47/2016
Use of CytoSorb in severe sepsis after hemicolectomy and anastomosis dehiscence

Dr. Milan Margoc, Dr. S. Montag, Doz. Alexander Kulier, Anaesthesiological Intensive Care Unit, Hospital-Elisabethinen Linz

Summary:

This case study reports on a 80-year-old female patient (previous medical history of: arterial hypertension, coronary heart disease, atrial fibrillation, NIDDM II, aortic stenosis, peripheral vascular disease, chronic renal failure III), who was admitted to hospital for elective right-sided hemicolectomy for colon carcinoma.

button_EN

Case presentation

  • Admission to normal surgical ward for scheduled operation and subsequent postoperative transfer to intensive care unit
  • Her stay on ICU was complicated by secondary bleeding on the 1st postoperative day necessitating an immediate re-laparotomy with removal of hematoma
  • After a short stay in ICU, transfer to the normal surgical ward for further treatment for a total of 10 days
  • On the 10th day, acute deterioration of her general condition, diagnosis of severe sepsis after  anastomosis dehiscence with fecal peritonitis
  • Immediate surgical care with re-laparotomy, anastomotic resection, installation of a new anastomosis, lavage and drainage
  • Antibiotic therapy initially with tazobactam/piperacillin and after microbiological findings were available, changed to meropenem/echocantine (gram-negative sepsis)
  • 8 days later again deterioration with re-laparotomy and placement of a terminal ileostoma and abdominal dressing (VAC treatment for wound closure)
  • Retransfer to ICU, orotracheally intubated, mechanically ventilated, noradrenaline-dependent with doses of
    0.5-0.83 μg/kg/min at a heart rate of 90-140/min and a blood pressure of 80/45 mmHg, which improved to
    110/60 mmHg with noradrenaline
  • At this point she exhibited highly elevated inflammatory parameters (CRP 33.7 mg/l, leukocytes 28.400/μl,
    PCT 75 ng ml)
  • Additional impairment of renal function: GFR 14.7 ml/min
  • Due to her acute-on-chronic renal insufficiency as well as her hemodynamic instability and the increased inflammatory markers, the decision was made to initiate CytoSorb as an adjunctive therapy together with CVVHD

Treatment

  • Two  treatments with CytoSorb for a total treatment time of 66 hours (1st  and 2nd  treatment for 24 hours each, treatment pause of 18 hours between both treatments)
  • CytoSorb was used in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) performed in CVVHD mode
  • Blood flow rate: 150 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Demand for catecholamines
  • Renal function (GFR, excretion)
  • Inflammatory parameters (CRP, PCT, leucocytes)

Results

  • Hemodynamic stabilization with a significant reduction in catecholamine doses –norepinephrine doses could be reduced to 0.09-0.2 μg/kg/min during both treatments, patient was free from catecholamines 96 hours after completion of both CytoSorb treatments
  • Clear reduction of inflammatory parameters under CytoSorb therapy (CRP 10.38 mg/l,  leucocytes 14.500/µl,  PCT 22.5 ng/ml)
  • Clear improvement in kidney function: GFR from 14.7 to 45.6 ml/min

Patient Follow-Up

  • Termination of renal replacement therapy 2 days after the last CytoSorb treatment, recovery of diuresis to initial quanitity 7 days after the last CytoSorb treatment
  • Weaning and extubation successful 6 days after CytoSorb application
  • 11 days after the CytoSorb application, the patient could be transferred to the normal surgical ward
  • Over the following days the patient was clinically stable, awake, adequately alert, mentally appropriate, and with complete oral nutrition
  • Final surgical healing successful following installation of a terminal ileostoma

CONCLUSIONS

  • The treatment with CytoSorb resulted in stabilization of vital functions (improvement in the circulatory and renal function) as well as declining doses and finally complete cessation of catecholamines
  • CytoSorb was safe and easy to use