35/2017
Use of CytoSorb in catheter-associated sepsis and mitral valve endocarditis

Dr. med. Anke Pape, Dr. med. Arne Gäfgen, Prof. Dr. med. Reinhard Brunkhorst Department for Nephrology, Angiology, and Rheumatology, Hospital Region Hannover, Hospital Siloah

Summary:

This case study reports on a 78-year-old female patient (pre-existing diseases: congenital renal cysts, chronic renal insufficiency with dialysis dependency for 1 month, with dialysis performed via a tunnelled atrial catheter), who was admitted to the emergency department with worsening general condition and progressive somnolence.

Case presentation

  • Two weeks prior to this admission, the patient had already presented to a peripheral hospital due to malaise, fever, thirst and frequent diuresis and was treated with antibiotics (piperacillin/tazobactam) due to positive blood cultures (Staph aureus).  She was discharged after 7 days with decreasing inflammatory parameters and her tunneled atrial dialysis catheter was left in place.
  • Four days after discharge, the patient was admitted to the emergency room of our hospital with increasing exhaustion and somnolence. Laboratory markers showed raised inflammatory parameters (CRP 240 mg/l, leukocytes 13920/μl, Quick value of 84%)
  • Due to suspected infection the tunneled atrial dialysis catheter was removed and a new central venous access was installed.
  • Immediate initiation of antibiotic therapy with vancomycin 2 g and meropenem 1 g i.v
  • After overnight monitoring on the normal ward, the patient developed a septic picture with arterial hyptotension (105/57 mmHg) and tachycardia (100 / min) and  was therefore transferred to the intensive care unit
  • On the intensive care unit, arterial hypotension (90/40 mmHg, HF 110 /min) rapidly increased during the first 30 minutes and catecholamine therapy (norepinephrine) was started.
  • Inflammatory parameters continued to increase (CRP 407 mg/l, leukocytes 15480/μl). The Quick value was 64%.
  • As the need for catecholamine support increased further over the next 30 minutes (from 1 µg/min to 3 µg/min), anuria, and due to increasing lactic acidosis (lactate 3.02 mmol/l) and her rapid clinical deterioration (increasing somnolence), we decided to start continuous renal replacement therapy (CVVH) in combination with CytoSorb therapy.
  • Before the start of CytoSorb therapy, blood was taken to determine IL-6 levels, however  therapy was started before results were available (IL-6 62.8 pg/ml).

Treatment

  • One CytoSorb treatment session for 19 hours
  • CytoSorb was used in conjunction with CVVH (Octo Nova; DIAMED Medizintechnik, Germany)
  • Blood flow rate: 160 ml/min
  • Anticoagulation: heparin (PTT 60-70 sec)
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Demand for catecholamines
  • Inflammatory parameters (CRP, IL-6, leucocytes)
  • Renal function (excretion)

Results

  • Hemodynamic stabilization of the patient with significantly decreased need for catecholamines within hours – 2 hours after CytoSorb start the maximum norepinephrine dose was 15 μg/min, after 6 hours this could be reduced to 5 μg/min and after 19 hours catecholamine therapy could completely be stopped.
  • Clearly decreasing inflammatory parameters during the course of treatment (IL-6 30.6 pg/ml after completion, CRP 329.7 mg/l after 16 hours with further decreases thereafter, leukocytes 12700/μl after 16 hours and at normal values (8700/μl) the following day)
  • Significant clinical improvement – after 16 hours of CytoSorb with CVVH the patient was no longer somnolent, but alert, responsive and oriented.

Patient Follow-Up

  • Staphylococcus aureus (MSSA) was detected microbiologically at the tip of the tunnelled atrial caterer as well as in the blood cultures.
  • A mitral valve endocarditis with severe insufficiency and an abscess at the mitral valve ring and perforation at the anterior mitral leaflet were diagnosed using transesophageal echocardiography.
  • After an initial clinical improvement in the patient’s condition over the following 10 days, she suffered an intercerebral hemorrhage with an intrusion into the ventricular system, and finally died.

CONCLUSIONS

  • Due to the rapid deterioration of the clinical situation over a few hours and the increased infection parameters – and in unawareness of IL-6 levels -, severe sepsis was suspected and the decision was made for early use of CytoSorb and renal replacement therapy.
  • The overall situation improved rapidly, accompanied by a rapid recovery of the organ functions. Whether this was caused by the early application of Cytosorb can not be finally concluded.
  • During combined treatment with CVVH with CytoSorb significant stabilization in hemodynamics with declining needs for catecholamines and an improvement in the inflammatory situation could be observed.
  • Handling of the adsorber was easy.