Case of the week 15/2017

Use of CytoSorb in traumatic amputation of the forearm and severe septic shock

Prof. Heinz Steltzer, Alexander Grieb, Karim Mostafa Anaesthesiology and Intensive Care Medicine, UKH Meidling & Sigmund Freud Private University, Vienna, Austria

Summary:

This case study reports on a 49-year-old patient, who was admitted to the hospital via helicopter transport after a traumatic amputation of his right forearm.

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Case presentation

  • While working on a landfill cleaning surfaces with a high pressure cleaner, the air pressure tube caught his arm and his right forearm was cut off at the elbow joint
  • The amputate was not damaged macroscopically, however a wide spectrum of various aerobic and anaerobic pathogens was detected in the wound, many of which were multi-resistant. These included, for example, Aeromonas hydrophila, an enterotoxin-producing bacterium which is endemic in the American tropics; Stenotrophomonas maltophilia, a multi-resistant nosocomial pathogen detected in dialysis fluid; and Clostridium subterminale, which has been described in the medical literature only in nine case reports as being pathogenic. This microbiologic diversity was most probably due to the location of the accident being a landfill.
  • On admission the patient was treated for shock, followed by X-ray examination and immediate replantation (operation time approx. 8 hours)
  • After successful surgery and a well-perfused transplant, the patient was postoperatively transferred to the intensive care unit intubated, ventilated and catecholamine-dependent (0.41 μg/kg/min with a mean arterial pressure of 65 mm/Hg)
  • Development of lactic acidosis (3.6 mmol/l)
  • Sharp increase in inflammation-relevant parameters (leukocytes 18,700/μl, CRP 13.5 mg/dl, IL-6 539 pg/ml)
  • Initiation of antibiotic therapy with 3g sultamicillin
  • Administration of hydrocortisone 20 mg/h + 3 Red Packed Blood Cells
  • Immediate initiation of continuous renal replacement therapy in combination with CytoSorb because of the anticipated risk of a complex infection due to the accident and the location of the accident (landfill)

Treatment

  • A total of 8 treatments with CytoSorb over 8 days with therapy intervals of 24 hours each were carried out (interrupted by surgical procedures)
  • CytoSorb was used in combination with CRRT (Multifiltrate, Fresenius Medical Care) in CVVHDF mode
  • Blood flow: 100 ml/min
  • Anticoagulation: Citrate
  • CytoSorb Adsorber position: pre-hemofilter

Measurements

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

Results

  • Clear improvement in hemodynamics with reduction of catecholamine dosages
  • Significant reduction of inflammatory parameters, in particular IL-6 decreased from 1804 pg/ml to 20.1 pg/ml with CytoSorb therapy
  • Declining lactate values during the 8 treatments

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Patient Follow-Up

  • During the course of the following week development of sepsis with multiple organ failure
  • Infection and necrosis of the amputate followed by removal of the necrotic tissue and ultimately amputation of the forearm
  • Continuous stabilization and improvement after amputation while still under CytoSorb for two more days
  • Daily surgical wound care, disinfection, removal of necrotic tissue
  • 18 days after initial admission the patient was transferred to the normal trauma-surgical ward
  • Eventual adaptation of a robotic prosthesis and complete recovery of the patient

CONCLUSIONS

  • The early treatment with CytoSorb was accompanied by a relatively modest systemic inflammatory reaction which subsided without major or permanent organ damage, despite the impressive pathogen spectrum and the pronounced local damage
  • The early and continuous use of the CytoSorb adsorber was easy and safe for the entire staff of the intensive care unit