51/2016
Use of CytoSorb in severe necrotizing ethyltoxic pancreatitis and ARDS due to bilateral pneumonia

Dr. med. Klaus Kogelmann , Matthias Drüner, Morten Scheller Hospital Emden, Department for Anesthesiology and Intensive Care Medicine

Summary:

This case study reports on a 45-year-old patient (pre-existing diseases: arterial hypertension, steatosis hepatis, sigma diverticulosis, previous gastric ulcer, 20 year history of chronic alcohol consumption), who was admitted to the psychiatric clinic primarily for alcohol withdrawal after increased alcohol consumption in the previous month.
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Case presentation

  • Transfer of the patient to the intensive care unit (ICU) two days after initial admission with unclear abdominal symptoms and suspicion of pancreatitis (elevation of lipase to 1780 I/U)
  • On admission, the patient had an APACHE 2 score of 28, severe SIRS, and acute renal failure
  • The abdominal CT confirmed an extensive exudative pancreatitis, while the chest CT showed signs of beginning infiltrates and bilateral pneumonia
  • Despite antibiotic therapy, as well as protocol-based volume therapy, there was increasing respiratory insufficiency, resulting in endotracheal intubation on the day of ICU admission after an unsuccessful initial attempt of non-invasive ventilation
  • After 24 hours of (ineffective) maximum standard therapy and the onset of acute renal failure with anuria despite sufficient positive fluid balance, continuous renal replacement therapy was started in combination with CytoSorb (due to the protracted shock) in spite of therapy with dobutamine and adjunctive hydrocortisone

Treatment

  • Four consecutive treatments with CytoSorb for a total duration of 72 hours (1st  treatment: 24 hours,
    2nd + 3rd treatment 12 hours each, 4th treatment: 24 hours)
  • Cytosorb was applied in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) run in CVVHD mode
  • Blood flow: 100-150 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Demand of catecholamines (dose of norepinephrine vs. the thereby achieved MAP)
  • Creatinine
  • Bilirubin
  • Thrombocytes
  • Lung function PaO2/FiO2
  • SAPS 2 and SOFA
  • Lactate

Results

  • Shock-reversal after a total of 4 treatment cycles to <10% of the initial norepinephrine dose; i.e. after the end of the last CytoSorb treatment only 10% of the norepinephrine administration was still required – most probably due to the ongoing need for analogosedation.  From day 10 the patient was catecholamine-free
  • Reduction of creatinine and bilirubin during the four treatment cycles. Bilirubin showed a rebound after the end of the last treatment
  • Dose adjustment of the calculated antibiotic therapy with high dose meropenem (4g/day) was not necessary

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Patient Follow-Up

  • Already during the initial treatment phase including cytokine adsorption. extracorporeal oxygenation with a Novalung X-Lung membrane became necessary and was continued for a total of 10 days due to ARDS (Horowitz index of 60). Due to severe multiple organ failure. a dilatation tracheotomy was performed during the course of the day and the patient was weaned from the respirator on day 15 of treatment after successful weaning from the ECMO. He was  decannulated two days later
  • Pancreatitis resolved and the alcohol withdrawal was completed after 27 days in the intensive care unit
  • Hepatic function: ongoing  increased bilirubin levels at the end of treatment and low platelets. however plasmatic coagulation proved intact and the patient exhibited standard values on discharge
  • Further recovery was completed without complications. The patient was fully oriented at all times as well as hemodynamically stable. Clinically. there were sensitivity disorders in the patients’ hands and neuropathic pain in the area of the lower and upper thighs pointing towards critical-illness polyneuropathy
  • His arterial hypertension continued. so that the antihypertensive medication had to be adapted
  • The patient continued to improve. was able to tolerate a normal diet and mobilization. and on the 27th day was discharged to the rehabilitation unit in good general condition

CONCLUSIONS

  • Treatment with CytoSorb became necessary for two reasons – on the one hand due to the severe necrotizing pancreatitis with severe SIRS/shock, and on the other hand also because of pneumonia with ARDS and septic shock, both of which resolved
  • Treatment with CytoSorb was safe and application possible without technical problems