Tuesday, August 30, 2016 10:26:36 AM
Use of CytoSorb in hepatic encephalopathy
C. Steinfort#, Dr. M. Bellgardt*, Prof. T. Weber*, Prof. W. Uhl# St. Josef Hospital, Hospital of Ruhr-University Bochum # Clinik for General and Visceral Surgery *Clinic for Anaesthesiology
Summary:
This case study reports on a 58-year-old female patient (condition post pancreatectomy after ethyltoxic pancreatitis), who presented to the hospital for a routine imaging investigation due to a drainage problem of her bilio-digestive anastomosis, which had been installed a few years earlier.
Case presentation
On presentation the patient was alert and responsive, however it was noted that she had consumed large amounts of alcohol in the period prior to admission
During the following days after diagnostic imaging, the patient deteriorated dramatically and had to be transferred to ICU on day 12 with severe pneumonia
Patient was intubated, ventilated, moderately catecholamine-dependent and in an unexpectedly poor general physical condition, without significant reconvalescence
Microbiological findings showed infection with E. coli, so there was immediate initiation of antibiotic therapy with Piperacillin/Tazobactam, later on Imipenem, after which her pneumonia improved considerably over the next days, as confirmed radiologically
Operation with installment of a new biliodigestive anastomosis
Postoperatively prolonged recovery. During the first weaning attempts the patient remained relatively unresponsive and was not vigilant for weeks despite spontaneous breathing
Determination of plasma ammonia levels showed a significant increase of up to> 230 µg/dl (normal range 19-87 µg/dl), other liver function tests also showed a moderate hepatic impairment – cholinesterase > 1500 U/l, gammaGT at 602 U/l, PDR 12.2%/min (normal range 18-25), R15 16% (normal range 0-10), Quick 60%, CRP also low with 48 mg/l
In this phase the patient received a low-dose norepinephrine infusion (<0.5 mg/h)
In the further course she suffered recurrent bouts of pneumonia and CVC infections
Conservative lactulose therapy (orally or as an enema) and selective intestinal decontamination proved unsuccessful
Due to the extremely high plasma ammonia levels (> 230 µg/dl), the decision was made to use CytoSorb as adjunctive therapy
Treatment
Two treatments with CytoSorb, 1st treatment for 72 hours with significant reduction of ammonia levels to 66 µg/dl, thereafter treatment pause for 11 days during which ammonia levels rose back to 116 µg/dl, 2nd treatment for 72 hours
CytoSorb was used in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) performed in CVVHD mode
Blood flow rate: 120 ml/min
Anticoagulation: citrate
CytoSorb adsorber position: pre-hemofilter
Measurements
Ammonia
Inflammatory parameters (CRP)
Results
CRP continuously low between 40-50 mg/l during both treatment cycles
After the first treatment reduction of ammonia to 66 µg/dl, rebound to 116 µg/dl during the 11 day treatment pause period, during the 2nd treatment ammonia could be reduced to 76 µg/dl
Reduction of gammaGT in the course of the first treatment to 313 U/l, after treatment 2 there was no further reduction
Patient improved significantly during the first CytoSorb treatment, and started to respond specifically and follow instructions; with increasing ammonia levels after the first treatment the patient was again somnolent, however during the 2nd treatment cycle she improved again, thereafter ammonia levels remained at a low level over the next weeks
Patienten Follow-Up
Patient could be weaned off the ventilator 6 days after the second CytoSorb treatment
Termination of renal replacement therapy immediately post second CytoSorb use
After further improvement, patient could be mobilized whilst still in ICU
Due to recurrent infections and lung problems, therapy was discontinued 50 days after the initial admission and the patient died
CONCLUSIONS
CytoSorb represents a good and practicable treatment option for patients with high ammonia levels
According to the medical team and since the treatment of this patient, the use of CytoSorb is now considered in patients with liver resection and post-operative hepatic dysfunction
Treatment with CytoSorb was safe and easy to apply
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