37/2016
Use of CytoSorb in a case of acute septic cholecystitis due to E.coli sepsis

Dr. med. Björn Jäschke , Dr. med. Jan Adamski | Satakunta District Central Hospital, Intensive Care Unit, Finnland

Summary:

This case study reports on a 65-year-old male patient (preexisting comorbidities chronic alcohol abuse, fibromyalgia), who was admitted to the emergency department via ambulance transport due to severe pressure pain in the right upper abdomen.

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Case presentation

  • Ultrasound examination showed an enlarged gallbladder with stones, however no dilated bile ducts; no increase in transaminases; hepatic parenchyma, spleen and kidney without pathological findings
  • Diagnosis: acute cholecystitis
  • Admission to surgical ward and initiation of antibiotic therapy with cefuroxime
  • In the following night, the emergency medical team was alerted due to hypotension and increased respiratory rate
  • Instantaneous transfer to ICU with diagnosis septic shock
  • Blood cultures immediately withdrawn after ICU admission confirmed E. coli and Klebsiella oxytoca bacteremia, resulting in immediate switch of antibiotic regimen to Piperacilin/Tazobactam
  • At this point of time the patient exhibited severe impairment of hemodynamics (norepinephrine 1.2 µg/kg/min), oliguria (<700ml/24h), acute liver dysfunction (INR 2.0; NH4- 69 µmol/l), increased retention parameters (creatinine 172 µmol/l, urea 7 mmol/l), metabolic acidosis (pH 7.12, lactate 11 mmol/l, base excess -20) as well as increased markers of inflammation and infection (CRP 182 mg/l, PCT 8.4 µg/l, leukocytes 57.8 E9/l, thrombozytes 92 E9/l)
  • Installation of a gallbladder drainage
  • Initiation of renal replacement therapy 5 hours after admission to ICU
  • Despite adequate vasoconstrictor and fluid resuscitation and treatment according to the sepsis bundle, there was no noticable clearance of lactate
  • Due to hemodynamic instability, the non-response to conventional treatment, acute renal and liver failure as well as metabolic acidosis with severely impaired lactate clearance, CytoSorb therapy was commenced in the further course
  • Final diagnosis: acute septic cholecystitis

Treatment

  • One treatment with CytoSorb for a total treatment time of 24 hours
  • CytoSorb was used in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) performed in CVVHD mode
  • Blood flow rate: 100-130 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Demand for catecholamines
  • Renal function (creatinine, urea, excretion)
  • Liver function (INR, NH4)
  • Inflammatory parameters (CRP, PCT)
  • Metabolics (Lactate, base excess, pH)

Results

  • Hemodynamic stabilization with significant reduction of catecholamine dosages – after 24 hours of treatment norepinephrine requirement at 0.23 µg/kg/min – thereafter infusion in minimal doses – 36 hours after termination of the adsorber therapy norepinephrine could be completely tapered off
  • After treatment the patient was still oliguric, however there was a significant drop in retention parameters (creatinine at 82 µmol/l, urea at 3.8 mmol/l)
  • Liver function: One day after after discontinuation of treatment INR was at 1.6 and NH4 at 32 µmol/l
  • Inflammatory parameters: PCT dropped to 5.6 ng/ml, CRP levels after treatment slightly higher at 195 mg/dl
  • Lactate after treatment at 1.9 mmol/l, base excess at -3, pH back to a normal level (7.44)

Patient Follow-Up

  • Termination of renal replacement therapy 2 days after CytoSorb treatment with spontaneous diuresis
  • Development of a critical illness delirium
  • Patient stayed on ICU for a total of 7 days, followed by a stay on the surgical ward for another 2 weeks and final discharge of the patient directly to his home environment
    Conclusions
  • Treatment with CytoSorb was accompanied by an unexpectedly rapid and significant stabilization of hemodynamics and declining catecholamine dosages within hours
  • Metabolic acidosis improved, also liver dysfunction parameters and PCT declined during combined CRRT/CytoSorb therapy. As a result, the patients status stabilized quickly.
  • Safe and easy application of CytoSorb

Conclusions

  • Treatment with CytoSorb was accompanied by an unexpectedly rapid and significant stabilization of hemodynamics and declining catecholamine dosages within hours
  • Metabolic acidosis improved, also liver dysfunction parameters and PCT declined during combined CRRT/CytoSorb therapy. As a result, the patients status stabilized quickly.
  • Safe and easy application of CytoSorb