42/2016
CytoSorb in severe sepsis following rectal necrosis

Dr. med. Jan Adamski, Dr. med. Björn Jäschke Satakunta District Central Hospital, Intensive Care Unit, Finnland

Summary:

This case study reports on an 81-year-old male patient (history of asthma, arterial hypertension, aortic valve insufficiency, polymyalgia rheumatica) who was admitted to hospital with acute abdominal pain.

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Case presentation

  • Immediate admission to ICU and initiation of antibiotic therapy with cefuroxim/metronidazole. At this time the patient was hypotensive and had a CRP plasma level of 314 mg/l
  • The same day an abdominal CT was performed, however no evidence of a perforation was found
  • During the following hours the patient developed signs of sepsis, with hyperlactatemia (3.36 mmol/l) and could not be adequately stabilized
  • Subsequent explorative laparotomy revealed rectal necrosis of unclear origin and the patient underwent rectal and partial sigmoid resection
  • Postoperatively, the patient was directly transferred to ICU in septic shock, ventilated and extremely hemodynamically unstable with high requirement for norepinephrine (1.6 mg/h)
  • He also showed increased plasma levels of inflammatory parameters (PCT 29 ng/ml, CRP 480 mg/l that continued to trend upwards, thrombocytes 119,000/µl, leucocytes 11,000/µl)
  • Pronounced lactic acidosis (3.6 mmol/l), base excess -8.5
  • Change of antibiotic therapy after the OR to Tazobactam/Piperacillin, which was then switched to an prolonged infusion prototol when CRRT was started (12 g/24 h)
  • Development of anuric acute renal failure (creatinine 254 µmol/l, urea 16.6 mmol/l)
  • Due to his acute anuric renal failure and condition of septic shock physicians decided to initiate CytoSorb as an adjunctive therapy together with CVVHDF
  • Subsequent final diagnosis: sepsis due to rectal necrosis

Treatment

  • Two consecutive CytoSorb treatment sessions for a total treatment time of 48 hours (24 hours each)
  • CytoSorb was used in combination with CRRT (Multifiltrate, Fresenius Medical Care) run in CVVHDF mode
  • Blood flow rate: 100 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Hemodynamics and demand for catecholamines
  • Inflammatory parameters (PCT, CRP)
  • Lactate clearance

Results

  • During the course of the two treatments there was a clear stabilization of hemodynamics, infusion rate of norepinephrine after 24 hours of treatment was 0.8 mg/h, and after 48 hours of CytoSorb therapy norepinephrine could be completely weaned off
  • Clear reduction in inflammatory parameters under CytoSorb therapy (after 24 h of treatment: CRP 332 mg/l, PCT 16 ng/ml; after 48 h: CRP 182 mg/l, PCT 7.6 ng/ml; thereafter both parameters trended towards normal levels, thrombocytes: decreased to 78,000/µl within 48 h and bounced back to 130,000/µl two days after discontinuation of CytoSorb therapy
  • Stabilization of lactic acidosis (lactate after 24 h of treatment: 1.57 mmol/l, after 48 h 1.04 mmol/l)
  • Antibiotic dosages did not have to be adjusted at any time

Patient Follow-Up

  • Extubation on day 3 of CRRT
  • Reestablishment of spontaneous diuresis on the 4th day followed by discontinuation of CRRT and discharge to the normal ward
  • 2 days after discharge from ICU the patient developed bleeding problems with need for a re-laparotomy where the source of the bleeding was found
  • Thereafter readmission to ICU for another 2 days, however with no further problems, he was discharged to normal ward and later discharged to home in good health

CONCLUSIONS

  • Clear stabilization and consolidation of hemodynamics and inflammatory mediators under CytoSorb within 48 hours
  • According to the medical team CytoSorb should always be considered and applied in the early phase of septic shock
  • The application of CytoSorb therapy was simple, safe and there were no problems installing the adsorber in a pre-hemofilter position