Case of the week 43/2016
CytoSorb in severe septic shock after colon perforation
Dr. med. Alexander Rothe, Dr. med. Karin Siegert, Clinic for Anesthesiology, Intensive Care and Pain Therapy, Ev. Diakonissenkrankenhaus Leipzig gemeinnützige GmbH
This case study reports on an 82-year-old male patient (medical history: previous myocardial infarction, arterial hypertension, coronary heart disease, aneurysm, atrial fibrillation with oral anticoagulation, diabetes mellitus) who presented at the hospital with an acute abdomen after he had undergone an outpatient colonoscopy where he was found to have a suspicious (malignant) stenotic process in the ascending colon.
Case presentation
Admission to the surgical ward and initiation of preoperative intestinal preparation (administration of rinsing solution) for elective laparotomy
Meanwhile dramatic acute deterioration in his general condition and development of a circulatory insufficiency as well as of an ileus
Transfer to intensive care unit for further monitoring
In the following 12 hours development of an acute abdomen accompanied by full-blown septic shock and immediate initiation of an emergency laparotomy
Already preoperative commencement of antibiotic therapy with ceftriaxone 1x2g, ampicillin 3x2g, metronidazole 3x 500 mg (24 hours later change to imipenem 4×500 mg)
Intraoperative diagnosis of an intestinal gangrene above the stenotic process as well as an intestinal wall rupture with resulting peritonitis
Operative treatment by means of extended right hemicolectomy
Postoperatively, the patient was readmitted to ICU in septic shock, mechanically ventilated, catecholamine-dependent and with multi-organ failure
Laboratory values showed greatly deranged inflammatory parameters with leukopenia 1.5 Gpt/l, CRP 250 mg/l, PCT 101 ng ml and severe lactic acidosis (12 mmol/l)
Hemodynamic instability with increased doses of noradrenaline (0.8 µg/kg/min)
Development of anuric renal failure (creatinine 160 µmol/l, urea 6.3 mmol/l) despite extensive volume resuscitation (fluid balance +16 liters in the first 24 hours) and subsequent initiation of renal replacement therapy
Upon connection to the dialysis machine patient had a cardiac arrest with pulseless electrical activity (PEA) followed by a 5-minute cardiac massage
In addition, establishment of liver failure: ALT 4140 IU/l, AST 6180 IU/l, Quick 35%, ATIII 28 %, platelets 30 Gpt/l, GGT 2219 IU/l
Initiation of PiCCO-guided hemodynamic volume management
Due to the multi-organ failure (mainly kidney, liver) and as a last resort therapy option the decision was made to incorporate CytoSorb as adjunctive therapy in addition to renal replacement therapy
Treatment
Two consecutive CytoSorb treatment sessions for a total treatment time of 48 hours (both sessions for 24 hours)
CytoSorb was used in combination with CRRT (Prismaflex, Gambro) run in CVVHDF mode
Blood flow rate: 130 ml/min
Anticoagulation: citrate
CytoSorb adsorber position: post-hemofilter
Measurements
Hemodynamics and demand for catecholamines
Inflammatory parameters (PCT, CRP, leucocytes)
Lactate clearance
Markers of liver failure (ALT, AST, GLDH)
Results
Noradrenaline doses could be significantly reduced during the first treatment (0.42 µg/kg/min after 24 hours) and were almost tapered off after 48 hours (0.05 µg/kg/min)
This was accompanied by an improvement in cardiac index from initially 2.4 l/min/m² to 3.6 l/min/m² and a clear improvement in the systemic vascular resistance index (SVRI) from 520 to 2600 dyn*s/cm5*m2 during the course of the 2 treatments
Clear reduction in the inflammatory parameters under CytoSorb therapy: PCT after 24 hours at 57 ng/ml and after 48 h at 23.8 ng/ml; CRP after 48 hours at 200 mg/l, leucocytes after 48 hours at 8.9 Gpt/l
Stabilization of lactic acidosis – after 24 hours lactate was 8 mmol/l, after 48 hours 6.2 mmol/l, after 4 days normalization of plasma lactate levels
Significant improvement in liver function associated with a decrease in transaminases: after 48 hours ALT 312 IU/l, AST 84 IU/l and GLDH at 381 IU/l with complete normalization of all parameters after 4 days
Antibiotic dosages did not have to be adjusted at any time
Patienten Follow-Up
Termination of renal replacement therapy 7 days after completion of CytoSorb treatment
Transfer to normal ward 58 days after the last absorber use with normal renal values
In the further course of his postoperative stay in intensive care unit, development of wound healing disorders of the abdominal wall and successful closure using vacuum-assisted closure therapy
Transfer to neurological rehabilitation with Critical Illness Polyneuropathy and Critical Illness Myopathy
4 months after the procedure discharge from rehabilitation to his home environment with good neurological outcome
CONCLUSIONS
Impressively rapid reversal of shock with rapid stabilization of hemodynamics and a prompt reduction in catecholamine doses
According to the medical team, the effect of reversing liver failure was particularly impressive, especially as patients with this manifestation of liver failure usually die
This case using CytoSorb showed a very good outcome, resulting in the fact that the adsorber is now used much more regularly in patients with septic shock in the department
The application of CytoSorb therapy was simple, safe and with no problems installing the adsorber in a post-hemofilter position
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