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First successful hemoadsorption using CytoSorb® in a septic pediatric patient in Kazakhstan: A case report
Saparov A1, Sazonov V1,2, Tobylbaeva Z1, Isakov S1, Bekpan A1, Autalipov D1, Muratbekova B1, Manaybekova Z1, Anikin V1 | 1 National Research Center for Maternal and Child Health, Astana, Kazakhstan | 2 Nazarbayev University School of Medicine, Astana, Kazakhstan
01/29/2019
Reduction in catecholaminesCRRT (pre or post filter)Anticoagulation HeparinSafetyInflammatory parametersNew!Case of the weekCritical CarePediatricsSepsisCase report
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Summary
CoW 05/2019 – This report describes the case of an 8-month-old patient with a body weight of 5600 grams, who was admitted with the diagnosis of acquired severe laryngeal stenosis, chronic tracheal cannulation, and protein energy malnutrition.
Case presentation
Medical history revealed that the patient was born prematurely at 34 weeks of gestation, with a weight of 2200 g and that he had received in- hospital treatment for pneumonia and cytomegalovirus infection in regional hospitals four times over the last 6 months
On day 2 after admission, balloon dilatation was performed under direct suspension laryngoscopy followed by prescription of cefazolin (75 mg/kg per day) according to the clinical protocol
The following day the patient’s condition worsened with fever and dyspnea
Medical examination revealed bilateral pneumonia, respiratory failure and fungal-bacterial sepsis (Burkholderia cepacia + Staphylococcus aureus ?RSA + Candida albicans) resulting in the initiation of antibacterial and antifungal therapy (ceftriaxone 100 mg/kg per day, azithromycin 10 mg/kg per day, and fluconazole intravenously 5 mg/kg). Later, antibiotics were changed to ciprofloxacin (30 mg/kg per day) with vancomycin (45 mg/kg per day) due to continued worsening of the patient’s condition
After transfer to the pediatric intensive care unit (PICU) he received prolonged mechanical ventilation (APV SIMV mode, RR 40 per minute, VT 38 mL, ???? 6.0 mmHg, FiO2 40%) with subsequent stabilization over the following days
However, despite intensive care management with a combination of potent antibacterial and antifungal agents, sepsis progressed with increasingly unstable hemodynamics (blood pressure values 42/23 mmHg) necessitating escalating inotropic support with dopamine of up to 7.5 µg/kg/min
The patient’s condition became extremely severe with multiple organ failure syndrome and acute kidney injury. Eight days after transfer to the PICU, blood examination showed the following: leucocytosis up to 103.0 × 109/l, increased C-reactive protein (CRP) to 336.2 mg/ml, alanine transaminase (ALT) 1118.3 IU/L; aspartate transaminase (AST) 2372.2 IU/l, urea 17.5 mmol/l, creatinine 57.6 µmol/l, procalcitonin (PCT) 55.7 ng/ml) resulting in the initiation of pediatric CVVHD in combination with CytoSorb hemoadsorption
Treatment
One treatment with CytoSorb for 36 hours
Cytosorb was used in combination with CRRT (Multifiltrate, Fresenius Medical Care) run in CVVHD mode
Blood flow rate: 56 ml/min, replacement fluid (as predilution only) 250 ml/h
Ultrafiltration rate: 30 ml/h
Anticoagulation: prolonged heparinization 5–30 IU/kg/h
CytoSorb adsorber position: the system was installed in series before the KitPaed filter
Special priming procedure: normal saline was used for priming of the circuit and system testing, prior to connecting the device to the patient normal saline was replaced by red blood cell suspension
Measurements
Hemodynamic situation
Inflammatory parameters
Transaminases, creatine kinase (CK), troponin
Renal function
Lung function
Acid–base balance
Effect on electrolyte balance
Results
Clear stabilization of the hemodynamic condition (blood pressure 109/52 mmHg at 36 hours) accompanied by discontinuation of vasopressor support at the end of the treatment
Application of CytoSorb therapy resulted in a rapid reduction of inflammatory mediators such as IL-6, S100, PCT, and CRP reaching slightly supra normal levels after 36 hours
Simultaneously, the level of transaminases, creatine kinase (CK), and troponin normalized
Improvement of renal function as evidenced by increasing diuresis and decreasing retention parameters (urea, creatinine)
Improvement in lung function with successful weaning from mechanical ventilation and change to spontaneous breathing while still under CytoSorb
Stabilization of the acid–base balance as seen by an increase of pH from 7.05 pre-treatment to 7.35 post-treatment
There was no effect on the patients electrolyte balance
Patient Follow-Up
Ultimately, the patient was transferred to the general pediatric department and subsequently discharged from the hospital
Conclusion
Combined application of CVVHD and CytoSorb was associated with a rapid hemodynamic and metabolic stabilization with concomitant reduction of vasopressor therapy, a reduction of inflammatory mediators and an improvement in renal and lung function
CytoSorb treatment was shown to be effective and has proven its practical value as a promising adjuvant therapy for sepsis and related conditions in this population
CytoSorb was safe, well-tolerated and easy to use with CVVHD in this very small pediatric patient with no adverse side effects during or after the combined extracorporeal support
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