Case of the week 41/2017
Use of CytoSorb in severe post-reanimation shock and abdominal compartment syndrome
Dr. med. Hendrik Haake, Dr. med. Katharina Grün-Himmelmann & Prof. Jürgen vom Dahl Department of Cardiology and Intensive Care Medicine, St. Franziskus-Hospital Mönchengladbach, Germany
Summary:
This case study reports on a 57-year-old male patient who was admitted to hospital after a cardiac arrest with ventricular fibrillation and successful cardiopulmonary resuscitation.
Case presentation
The emergency physician was alerted due to acute left thoracic pain and found the patient still alert and adequately responsive
After a period of time the patient suffered a circulatory arrest with therapy-refractory ventricular fibrillation alternating with ventricular tachycardia
On arrival at the intensive care unit, the patient had already been resuscitated by the emergency physician for about 65 minutes, and 600 mg of amiodarone had been cumulatively administered
Initially, a Torsade-de-Pointes tachycardia was confirmed, and despite the administration of Ajmalin (1 ampoule) and 2 g magnesium, the arrhythmia could not be reversed, so that resuscitation had to be continued
A rescue VA-ECMO was installed in parallel and the ongoing ventricular tachycardia was successfully converted to a sinus rhythm by defibrillation
The patient showed a pronounced requirement for intravenous fluids. Despite aggressive volume therapy, the venous ECMO limb was repeatedly occluded so that a flow of only approx. 1.5 l/min could be established, however with a mean arterial pressure of 60 mmHg
After administration of 5,000 I.U. Heparin (by the emergency physician) as well as administration of 500 mg aspirin the patient underwent coronary angiography where a posterior infarction with occlusion of the right coronary artery was diagnosed followed by uneventful implantation of 2 drug-eluting stents
Furthermore, an axial circulation pump (Impella CP) was installed for LV venting
Afterwards, the patient was intubated and ventilated and transferred to the internal intensive care unit in a hemodynamically unstable condition
On the morning of the same day, the patient exhibited an acutely swollen abdomen, accompanied by increasing lactate levels (8 mmol/l) and the diagnosis of an abdominal compartment syndrome was made
In CT, ischemia of the transverse colon and all adjacent sections was diagnosed, compressing the vena cava and thus causing the lack of flow across the ECMO cannulas
Due to acute oliguric renal failure post reanimation with strongly increased retention markers (creatinine 2.49 mg/dl, urea 100 mg/dl, GFR 29 ml/min) continuous hemofiltration was initiated
Additionally, antibiotic therapy with vancomycin and ceftazidime was commenced due to increased inflammatory and infection parameters
After consultation with the Department of Surgery, emergency surgery was planned for the same day and a Hartmanns procedure with subtotal colectomy with terminal ileostoma and sigmoid occlusion, as well as simultaneous cholecystectomy performed. The patient remained severely hemodynamically unstable throughout the entire operation with continuously increasing lactate values
After surgery, the patient was brought to the intensive care unit and rapidly developed a massive post-reanimation shock syndrome with significantly increased inflammatory parameters (leukocytes 12,000/µl, CRP 20 mg/l, PCT 44 ng/ml, IL-6 1753 pg/ml) and significant needs for catecholamines (norepinephrine 10 mg/h, dobutamine 50 mg/h), hence a CytoSorb adsorber was additionally installed into the CRRT circuit
Treatment
One CytoSorb treatment for a total treatment time of 48 hours
CytoSorb was used in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) in CVVHD mode
Blood flow rate: 150 ml/min
Anticoagulation: citrate
CytoSorb adsorber position: pre-hemofilter
Measurements
Hemodynamics and demand for catecholamines
Lactate
Renal function (creatinine, urea, diuresis)
Inflammatory parameters (CRP, PCT, IL-6, WBC)
Results
Hemodynamic stabilization of the patient along with significantly decreased needs for catecholamines within 24 hours (noradrenaline 2 mg/h, dobutamine 0 mg/h )
Resolution of metabolic acidosis within 24 hours (decrease of lactate to 1.7 mmol/l)
Normalization of retention parameters under CVVHD and CytoSorb
Clear reduction in inflammatory parameters during the course of treatment (IL-6 to 94.6 pg/ml, PCT to 14.6 ng/ml) – with this downward trend continuing
Patient Follow-Up
The axial circulation pump was dislocated during the operation and had to be removed on the same day
Significant improvement in the general condition after treatment
Renal replacement therapy could be stopped after 5 days with good diuresis and markedly reduced metabolic acidosis
After gradual reduction in the invasiveness of ventilation the patient could be successfully extubated 7 days after admission without the need for non-invasive ventilation at any time thereafter
The patient showed fluctuating delirium, dysphagia, and a wound healing disorder in the area of the abdominal sutures
Finally, the patient was transferred to a step down ward in a generally stable condition
Conclusions
Successful application of CytoSorb in a case of severe post-reanimation shock and abdominal compartment syndrome
Treatment with CytoSorb resulted in significant stabilization of hemodynamics with declining needs for catecholamines and decreasing lactate values within a few hours
Application of CytoSorb was safe and easy
