Reports Sepsis

Effect of extracorporeal cytokine removal on vascular barrier function in a septic shock patient

David S, Thamm K, Schmidt BM, Falk CS, Kielstein JT
J Intensive Care 2017; 5: 12

A 32-year-old female presented with septic shock and accompanying acute kidney injury to ICU. In...

A 32-year-old female presented with septic shock and accompanying acute kidney injury to ICU. In spite of a broad anti-infective regimen, adequate fluid resuscitation, and high doses of inotropics and catecholamines, she remained in refractory hypotensive shock. The extraordinary severity of septic shock suggested an immense overwhelming host response assumingly accompanied by a notable cytokine storm. Thus, a CytoSorb adsorber was added to the dialysis circuit. To analyze the endothelial phenotype in vitro before and after extracorporeal cytokine removal, the authors tested the patient’s serum on human umbilical vein endothelial cells (HUVECs) and the effect on the endothelial integrity was assessed. The authors found severe alterations in cell-cell contacts, the cytoskeletal architecture, and profound functional permeability changes (in other words clinical vascular leakage syndrome) when blood from the patient taken prior to the CytoSorb adsorber was added to the HUVECs. However, the endothelial barrier was protected from these profound adverse effects when blood serum was collected after the CytoSorb adsorber (cytokine removal) and added to the HUVECs. In conclusion the benefit of extracorporeal cytokine removal with CytoSorb in septic shock patients might-at least in part-be promoted via protection of vascular barrier function.

Use of Hemadsorption in a Case of Pediatric Toxic Shock Syndrome

Berkes A, Szikszay E, Kappelmayer J, Kerenyi A, Szabo T, Ujhelyi L, Bari K, Balla G, Balla J
Case Rep Crit Care 2017: 3818407

This case report describes the successful treatment of toxic shock syndrome (a potentially fatal disease...

This case report describes the successful treatment of toxic shock syndrome (a potentially fatal disease mediated by gram-positive bacterial toxins) in a 5 year old female pediatric Downs syndrome patient who presented with an inflamed area surrounding an insect bite, signs of systemic inflammation, and multiple organ failure. As attempts at resuscitation (including fluids, catecholamines and antibiotics), and immune modulatory therapies (including hydrocortisone, plasma exchange therapy and immunoglobulin therapy) were unsuccessful, renal replacement therapy supplemented with the CytoSorb adsorber was started. This was associated with a rapid and significant stabilization in the hemodynamic situation, and a decrease in inflammatory mediators within hours after the initiation of therapy. The application of CytoSorb therapy was simple and safe. The use of CytoSorb proved potentially beneficial by removing bacterial toxins and inflammatory mediators in this case and could therefore play a role in the clinical management of toxic shock syndrome.

Hemadsorption with Adult CytoSorb(R) in a Low Weight Pediatric Case.

Cirstoveanu CG, Barascu I, Mc Kenzie Stancu S
Case Rep Crit Care 2017: 6987167

This case study describes a nine-month old male infant admitted to the Neonatal Intensive Care...

This case study describes a nine-month old male infant admitted to the Neonatal Intensive Care Unit due to sepsis post cardiac surgery (Fallot tetralogy), and multi-system organ failure (MSOF), including liver and renal failure which was successfully treated by a combination of continuous hemodiafiltration (HDF) and hemoadsorption with CytoSorb®. CytoSorb added to the set up on day 9 due to increasing bilirubin levels. Over the 49 hour period of hemoadsorption plus CytoSorb, total bilirubin decreased from 54 to 14 mg/dl, the patient’s general status improved considerably, accompanied by a rapid decrease in his liver enzymes (aminotransferases). Hemodynamic status also improved and requirement for inotropes decreased rapidly during the two days of CytoSorb treatment. The patient was discharged home after 34 days of hospitalization, in good general health. This is the first published case of the successful use of CytoSorb treatment in such a young patient (9 months old, 9 kilos in weight).

Hybrid blood purification strategy in pediatric septic shock

Bottari G, Taccone FS, Moscatelli A
Crit Care 20(1): 366

In this letter to the editor, the case of a 12 year old girl with...

