32/2017
Use of CytoSorb in necrotizing fasciitis and severe septic shock

Moritz Lutterkord, Dr. med. Marcel Frimmel, PD Dr. med Friedhelm Sayk Interdisciplinary Intensive Care Medicine, Sana Clinics Lübeck GmbH, Germany

Summary:

This case study reports on a 49-year-old male patient (condition post incomplete cross-section paralysis after fracture of the thoracic vertebrae 11 & 12 in the year 2000 and wheel chair dependent ever since), who was admitted to the emergency department via the rescue services with fever, tachycardia and hypotension.

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Case presentation

  • After initial admission immediate transfer to the intermediate care unit and laboratory determination of renal failure
  • The same night he was treated surgically for debridement of his Fournier gangrene, with intraoperative diagnosis of advanced necrotizing fasciitis
  • Postoperative transfer to ICU in fulminant hypovolemic septic shock with further deterioration in his circulatory (norepinephrine 1.4 µg/kg/min) and metabolic status (lactate 10.7 mmol/l, pH 7.07)
  • Highly elevated inflammatory parameters (leukocytes 42,000, CRP 277 mg/dl, PCT >100 ng/ml) and greatly impaired renal function (creatinine 2 mg/dl, urea 180 mg/dl, GFR 35 ml/min, oliguria)
  • Antibiotic therapy initially with cefazolin and clindamycin and later escalation to  piperacillin/tazobactam, plus clindamycin, plus vancomycin
  • Initiation of advanced hemodynamic monitoring using PiCCO
  • Intraoperative bacterial smears showed the following species: E. coli, Enterobacter cloacae, Enterococcus fecalis, Staph aureus
  • Due to his acute renal insufficiency in the context of his septic condition, as well as the hemodynamic instability and the increased inflammation markers, the decision was made to initiate CytoSorb as an adjunctive therapy together with CVVHD

Treatment

  • Four treatments with CytoSorb for 24 hours each
  • CytoSorb was used in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) performed in CVVHD mode
  • Blood flow rate: 100-150 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Demand for catecholamines
  • Inflammatory parameters (CRP, PCT, leucocytes)
  • Renal function (creatinine, urea, GFR, excretion)
  • Metabolic variables: lactate, pH

Results

  • Hemodynamic stabilization with a significant reduction in catecholamine doses – norepinephrine could be reduced to 10% of the initial dose within the first 24 hours
  • Clear reduction in inflammatory parameters under CytoSorb therapy with values daily halving over the four treatment days
  • Significant improvement in renal function during the four treatment cycles: normalization of creatine and urea values, of GFR, moderate improvement of quantitative excretion
  • Lactate decreased to 1.2 mmol/l, pH 7.4

Patient Follow-Up

  • Daily surgical wound care, disinfection, removal of necrotic tissue
  • Transfer of the patient once he was cardiopulmonary stable to the UKSH (University Hospital Schleswig-Holstein, Campus Lübeck), Department of Plastic Surgery for split-skin grafting

CONCLUSIONS

  • Applying all therapeutic interventions in a combined manner (volume administration, antibiotic therapy and CytoSorb as adjunctive therapy) resulted in rapid improvement in the hemodynamic situation accompanied by a resolution of lactic acidosis and a marked reduction in inflammatory parameters
  • The installation of the absorber into the CVVH circuit as well as the application of CytoSorb itself was simple and safe