Case of the week 37/2017
Successful treatment with Cytosorb in a case of septic shock, ARDS, multiorgan failure and purpura fulminans due to Acinetobacter baumannii pneumonia
Dr. Klaus Kogelmann, Dr. Morten Scheller, Dr. Dominik Jarczak, Matthias Drüner Department for Anesthesiology and Intensive Care Medicine, Hospital Emden, Germany Infection (2017) 45 (Suppl 1)
Summary:
This case study reports on a 47-year-old male patient without any chronic diseases (except for regular alcohol abuse), who was admitted to the ICU from a peripheral hospital already mechanically ventilated and in septic shock.
Case presentation
On admission, he was febrile (38.5°C), had an APACHE II score of 38, heartrate was 133 bpm and a mean arterial pressure of 60 mmHg
He further exhibited profound hemodynamic instability necessitating considerable catecholamine support (norepinephrine 2.8 mg/h)
In addition, a purpura fulminans developed rapidly with clinically typical bullous-necrotic skin changes
The patients’ pulmonary condition deteriorated culminating in the development of severe ARDS (PaO2/FiO2 95)
Initial protocol-based treatment including lung protective-ventilation and volume resuscitation failed and the patient was therefore treated with ECMO (X-Lung®, Novalung)
For the treatment of the purpura fulminans, 3000 IU protein C were administered and a continuous renal replacement procedure due to anuric renal failure and rhabdomyolysis using CVVHD (CiCa Fresenius multifiltrate) initiated in addition
After 24 hours of maximum therapy even with adjunctive treatment (hydrocortisone) without any clear improvement, the indication for the additional treatment with CytoSorb was set
Treatment
In total seven consecutive treatments with CytoSorb (1st + 2nd for 12 hours each, 3rd to 7th treatment for 24 hours each)
Cytosorb was used in combination with CRRT (Multifiltrate, Fresenius Medical Care) run in CVVHD mode
Blood flow: 150 ml/min
Anticoagulation: citrate
CytoSorb Adsorber position: pre-hemofilter
Measurements
Hemodynamics and need for catecholamines (dose of norepinephrine vs. the achieved MAP)
PCT, CRP, leukocyte count
Lactate
Lung function PaO2/FiO2
SAPS 2 and SOFA
Results
Shock reversal was achieved after 3 cycles of Cytosorb therapy (norepinephrine requirement reduced by ~85%), and several days later there was no more need for catecholamines
Markers of inflammation (i.e. CRP, leucocyte count) and infection (i.e. PCT) were clearly reduced under treatment with CytoSorb
Lactic acidosis resolved under CytoSorb treatment
PaO2/FiO2 was initially stable after bridging with the veno venous-ECMO and improved rapidly and clearly thereafter
During the course of the treatments SOFA score decreased from 15 to 10, while SAPS 2 reduced from 58 to 43
Patient Follow-Up
After 7 days weaning from the veno-venous ECMO was started, the patient was awake and vigilant, however conventional mechanical ventilation (BiPAP) had to be continued due to persistent tetraparesis caused by severe critical illness polyneuropathy
ECMO was explanted after 10 days (PaO2/FiO2 308)
After application of 3000 IE protein C, tissue necrosis could be stopped within hours and plasma protein c levels normalized (from 26% to 83 %)
Skin necrosis improved with no surgical intervention being necessary
In the next 4 weeks the patient developed stable clinical conditions and could be discharged from ICU after 57 days to a rehabilitation center
CONCLUSIONS
Complete shock reversal as well as a total restitution of the purpura fulminans could be achieved after seven applications of Cytosorb therapy
Pulmonary function improved rapidly and persistently under cytokine adsorption therapy and allowed for a fast weaning from venous-venous ECMO
Treatment with CytoSorb was safe and without side effects nor technical problems
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