23/2016
CytoSorb in septic shock after perforated Ulcus ventriculi

Dr. Markus Teipel, head physician, Interdisciplinary Intensive Care, Nordwest-Krankenhaus Sanderbusch GmbH

Summary:

This case study reports on a 43-year-old male patient, who was transferred to hospital via emergency boat and ambulance service from Langeoog island with initially belt-shaped and then diffuse radiating acute pain in the upper abdomen, dark vomitus, diarrhea and dyspnea.

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Case presentation

  • Diagnosis: perforated ulcus ventriculi at the small curvature
  • Immediate emergency laparoscopy and laparotomy within 2 hours after admission followed by surgical suturing and covering of the perforation
  • The patient was transferred to ICU intubated and ventilated
  • At this time the patient was hemodynamically unstable, hypotonic, tachycardic with high requirement for catecholamines (noradrenaline 0.5 ug / kg / min)
  • Significantly increased inflammatory parameters: PCT> 200 ng/ml, leukocytes 6.900/µL, CRP >27 mg/dl
  • Advanced hemodynamic monitoring showed septic shock with high volume requirements (SVRI 1500 dyn*s*cm-5*m², ELWI 5.6 ml/kg, GEDI 496 ml/m²)
  • High loading volumes (positive fluid balance 12 liters) with poor and further decreasing spontaneous diuresis (200 ml/day), creatinine 5.8 mg/dl, GFR 11.3 ml/min, urea 95 mg/dl
  • Initiation of antibiotic therapy with ertapenem followed by additional calculated antifungal treatment with caspofungin
  • Hydrocortisone 200 mg/day, continuous Amiodarone with 300 mg loading dose (maintenance dose 900 mg/d)
  • Insertion of a Shaldon catheter and initiation of continuous veno-venous hemodiafiltration (CVVHDF)
  • Due to acute renal failure, sharp increase in inflammatory markers, progressive need for vasopressors and septic shock, CytoSorb was started 24 hours after initiation of CVVHDF

Treatment

  • Two consecutive CytoSorb treatment sessions for 24 hours each
  • CytoSorb was used in conjunction with citrate dialysis (Prismaflex; Gambro) in CVVHDF mode
  • Blood flow rate: 150 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: post-hemofilter

Measurements

  • Demand for catecholamines
  • Advanced hemodynamic monitoring parameters (SVRI, GEDI)
  • Lactate clearance
  • Inflammatory parameters (PCT, CRP)
  • Renal function (excretion)

Results

  • Clear stabilization of hemodynamics during the course of the two CytoSorb treatments (GEDI 840 ml/m², SVRI 2600 dyn*s*cm-5*m²)
  • With installation of the adsorber the norepinephrine dose could be reduced significantly to around 1/5 of the initial dose after completion of the first CytoSorb treatment and a further reduction to 0.08µg/kg/min after completion of the second treatment. Five days after the first treatment norepinephrine could be completely tapered off
  • Reduction of inflammatory parameters during the two treatments: PCT to 45 ng/ml after the first and to 23 ng/ml after the second treatment, CRP at >27 mg/dl after the first treatment and 7.4 mg/dl after the second treatment
  • Two days after completion of CytoSorb therapy increasing spontaneous diuresis
  • Antibiotic dosages did not have to be adjusted at any time

Patient Follow-Up

  • Cessation of renal replacement therapy 5 days after last CytoSorb treatment
  • Extubation on postoperative day 11
  • Antibiotic treatment with ertapenem could be discontinued 10 days and the antifungal treatment 14 days after admission
  • After extubation, patient had ongoing delirium which normalized over the next 4 days
  • No neuropathic sequelae
  • Transfer to IMC 16 days after initial admission and 4 days later to the normal ward

Conclusions

  • Clear stabilization and consolidation of hemodynamic and inflammatory mediators with CytoSorb within 48 hours
  • Conventional therapy using the sepsis bundle was not enough to hemodynamically stabilize the patient during his acute septic phase, however, after using the CytoSorb adsorber this could be achieved in a short period of time
  • The application of CytoSorb therapy was simple, safe with no problems installing the adsorber in a post-hemofilter position