36/2016
CytoSorb in postoperative sepsis after aortic valve replacement

Dr. Andreas Baumann*, Prof. Peter K. Zahn*, Dr. Peter L. Haldenwang# *Department of Anaesthesiology, Intensive Care, Palliative Care and Pain Medicine # Department of Cardiosurgery and Thoracic Surgery BG University Hospital Bergmannsheil gGmbH

Summary:

This case study reports on a 73-year-old female patient who presented at the hospital for elective aortic valve replacement due to combined aortic valve vitium with predominant stenosis.

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Case presentation

  • Uncomplicated intraoperative course with subsequent transfer to the cardiosurgical intensive care unit and further transfer to intermediate care the next day
  • However, on the same day the patient was transferred back to ICU due to pericard tamponade followed by immediate re-thoracotomy
  • Postoperative initiation of CVVHD for fluid balance control due to oliguria and central congestion
  • Postoperative a persistent fistula of the lung developed due to preexisting emphysema with subsequent revision by mini-thoracotomy 9 days after the first thoracotomy
  • This was followed by a period of relative clinical and hemodynamic stability when the patient attempted to mobilize and began eating
  • 5 days after the lung surgery an acute abdomen developed based on an obstructive ileus (a previous condition post appendectomy from several years previously)
  • Patient had to have an emergency intubation for surgery, during which she aspirated
  • She then had an emergency laparotomy with resolution of the obstructed ileus and installation of a double-barreled transversostomy
  • Noradrenaline was required postoperatively at 2 mg/h, CRP significantly increased with 13.2 mg/dl, PCT only increased moderately at 0.4 ng/ml
  • This was followed by rapid respiratory deterioration and development of aspiration-associated pneumonia with immediate initiation of treatment in accordance with the sepsis bundle and installation of veno-venous ECMO
  • Start of calculated anti-infective therapy with Piperacillin/Tacobactam and on the following day with Levofloxacin. In the further course confirmation of Candida glabrata and Stenotrophomonas maltophilia in the tracheal secretions. As a result, extension to Cotrimoxazole (following resistogram) and due to absence of clinical improvement to Anidulafungin
  • Withdrawal of blood cultures and repeated proof of Candida glabrata in blood cultures Diagnosis: Candida glabrata sepsis
  • Because of acute renal failure and due to multiple conditions (lung surgery, long stay on the ICU, suspected aspiration pneumonia and assumed septic course) CytoSorb therapy was started simultaneously with the installation of the veno-venous ECMO (pre-emptive use)

Treatment

  • Six consecutive CytoSorb treatment sessions for 24 hours each with a total treatment time of 144 hours
  • CytoSorb was used in conjunction with citrate dialysis (Multifiltrate; Fresenius Medical Care) in CVVHD mode
  • Blood flow rate: 100-180 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Need for catecholamines
  • Inflammatory parameters (PCT, CRP)

Results

  • After the first treatment there was already a significant reduction in CRP – within 6 hours after the start of CytoSorb CRP decreased to 8.2 mg/dl, 24 hours after initiation of treatment CRP was 5.7 mg/dl. However, despite continuing the therapy over the next 5 days there was a temporary rebound to 20.7 mg/dl followed by another decrease
  • PCT remained low over the entire treatment period, however it increased greatly after discontinuation of CytoSorb therapy to levels of 5.4 ng/ml
  • Norepinephrine could be significantly reduced during the first treatment (1.1 mg/h after 6 hours, 0.6 mg/h after 15 hours) with a tendency to further declining doses. Immediately after stopping CytoSorb therapy, physicians noticed a sharp increase back to 1.1. mg/h with further continuing high levels
  • Antibiotics dosages were not adjusted under CytoSorb therapy

Patienten Follow-Up

  • No further need for revision of the abdomen
  • Transfer to a respective center for further ECMO weaning
  • Confirmation of pronounced small intestine ischemia from abdominal CT, relating to a NOMI (non-occlusive mesenteric ischemia) with preexisting mesenteric vessel stenoses
  • All further therapy modalities were withdrawn and the patient died

CONCLUSIONS

  • In this multi-morbid patient with a diagnosis of Candida glabrata sepsis with already a very high chance of mortality, the preemptive use of CytoSorb showed an acute beneficial effect
  • Despite treatment with sufficiently high doses of anidulafungin the patient showed persistently detectable Candida in her blood cultures which resulted in an immediate septic exacerbation and clinical deterioration after discontinuation of CytoSorb treatment
  • There was effective clinical stabilization and consolidation of hemodynamics and inflammatory mediators under CytoSorb
  • Application of the CytoSorb adsorber in a pre-hemofilter position was simple, safe and without problems