08/2017
Use of CytoSorb in Streptococcus pneumoniae Sepsis

Saija Mäki-Petäjä MD, Kari Saarinen MD Chief Physician ICU Seinäjoki Central Hospital, Finland

Summary:

This case study reports on a 70-year-old male patient who was admitted to hospital with acute respiratory failure. Patient´s previous medical history included coronary artery disease with a history of coronary artery bypass craft surgery (CABG), atrial fibrillation, heart failure, type II diabetes, obesity, chronic obstructive pulmonary disease, liver cirrhosis and methicillin-resistant staphylococcus aureus (MRSA) colonisation.

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Case presentation

  • Initially the patient’s blood pressure was 102/67 mmHg, heart rate 141/min, body temperature 38.6°, respiratory rate 25-30/min, oxygen saturation 94% with 1.5l/min oxygen flow
  • Slightly elevated inflammatory parameters (CRP 28mg/l, leukocytes 10.1 E9/l, PCT 34.5 ng/ml), moderate to severe loss of kidney function (creatinine 181 µmol/l, GFR 32ml/min/m2)
  • Hemoglobin 110 g/l, thrombocytes 112 E9/l
  • Compensated metabolic acidosis: pH 7.43, lactate 4.5 mmol/l, base excess -6.9 mmol/l, PaCO2 3.33 kPa, PaO2 12.6 kPa with 4l/min oxygen flow
  • Chest radiograph exhibited a tight consolidation of right upper lobe due to pneumonia
  • Patient was transferred to the Critical Care Unit with diagnosis of pneumonia and acute heart failure
  • Treatment with bi-level positive airway pressure (BIPAP), cefuroxime and prednisolone
  • Patient´s hemodynamic situation rapidly deteriorated so that both norepinephrine and dobutamine were started at maximum rates
  • Rapid transfer to ICU with diagnosis of severe septic shock
  • Change of antibiotics to ceftriaxone and levofloxacin
  • Due to acute hemodynamic instability and his state of severe septic shock the decision was made to initiate CytoSorb as an adjunctive therapy together with a CVVHD

Treatment

  • One treatment with CytoSorb for 24 hours
  • CytoSorb was used in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) performed in CVVHD mode
  • Blood flow rate: 150 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Demand for catecholamines
  • Inflammatory parameters (CRP, PCT, leukocytes)
  • Metabolic variables (lactate, base excess, pH)
  • Renal function (creatinine, GFR, urinary excretion)
  • Oxygenation and ventilation (PaO2, PaCO2, SaO2)

Results

  • Hemodynamic stabilization with a significant reduction in catecholamine doses – norepinephrine from 0.28 to 0.10 µg/kg/min and dobutamine from 3.7 to 1.2 µg/kg/min within the first 24 hours. Patient was free from catecholamines 11 hours after completing CytoSorb treatment
  • Clear reduction in inflammatory parameters (CRP from 232.4 mg/l to 19.0 mg/l, leukocytes from 10.1 E9/l to 5.8E9/l)
  • Lactate and  base excess decreased to normal levels
  • Slight improvement in renal function (creatinine 140 µmol/l, GFR of 44 ml/min/m2)

Patient Follow-Up

  • Patient stayed in the ICU for a total of 2 days, followed by a period of 4 days in a normal medical ward.
  • Finally, the patient was transferred to a health center for follow-up

CONCLUSIONS

  • A rapid start of ICU treatment with the combination of appropriate antibiotics, CytoSorb and CVVHD stabilized patient´s sepsis associated hemodynamic instability effectively
  • The installation of the Cytosorb absorber into the CVVHD circuit was simple
    and safe