34/2016
Use of CytoSorb in hepatic encephalopathy

C. Steinfort#, Dr. M. Bellgardt*, Prof. T. Weber*, Prof. W. Uhl# St. Josef Hospital, Hospital of Ruhr-University Bochum # Clinik for General and Visceral Surgery *Clinic for Anaesthesiology

Summary:

This case study reports on a 58-year-old female patient (condition post pancreatectomy after ethyltoxic pancreatitis), who presented to the hospital for a routine imaging investigation due to a drainage problem of her bilio-digestive anastomosis, which had been installed a few years earlier.

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Case presentation

  • On presentation the patient was alert and responsive, however it was noted that she had consumed large amounts of alcohol in the period prior to admission
  • During the following days after diagnostic imaging, the patient deteriorated dramatically and had to be transferred to ICU on day 12 with severe pneumonia
  • Patient was intubated, ventilated, moderately catecholamine-dependent and in an unexpectedly poor general physical condition, without significant reconvalescence
  • Microbiological findings showed infection with E. coli, so there was immediate initiation of antibiotic therapy with Piperacillin/Tazobactam, later on Imipenem, after which her pneumonia improved considerably over the next days, as confirmed radiologically
  • Operation with installment of a new biliodigestive anastomosis
  • Postoperatively prolonged recovery. During the first weaning attempts the patient remained relatively unresponsive and was not vigilant for weeks despite spontaneous breathing
  • Determination of plasma ammonia levels showed a significant increase of up to> 230 µg/dl (normal range 19-87 µg/dl), other liver function tests also showed a moderate hepatic impairment – cholinesterase > 1500 U/l, gammaGT at 602 U/l, PDR 12.2%/min (normal range 18-25), R15 16% (normal range 0-10), Quick 60%, CRP also low with 48 mg/l
  • In this phase the patient received a low-dose norepinephrine infusion (<0.5 mg/h)
  • In the further course she suffered recurrent bouts of pneumonia and CVC infections
  • Conservative lactulose therapy (orally or as an enema) and selective intestinal decontamination proved unsuccessful
  • Due to the extremely high plasma ammonia levels (> 230 µg/dl), the decision was made to use CytoSorb as adjunctive therapy

Treatment

  • Two treatments with CytoSorb, 1st treatment for 72 hours with significant reduction of ammonia levels to 66 µg/dl, thereafter treatment pause for 11 days during which ammonia levels rose back to 116 µg/dl, 2nd treatment for 72 hours
  • CytoSorb was used in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) performed in CVVHD mode
  • Blood flow rate: 120 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Ammonia
  • Inflammatory parameters (CRP)

Results

  • CRP continuously low between 40-50 mg/l during both treatment cycles
  • After the first treatment reduction of ammonia to 66 µg/dl, rebound to 116 µg/dl during the 11 day treatment pause period, during the 2nd treatment  ammonia could be reduced to 76 µg/dl
  • Reduction of gammaGT in the course of the first treatment to 313 U/l, after treatment 2 there was no further reduction
  • Patient improved significantly during the first CytoSorb treatment, and started to respond specifically and follow instructions; with increasing ammonia levels after the first treatment the patient was again somnolent, however during the 2nd treatment cycle she improved again, thereafter ammonia levels remained at a low level over the next weeks

Patienten Follow-Up

  • Patient could be weaned off the ventilator 6 days after the second CytoSorb treatment
  • Termination of renal replacement therapy immediately post second CytoSorb use
  • After further improvement, patient could be mobilized whilst still in ICU
  • Due to recurrent infections and lung problems, therapy was discontinued 50 days after the initial admission and the patient died

CONCLUSIONS

  • CytoSorb represents a good and practicable treatment option for patients with high ammonia levels
  • According to the medical team and since the treatment of this patient, the use of CytoSorb is now considered in patients with liver resection and post-operative hepatic dysfunction
  • Treatment with CytoSorb was safe and easy to apply