Case of the week 23/2016
CytoSorb in septic shock after perforated Ulcus ventriculi
Dr. Markus Teipel, head physician, Interdisciplinary Intensive Care, Nordwest-Krankenhaus Sanderbusch GmbH
This case study reports on a 43-year-old male patient, who was transferred to hospital via emergency boat and ambulance service from Langeoog island with initially belt-shaped and then diffuse radiating acute pain in the upper abdomen, dark vomitus, diarrhea and dyspnea.
Case presentation
Diagnosis: perforated ulcus ventriculi at the small curvature
Immediate emergency laparoscopy and laparotomy within 2 hours after admission followed by surgical suturing and covering of the perforation
The patient was transferred to ICU intubated and ventilated
At this time the patient was hemodynamically unstable, hypotonic, tachycardic with high requirement for catecholamines (noradrenaline 0.5 ug / kg / min)
Significantly increased inflammatory parameters: PCT> 200 ng/ml, leukocytes 6.900/µL, CRP >27 mg/dl
Advanced hemodynamic monitoring showed septic shock with high volume requirements (SVRI 1500 dyn*s*cm-5*m², ELWI 5.6 ml/kg, GEDI 496 ml/m²)
High loading volumes (positive fluid balance 12 liters) with poor and further decreasing spontaneous diuresis (200 ml/day), creatinine 5.8 mg/dl, GFR 11.3 ml/min, urea 95 mg/dl
Initiation of antibiotic therapy with ertapenem followed by additional calculated antifungal treatment with caspofungin
Hydrocortisone 200 mg/day, continuous Amiodarone with 300 mg loading dose (maintenance dose 900 mg/d)
Insertion of a Shaldon catheter and initiation of continuous veno-venous hemodiafiltration (CVVHDF)
Due to acute renal failure, sharp increase in inflammatory markers, progressive need for vasopressors and septic shock, CytoSorb was started 24 hours after initiation of CVVHDF
Treatment
Two consecutive CytoSorb treatment sessions for 24 hours each
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
Advanced hemodynamic monitoring parameters (SVRI, GEDI)
Lactate clearance
Inflammatory parameters (PCT, CRP)
Renal function (excretion)
Results
Clear stabilization of hemodynamics during the course of the two CytoSorb treatments (GEDI 840 ml/m², SVRI 2600 dyn*s*cm-5*m²)
With installation of the adsorber the norepinephrine dose could be reduced significantly to around 1/5 of the initial dose after completion of the first CytoSorb treatment and a further reduction to 0.08µg/kg/min after completion of the second treatment. Five days after the first treatment norepinephrine could be completely tapered off
Reduction of inflammatory parameters during the two treatments: PCT to 45 ng/ml after the first and to 23 ng/ml after the second treatment, CRP at >27 mg/dl after the first treatment and 7.4 mg/dl after the second treatment
Two days after completion of CytoSorb therapy increasing spontaneous diuresis
Antibiotic dosages did not have to be adjusted at any time
Patient Follow-Up
Cessation of renal replacement therapy 5 days after last CytoSorb treatment
Extubation on postoperative day 11
Antibiotic treatment with ertapenem could be discontinued 10 days and the antifungal treatment 14 days after admission
After extubation, patient had ongoing delirium which normalized over the next 4 days
No neuropathic sequelae
Transfer to IMC 16 days after initial admission and 4 days later to the normal ward
Conclusions
Clear stabilization and consolidation of hemodynamic and inflammatory mediators with CytoSorb within 48 hours
Conventional therapy using the sepsis bundle was not enough to hemodynamically stabilize the patient during his acute septic phase, however, after using the CytoSorb adsorber this could be achieved in a short period of time
The application of CytoSorb therapy was simple, safe with no problems installing the adsorber in a post-hemofilter position
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