40/2016
CytoSorb in peritonitis after perforation and pronounced SIRS

Dr. Bodo Albrecht, Dr. Peter Wolf, Department for Anesthesiology and Intensive Care Medicine, Zeisigwald Clinics Bethanien Chemnitz

Summary:

This case study reports on a 63-year-old grossly obese (BMI 37) female patient who was admitted to the emergency department with an acute abdomen and signs of shock (tachycardia, hypotension).

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Case presentation

  • Patient had a preexisting incisional hernia in the lower abdomen following gynecological surgery several years before
  • On the day of admission the patient immediately underwent surgical procedure (laparotomy, adhesiolysis, lavage, ileum resection, hernia sac resection, appendectomy)
  • Preoperative commencement of antibiotic treatment with ampicillin/sulbactam and metronidazole, which was extended to imipenem on postoperative day 2 after microbiological findings from the intraoperative smear were available
  • Postoperatively, the patient was directly transferred to ICU, ventilated and catecholamine-dependent
  • On day 1 postop, patient developed significant capillary leak syndrome with high volume requirement (hematocrit of 44.7% could not be decreased despite volume administration of 6 liters/11 h and positive fluid balance, and was even trending upwards)
  • In addition, the patient developed a severe SIRS accompanied by rapidly increased plasma levels of IL-6 (3,625 pg/ml), PCT (10 µg/l) and leukocytes (21.000/µl)
  • Hemodynamic instability with need for high doses of norepinephrine (4.5 mg/h) and concomitant  Mean Arterial Pressure of 67 and tachycardia (rate 150)
  • Patient developed acute oliguric kidney failure with increased retention parameters (creatinine 149  µg/l, urea 8.2 mmol/l) and progressively declining diuresis of 150 ml in the first 12 hours of her ICU stay
  • Pronounced lactic acidosis (5.4 mmol/l)
  • Patient received hydrocortisone 200 mg/24h continuously without bolus
  • Due to the significant capillary leak syndrome despite high fluid supplementation and due to the unabated rise in the need for catecholamine support, CytoSorb therapy was started 12 h after admission to ICU
  • Microbiological findings on the 2nd postoperative day: E.coli, Enterococcus faecalis, Enterococcus faecium, Streptococcus salivarius, Bacteroides vulgatus
  • Subsequent final diagnosis: perforated ileitis

Treatment

  • Two consecutive CytoSorb treatment sessions (1st session for 24 hours, 2nd session for 30 hours)
  • CytoSorb was used with machine type BM11/BM14 (Baxter), while the first treatment session was carried out in hemoperfusion mode only and the 2nd session in combination with CVVHF
  • Blood flow rate: 200 ml/min
  • Anticoagulation: heparin
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Hemodynamics and demand for catecholamines
  • Capillary leak syndrome (fluid requirement)
  • Inflammatory parameters (PCT, leucocytes, IL-6)
  • Renal function (excretion, retention parameters)
  • Lactate clearance

Results

  • With installation of the adsorber the norepinephrine dose could be significantly reduced (dose before treatment 4.5 mg/h, reduction to 2.5 mg/h after the 2nd treatment , one day later to 1 mg/h, the day thereafter 0.5 mg/h, the following day norepinephrine could be completely tapered off)
  • Tachycardia as an expression of her inflammation-associated cardiomyopathy could be normalized (after 48 h heart rate was at 130 bpm and at 110 bpm upon completion of CytoSorb therapy)
  • Clear containment of capillary leak syndrome: volume requirement (i.e. net fluid supply) decreased rapidly during the course of the two treatments (1st day of treatment 12 liters, 2nd day of treatment 8 liters and 4.5 liters on the day after the end of the 2nd treatment)
  • Significant reduction in inflammatory parameters during the two treatment sessions: IL-6 109 pg/ml after the first treatment and 10 pg/ml one day after the second treatment, PCT 11.7 ng/ml after the first and 6.5 ng/ml after the second treatment, leucocytes 32,000/µl after the first treatment and 33,000/µl after the second treatment, on the following day leucocytes then fell to 19,000 /µl with further decreasing levels thereafter
  • Already in the first 12 hours of the first CytoSorb treatment (without CVVHF), diuresis rapidly increased to 570 ml, during the 2nd treatment with combined CVVH/CytoSorb therapy diuresis progressively improved further
  • Antibiotic dosages did not have to be adjusted at any time

Patient Follow-Up

  • Extubation on postoperative day 7
  • 4 days after extubation, the patient developed a delirium, which then normalized over the following days with appropriate treatment
  • Transfer to surgical ward 11 days after initial admission and discharge to her home environment 4 days later

CONCLUSIONS

  • Rapid application of CytoSorb led to a clear stabilization and consolidation of hemodynamic and inflammatory parameters, as well as significant containment of capillary leak syndrome within 48 hours
  • The early application of the procedure may therefore have prevented the onset of additional organ failure
  • The application of CytoSorb therapy was simple, safe and with no problems installing the adsorber in a post-hemofilter position