Hybrid blood purification strategy in pediatric septic shock

Gabriella Bottari1, Fabio Silvio Taccone2, Andrea Moscatelli1 1Istituto Giannina Gaslini, Neonatal and Paediatric Intensive Care Unit, Largo Gerolamo Gaslini 5, 16147 Genoa, Italy 2Department of Intensive Care, Hopital Erasme, Route de Lennik 808, 1070 Brussels, Belgium

Summary:

This case study reports on a 12-year-old female patient with refractory septic shock (clinical history of acute lymphatic leukemia and recent chemotherapy) who was admitted to the emergency department because of fever and fatigue

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Case presentation

  • In the emergency department, mean arterial pressure (MAP) was below 50 mmHg and did not improve after initial fluid resuscitation (20 ml/kg)
  • Empiric antimicrobial therapy was initiated and the patient was admitted to the pediatric intensive care unit
  • Because of severe persistent hypotension with arterial lactate concentrations of 74 mg/dl, epinephrine and norepinephrine were initiated at 0.2 μg/kg/min and 0.08 μg/kg/min, respectively
  • Six hours after admission, the patient remained severely hypotensive (MAP of 45 mmHg) despite fluid and vasopressor therapy and low-dose hydrocortisone administration
  • Later microbiological findings confirmed that blood cultures yielded Klebsiella pneumonia, related to a percutaneously inserted central line infection

Treatment

  • In the absence of oliguria, continuous renal replacement therapy (CRRT) was started (CVVHDF modality; dialysate flow of 35–40 ml/kg/h) with a high cutoff (HCO) filter (Septex®) in combination with a Cytosorb cartridge

Measurements

  • Vasopressor doses
  • Lactate
  • Procalcitonin

Results

  • A significant reduction of vasopressor doses was observed 48 hours after the initiation of extracorporeal blood purification
  • A similar positive trend was observed for lactate (74 vs 32 mg/dl) and procalcitonin (65 vs 18 ng/ml) concentrations
  • The combined treatment was continued for 72 hours without adverse events

Post-treatment period and follow-up

  • The patient was successfully discharged after 10 days.

CONCLUSIONS

  • The combination of HCO-CRRT and CytoSorb might have had a synergistic effect in this setting; this association has not yet been explored in the treatment of pediatric septic shock
  • The treatment with CytoSorb in this pediatric patient could be carried out for 72 hours without problems and proved to be well tolerated
  • Further studies are needed to assess the feasibility as well as the optimal timing of initiation of such an approach in children suffering from septic shock.