CytoSorb in a case of severe infection of an implantable cardioverter defibrillator (ICD) lead

Dr. med. Burkhard Hinz, Head of Interdisciplinary ICU, KMG Clinic Güstrow, Germany Dr. med Toralf Noky, Head of Department of Anesthesiology and Intensive Care Medicine, KMG Clinic Güstrow Dr. med. Rolf Kaiser, Head of Department of Internal Medicine, Cardiology and Intensive Care Medicine, KMG Clinic Güstrow

Summary:

This case study reports on a 73-year-old female patient who was admitted to hospital with back pain due to severe degenerative spine manifestations and who deteriorated significantly in the further course.

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Case presentation

  • Development of septic shock with multiple organ failure (circulatory, renal, lung)
  • Proof of Methicillin-Susceptible Staphylococcus aureus (MSSA)
  • Excessively elevated inflammatory parameters (CRP, PCT, leucocytes)
  • Excessively high demand for catecholamines (noradrenaline up to 2 µg/kg/min)
  • Initiiaton of mechanical ventilation with high inspiratory pressures
  • Severly impaired renal function with increased retention parameters and anuria with immediate initiation of citrate dialysis
  • Due to sharp increase of inflammatory markers and progressive need for catecholamine, the patient was treated with CRRT in combination with CytoSorb

Treatment

  • Three CytoSorb treatment sessions for three days with treatment time of 24-27 hours each
  • CytoSorb was used in conjunction with citrate dialysis (Multifiltrate; Fresenius Medical Care) in CVVHD mode
  • Blood flow rate: 180 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Demand for catecholamines
  • Renal function (creatinine, urea, excretion)
  • Inflammatory parameters (CRP, PCT, leucocytes)
  • PiCCO measurements – volume- and hemodynamic parameters, Extravascular lung water (ELWI)

Results

  • Hemodynamic stabilization of the patient with significantly decreased needs for catecholamines
  • Significantly declining renal retention parameters and reduction of inflammatory parameters during the CytoSorb sessions
  • Reduction of capillary leakage including ELWI under treatment

Patient Follow-Up

  • In the further course an infection of an implantable cardioverter defibrillator (ICD) lead with resulting endocarditis was confirmed as focus
  • Focus was eradicated by surgical removal of the ICD and its lead
  • After further hemodynamic stabilization catecholamines could be completely tapered out
  • Termination of renal replacement therapy
  • Persisting but decreasing septic encephalopathy

Conclusions

  • Combined treatment of CRRT with CytoSorb resulted in significant stabilization of hemodynamics with declining needs for catecholamines and an improvement of capillary leakage and the inflammatory situation
  • Handling of the adsorber was easy and intuitive