CytoSorb in a case of necrotizing fasciitis and septic shock

Dr. Radovan Novak, Hospital Zittau

Summary:

This case study reports on a 19-year-old male, who was taken to hospital by emergency ambulance with an erysipelas on his right hand and signs of systemic inflammation (fever, hypotonic, tachycardic and somnolent).

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Case presentation

  • Suspected necrotizing tendovaginitis/fasciitis with later proof of beta-hemolytic streptococci
  • Immediate initiation of antibiotic therapy with imipenem, PCT plasma levels grossly elevated with >500 ng/ml
  • In the further course beginning of renal failure, hemodynamic instability and shock
  • Shortly thereafter necessity for mechanical ventilation
  • On the same day surgical wound revision with extensive debridement of skin and subcutaneous tissue
  • After surgery, very high and further rising catecholamine dosage required
  • Initiation of CRRT due to onset of oliguria
  • Indication for CytoSorb: existing access through CRRT, high catecholamine needs, refractory to standard treatment

Treatment

  • Two CytoSorb sessions for 6 and 25 hours separated by a pause interval of 8 hours
  • Premature stop of the first treatment after 6 hours due to a thrombus in Sheldon catheter
  • Confirmed diagnosis of HIT II after prior drop of platelets
  • Switch from heparin to argatroban for the second treatment due to HIT II diagnosis
  • Cytosorb was run in combination with CRRT (Multifiltrate) in CVVH mode
  • Blood flow rate: 150 ml / min, pre-hemofilter position of CytoSorb

Measurements

  • IL-6, PCT, CRP, leucocytes
  • Catecholamine dosage
  • Renal function
  • PTT during argatroban anticoagulation
  • Hemodynamic variables via PiCCO: CI, SVRI, GEDI and ELWI

Results

  • Treatment resulted in hemodynamic stabilization of the patient with a significant reduction of catecholamines already during the first 6 hour treatment, and a drop to 10% of the initial dosage after the second CytoSorb session
  • Reduction of PCT and other inflammatory parameters during treatment
  • Decline of IL-6 from 2300 pg/ml to 36 pg/ml during the course of the two treatments
  • Improved renal function with return of spontaneous diuresis

Patient Follow-Up

  • CRRT could be stopped after the second CytoSorb treatment
  • Extubation of the patient four days after the second treatment under stable conditions
  • Routine debridement and dressing changes in the following days

Conclusions

  • In this patient, treatment with CytoSorb resulted in a significant stabilization of hemodynamics with declining needs for catecholamines and improved organ functions
  • Due to the early stabilization of the patient amputation could probably be avoided
  • Handling of the adsorber was simple and intuitive
  • Hospital team was enthusiastic and impressed about the fast, positive course