In this letter to the editor, the case of a 12 year old girl with a history of acute lymphatic leukemia and recent chemotherapy admitted to the ED with fever and fatigue is described (cause of which later found to be klebsiella pneumonia from a central line infection). She was give fluid resuscitation, empiric antibiotics and admitted to ICU. Because of ongoing hypotension, epinephrine and norepinephrine were initiated, however she remained severely hypotensive. Continuous renal replacement therapy was started with a high cut off filter (Septex) along with a CytoSorb adsorber. After 48 hours a significant reduction in the vasopressors was observed, lactate decreased as did procalcitonin. The ‘hybrid’ extracorporeal blood purification – EBP (combination of CtoSorb and Septex) was continued for 72 hours in total and the patient could be discharged after 10 days. No adverse events related to the blood purification procedure were observed. The authors state that the Literature list CytoSorb® 10 November 2016 combination of ‘hybrid’ EBP might have a synergistic effect in the setting of pediatric septic shock.

Can cytokine adsorber treatment affect antibiotic concentrations? Acase report.

Zoller M, Döbbeler G, Maier B, Vogeser M, Frey L, Zander J
J AntimicrobChemother. 2015 Jul;70(7):2169-71

This case study reports on a patient with an excessive inflammatory response, septic shock and...

This case study reports on a patient with an excessive inflammatory response, septic shock and MOF who was admitted to the ICU. Initial laparotomy revealed an ischemic bowel with peritonitis requiring immediate jejunum and colon segmental resection and ileotransverse colostomy. Antibiotic treatment with Meropenem was started immediately and with Linezolid 5 hours after admission, both administered intravenously with short infusion times (15-60 min).Due to persisting excessive cytokine storm, a CytoSorbadsorber was repeatedly used (4 times over 96 hours). Therapy of septic shock including surgery, antibiotic treatment and CytoSorbresulted in a substantialimprovementof the patient’s condition including improvement in renal and liver function and cardiorespiratory status.However, after 4 weeks and seven further repeat laparotomies, the patient died from multiple organfailure.
TheuseofCytoSorbinthis patient proved to be effective (decayofIL-6 from 563.000pg/ml on day 1 to 19.400 pg/ml on day 4) andsafe(levels of meopenem and linezolid wellabove thelowertherapeutic range). Of note, intra-patient variability of antibiotic levels was high with substantially lower peak levels for both antibiotics when CytoSorb was in use, pointing towards a potential adsorption, however also due to the effects of the critical illness itself. This is the first time anin vivo pharmacokinetic monitoring of Linezolid and MeropenemduringtreatmentwithCytoSorbis described. Applyingthis regimen of dosing for Linezolid and Meropenem no negative impact on the effectiveness of antibiotic therapy was detected.
The authors suggest therapeutic drug monitoring wherever possible and if not available, high loading doses or shorter intervals of administration should be used to achieve adequate antibiotic levels. However, further studies are needed to determine the effect of CytoSorb on antibiotic levels.

Combination of ECMO and cytokine adsorption therapy for severe sepsis with cardiogenic shock and ARDS due to Panton-Valentine leukocidin-positive Staphylococcus aureus pneumonia and H1N1

Lees NJ, Rosenberg A, Hurtado-Doce AI, Jones J, Marczin N, Zeriouh M, Weymann A, Sabashnikov A, Simon AR, Popov AF
J Artif Organs 2016; 19(4): 399-402

Sepsis-induced cardiogenic shock in combination with severe acute respiratory failure represents a life-threatening combination that...

Sepsis-induced cardiogenic shock in combination with severe acute respiratory failure represents a life-threatening combination that is often refractory to the conventional methods of treatment. Here the authors describe the case of a 33-year-old patient who developed acute cardiovascular collapse and ARDS secondary to superinfection of Panton-Valentine leukocidin-positive Staphylococcus aureus and H1N1 pneumonia who underwent successful combination therapy for severe sepsis-related cardiomyopathy and respiratory failure using extracorporeal membrane oxygenation and Cytosorb therapy. Use of the Cytosorb appeared to resut in rapid resolution of neutropenia, reversal of toxic shock and rapid weaning off of the high dose vasopressor infusions.

Cytokine Reduction in the Setting of an ARDS-Associated Inflammatory Response with Multiple Organ Failure

Traeger K, Schuetz C, Fischer G, Schroeder J,Skrabal C, Liebold A, Reinelt H
Case Rep Crit Care 2016: 9852073

This case study reports on a 45-year-old male who was admitted to the hospital with...

