28/2016
CytoSorb in septic shock after infection of a knee endoprosthesis

Dr. med. Burkhard Hinz, Head of Interdisciplinary ICU, KMG Clinic Güstrow Dr. med Oliver Jauch, Senior Physician, Department of Anesthesiology and Intensive Care Medicine, KMG Clinic Güstrow Dr. med. Rolf Kaiser, Head of Department of Internal Medicine, Cardiology and Intensive Care Medicine, KMG Clinic Güstrow

Summary:

This case study reports on a 55-year-old male patient (pre-existing conditions: obesity, insulin dependent type 2 diabetes mellitus, arterial hypertension), who was admitted to hospital with signs of sepsis due to an infection of his knee endoprosthesis implanted 1 year before, after an ambulatory puncture of the knee.

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Case presentation

  • On admission the patient exhibited high temperature and poorly detectable blood pressure, with an immediately identifiable infection focus (knee endoprosthesis)
  • Immediate surgical removal of the knee endoprosthesis and insertion of a Palacos spacer
  • Postoperative transfer to ICU. From this time the patient was already in septic anuric renal failure, including septic cardiomyopathy, lactic acidosis, and infection-related anemia (Hb 5.2 mmol/l, hematocrit 0.26, thrombocytes 127 Gpt/l, ATIII 46%)
  • Greatly increased inflammatory (leukocytes 8.3 Gpt/l, PCT 42.5 µg/l, CRP 450.8 mg/l) and retention parameters (creatinine 633 mol/l, urea 27.3 mmol/l)
  • Patient had ongoingcirculatory instability (norepinephrine 1.1 µg/kg/min) with progressive clinical deterioration
  • PiCCO-guided volume therapy with Ringers-Acetate (12 l/24 h) with which norepinephrine doses could be decreased to 0.99 µg/kg/min
  • Antibiotic treatment: Rifampicin/ciprofloxacin later changed to rifampicin/ceftriaxone
  • Due to the high and ongoing demand for catecholamines with persisting renal failure, CytoSorb therapy was initiated in combination with CRRT

Treatment

  • Three consecutive CytoSorb sessions for a total treatment time of 80 hours (two sessions for 24 hours each, one session for 32 hours)
  • CytoSorb was used in conjunction with a Multifiltrate CRRT machine (Fresenius Medical Care) in CVVHD mode
  • Blood flow rate: 180 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Demand for catecholamines
  • Inflammatory parameters (CRP, PCT, leucocytes)
  • Renal function (creatinine, urea)

Results

  • During the first treatment the hemodynamic condition of the patient could be stabilized considerably and the demand for catecholamines (noradrenaline) could be reduced from an initial dose of 0.99 µg/kg/min to 0.6 µg/kg/min, and in the course of the second treatment to 0.12 µg/kg/min and after the last treatment to 0.03 µg/kg/min
  • Rapid reduction of inflammatory parameters within the first five postoperative days (POD): PCT 10.76 µg/l (1. POD), 4.67 µg/l (2. POD), 4.1 µg/l (3. POD), 0.43 µg/l (5. POD); CRP 371.2 mg/l (1. POD), 148 mg/l (2. POD), 223 mg/l (3. POD), 94 mg/l (5. POD)
  • Equally quick decrease of retention parameters under CVVHD within the first five postoperative days (POD): creatinine 387 µmol/l (1. POD), 148 µmol/l (2. POD), 117 µmol/l (3. POD), 98 µmol/l (5. POD); urea 21 mmol/l (1. POD), 10 mmol/l (2. POD), 9.5 mmol/l (3. POD), 8.0 µmol/l (5. POD)

Patient Follow-Up

  • Ongoing rapid and sustained stabilization of hemodynamics and organ functions
  • Extubation 1 day after the last CytoSorb treatment
  • Transfer to normal ward possible within a few days

Conclusions

  • Fast decision and the early start of treatment with CytoSorb in this patient led to a rapid stabilization of the clinical situation within the first 24 hours
  • According to the medical team, the patient would presumably not have survived without the CytoSorb treatment
  • Significant stabilization and consolidation of hemodynamic and inflammatory parameters under CytoSorb
  • The application of CytoSorb therapy was easy and safe without any complications during or after the procedure