Case of the week #11/2016
Use of CytoSorb in a case of severe ARDS after H1N1 infection and septic multiple organ failure
PD Dr. med. Stephan Ziegeler
Department of Anaesthesiology, Operative Intensive Care Medicine, Pain Management and Emergency Medicine, Hospital Ibbenbüren, Germany
Summary:
This case study reports on a 48-year-old female patient presenting at the hospital with flu-like symptoms and whose respiratory situation deteriorated rapidly in the further course.
Case presentation
Patient was admitted to ICU mechanically ventilated with severe ARDS and full-blown septic shock and multiple organ failure (pulmonary, hepatic, renal, circulatory)
Virus diagnosis proved infection with H1N1 and subsequent antiviral therapy with Tamiflu
Fast progression to circulatory failure
Progressive global respiratory failure necessitating implantation of venovenous ECMO with subsequent change to veno-veno-arterial ECMO due to development of right heart failure
Development of acute, anuric, dialysis-dependent kidney insufficiency with indication for renal replacement therapy
Due to the fast progression to septic multiple organ failure with highly catecholamine-dependent circulatory insufficiency a CytoSorb adsorber was installed in combination with CVVHD
Significantly elevated plasma levels of PCT at start of therapy (26 ng/ml)
Treatment
Two CytoSorb treatments for 24 hours each
CytoSorb was used in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) in CVVHD mode
Blood flow rate: 100 ml/min
Anticoagulation: Argatroban (0.2 mcg/kg/min)
CytoSorb adsorber position: pre-hemofilter
Measurements
Demand for catecholamines
Infection parameters (PCT)
Results
Hemodynamic stabilization of the patient along with significantly decreased needs for catecholamines, vasopressors could be tapered out as early as 36 h after start of CytoSorb therapy
Fast decrease of plasma PCT levels to 5.4 ng/ml after stop of CytoSorb therapy
Patient Follow-Up
In the further course rapid improvement of the respiratory situation and stop of ECMO 7 days after cessation of CytoSorb therapy
Termination of renal replacement therapy 7 days after the last CytoSorb treatment
Due to a recurring pulmonary deterioration the ECMO therapy had to be initiated again on week after stop of the the initial ECMO treatment
Return to only One-Organ-failure (lung) in the context of severe influenza with ongoing clinical improvement
Conclusions
Successful application of CytoSorb in a case of severe ARDS after H1N1 infection and septic multiple organ failure
Overall rapid improvement of circulatory insufficiency within a few hours and reversal of multiple organ failure
Also rapid reduction of PCT levels which was potentially favored by the application of CytoSorb in conjunction with causal sepsis therapy
Application of CytoSorb was possible without problems even in first-time application