This case study reports on a 45-year-old male who was admitted to the hospital with a small bowel obstruction due to torsion and immediately scheduled for surgical intervention. At anesthesia induction, the patient aspirated and subsequently developed a severe SIRS with ARDS and multiple organ failure requiring the use of ECMO, CRRT, antibiotics, and low dose steroids. Due to a rapid deterioration in clinical status and a concurrent surge in inflammatory biomarkers, CytoSorb was added to the CRRT blood circuit. The combined treatment resulted in a rapid and significant reduction in the levels of circulating inflammatory mediators. This decrease was paralleled by marked clinical stabilization of the patient including a significant improvement in hemodynamic stability and a reduced need for norepinephrine and improved respiratory function and indirect measures of capillary leak syndrome. The patient could be discharged to a respiratory weaning unit where successful respiratory weaning could be achieved later on. The authors attribute the clinical improvement to the rapid control of the hyperinflammatory response and the reduction of inflammatory mediators using a combination of CytoSorb and these other therapies. CytoSorb treatment was safe and well tolerated, with no device-related adverse effects observed.

CytoSorb-friend or foe!!

Pattnaik SK, Panda B.
Indian J Crit Care Med. 2015 May;19(5):296.

In this letter to the editor the authors refer to the case report by Basu...

In this letter to the editor the authors refer to the case report by Basu et al. (PMID 25538418), share their experiences with a similar patient treated with CytoSorband discuss some of the intriguing points of that treatment.A 79-year-old male patient with severe septic shock (urosepsis) and multi-organ failure and anAPACHE II score of 32, was started on CytoSorb therapy plus sustained low effusion dialysis along with standard surviving sepsis guidelines treatment. Within 3 days, hemodynamic parameters, ventilator requirements and urine output improved. APACHE II score improved from 32 before to 8 after day 3 of therapy, while IL-6 levels were reduced from 1356.3 pg/ml before to 26.12 pg/ml after the last session. Since the patient started to deteriorate clinically on the 5th day onwards despite on-going supportive care, the authors bring up a possible immunosuppressive effect and express their concern whetherCytoSorb therapy could be involved. They feel that randomized controlled trials are necessary to check the risk-benefit ratio of hemadsorption therapy in severe septic patients.

CytoSorb, a novel therapeutic approach for patients with septic shock: a case report

Hinz B, Jauch O, Noky T, Friesecke S, Abel P, Kaiser R
Int J ArtifOrgans. 2015 Sep 18;38(8):461-4

This case study reports on 72-year-old male patientwith periodically recurring infectious episodes who was admitted...

This case study reports on 72-year-old male patientwith periodically recurring infectious episodes who was admitted with the suspicionof urosepsis. In the following hours his hemodynamic situation deteriorated markedly, exhibiting respiratory-metabolic acidosis, elevated inflammatory marker plasma levels, a  severely disturbed coagulation,increasedretention parameters, liver dysfunction, and confirmation of bacteria and leucocytes in urine. After admissionto the ICU in a state of septic shock the patient received renal support with additional hemoadsorption using CytoSorb. Three CytoSorb sessions were run during the following days.The first and consecutive second session resulted in a reduction of procalcitonin, C-reactive protein and bilirubin and a markedly reduced need for vasopressors while hemodynamics improved significantly (i.e., cardiac index, extravascular lung water). Due to a recurring inflammatory “second hit” episode, another session with CytoSorb was run, resulting in a marked decrease in leukocytosis and liver (dys)function parameters. The rapid hemodynamic stabilization with reduction of vasopressor needs within hours and reduction of the capillary leakage as well as a quick reduction in infection markers were the main conclusions drawn from the use of CytoSorb in this patient. Additionally, treatment appeared to be safe and was well tolerated. Despite the promising results of CytoSorb application in his patient, further studies are necessary to elucidate to what extent these favorable consequences are attributable to the adsorber itself.

Effects of a novel cytokine haemoadsorbtion system oninflammatory response in septic shock after cephalicpancreatectomy – a case report

Tomescu D, Dima SO, Tănăsescu S, Tănase CP, NăstaseA ,Popescu M
Romanian Journal of Anaesthesia and Intensive Care2014;21(2):134-138

This case study reports on a 50 year old man with postoperative septic shockafter undergoing...

This case study reports on a 50 year old man with postoperative septic shockafter undergoing cephalic pancreatectomy for a pancreatic cystic tumor. In total,two consecutive CVVH sessions withCytoSorb were performed over a period of 64 hours(24 hours each).The clinical effects associated with CytoSorbcorrelated with a rebalance in cytokine levels and translated into a more stablehaemodynamicprofile with a stable cardiac output and normalization of systemic vascular resistance indexand decreased vasopressor requirements.Thetechnology was simple to use and could be easily added onconventional CVVH machines.The therapy was welltolerated with no adverse effects.The timing of Cytosorb whether early (after onsetof SIRS) or late (after onset of organ dysfunction) useof this novel therapy, has still to be established.

