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Use of CytoSorb in viper snakebite-induced septic shock with multiple organ failure
Dr. Kamlesh Parikh, Dr. Hardik Patel, Dr. Monika Kothari, Dr. Lalit Maheshwari Sunshine Global Hospital, Vadodara, India
02/19/2019
Reduction in catecholaminesARDSAnticoagulation HeparinMOFSafetyInflammatory parametersNew!Case of the weekCritical CareSepsisOther indicationsCase reportCRRT post filter
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Summary
CoW 08/2019 – This report describes the case of a 40-year-old male patient, who encountered a snakebite on his right lower limb followed by severe pain, swelling and dyspnea.
Case presentation:
Subsequently, he was taken to the Godhra Railway Hospital and received symptomatic treatment before he was referred to Vadodara Railway Hospital where antibiotic therapy was commenced accompanied by administration of anti-snake venom (single vial), after which the patient was then referred to the Sunshine Global Hospital 24 hours after the bite
Upon admission to the intensive care unit (day 2), the patient’s condition gradually deteriorated with hypotensive, circulatory shock with a mean arterial pressure (MAP) of 53 mmHg, decreasing SpO2 in addition to declining hemoglobin levels (from 15 g/dl to 9.75 g/dl), leukocytosis (43×10³/µl) and thrombocytopenia (82×10³/µl)
Standard of care treatment was initiated by intravenous fluids administration, antibiotic therapy (meropenem) and 1 vial of anti-snake venom followed by high-dose noradrenaline administration to normalize the MAP, and twenty sequential blood transfusions
Despite full standard therapeutic measures, the patients’ condition worsened with signs of incipient respiratory, renal and hepatic failure
On day 3, the patient was clinically and radiologically diagnosed as having acute respiratory distress syndrome (ARDS) accompanied by oliguria, increasing creatinine (2.3 mg/dl) and total bilirubin levels (2.0 mg/dl, SGOT 840 U/l, SGPT 635 U/l)
Arterial blood gas analyses confirmed severe metabolic acidosis (HCO3 11 mmol/l) while inflammatory markers were clearly elevated with a PCT of 3 ng/dl and CRP at 600 mg/l suggesting hyperinflammation
BiPAP ventilation support was initiated due to development of acute respiratory failure
To address progressing acute renal failure the patient was put on hemodialysis, and a CytoSorb adsorber was additionally integrated into the hemodialysis circuit to regain control of the hyperinflammatory situation (day 4)
Treatment:
One CytoSorb treatment for a total treatment time of 8 hours
CytoSorb was used in conjunction with hemodialysis (4008s machine, Fresenius Medical Care) run in CVVHD mode
Blood flow rate: 150 ml/min
Anticoagulation: Low-dose heparin
CytoSorb adsorber position: post-dialyzer
Measurements:
Hemodynamics (MAP) and need for catecholamines
Organ recovery (renal, pulmonary and hepatic)
Hemogram (Hb, leucocytes and thrombocytes)
Inflammatory response
Results:
After the CytoSorb treatment (Day 5 after the snake bite), a significant reduction in norepinephrine requirement was observed which could gradually be weaned off in the following hours. This was paralleled by a clear improvement in the MAP indicating hemodynamic recovery
Liver function as well as pulmonary function improved (PaO2 from 60 to 150 mmHg, FiO2 from 100% to 21%) followed by weaning of the ventilatory support
Post CytoSorb, there was a significant improvement in renal function particularly an increase in urine output (from 400ml/day to 2500ml/day) and a decrease in creatinine (from 2.3mg/dl to 1.1mg/dl)
Normalization of hemoglobin, leucocyte and platelet counts during the course of the treatment
Moreover, the hyperinflammatory response attenuated as evidenced by a marked reduction in the relevant inflammatory biomarkers
Patient Follow-Up:
Hemodialysis was stopped immediately after CytoSorb treatment
The patient was discharged to the normal ward within 6 hours post CytoSorb
He was finally discharged from the hospital 3 days post CytoSorb with complete recovery
Conclusion:
This case highlights the potential role of immunomodulation using CytoSorb hemoadsorption in vasculotoxic viper snakebite envenomation with septic shock and multiple organ failure
The early use of CytoSorb along with standard of care and renal replacement therapy helped to stabilize hemodynamics, reduce vasopressor dependency and to restore organ function and overall homeostasis
CytoSorb should be used to arrest the excessive cytokine release triggered by Damage-associated molecular patterns (DAMPs), which are generally released due to myolysis post viper snake bites, thereby preventing further multiple organ failure
The application of CytoSorb in this setting proved safe and easy
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