CytoSorbents Corporation (CTSO)

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Case of the week 17/2016
CytoSorb in pneumogenic septic shock after ethyltoxic bone marrow depression and increased comorbidity (alcohol abuse, 3-fold ACVB)

Dr. Matthias Lutze, Head of Department for Anaesthesiology and Intensive Care Medicine, Hospital Teterow, Germany
This case study reports on a 53-year-old male patient (medical history of 3-fold ACVB and pacemaker implantation) who presented at the hospital with ethyltoxic pancytopenia, acute alcohol withdrawal delirium and hypostatic bilateral pneumonia.
Case presentation

Immediate transfer to intensive care unit – at this point of time the patient was awake, responsive, tachycardic and hallucinating
Instant initiation of anti-delirious therapy (gamma hydroxybutyrate, Haloperidol) as well as administration of ampicillin/sulbactam for treatment of community acquired pneumonia
On the 2nd day, deterioration of the patients‘ clinical condition, delirious alcohol withdrawal went more complex and the patient exhibited psychological abnormalities – changeover of sedation to midazolam
Respiratory exhaustion in the afternoon followed by intubation and mechanical ventilation
Diagnosis of complete lower lobe pneumonia left and diffuse pneumonia right
Change of antibiotic regimen to meropenem
Aggravation of the patients’ condition to septic shock (circulation, kidney, lung)
Drastically increased inflammatory parameters (PCT 44 ng/ml, CRP 176 mg/dl, lactate 8.8 mmol/l)
Further deterioration of renal function with oliguria (excretion 20 ml/h), however tending towards further declining urinary output
Excessive increase of catecholamine dosages (norepinephrine 1 µg/kg/h)
Due to acute renal as well as lung failure, a sharp increase of inflammatory markers and progressive need for catecholamine and septic shock with multiple organ failure CytoSorb was started simultaneously with early CRRT
Treatment

One CytoSorb treatment session for 72 hours (CRRT and CytoSorb were started and stopped simultaneously after one cycle of CVVH à 72 hours)
CytoSorb was used in conjunction with citrate dialysis (Prismaflex; Gambro) in CVVHDF mode
Blood flow rate: 150 ml/min
Anticoagulation: citrate
CytoSorb adsorber position: post-hemofilter
Measurements

Demand for catecholamines
Inflammatory parameters (PCT, CRP, leucocytes)
Renal function (excretion)
Lactate
Results

Clear stabilization of hemodynamics during the course of the combined CVVH and CytoSorb treatment with a reduction of catecholamine dosages – after 6 hours, norepinephrine could be reduced significantly and after 72 hours dosages were at 0.08 µg/kg/h constantly
Improvement of lung function after 72 hours of treatment, also invasiveness of mechanical ventilation could be reduced significantly (FiO2 from 70% to 45 %)
Marked decrease of inflammatory parameters during the course of the treatment: PCT to 26 ng/ml, CRP to 129 mg/dl
Normalization of leucocytes to almost normal values of 11.200/µl
Lactate stable at 1.4 mmol/l
Quick recovery of kidney function after one cycle of CVVH and CytoSorb (72 hours) all the way to polyuria (150-200 ml/h)
Patient Follow-Up

Termination of renal replacement therapy after 72 hours together with CytoSorb
In the further course a second septic episode developed (MRSA, 40°C fever) with increasing dosages of catecholamines, which was handled successfully within 6 hours (however without application of CytoSorb)
Patient clearly stabilized, still intubated and ventilated, sedation with Propofol and Sufentanil
Conclusions

Acute phase of septic shock could be overcome surprisingly quick despite multiple comorbidities (bone marrow depression, alcohol abuse, vitamin deficiency, heart disease, severely impaired synthesis function of the liver)
Physicians did not expect the patient to survive the next day
Kidney function was unexpectedly re-established after 48 hours of CVVH+CytoSorb, which to the impression of the treating physicians is quite uncommon to happen in septic shock (potentially due to the reduction of plasma cytokine levels)
Clear stabilization and consolidation of hemodynamics and inflammatory mediators during CytoSorb treatment
Handling of the adsorber was easy and safe, even after 72 hours there were no issues with transmembrane pressure and clotting
http://cytosorb-therapy.com/the-therapy/case-of-the-week/