30/2016
Use of CytoSorb in a case of severe septic shock and MOF due to urosepsis

Dr. med. Hendrik Haake, Dr. med. Katharina Grün-Himmelmann & Prof. Jürgen vom Dahl | St. Franziskus-Hospital Mönchengladbach, Department of Cardiology and Intensive Care Medicine

Summary:

This case study reports on a 75-year-old male patient who presented at the urology department for routine ambulatory elective single J- ureter splint exchange (condition after conduit installation with urostoma due to urothelial carcinoma) developing 40°C fever in the course of the following night and was hospitalized after re-presentation at the hospital with elevated infection parameters.
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Case presentation

  • At previous ureter splint exchanges the patient regularly developed slight fever, however always without signs of generalized infection
    Immediate initiation of antibiotic therapy with Unacid (ampicillin/sulbactam)
  • As a result of subsequent volume administration patient noticably reversed fever
  • Development of dyspnea after which the patient refractory decompensated and was transferred to IMC
  • Development of hypotension
  • Escalation of antibiotic therapy to piperacillin/tazobactam
  • Increasing respiratory insufficiency despite NIV therapy, followed by intubation and transfer to ICU with further escalation of antibiotic therapy to meropenem and fosfomycin, further increasing lactate levels
  • Highly increased inflammatory (PCT 64.74 ng/ml, leukocytes 20,000/µl, CRP 25 mg/dl, platelets 23,000/µl) and retention parameters (creatinine 1.6 mg/dl, urea 52 mg/dl, anuric)
  • Initiation of renal replacement therapy
  • Despite further massive volume resuscitation (9 l/24 h) patient remained unstable with increasing clinical deterioration (increase of lactate to a maximum of 14.3 mmol/l, norepinephrine 1 mg/h, dobutamine 15 mg/h – trending towards a refractory state), which led to the decision to implement CytoSorb into the CVVH circuit
  • All blood cultures which were taken during the course of the first few hours after admission later showed bacteremia with a multisensible E. coli

Treatment

  • One treatment with CytoSorb for a total treatment time of 30 hours
  • CytoSorb was used in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) performed in CVVHD mode
  • Blood flow rate: 150 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: pre-hemofilter

Measurements

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

Results

  • Hemodynamic stabilization with significant reduction of catecholamine dosages – dobutamine could be tapered after 3 hours, noradrenaline could be halved within the first 24 hours
  • Volume of initially 1,200 ml/h could be reduced to 600 ml/h after 3 hours, after 8 hours at 100 ml/h and could be completely discontinued after 24 hours
  • Lactate could be halved after 10 hours, after 24 hours lactate was at normal values (1.8 mmol/l)

Patient Follow-Up

  • Termination of renal replacement therapy and extubation 6 days after the last CytoSorb treatment
  • Within the following 48 hours after extubation, the patient could be mobilized into a chair, was awake and adequately contactable
  • 14 days after CytoSorb treatment the patient could be transferred to a normal ward

Conclusions

  • Treatment with CytoSorb was accompanied by an unexpectedly rapid and significant stabilization of hemodynamics and declining catecholamine dosages within hours
  • Patient showed ever increasing needs volume and catecholamines, from the moment CytoSorb was implemented the patient clinically improved noticeably
  • According to the medical team patient would presumably not have survived without the absorber
  • Safe and easy application of CytoSorb