Case of the Week
Literature Database
Use of CytoSorb in a patient with severe septic shock in the context of bone marrow depression after chemotherapy
Julia Hahnemann | Intensive Care Unit, Frankfurt Bethanien Hospital, Germany
10/16/2019
Summary
CoW 42/2019 – This case reports on a 30-year-old male patient (known pre-existing conditions: HIV and Hodgkin’s lymphoma), who was transferred to intensive care with a febrile infection, leukopenia and deterioration in his general clinical condition during his hospital stay for chemotherapy.
Case presentation
During the night and within a few hours, the patient developed a picture of full-blown septic shock with pronounced hemodynamic instability and extremely high catecholamine requirements (norepinephrine 6.2 mg/h, epinephrine 1 mg/h)
In the context of pre-existing hypotension, the patient’s blood pressure became non-detectable during anesthetic induction for intubation due to respiratory insufficiency and he subsequently required cardiopulmonary resuscitation. A stable return of spontaneous circulation could be re-established after 30 minutes, after repeated resuscitation
Start of anti-infective therapy with linezolid, meropenem, voriconazole, ciprofloxiacin and metronidazole
Initially anti-retroviral HIV medication was paused and was then continued with Emtricitabin/Tenofoviralafenamid as well as Dolutegravir after consultation with the infections department of the University hospital
Significantly increased inflammatory parameters (CRP 475 mg/l, PCT 416 ng/ml, in leukopenia) indicated a pronounced hyperinflammatory state
Initiation of anti-viral therapy with ganciclovir following detection of cytomegalovirus
In addition, the patient showed severe metabolic acidosis (lactate 34 mg/dl)
Due to the severe state of septic shock with pronounced hemodynamic instability and incipient oliguric renal failure, treatment was started with a combination of continuous renal replacement therapy (CRRT) and CytoSorb hemoadsorption
Treatment
A total of 11 consecutive treatments with CytoSorb for a total treatment time of 9 days (first 3 treatments for 12 hours, treatments 4-11 for 24 hours each)
CytoSorb was used in combination with CRRT (Prismaflex, Gambro) run in continuous veno-venous hemodialfiltration mode (CVVHDF)
Blood flow rate: 150 ml/min
Anticoagulation: citrate
CytoSorb adsorber position: post-hemofilter
Measurements
Vasopressor requirements
Inflammatory parameters
Renal parameters
Lactate
Results
CytoSorb treatment was associated with an impressive improvement in his hemodynamic situation. Within one day, epinephrine administration could be completely stopped accompanied by a significant reduction of the norepinephrine requirements. During the further course of the treatment, norepinephrine demand could be markedly reduced and was finally tapered off by completion of the CytoSorb treatments
Furthermore, the treatment resulted in the rapid and sustained control of the hyperinflammatory condition accompanied by a consecutive reduction of the inflammatory parameters. Within 10 days, CRP plasma concentrations decreased from 475 to 30 mg/l and PCT levels from 416 ng/ml to 1 ng/ml
The combined treatment of CRRT and CytoSorb stopped the progression of acute renal failure and renal function fully recovered as indicated by an onset of diuresis and normalization of retention parameters over the following days
A resolution of severe hyperlactatemia was also observed, with plasma lactate levels being reduced from 24 to 8 mg/dl within 6 days
Incipient ARDS and disseminated intravascular coagulopathy decreased with the combination of intensive care therapy including CRRT and CytoSorb, and there was only a slight and transient increase in liver parameters
Patient Follow-Up
Following adjuvant CytoSorb therapy, a complete recovery of organ functions occurred, the patient was free from catecholamines and showed no signs of increased infection parameters
However, the wake-up phase after reduction of the sedative drugs proved to be difficult
During transfer to the University Hospital Frankfurt for further therapy of his two malignant underlying diseases as well as his severe infectious condition, severe hypoxic brain damage was diagnosed by means of magnetic resonance imaging (patient still ventilated)
After being transferred back to the intensive care unit of the Frankfurt Bethanien Hospital due to the given medical futility, further therapy was discontinued after consultation with the family and the patient died
Conclusions
In this patient with severe septic shock as part of bone marrow depression after chemotherapy, combined treatment with standard intensive care therapy, CRRT and CytoSorb hemoadsorption resulted in the rapid stabilization of hemodynamics with an improvement of metabolic acidosis, control of the inflammatory situation and prevention of prolonged renal failure
According to the medical team, the combined extracorporeal therapy, including CytoSorb, contributed to the rapid control of severe full-blown septic shock. Given the rapid deterioration and the poor prognosis, early use of CytoSorb probably contributed significantly to the survival of the patient during the acute phase
CytoSorb was safe and easy to use in combination with CRRT and there were no device-related side effects