First case of toxic shock treated with haemoadsorption by CytoSorb in the Netherlands

van der Linde GW, Grootendorst A
Neth J Crit Care. 24(2): 27-29

This case study reports on a 17-year-old male who reported to the pediatrician at a...

This case study reports on a 17-year-old male who reported to the pediatrician at a local rural hospital with complaints of pretibial pain in his right leg, after he accidentally cut his leg while in the fields a few days earlier. He was diagnosedfor having aphlegmon with an abscess followed by surgical debridement with wound nettoyage with no clinical signs of subcutaneous emphysema or necrotising fasciitis. Postoperatively the patient’s condition deteriorated and after admission to ICU he developed erythema, spreading from the right lower leg to the right upper leg, abdominal wall and the left leg, consistent with toxic shock syndrome and subsequent development of septic shock due to invasive S. aureus infection with respiratory failure, hemodynamic instability treated with vasopressors, hydrocortisone, antibiotic therapy. Due disease severity, CRRT was initiated with a CytoSorbadsorber with the only goal to remove cytokines (despite absence of acute kidney injury and no need for renal replacement therapy). Within six hours after the start, the erythema progression stopped and after 12 hours the need for vasopressors diminished. The erythema diminished after a few hours and had disappeared after 24 hours. After cessation of CytoSorb physicians concluded that the patient was no longer septic and diuretics were started because of fluid overload. Respiration improved, the ventilator support was diminished and the patient was extubated on day 5 after admission, within 72 hours of cessation of CRRT. In the authors opinion, the patient would have survived without the CytoSorb, but they feel that his stay in our ICU might have been shortened by the CytoSorb adsorber

First successful combination of ECMO with cytokine removal therapy in cardiogenic septic shock: A case report

Bruenger F, Kizner L, Weile J, Morshuis M, Gummert JF
Int J Artif Organs. 2015 Mar 6;38(2):113-6

This case study reports on a 39-year-old patient presenting at a hospital with fulminant ARDS...

This case study reports on a 39-year-old patient presenting at a hospital with fulminant ARDS and cardiogenic septic shock. After implantation of a veno-arterial ECMO for circulatory support the patient developed acute renal failure making initiation of CVVH necessary.Due to a complete cardiac arrest in both ventricles, a left ventricular assist device (LVAD) in combination with right ECMO (rECMO) was implanted despite manifest septic conditions. In the post-operative course his condition detoriorated drastically and aCytoSorbhemoadsorption device was therefore installed in the CVVH circuit resulting in a decrease of IL-6, procalcitonin, and C-reactive protein concomitant with significantly reduced vasopressor support. No adverse device-related side effects were documented during or after the treatment sessions.This is the first clinical case report of a highly septic patient treated with the combined use of LVAD, rECMO, CVVH, and CytoSorb. The combination was practical, technically feasible, and beneficial for the patient and might represent a reasonable approach to improve survival in patients with multiple organ dysfunction necessitating several organ supportive techniques.

Hemoadsorption using Cytosorb beads (Cytosorbents) in a cirrhotic patient with septic multiorgan failure

Gruber A, Firlinger F, Lenz K, Clodi M
Infection (2013) 41 (Suppl 1):S1–S90; Abstract No. 056

In this case study a 37 year old patient with alcoholic liver cirrhosis and occurring...

In this case study a 37 year old patient with alcoholic liver cirrhosis and occurring septic shock with multiorgan failure due to bilateral pneumonia (staphylococcus aureus) was successfully treated with CytoSorb. The authors found an immediate change inorgan function with stabilization of hemodynamics, as well as pulmonary andrenal function.

Improvement of hemodynamic and inflammatory parameters by combined hemoadsorption and hemodiafiltration in septic shock: a case report.

Mitzner SR, Gloger M, Henschel J, Koball S
Blood Purif. 2013;35(4):314-5.

This case study reports on an 80 year old male diagnosed of having pneumogenic septic...

This case study reports on an 80 year old male diagnosed of having pneumogenic septic shock. The patient was in clinical need for renal replacement therapy and was therefore started on citrate-anticoagulated CVVHD in combination with a CytoSorbadsorberfor 24 hours.
In the further course, plasmatic IL-6 and other markers of inflammation as well as need for vasopressors could be reduced drastically while treatment was safe and well tolerated.

Intermittent use of cytokine adsorption in combination with CRRT in a patient with necrotising pancreatitis, septic shock and MOF

Emmerich M, Zietlow S, Tiesmeier J
Infection. 2015 Aug;43Suppl 1:1-73. Abstract No. 72

This case study reports on a 60-year-old female patient with septic shock andMOF after cholecystectomy...

