20/2016
CytoSorb in pneumogenic sepsis due to influenza A H1N1

Dr. Markus Nitsch & Dr. Hendrik Liedtke, Clinic for Anaesthesiology, Intensive Care, Palliative, Emergency Medicine and Pain Therapy, Hospital St. Elisabeth and St. Barbara Halle (Saale) GmbH, Germany

Summary:

This case study reports on a 68-year-old male patient (medical history of COPD IV°, atrial fibrillation hypertension and chronic nicotine and alcohol abuse) who was admitted to the hospital by emergency medical service.

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Case presentation

  • Direct transfer from emergency department to ICU under non-invasive ventilation
  • Intubation and invasive ventilation due to persistent hypercapnia (respiratory acidosis)
  • CT diagnosis did not show acute infiltration, at bronchoscopy no secretion in bronchi visible, bronchial wall thickening due to COPD was the only abnormality
  • In the further course significantly increasing needs for volume and norepinephrine (2.3 µg/kg/min)
  • Suspicion for pneumogenic sepsis with immediate start of antibiotic therapy (piperacillin/tazobactam)
  • Progressing renal failure with oliguria up to anuria
  • Increase of pCO2 to 18 kPa, pO2 15 kPa at FiO2 of 0.5, pH 7.04
  • Increased inflammatory parameters: PCT 1.28 ng/ml, CRP 114.4 mg/l
  • Microbiological finding: Influenza A H1N1 (from bronchoscopy at admission)
  • Due to pneumogenic sepsis and increasing needs for catecholamines and volume, CytoSorb was started simultaneously with CRRT

Treatment

  • Two CytoSorb treatment sessions for 24 hours each (pause interval of 3 hours between both treatment sessions)
  • CytoSorb was used in conjunction with citrate dialysis (Multifiltrate; Fresenius Medical Care) in CVVHD mode
  • Anticoagulation: citrate
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Demand for catecholamines
  • Demand for volume
  • Inflammatory parameters (PCT, CRP)

Results

  • Norepinephrine could be reduced as early as 6 hours after start of CytoSorb – first to 1.8 µg/kg/min and to 0.6 µg/kg/min over the next 24 hours
  • After stop of the first CytoSorb treatment the norepinephrine dosage had to be increased again to 2 µg/kg/min
  • After start of the second CytoSorb treatment, noradrenaline could be tapered off within the next 12 hours
  • Volume requirement declined significantly over this time
  • PCT and CRP plasma levels initially increased but continued to fall in the further course following the second treatment session

Patient Follow-Up

  • Cessation of renal replacement therapy 2 days after the last CytoSorb treatment with full recovery of spontaneous diuresis after stimulation with diuretics
  • Weaning trials over 6 weeks after the end of CytoSorb, thereafter adjustment to non-invasive ventilation
  • Transfer to pneumology department with persistent critical illness myopathy and neuropathy
  • Discharge from hospital 10 weeks after initial admission into early stage rehabilitation

Conclusions

  • Remarkable stabilization of hemodynamics with declining catecholamine and volume requirements under CytoSorb within 48 hours
  • According to medical team they were positively surprised because of the rapid stabilization of the patient and due to the fact that catecholamines could be tapered off that rapidly
  • Handling of the adsorber was easy and safe