Case of the week 11/2017
Use of CytoSorb in a case of early recovery after cardiogenic shock and ACVB operation and ECMO therapy
Dr. Andreas Baumann*, Prof. Peter K. Zahn*, Dr. Peter L. Haldenwang# *Department of Anaesthesiology, Intensive Care, Palliative Care and Pain Medicine # Department of Cardiosurgery and Thoracic Surgery BG University Hospital Bergmannsheil gGmbH, Germany
Summary:
This case study reports on a 79-year-old female patient (pre-existing conditions: 3-vessel coronary heart disease, main stem stenosis LCA), who presented for elective coronary artery bypass surgery (ACVB). However, an emergency triple ACVB operation ahead of schedule became necessary due to acute angina pectoris.
Case presentation
In the course of the anaesthetic induction the patient had to be resuscitated and an Extracorporeal Life Support System (ECLS) was installed as a veno-arterial (VA) bypass procedure in this cardio-pulmonary emergency situation
Uneventful ACVB operation afterwards
The patient was transferred to the intensive care unit on high-dose norepinephrine (600 µg/h) with vaECLS and high-grade low-output syndrome
A few hours later catecholamines continued to rise to 2000 µg/h
Metabolic derangement (lactate 5.3 mmol/l) and renal failure with oliguria (20 ml/h)
Highly elevated leukocyte levels of 47,000/µl
In anticipation of a post-reanimation syndrome with suspected cytokine storm, the metabolic derangement and arising renal failure, continuous renal replacement therapy in combination with CytoSorb were started 3 hours after the end of surgery
Treatment
Nine treatments with CytoSorb for a total treatment time of 9 days (treatment for 24 hours each)
CytoSorb was used in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) performed in CVVHD mode
Blood flow rate: 100ml/min
Anticoagulation: citrate
CytoSorb adsorber position: pre-hemofilter
Measurements
Demand for catecholamines
Renal function (excretion)
Lactate
Need for volume
Inflammatory parameters (leucocytes)
Results
Hemodynamic stabilization with significant reduction in catecholamine doses – after an initial increase in catecholamine doses under CytoSorb, norepinephrine could be completely tapered out after 18 hours
Pronounced stabilization of the capillary leak/ volume shift: fluid balance within the first 11 hours of treatment equaled +7 liters, the following 24 hours this increased to +10 liters, another 24 hours later the balance was only +500 ml and continuous negative balance was possible from then on
Lactate fell to normal values (1.5 mmol/l) within 18 hours after initiation of therapy
Leukocyte plasma concentrations were 30,000/µl after 18 hours, twelve hours later 21,000/µl and a tendency towards further normalization, with normal values reached another 4 days later
There was no acute improvement in renal function and the patient remained oliguric/anuric CytoSorb)
Patient Follow-Up
Despite the marked improvement in the measured parameters, CytoSorb treatment was maintained for another 7 days in order to prevent re-occurrence of the inflammatory reaction in this case of a severely affected patient with persistent low output syndrome and the expectation of a persistent stimulus from the release of cytokines
Conversion of the ECLS from veno-arterial to veno-venous 5 days after surgery
Six days after the operation, the patient was tracheotomized, awake, alert, and responding adequately to stimuli
Decannulation of the veno-venous ECLS 7 days later
Development of a Critical-Illness Myopathy (CIM) and Critical Illness Polyneuropathy (CIP).
CONCLUSIONS
Treatment with CytoSorb was accompanied by an unexpectedly rapid and significant stabilization in hemodynamics and declining catecholamine dosages within hours of its introduction
Clear and rapid stabilization of the volume shift. According to the medical team, such highly complex patient courses usually show a positive fluid balance throughout the seventh postoperative day.
Considering the age and the severity of the disease of the patient, and notwithstanding the persistence of low-output syndrome, the physicians were able to support cardiac function through the rapid stabilization of the hemodynamics including control of the inflammatory reaction and the avoidance of additional cardio-depressing mechanisms (septic cardiomyopathy)
Application of CytoSorb in combination with two other extracorporeal therapies (CVVHD, ECLS) was safe and easy
