41/2016
CytoSorb in severe sepsis following peritonitis in chronic ulcerative colitis

Dr. med. Nikolaus Golecki, Alexander Bischel, Anesthesiology, Intensive Care and Emergency Medicine, AMEOS Hospital Bernburg

Summary:

This case study reports on a 77-year-old male patient (known pre-existing conditions: ulcerative colitis, Parkinson‘s disease, diabetes mellitus, arterial hypertension, hypothyroidism) who was admitted to the emergency department with ileus symptoms and recurrent vomiting.

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Case presentation

  • Admission to the department of internal medicine and 2 days later presentation at the surgical department
  • Patient was surgically treated for incipient peritonitis in known ulcerative colitis (laparotomy, sigma-resection, Hartmann surgery)
  • Postoperatively, the patient was directly transferred to ICU in septic shock, ventilated and catecholamine-dependent
  • Sharply increased inflammatory parameters (PCT 96.7 µg/l, CRP 460 mg/l)
  • Initiation of antibiotic therapy with Tazobactam (later change to Linezolid and Meropenem), as a consequence inflammatory parameters clearly decreased (PCT 13.5 µg/l, CRP 280 mg/l) and hemodynamics stabilized (norepinephrine 0.25 µg/kg/min)
  • 9 days after the surgical intervention occurrence of a second inflammatory surge with an increase of PCT to 163 µg/l and CRP to 400 mg/l as well as hemodynamic instability with need for high norepinephrine doses of up to 1.8 µg/kg/min
  • Pronounced lactic acidosis (4.6 mmol/l)
  • Initiation of PiCCO-guided hemodynamic volume management
  • Re-laparotomy with insertion of a retroperitoneal drain due to a suspected abscess
  • Development of anuric acute renal failure (creatinine 115 µmol/l) despite administration of  high amounts of fluids
  • Due to his acute anuric renal failure and the recurring acute inflammatory response, physicians decided to initiate CytoSorb as adjunctive therapy together with CVVHDF
  • Subsequent final diagnosis: severe sepsis following peritonitis  caused by migration of gut bacteria in chronic ulcerative colitis

Treatment

  • Two consecutive CytoSorb treatment sessions for a total treatment time of 10 hours (1st session for 7 hours, 2nd session for 3 hours)
  • CytoSorb was used in combination with CRRT (Prismaflex, Gambro) run in CVVHDF mode
  • Blood flow rate: 130 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: post-hemofilter

Measurements

  • Hemodynamics and demand for catecholamines
  • Inflammatory parameters (PCT, CRP)
  • Lactate clearance

Results

  • During the course of the two treatments there was a temporary improvement in the systemic vascular resistance index (SVRI) from 900 to 1500 dyn*s/cm5*m2, however there was an continuing high demand for norepinephrine
  • Clear reduction of inflammatory parameters under CytoSorb therapy (PCT 46 µg/l, CRP 257 mg/l)
  • Stabilization of lactic acidosis
  • Antibiotic dosages did not have to be adjusted at any time

Patient Follow-Up

While still under maximum therapy there was a manifestation of an asystole, as a consequence and in agreement with the next of kin further resuscitation attempts were omitted and the patient eventually died

CONCLUSIONS

  • The use of CytoSorb in this patient was a last resort decision and may have resulted in a better outcome of the patient if applied earlier (at best as he started to deteriorate or at the time of the re-occurence of the second inflammatory surge)
  • According to the medical team, from this time on CytoSorb is always considered and applied in cases of severe sepsis with concomitant severe inflammatory reactions (even if renal function is good)
  • The application of CytoSorb therapy was simple, safe and with no problems installing the adsorber in a post-hemofilter position