This case study reports on a 60-year-old female patient with septic shock andMOF after cholecystectomy which was complicatedbymassive aspiration during emergency gastroscopy and necrotizing pancreatitisrequiring necrostomy. On admission to ITU, the patient was in respiratory and acute renal failure and exhibited high needs for vasopressors and fluids. Following initial stabilization, colonic perforation and renewed septic shock occurred on day 13 post-operation,necessitating colectomy and further necrostomy on day 14.Lung-protectiveventilation and hemodynamic stabilization, antibiotic therapy and CRRT were started in the further course with a first application of Cytosorbfor 48 honday 2 post-operation anda second session for 96 h from day 13 post-operation. During thefirst 48 h of hemoadsorption, norepinephrinerequirements decreased from 0.13 to 0.00 mcg/kg/min. During thesecond use of CytoSorb the initial norepinephrine need was0.13 mcg/kg/min and rose to a maximum of 0.43 mcg/kg/min twelve hours post-operatively, however infusion could be stopped later after 40 h. Thegeneral condition of the patient improved dramatically despite further multiple operations for intra-abdominal bleeds, necrosis andwound healing impairment. CRRT could be stopped 11 days after thesecond CytoSorb treatment andtwo days later the patientwas successfully weaned from ventilation. The authors conclude that they could successfully use intermittent cytokine hemoadsorption to manage a patient with recurrent septic shock, necrotizing pancreatitis and MOF. Supplementing the standard treatment forsepsis with two applicationsof hemoadsorption facilitated rapid hemodynamic stabilization. Cytosorb was easy to use and noadverse effects were observed.

Pattern of cytokine removal using an adsorption columnCytoSorbduring severe Candida albicans induced septic shock

Bracht H, Schneider EM, Weiß M, Hohmann H, Georgieff M, Barth E
Infection (2013) 41 (Suppl 1):S1–S90; Abstract No. 133

This case study reports on a 46 old female with hypo dynamic septic shock and documented...

This case study reports on a 46 old female with hypo dynamic septic shock and documented candidemiainfection. CRRT was started in combination with CytoSorb therapy. Within 24 h of hemoadsorption, vasopressor and inotropic support could be withdrawn. Several inflammatory mediators (e.g. IL-6, 8, 10) could be reduced significantly. Interestingly, the authors also found an almost perfect immunologicalreconstitution of a variety of immune parameters including HLA-DR.

Septic shock secondary to β-hemolytic streptococcus-induced necrotizing fasciitis treated with a novel cytokine adsorption therapy.

Hetz H, Berger R, Recknagel P, Steltzer H.
Int J Artif Organs. 2014 May;37(5):422-6

This case study reports on a 60-year-old female who was admitted to hospital due to...

This case study reports on a 60-year-old female who was admitted to hospital due to a forearm fracture. After surgical wound care by osteosynthesis the patient developed surgical wound infection progressing to necrotizing fasciitis with additional proven infection from β-hemolytic streptococcus. The patient went into septic shock exhibiting a full picture of a MODS. Therefore, the patient was treated with CytoSorb therapy over a period of four days, resulting in a significant reduction of IL-6 and an overall improvement of the patient’s condition. In this case, CytoSorbseems to be an interesting and safe extracorporeal therapy to stabilize and bridge septic patients to surgery or recovery.

Use of a novel hemoadsorption device for cytokine removal as adjuvant therapy in a patient with septic shock with multi-organ dysfunction: A case study

Basu R, Pathak S, Goyal J, Chaudhry R, GoelRB, BarwalA
Indian J Crit Care Med 2014;18:822-4

This case study reports on a 36-year-old female diagnosed to have septic  (urosepsis) with multi-organ...

This case study reports on a 36-year-old female diagnosed to have septic  (urosepsis) with multi-organ dysfunction (ARDS, AKI, arterial hypotension) and a low perfusion state.SOFA score was 15, MODS score 10 and APACHE II score 30. CytoSorb was added along with CRRT. The patient received three consecutive treatments with CytoSorb in the following three days. After initiation of therapy the patient improved hemodynamically. During the further course urine output increased with improvement in ventilator parameters. SOFA score at the end of treatment was 4, MODS score was 5 and APACHE II score was 7. There were no adverse events and laboratory parameters before and after CytoSorb therapy were within normal range. CytoSorb therapy in septic shock patients with multi-organ failure might be an option as rescue therapy.