44/2016
Use of CytoSorb in necrotizing fasciitis and severe septic shock

Dr. Milan Margoc, Dr. Silvia Montag, Doz. Alexander Kulier, Anaesthesiological Intensive Care Unit, Hospital-Elisabethinen Linz

Summary:

This case study reports on a 53-year-old male patient (previous medical history: arterial hypertension, DM II, COPD,  bipolar affective disorder) who was admitted to hospital with a suspected acute scrotal erysipelas.

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Case presentation

  • Admission to the dermatological department with additional presentation to the urological department
  • One day after admission rapid deterioration of the general condition with presentation at the urological department and immediate referral for surgical procedure (radical inguinal-rectal fasciotomy of Fournier gangrene and necrotizing fasciitis)
  • Additional need for cardiopulmonary resuscitation whilst still in the operating room and installation of a temporary pacemaker
  • Postoperative transfer to the intensive care unit in very severe septic shock with multi-organ failure (renal insufficiency, vasoplegia, hemodynamic instability, septic cardiomyopathy), ventilated, under volume therapy, catecholamine-dependent
  • Highly elevated inflammation parameters (PCT 35.81 ng/ml, leukocytes 37.500/μl, CRP 35.8 mg/dl) and greatly impaired renal function (GFR of 8.8 ml/min)
  • Antibiotic therapy initially with piperacillin + tazobactam as well as clindamycin, after microbiological findings, plus micafungin
  • Short-term stabilization under conventional therapy, however, due to his acute renal insufficiency as well as the hemodynamic instability and the increased inflammation markers, the decision was made to initiate CytoSorb as adjunctive therapy together with a CVVHD

Treatment

  • One treatment with CytoSorb for a total treatment time of 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
  • Renal function (GFR, excretion)
  • Inflammatory parameters (CRP, PCT, leucocytes)

Results

  • Hemodynamic stabilization with a significant reduction in catecholamine doses – norepinephrine from initially 0.3-0.91 μg/kg/min to 0.09-0.2 μg/kg/min within the first 24 hours, patient was free from catecholamines 48 hours after completion of CytoSorb treatment
  • Clear reduction in inflammatory parameters under CytoSorb therapy (CRP 10 mg/l, leukocytes 22.500/μl, PCT 7.39 ng / ml)
  • Clear improvement in renal function: GFR from 8.8 to 26.6 ml/min within 4 days

Patient Follow-Up

  • Daily surgical wound care, disinfection, removal of necrotic tissue
  • Termination of renal replacement therapy 3 days after CytoSorb application with complete recovery of diuresis 13 days later
  • Weaning and extubation successful 11 days after CytoSorb application
  • In the days post extubation, the patient presented as clinically stable, was awake, adequately alert, mentally appropriate and was able to tolerate complete oral nutrition
  • 26 days after the use of CytoSorb the patient was discharged to the urological ward with a VAC system

CONCLUSIONS

  • Treatment with CytoSorb was accompanied by an unexpectedly rapid and significant stabilization in vital functions (renal function, hemodynamics) as well as declining catecholamine doses within a few hours
  • According to the medical team, the rapid start of treatment with the combination of CytoSorb and CVVHD may have saved the patient‘s life
  • The installation of the absorber into the CVVH circuit as well as the application of CytoSorb itself was simple and safe