35/2016
Combination of ECMO and cytokine adsorption therapy for severe sepsis with cardiogenic shock and ARDS due to Panton-Valentine leukocidin-positive Staphylococcus aureus pneumonia and H1N1

Lees NJ, Rosenberg A, Hurtado-Doce AI, Jones J, Marczin N, Zeriouh M, Weymann A, Sabashnikov A, Simon AR, Popov AF, Department of Anaesthetic and Critical Care, Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, England

Summary:

This case study reports on a 33-year-old previously fit female (5-month post-partum), who presented to the local emergency department following a 4-day history of flu-like symptoms with breathlessness, delirium, chest, and abdominal pains

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Case presentation

  • On the initial assessment, she was pyrexial, tachypneic, tachycardic, and hypotensive with cool peripheries
  • Examination and investigations revealed clinical evidence of severe acute respiratory failure with extensive air space shadowing throughout with hypoxemia and metabolic acidosis (pH 7.1, lactate 5 mmol/l, base deficit -11 mmol/l)
  • Cardiac assessment by transthoracic echocardiography revealed severe left ventricular failure with a left ventricular ejection fraction (LVEF) of 5–15 %
  • Furthermore, she was severely neutropenic (white blood cell count 0.6×109/l , neutrophils 0.3 x109/l)
  • She rapidly deteriorated requiring intubation and mechanical ventilation and treatment was initiated for community acquired pneumonia
  • In addition, she required significant amounts of vasopressor and inotropic support to achieve an adequate mean arterial pressure, highlighting the central cardiovascular involvement in her critical state
  • In view of clinical deterioration and cardiovascular and respiratory instability, she was transferred to the hospital of the authors for ongoing care and consideration of extracorporeal life support
  • On arrival, she had severe respiratory failure with a Murray score of 3.7 (PaO2 /FIO2 ratio 11.1 kPa, PEEP 12, compliance 32 ml/cmH20, four-quadrant infiltration on chest radiograph)
  • She was hypotensive with a MAP of 50 mmHg, despite high-dose infusions of norepinephrine (1–1.5 µg/kg/min) and vasopressin 0.04 U/h in addition to dobutamine 7.5 µg/kg/min
  • Transthoracic echocardiography revealed a severely impaired, non-dilated left ventricle and normally functioning, non-dilated right ventricle
  • There was metabolic acidosis (base deficit -6 mmol/l, lactate 4 mmol/l) and oliguria
  • Care was initially supportive comprising mechanical ventilation, titration of high-dose inotropic and vasopressor agents, fluids, and continuous veno-venous hemodiafiltration
  • She was treated empirically for severe sepsis and community acquired pneumonia and influenza. Subsequent analysis of sputum from direct bronchoscopy showed a heavy growth of Staphylococcus aureus (S. aureus) positive for expression of Panton–Valentine leukocidin (PVL). Viral PCR was also positive for H1N1 Influenza A. Clindamycin was added and intravenous immunoglobulin G (IVIg) therapy was commenced.
  • In view of the severity of the combined respiratory and cardiac failure and evidence of worsening organ function, peripheral veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) was instituted within 5 h of arrival and in view of the severe sepsis and high amount of vasopressors, CytoSorb was added to the hemofilter circuit

Treatment

  • CytoSorb was added to the CVVH circuit (Prismaflex, Gambro, Sweden) and run parallel to the VA-ECMO circuit (Thoratec Centrimag pump at 4 L/min with inspired oxygen through the Medos hilite 700LT oxygenator set at 100%)
  • Run time: One treatment session for 24 h
  • Anticoagulation: Heparin, targeting activated partial thromboplastin time (aPPT) of 60–80 s
  • Adsorber position: pre-hemofilter

Measurements

  • Hemodynamics, inotropes and vasopressors doses
  • Neutropenia and CRP levels
  • Lactate

Results

  • There was an improvement in oxygenation and gradual resolution of lactic acidosis after institution of the therapies
  • Most notably, the initially very high doses of vasopressors could be weaned off after 12 h and she had no requirement for catecholamine support by 24 h
  • The neutropenia also fully recovered to normal by day 2 and the serum C-reactive protein level reduced
  • There were no adverse events related to the treatment

Clinical course of the first 24 h, showing doses of inotropes and vasopressors after starting ECMO and CytoSorb therapies. Doses are in µg/kg/min (adrenaline and noradrenaline); units/h (vasopressin)

Patienten Follow-Up

  • ECMO therapy was continued for a total of 9 days
  • At the time of ECMO removal, lung compliance and oxygenation (PaO2/FiO2 ratio) had improved significantly; however, hypercapnia remained a problem. To facilitate removal of carbon dioxide and to allow ongoing protective mechanical ventilation, a less invasive mode of extracorporeal lung support was established using the Hemolung RAS (ALung Technologies, Pittsburgh, USA) remaining in place for 5 days without complication
  • A percutaneous tracheotomy was performed on day 12
  • Despite chest CT showing evidence of cavitating, necrotizing pneumonia, lung function continued to improve
  • The tracheal cannula was removed on day 23 and the patient was discharged to the ward on day 30
  • She was reviewed in the follow-up clinic 2 months later and was well, with normal heart function on echocardiography
  • Her lung function was reduced (FEV1 60 %, FVC 56 %, TLCO 55 %), but she has remained asymptomatic

CONCLUSIONS

  • This case is the first report of the successful use of extracorporeal support and CytoSorb hemoadsorption therapy in combination to treat a patient with severe acute respiratory failure, septic, and cardiogenic shock due to PVL-S. aureus superinfection with H1N1
  • The authors state, that the reversal of septic shock, the rapid weaning off of the high-dose vasopressor infusions as well as the quick resolution of neutropenia and reduction in CRP levels are unusual for such severe presentation, and that they feel that CytoSorb was a beneficial factor in the combination therapy with ECMO therapy
  • This case report also demonstrates that multiple extracorporeal technologies, including VA ECMO, hemofiltration, and hemoadsorption with CytoSorb can be successfully combined in severe septic shock with myocardial involvement