consolidation of hemodynamics and inflammatory mediators under CytoSorb
  • Treatment appeared to be safe and was well tolerated by the patient