36/2017
CytoSorb in 4-quadrant fecal peritonitis and septic shock

Dr. Matthias Lutze, Head of Department for Anesthesiology and Intensive Care Medicine, Hospital Teterow, Germany

Summary:

This case study reports on a 73-year-old patient (pre-existing diseases: chronic obstructive pulmonary disease (COPD), diabetes mellitus type 2, arterial hypertension, giant scrotal hernia present for 20 years), who was admitted to hospital with an acute abdomen and signs of shock.

Case presentation

  • Previously, the patient had already been treated in our clinic for a total of 4 weeks due to a pneumogenic sepsis in the context of his COPD and was discharged to early rehabilitation  tracheotomized, long-term ventilated and in a difficult to wean condition
  • On the 5th day of rehabilitation, the patient was transferred back to our clinic directly to the intensive care unit with an acute abdomen, signs of septic shock, tachycardia (HR 140-160 bpm), hypotension (blood pressure 90/39), fever (40.6°C) catecholamine-dependency (norepinephrine 0.15 μg/kg/min), still tracheotomized and under BiPAP ventilation
  • Preoperative diagnosis was acute abdomen and giant scrotal hernia with suspected intestinal perforation and ischemia
  • The following morning, an extended operation over several hours was performed including opening of the hernial sac, repositioning of all internal parts of the intestine, extensive rinsing and draining, orchiectomy, colectomy and jejunorectostomy with upstream connection of a loop ileostoma and 90 percent resection of the hernial sac
  • Intra-operative initiation of antibiotic therapy with meropenem and micafungin
  • In addition, the patient received intraoperatively and postoperatively a total of 6 units of red packed blood cells, 3 units of fresh frozen plasma, and postoperatively hydrocortisone 200 mg/day for a total of 5 days
  • Presence of a pronounced metabolic acidosis pH 7.11, lactate 14.2 mmol/l, BE-15 as well as strongly elevated plasma levels of PCT (16 ng/ml) and CRP (109 mg/l)
  • Development of a significant capillary leak syndrome with enormous volume requirement and a daily positive fluid balance of +6980 ml
  • Despite standard execution of the sepsis bundle including volume administration, catecholamines (norepinephrine 1.5 μg/kg/min and increasing) and antibiotic therapy, the patient remained in septic shock with progressive development of anuric renal failure, which is why simultaneously with renal replacement therapy CytoSorb was started
  • Final postoperative diagnosis: Perforation of the transverse colon with 4-quadrant fecal peritonitis, small intestinal gangrene in the hernial sac and left lateral hernia, marked ischemia of the incarcerated sigmoid colon (in the hernial sac) as well as parts of the descending colon

Treatment

  • One CytoSorb treatment session for 72 hours (CRRT and CytoSorb were started and CytoSorb was stopped after one cycle of CVVHDF à 72 hours, 2 more CVVHDF cycles were run afterwards without CytoSorb)
  • CytoSorb was used in conjunction with citrate dialysis (Prismaflex; Gambro) in CVVHDF mode
  • Blood flow rate: 150 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: post-hemofilter

Measurements

  • Hemodynamics and demand for catecholamines
  • PCT and Lactate
  • Capillary leak syndrome (fluid balance)
  • Renal function (excretion)

Results

  • With the initiation of combined CVVHDF/CytoSorb therapy the norepinephrine dose could clearly and rapidly be reduced: decrease in norepinephrine demand to 0.5 μg/kg/min within the first 6 hours, to 0.3 μg/kg/min after 24 hours, low dose infusion (0.2-0.1 μg/kg/min) over the next 3 days and complete withdrawal of catecholamine therapy on the 4th day
  • In parallel and within the first 12 hours of therapy, sepsis-induced tachycardia could be reduced to a stable 100 bpm with further stabilization over the following days
  • Clear reduction in inflammatory parameters during the treatment session including a daily 50% reduction in PCT plasma values in the 4 postoperative days, and declining CRP levels
  • Resolution of lactate acidosis: lactate was reduced to 6.9 mmol/l after 6 hours and to 2.2 mmol/l after 24 hours
  • Significant containment of capillary leak syndrome: volume requirement (i.e. net fluid balance) had already equalized  (-110 ml) within the first 24 hours after surgery and improved markedly after 48 hours (+95 ml), after 72 hours (-820 ml), after 96 hours (-1445 ml), and after 120 hours (-1130 ml) accompanied by the onset of spontaneous diuresis (255 ml/day)

Patient Follow-Up

  • Cessation of antibiotic therapy after 10 days
  • Later, development of a spontaneous bilateral pneumothorax due to perforated bullae in the context of his COPD, followed by transfer to the Clinic for Thoracic Surgery, University Hospital Rostock and subsequent lung segment resection
  • Subsequent discharge to rehabilitation

CONCLUSIONS

  • Despite a severe second septic surge within 4 weeks, the combined treatment including CVVHDF and CytoSorb resulted in the surprisingly rapid control of the acute phase of septic shock, accompanied by a dramatic decrease in norepinephrine doses paralleled by an improvement in the metabolic acidosis
  • This relatively rapid recovery could possibly be the result of a marked improvement in microcirculation due to the shortened time of high-dose catecholamine treatment
  • As long as causal therapy (correct antibiotics, infectious source control, etc.) is adequate, CytoSorb can be a promising treatment option as an adjuvant therapy in these patients with abdominal focus and severe septic shock
  • The application of CytoSorb therapy was simple and safe