Case of the week 47/2016
Use of CytoSorb in severe sepsis after hemicolectomy and anastomosis dehiscence
Dr. Milan Margoc, Dr. S. Montag, Doz. Alexander Kulier, Anaesthesiological Intensive Care Unit, Hospital-Elisabethinen Linz
This case study reports on a 80-year-old female patient (previous medical history of: arterial hypertension, coronary heart disease, atrial fibrillation, NIDDM II, aortic stenosis, peripheral vascular disease, chronic renal failure III), who was admitted to hospital for elective right-sided hemicolectomy for colon carcinoma.
Case presentation
Admission to normal surgical ward for scheduled operation and subsequent postoperative transfer to intensive care unit
Her stay on ICU was complicated by secondary bleeding on the 1st postoperative day necessitating an immediate re-laparotomy with removal of hematoma
After a short stay in ICU, transfer to the normal surgical ward for further treatment for a total of 10 days
On the 10th day, acute deterioration of her general condition, diagnosis of severe sepsis after anastomosis dehiscence with fecal peritonitis
Immediate surgical care with re-laparotomy, anastomotic resection, installation of a new anastomosis, lavage and drainage
Antibiotic therapy initially with tazobactam/piperacillin and after microbiological findings were available, changed to meropenem/echocantine (gram-negative sepsis)
8 days later again deterioration with re-laparotomy and placement of a terminal ileostoma and abdominal dressing (VAC treatment for wound closure)
Retransfer to ICU, orotracheally intubated, mechanically ventilated, noradrenaline-dependent with doses of
0.5-0.83 µg/kg/min at a heart rate of 90-140/min and a blood pressure of 80/45 mmHg, which improved to
110/60 mmHg with noradrenaline
At this point she exhibited highly elevated inflammatory parameters (CRP 33.7 mg/l, leukocytes 28.400/µl,
PCT 75 ng ml)
Additional impairment of renal function: GFR 14.7 ml/min
Due to her acute-on-chronic renal insufficiency as well as her hemodynamic instability and the increased inflammatory markers, the decision was made to initiate CytoSorb as an adjunctive therapy together with CVVHD
Treatment
Two treatments with CytoSorb for a total treatment time of 66 hours (1st and 2nd treatment for 24 hours each, treatment pause of 18 hours between both treatments)
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 (GFR, excretion)
Inflammatory parameters (CRP, PCT, leucocytes)
Results
Hemodynamic stabilization with a significant reduction in catecholamine doses –norepinephrine doses could be reduced to 0.09-0.2 µg/kg/min during both treatments, patient was free from catecholamines 96 hours after completion of both CytoSorb treatments
Clear reduction of inflammatory parameters under CytoSorb therapy (CRP 10.38 mg/l, leucocytes 14.500/µl, PCT 22.5 ng/ml)
Clear improvement in kidney function: GFR from 14.7 to 45.6 ml/min
Patient Follow-Up
Termination of renal replacement therapy 2 days after the last CytoSorb treatment, recovery of diuresis to initial quanitity 7 days after the last CytoSorb treatment
Weaning and extubation successful 6 days after CytoSorb application
11 days after the CytoSorb application, the patient could be transferred to the normal surgical ward
Over the following days the patient was clinically stable, awake, adequately alert, mentally appropriate, and with complete oral nutrition
Final surgical healing successful following installation of a terminal ileostoma
CONCLUSIONS
The treatment with CytoSorb resulted in stabilization of vital functions (improvement in the circulatory and renal function) as well as declining doses and finally complete cessation of catecholamines
CytoSorb was safe and easy to use
