19/2016
CytoSorb in septic shock with multiple organ failure and ARDS (fast-in/fast-out)

Dr. Martin Bergold, Senior Consultant Clinic for Anaesthesiology, Intensive Care Medicine and Pain Management, Evangelisches Krankenhaus Oldenburg, Germany

Summary:

This case study reports on a 64-year-old male patient (medical history of arterial hypertension and insulin-dependent diabetes mellitus) who all of a sudden deteriorated massively (hemodynamically and respiratory) during his 3-week hitherto uneventful neurological first stage rehabilitation after media and cerebellar infarction.

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Case presentation

  • Diagnosis of sepsis with immediate start of antibiotic therapy (piperacillin/tazobactam)
  • Despite antibiotic therapy further aggravation of his clinical condition all the way to septic shock with further change of antibiotic regimen to Meropenem and Teicoplanin
  • Unstable hemodynamics despite 0.35 µg/kg/min norepinephrine: cardiac index 2.3 l/min/m2, SVRI 1100 dyn*s*cm-5*m², ELWI 16 ml/kg, lactate 6.7 mmol/l
  • Sharp increase of inflammatory parameters PCT 1.28 ng/ml, IL-6 7315 pg/ml, leucocytes 70.000/µl, CRP 4.9 mg/dl
  • Development of ARDS with proof of pseudomonas spec and diagnosis of pseudomonas-pneumonia
  • Despite initial spontaneous diuresis and normal retention parameters renal function deteriorated rapidly
  • Due to acute anuric renal failure, sharp increase of inflammatory markers and progressive need for catecholamine and septic shock with multiple organ failure CytoSorb was started simultaneously with CRRT

Treatment

  • Three CytoSorb treatment sessions for 24 hours each
  • CytoSorb was used in conjunction with citrate dialysis (Multifiltrate; Fresenius Medical Care) in CVVHD mode
  • Blood flow rate: 100 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Demand for catecholamines
  • Inflammatory parameters (IL-6, PCT, CRP, leucocytes)
  • Renal function (excretion)
  • Lactate

Results

  • Clear stabilization of hemodynamics during the course of the three CytoSorb treatments under 0.25 µg/kg/min norepinephrine and vasopressin: cardiac index now 3.54 l/min/m2, SVRI 1600 dyn*s*cm-5*m², ELWI 8 ml/kg, in TEE LV-EF 30-40%
  • Decrease of inflammatory parameters during the course of the three CytoSorb treatments: IL-6 to 1871 pg/ml, PCT to 0.44 ng/ml, CRP to 7.9 mg/dl, leucocytes to 8700/µl
  • Lactate level stable at 2.2 mmol/l

Patient Follow-Up

  • Cessation of renal replacement therapy 6 days after the last CytoSorb treatment
  • Complete recovery after acute septic phase with exception for his neurologic underlying problem (rehabilitation due to media and cerebellar infarction)
  • Transfer to neurological first stage rehabilitation

Conclusions

  • Clear stabilization and consolidation of hemodynamics and inflammatory mediators under CytoSorb within 48 hours
  • Control of septic shocks within a short period of time
  • Handling of the adsorber was easy and safe