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Use of CytoSorb in agranulocytosis-induced severe ARDS and septic shock
Dr. Ingolf Eichler | Cardio-surgical Intensive Care Unit, Dortmund Hospital gGmbH, Germany
11/14/2018
Reduction in catecholaminesARDSAnticoagulation CitrateECMO and CRRT parallelSafetyInflammatory parametersNew!Case of the weekCritical CareSepsisCase reportCRRT pre filter
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Summary
CoW 45/2018 – This case study reports on a 31-year-old female patient with acute myeloid leukemia and severe endogenous depression, who was hospitalized with dyspnoea and signs of infection.
Case presentation
The patient had already undergone chemotherapy at the hospital over the previous months
Patient was admitted to the internal (oncology) ward and shortly thereafter, due to rapid deterioration of her clinical situation including shortness of breath, she was transferred to the medical intensive care unit
Broad spectrum antibiotic therapy had already been initiated on the oncology ward
A short time later, she required intubation
Blood analysis revealed severe agranulocytosis (leucocytes 100/µl) and pronounced thrombocytopenia (19000/µl)
The patient developed a global gas exchange disorder during mechanical ventilation that could not be ameliorated under lung-protective ventilation and frequent changes in position
Diagnosis was severe ARDS as per the current classification
With a Horovitz index of <100 mmHg, she was therefore transferred to the cardio-surgical intensive care unit for installation of veno-venous ECMO
She required extremely high norepinephrine dosages (> 6 µg/kg/min) for circulatory support, was highly febrile, and showed markedly elevated infection and inflammation parameters (PCT 20 ng/ml, CRP 500 mg/l) as well as pronounced anasarca
In addition, the patient received pentaglobin and filgrastim (granulocyte-colony stimulating factor)
Gas exchange under ECMO and lung-protective ventilation was good
With clinical symptoms of severe septic shock and progressive development of anuric renal failure, combined continuous renal replacement therapy (CRRT) together with CytoSorb hemoadsorption (2 treatments) was commenced during ongoing ECMO therapy
Due to bleeding complications under ECMO therapy and evident hemolysis (drop in haptoglobin), a second therapy session with CRRT plus CytoSorb consisting of 2 consecutive treatments was performed 5 days later with the aim of protecting the kidneys
Treatment
A total of four treatments with CytoSorb (2×2 therapy sessions for 24 hours each, separated by a pause interval of 5 days)
Cytosorb was used in combination with CRRT (Multifiltrate, Fresenius Medical Care) in CVVHD mode
Blood flow rate: 100 ml/min
Anticoagulation: Citrate
CytoSorb adsorber position: pre-hemofilter
Measurements
Hemodynamics and norepinephrine dosages
Inflammatory parameters (CRP, PCT )
Haptoglobin
Lung function
Results
Clear improvement in the hemodynamic situation with a drastic reduction in catecholamine dosages – norepinephrine could be reduced after the first CytoSorb treatment and tapered off during the second treatment
Reduction of PCT from 20 to 9 ng/ml and CRP from 500 to 290 mg/dl within the first therapy session
Increase of haptoglobin as a marker of reducing hemolysis
Substantial improvement in ventilation parameters shortly after treatment and over the further course of treatment
Patient Follow-Up
Recovery of white blood cell count over the following days
Clearly improved diuresis 5 days after the last treatment session
Cessation of CRRT after recovery of renal function
Multiple severe bleeding complications (endobronchial, nasal – which were treated symptomatically)
Tracheostomy was performed
Following progressive improvement in lung function, the ECMO was explanted after a total of 21 days, and subsequently the patient was conservatively ventilated
Development of cholecystitis resulting in the removal of the gallbladder
Severe Critical Illness Polyneuropathy
19 days after the last CytoSorb treatment, the patient was transferred to the medical ICU for follow-up, start of enteral nutrition, physiotherapy, psychological and oncology care, and weaning from ventilation
At the time of documentation, the patient is on the internal medical ward with ongoing critical illness polyneuropathy and ongoing major depressive disorder
Conclusions
The use of CytoSorb in combination with continuous renal replacement therapy with ongoing ECMO therapy in this patient with severe ARDS and septic shock associated with agranulocytosis was associated with marked and rapid stabilization in the circulatory and acute hyperinflammatory situation
At the cardiac surgery intensive care unit of the Dortmund Hospital CytoSorb is mainly used in patients with sepsis and catecholamine dependency as well as in severe rhabdomyolysis and hemolysis
Safe and easy application of CytoSorb
