31/2017
Use of CytoSorb in Staph aureus Sepsis

Prim Priv. Doz. Dr. Gerhard Fritsch, Dr. Christian Schwarzwimmer Institute for Anesthesiology and Intensive Care Medicine, AUVA Lorenz Böhler Emergency Hospital, Vienna, Austria

Summary:

This case study reports on a 46-year-old male patient (previous known medical condition: type 1 diabetes mellitus), who was brought to the hospital via emergency jet transport after a spinal injury accident (fracture of lumbar vertebrae 1) whilst he was on a trip abroad.

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Case presentation

  • Previously, in the context of the first aid received abroad, venous access was obtained which then became infected. Thrombophlebitis developed at the peripheral venous catheter site
  • After transport of the patient back to Austria he was initially admitted to the normal ward
  • Initiation of antibiotic therapy with ciprofloxacin and fosfomycin
  • One day after admission, surgery was performed with fixation of the vertebral fracture and osteosynthesis
  • Postoperative transfer to intensive care unit with routine 2-day post-operative monitoring
  • Discharge from ICU to the normal ward for a total of 6 days followed by readmission to the intensive care unit due to the development of septic signs
  • Focus search by CT showed a psoas abscess and revision surgery was subsequently required including septic wound revision and insertion of a drain into the psoas abscess
  • Post-operative transfer to the intensive care unit with increasing inflammatory parameters (leukocytes 21,800/μl, CRP 43.9 mg/dl, platelets 139,000/μl) and catecholamine requirement (norepinephrine 0.2 μg/kg/min)
  • On the following day, further deterioration in the clinical condition with further increasing inflammatory parameters (CRP to 58 mg/dl, IL-6 1422 pg/ml), catecholamine requirement (norepinephrine 0.25 μg/kg/min) and progressive impairment of renal function (creatinine increased from 0.8 to 2 mg/dl) including oliguria
  • Due to his acute oliguric renal failure, increasing inflammatory parameters, and the progressive deterioration in the circulatory situation, continuous renal replacement therapy with the additional installation of a CytoSorb adsorber was started
  • Final diagnosis and detection of bacteria: Staph aureus sepsis after thrombophlebitis in the peripheral venous access infection,  and psoas abscess with colonization of the osteosynthesis material

Treatment

  • In total three consecutive treatments with CytoSorb for a total treatment time of 72 hours (each for 24 hours)
  • CytoSorb was used in conjunction with citrate dialysis (Multifiltrate, Fresenius Medical Care) performed in CVVHD mode
  • Blood flow rate: 100 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Need for catecholamines
  • Inflammatory parameters (leucocytes, CRP, IL-6)

Results

  • Hemodynamic stabilization with reduction in catecholamine doses to 0.03 μg/kg/min after completion of the first treatment with CytoSorb and gradual catecholamine cessation with complete discontinuation 4 days after initiation of the therapy
  • Leukocytes returned to normal levels (10,800 / μl) 24 hours after the onset of treatment
  • IL-6 decreased from 1422 to 534.3 pg/ml after the first treatment , after the second treatment day to 221.4 pg/ml and then decreased further
  • Increase of CRP initially to 70.3 mg/dl – but thereafter decreased to 61.8 on the first day of treatment with further decreasing levels thereafter

Patient Follow-Up

  • Further improvement in all organ functions over the following days
  • CRRT could be completely stopped 5 days after treatment with CytoSorb
  • After successful healing of the fractured vertebra the osteosynthesis material was removed
  • The patient was transferred to the normal ward 12 days after CytoSorb treatment

CONCLUSIONS

  • The combined treatment with CRRT and CytoSorb in this patient with Staph aureus sepsis resulted in rapid stabilization of the organ functions including hemodynamics, with decreasing catecholamine requirements and a significant reduction in the excessively high inflammatory parameters
  • The use of CytoSorb therapy was simple and safe