Case of the week 30/2016
Use of CytoSorb in a case of severe septic shock and MOF due to urosepsis
Dr. med. Hendrik Haake, Dr. med. Katharina Grün-Himmelmann & Prof. Jürgen vom Dahl | St. Franziskus-Hospital Mönchengladbach, Department of Cardiology and Intensive Care Medicine
This case study reports on a 75-year-old male patient who presented at the urology department for routine ambulatory elective single J- ureter splint exchange (condition after conduit installation with urostoma due to urothelial carcinoma) developing 40°C fever in the course of the following night and was hospitalized after re-presentation at the hospital with elevated infection parameters.
Case presentation
At previous ureter splint exchanges the patient regularly developed slight fever, however always without signs of generalized infection
Immediate initiation of antibiotic therapy with Unacid (ampicillin/sulbactam)
As a result of subsequent volume administration patient noticably reversed fever
Development of dyspnea after which the patient refractory decompensated and was transferred to IMC
Development of hypotension
Escalation of antibiotic therapy to piperacillin/tazobactam
Increasing respiratory insufficiency despite NIV therapy, followed by intubation and transfer to ICU with further escalation of antibiotic therapy to meropenem and fosfomycin, further increasing lactate levels
Highly increased inflammatory (PCT 64.74 ng/ml, leukocytes 20,000/µl, CRP 25 mg/dl, platelets 23,000/µl) and retention parameters (creatinine 1.6 mg/dl, urea 52 mg/dl, anuric)
Initiation of renal replacement therapy
Despite further massive volume resuscitation (9 l/24 h) patient remained unstable with increasing clinical deterioration (increase of lactate to a maximum of 14.3 mmol/l, norepinephrine 1 mg/h, dobutamine 15 mg/h – trending towards a refractory state), which led to the decision to implement CytoSorb into the CVVH circuit
All blood cultures which were taken during the course of the first few hours after admission later showed bacteremia with a multisensible E. coli
Treatment
One treatment with CytoSorb for a total treatment time of 30 hours
CytoSorb was used in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) performed in CVVHD mode
Blood flow rate: 150 ml/min
Anticoagulation: citrate
CytoSorb adsorber position: pre-hemofilter
Measurements
Demand for catecholamines
Renal function (creatinine, urea, excretion)
Inflammatory parameters (CRP, PCT, leucocytes)
Lactate
Results
Hemodynamic stabilization with significant reduction of catecholamine dosages – dobutamine could be tapered after 3 hours, noradrenaline could be halved within the first 24 hours
Volume of initially 1,200 ml/h could be reduced to 600 ml/h after 3 hours, after 8 hours at 100 ml/h and could be completely discontinued after 24 hours
Lactate could be halved after 10 hours, after 24 hours lactate was at normal values (1.8 mmol/l)
Patient Follow-Up
Termination of renal replacement therapy and extubation 6 days after the last CytoSorb treatment
Within the following 48 hours after extubation, the patient could be mobilized into a chair, was awake and adequately contactable
14 days after CytoSorb treatment the patient could be transferred to a normal ward
Conclusions
Treatment with CytoSorb was accompanied by an unexpectedly rapid and significant stabilization of hemodynamics and declining catecholamine dosages within hours
Patient showed ever increasing needs volume and catecholamines, from the moment CytoSorb was implemented the patient clinically improved noticeably
According to the medical team patient would presumably not have survived without the absorber
Safe and easy application of CytoSorb
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