Case of the week 44/2017

CytoSorb in septic shock following necrotizing fasciitis

Dr. Björn Brüning, Benjamin Rehm, Dr. B. Fröhmert, Prof. Dr. B. Bein; Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Asklepios Clinic St. Georg, Hamburg, Germany

Summary:

This case study reports on a patient who presented at the hospital with a 4 day history of fever, pain in the right shoulder and axilla without any memorable trauma or existing immunosuppression.

Case presentation:

  • Patient already had a history of 40 °C fever 2 days prior to presentation. At the same time one of his children suffered from exanthema due to contact with a domestic dog.
  • On admission the patient also exhibited generalized exanthema, extensive soft tissue swelling/redness/overheating of the right axilla progressing onto the right torso
  • Development of septic shock with hemodynamic instability, need for high dose norepinephrine and acute renal failure
  • Significantly increased inflammatory parameters: IL-6 > 50,000 ng/l, PCT 199 ng/ml , CRP >300 mg/l, thrombocytopenia 73/nl, renal parameters: creatinine 5.4 mg/dl, GFR 12 ml/min
  • On the same day transfer of the patient to the Department of Anesthesiology and Intensive Care Medicine, of our hospital
  • Suspicion of necrotizing fasciitis. Immediate surgical intervention with chest opening, necrosectomy and Vacuum Assisted Closure (VAC) therapy of the right flank
  • Intraoperative development of hemodynamic instability with need for high dose pressor support and aggressive fluid resuscitation
  • Subsequent intensive care therapy including PiCCO-guided volume therapy and vasopressin
  • Later, slight reduction in catecholamines (norepinephrine 119 µg/min) and relative stabilization although still at a critical level
  • Start of hemofiltration with oXiris-sepsis filter (Prismaflex; Gambro)
  • One day later escalation of antibiotic treatment with penicillin G due to identification of Streptococcus pyogenes in the blood cultures and surgical wound swabs (further antibiotics at this time: meropenem 2g 1-1-1)
  • Continuous administration of hydrocortisone
  • Due to acute renal failure, the sharp increase in inflammatory markers, progressive need for vasopressors and septic shock, CytoSorb was also installed into the CVVHDF – oXiris circuit

Treatment:

  • Six consecutive CytoSorb treatment sessions for 20 hours each. On one occasion absorber change did not take place due to planned VAC exchange the following morning, therefore one treatment ran for 2×20 hours
  • CytoSorb was used in conjunction with citrate dialysis (Prismaflex; Gambro) in CVVHDF mode
  • Anticoagulation: citrate
  • CytoSorb adsorber position: post-hemofilter

Measurements:

  • Demand for catecholamines
  • Inflammatory parameters (IL-6, PCT, CRP)
  • Renal function (retention parameters)

Results:

  • With the combination of therapies there was a significant stabilization in hemodynamics
  • Clear decline in infection parameters IL-6, PCT and CRP
  • Normalization of retention parameters during the course of treatments
  • Reduction in sedation, patient awake and responsive

Patient Follow-Up

  • Second septic episode followed by exchange of intravascular catheters, escalation of antibiotic therapy to vancomycin with no improvement
  • Exploratory laparotomy due to suspicion of abdominal compartment syndrome with multiple intra-abdominal infarctions, partial resection of the small intestine, appendectomy, cholecystectomy, splenectomy, VAC change to right arm/right trunk with significant intraoperative hemodynamic instability
  • Readmission to intensive care on extremely high doses of norepinephrine (20mg/h), with Mean Arterial Pressure ~ 40 mmHg, massive lactic acidosis, no response to volume resuscitation and increase in catecholamines, leading to death.

Conclusions

  • Clear stabilization and consolidation of hemodynamics and inflammatory mediators with CytoSorb
  • During treatment, patient was awake and responsive
  • CytoSorb therapy was limited to seven days. The patient developed a second septic episode that was refractory to treatment and led to patient death. According to the medical team, extended use of the CytoSorb may have prevented or at least attenuated the second septic shock
  • The use of CytoSorb therapy was simple, safe and there were no complications associated with the device