Use of CytoSorb in a case of severe ARDS after H1N1 infection and septic multiple organ failure

PD Dr. med. Stephan Ziegeler
Department of Anaesthesiology, Operative Intensive Care Medicine, Pain Management and Emergency Medicine, Hospital Ibbenb├╝ren, Germany

Summary:

This case study reports on a 48-year-old female patient presenting at the hospital with flu-like symptoms and whose respiratory situation deteriorated rapidly in the further course.

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Case presentation

  • Patient was admitted to ICU mechanically ventilated with severe ARDS and full-blown septic shock and multiple organ failure (pulmonary, hepatic, renal, circulatory)
  • Virus diagnosis proved infection with H1N1 and subsequent antiviral therapy with Tamiflu
  • Fast progression to circulatory failure
  • Progressive global respiratory failure necessitating implantation of venovenous ECMO with subsequent change to veno-veno-arterial ECMO due to development of right heart failure
  • Development of acute, anuric, dialysis-dependent kidney insufficiency with indication for renal replacement therapy
  • Due to the fast progression to septic multiple organ failure with highly catecholamine-dependent circulatory insufficiency a CytoSorb adsorber was installed in combination with CVVHD
  • Significantly elevated plasma levels of PCT at start of therapy (26 ng/ml)

Treatment

  • Two CytoSorb treatments for 24 hours each
  • CytoSorb was used in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) in CVVHD mode
  • Blood flow rate: 100 ml/min
  • Anticoagulation: Argatroban (0.2 mcg/kg/min)
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Demand for catecholamines
  • Infection parameters (PCT)

Results

  • Hemodynamic stabilization of the patient along with significantly decreased needs for catecholamines, vasopressors could be tapered out as early as 36 h after start of CytoSorb therapy
  • Fast decrease of plasma PCT levels to 5.4 ng/ml after stop of CytoSorb therapy
    Patient Follow-Up
  • In the further course rapid improvement of the respiratory situation and stop of ECMO 7 days after cessation of CytoSorb therapy
  • Termination of renal replacement therapy 7 days after the last CytoSorb treatment
  • Due to a recurring pulmonary deterioration the ECMO therapy had to be initiated again on week after stop of the the initial ECMO treatment
  • Return to only One-Organ-failure (lung) in the context of severe influenza with ongoing clinical improvement

Conclusions

  • Successful application of CytoSorb in a case of severe ARDS after H1N1 infection and septic multiple organ failure
  • Overall rapid improvement of circulatory insufficiency within a few hours and reversal of multiple organ failure
  • Also rapid reduction of PCT levels which was potentially favored by the application of CytoSorb in conjunction with causal sepsis therapy
  • Application of CytoSorb was possible without problems even in first-time application