Case of the week 31/2016
Use of CytoSorb in severe refractory SIRS with multiple organ failure after post-resuscitation syndrome and cardiac surgery
Dr. Mike Strunden, Dr. A. Salhi*, PD Dr. M. Laß*, Prof. Thoralf Kerner | Asklepios Clinics Hamburg GmbH – Asklepios Clinics Harburg; Anaesthesiology, Intensive Care Medicine, Emergency medicine, Pain therapy | * Asklepios Kliniken Hamburg GmbH – Asklepios Klinikum Harburg; Abteilung für Herzchirurgie
This case study reports on a 71-year-old male patient, who was admitted to hospital in an intubated, ventilated and highly catecholamine-dependent condition after experiencing an infarction-related avulsion of a papillary muscle and associated free mitral valve insufficiency and prior successful cardiopulmonary resuscitation.
Case presentation
Mitral valve replacement emergency surgery with extended cardiopulmonary bypass time > 2 hours on the day of admission
Post-operative transfer to ICU in intubated, ventilated, highly catecholamine-dependent condition and mechanical circulatory support with an intra-aortic balloon pump (IABP)
On the first postoperative day, development of multiple organ failure with kidney (anuric, creatinine 2.2 mg / dl) and circulatory failure
In addition, highly increased inflammatory parameters (IL-6 of 63 mg/l, CRP 167 mg/l, leukocytes 18,000/µl) and plasma myoglobin levels (2,001 µg/l)
Initiation of renal replacement therapy (CVVHDF)
Due to the high and stable catecholamine-dependency (norepinephrine 30 µg/min, adrenaline 4 µg/min), persistent renal failure, elevated inflammatory parameters, increased myoglobin plasma levels and condition after resuscitation and extended cardiopulmonary bypass time a CytoSorb adsorber was additionally installed into the CVVHDF circuit 12 hours after the start of renal replacement therapy
Treatment
Three treatments with CytoSorb for a total treatment time of 72 hours (1st treatment for 12 hours, 2nd and 3rd treatment for 30 hours each)
CytoSorb was used in conjunction with CRRT (Prismaflex, Gambro) performed in CVVHDF mode
Blood flow rate: 100-140 ml/min
Anticoagulation: citrate
CytoSorb adsorber position: post-hemofilter
Measurements
Demand for catecholamines
Renal function (creatinine, excretion)
Inflammatory parameters (IL-6, CRP, leucocytes)
Results
Hemodynamic stabilization with significant reduction of catecholamines doses
Kidney function – excretion rate rising after starting the 2nd treatment (400 ml/day), creatinine after 2nd treatment back in the normal range at 1.1 mg/dl
On day 2 of treatment IL-6 fell to 21 ng/l – trend towards further decrease; leukocytes rose to 22,000/µL, however normalized to 13,000/µl two days after the last CytoSorb treatment
Two days after completion of CytoSorb therapy CRP was at 120 mg/l – trend towards further decrease
Patient Follow-Up
Termination of renal replacement therapy and extubation 5 days after the last CytoSorb treatment
Mobilization was possible still on intensive care unit
10 days after CytoSorb treatment the patient could be transferred to a normal ward
Transfer without any residuals to a cardiac rehabilitation unit
CONCLUSIONS
Treatment with CytoSorb was accompanied by an unexpectedly rapid and significant stabilization of hemodynamics and declining catecholamine dosages
Based on the clinical course of this patient the internal decision was made that CytoSorb should be used in the future already intraoperatively in combination with the heart-lung machine when conditions apply as in the present case (emergency cardiosurgery, severe post- resuscitation syndrome SIRS) and should be continued in the post-operative course
CytoSorb use should be further considered in septic patients not responding to conventional standard therapy within 12 hours
Treatment with CytoSorb was safe and easy to apply
