CytoSorb in a case of ARDS and multiple organ failure

Karl Träger, University Hospital Ulm

Summary:

This case study reports on a 45 year old male patient who was admitted to hospital with small bowel obstruction due to torsion being immediately scheduled for surgical intervention

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Case presentation

  • At anesthesia induction the patient aspirated and immediately underwent bronchoscopy
  • Laparotomy was performed and decompression of the small bowel was achieved
  • During operation the patient developed severe respiratory failure with indication for installation of a veno-venous ECMO
  • On ICU the patient developed severe ARDS, alveolar edema, systemic vasoplegia, marked capillary leakage, leucocytopenia and acute kidney injury grade 3 with indication for CRRT
  • Further treatment included bronchoscopy, veno-arterial ECMO, protective ventilation, kinetic positioning and application of the sepsis bundle
  • Due to a massive increase in markers of inflammation Cytosorb was added to the circuit

Treatment

  • Cytosorb® was used in conjunction with CVVHD added in pre-dialyzer position of the CRRT machine (Multifiltrate)
  • Three treatments were consecutively performed for 85 hours in total (20+35+29 h)
  • Blood flow rate between 100-140 ml/min
  • Regional anti-coagulation was achieved using a citrate-based protocol

Measurements

  • Course of IL-6 and IL-8 throughout the three treatments
  • Need for norepinephrine throughout the treatment period
  • Fluid balance during the three consecutive CytoSorb treatments

Results

  • Pronounced decrease in the concentrations of IL-6 and IL-8 continuing to decrease further in the following days
  • Patient stabilized hemodynamically and the need for norepinephrine was significantly reduced
  • Respiratory function improved during the treatment course, with a disappearance of any signs of alveolar exudation
  • Severity of capillary leakage as demonstrated by daily fluid needs and daily fluid balance became less apparent
  • CytoSorb treatment was safe and well-tolerated with no device related adverse events, and easy to implement as part of the CVVH circuit

Patient Follow-Up

  • At postoperative Day 12, therapy was started with methylprednisolone, in order to inhibit fibroproliferation in the lung and risk of fibrosis during ARDS
  • A percutaneous tracheostomy was performed on Day 13
  • By post-operative Day 18, the patient’s respiratory function, along with gas exchange and lung mechanics, on mechanical ventilation had sufficiently improved such that VA-ECMO was discontinued
  • CRRT had to be continued for a period of 20 days and could then be stopped after sufficient recovery of renal function
  • On Day 27, the patient was transferred to a respiratory weaning unit where the patient was subsequently successfully weaned off mechanical ventilation, with a discontinuation of CRRT and the recovery of renal function

Conclusions

  • Stabilization and successful treatment of a complicated pulmonary aspiration post-surgical patient with septic shock and polymicrobial infection, severe exudative ARDS, renal failure, and a severe SIRS response with pronounced hypercytokinemia
  • Control over the patient’s initial hyper-inflammatory response was a key element in helping clinically stabilize the patient, allowing for organ recovery, and ultimately survival
  • More randomized controlled studies using CytoSorb in critically-ill patients will help to establish the true benefit of the therapy