50/2016
Use of CytoSorb in a case of severe septic shock and septic cardiomyopathy due to urosepsis

PD Dr. med. Harald Fritz, Dr. med. Sylke Schmidt, Henning Koch Hospital Martha-Maria Halle-Dölau, Department for Anesthesiology, Intensive Care Medicine and Pain Therapy

Summary:

This case study reports on a 82-year-old male patient (medical history of chronic renal insufficiency stage 3, prostate carcinoma), who presented at the hospital for elective radical cystectomy with ileum conduit installation after pre-existing urothelial carcinoma and recurrent urinary tract infections with urinary congestion.

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Case presentation

  • Post-operative admission to Intermediate Care (IMC)
  • Due to postoperative bleeding and subsequent hemorrhagic shock, the patient was taken back to surgery
  • After reoperation, the patient was monitored in ICU for 4 days and then transferred to the normal urological ward
  • 14 days later the patient was admitted back to the ICU in severe septic shock with hypotension, chills, ECG alterations and suspected myocardial infarction after he had undergone a routine ureter splint exchange on the previous day
  • At this time, the patient already required high doses of norepinephrine (0.5 μg/kg/min), showed excessively high inflammatory parameters (IL-6 73,020 pg/ml, LBP 28.2 μg/ml, leukocytes 48,600/µl) , impaired renal function (GFR at 30 ml/min, creatinine 179 μmol/l), an increased Troponin T high sensitivity (TroponinThs)  of 0.096 ng/ml and an increase in CK-MB
  • Immediate initiation of antibiotic therapy with imipenem, after E.coli was confirmed in the patients’ urine from the smear of the ureter splint exchange the previous day
  • The decision was made to treat the NSTEMI (Non-ST-Segment Elevation Myocardial Infarction) conservatively with Clopidogrel and ASS anticoagulation, i.e. in his current critical state no coronary intervention (coronarography with possible stent installation) at this point in time
  • Echocardiographic diagnosis confirmed severe aortic valve stenosis, which was probably only noticeable in the context of the septic cardiomyopathy and his impaired pump function
  • Noninvasive ventilation, administration of 200 mg/24 h hydrocortisone
  • Commencement of advanced hemodynamic monitoring with PiCCO, which showed clear signs of volume overload with concomitant oliguria (in pre-existing chronic renal insufficiency)
  • Further increase of lactate up to 5.1 mmol/l and of TroponinThs (1.2 ng/ml) as well as progressively increasing catecholamine demand (0.75 μg/kg/min)
  • Initiation of renal replacement therapy with cautious ultrafiltration and simultaneous initiation of CytoSorb therapy

Treatment

  • Three  treatment cycles with CytoSorb for 24 hours each
  • CytoSorb was used in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) performed in CVVHD mode
  • Blood flow rate: 125 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Demand for catecholamines
  • Renal function (creatinine, excretion)
  • Inflammatory parameters (IL-6, leucocytes)
  • Lactate

Results

  • Norepinephrine after the first treatment was 0.3 μg/kg/min, and after the 3rd  treatment was still 0.2 μg/kg/min, which was probably rather associated with the cardiac impairment, given the declining systemic inflammation response
  • Extremely efficient reduction of the initially high inflammatory parameters – IL-6 after the first treatment had already decreased to 687 pg/ml, after the second treatment 29.8 pg/ml and after the third treatment 40.8 pg/ml, with ongoing further decreases; normalization of LBP at 10.5 μg/ml during the course of the treatments; leucocytes initially increased to 87,000/μl after the first treatment, but then continued to fall over the following days to normal values
  • Continuously falling lactate levels with 2.3 mmol/l after the 2nd treatment and 1.2 mmol/l after the third treatment
  • Normalization of creatinine and GFR over the course of 3 treatments (after first treatment: creatinine 147 μmol/l, GFR 38 ml/min, after the 2nd treatment: creatinine 79 μmol/l, GFR 84 ml/min; after 3rd treatment: creatinine 102 μmol/l, GFR 60 ml/min)

Patient Follow-Up

  • Termination of renal replacement therapy together with the last CytoSorb treatment after 3 days
  • Patient remained stable and was transfered to the cardiology ward for further monitoring and for preparation for his aortic valve replacement (TAVI). Left ventricular ejection fraction was 25% at this time
  • Further course of treatment included several transfers from the cardiology ward to IMC and ICU for treatment of wound healing problems
  • Ultimately the patient was discharged to his home environment

CONCLUSIONS

  • Treatment with CytoSorb was accompanied by an unexpectedly rapid (within hours) and significant reduction in inflammatory parameters
  • It was the patients’ severe septic condition, the associated septic cardiomyopathy and the cardiac decompensation that revealed his aortic valve stenosis and made its diagnosis possible. According to the medical team, without the rapid control of the overwhelming inflammatory response and thus the prevention of manifest organ damage, the patient would not have survived to make it to the curative heart surgery and would have died with high probability
  • Safe and easy application of CytoSorb