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Use of CytoSorb in a multi-morbidity patient with ARDS in the context of a COVID-19 infection
Dr. Holger Fey | Department for Internal Intensive Care Medicine, Fürth Hospital, Germany
06/17/2020
Case reportCase of the weekCritical CareInflammatory parametersReduction in catecholaminesSafetyAnticoagulation CitrateARDSCRRT pre filterViral infectionNew!COVID-19
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Summary
CoW 25/2020 – This case reports on a 74-year-old male patient who was transferred from the normal ward to the intensive care unit of Fürth hospital due to progressive respiratory deterioration.
Case presentation
On initial presentation, the patient had a dry cough with progressive dyspnea and was therefore hospitalized
He had an extensive medical history, including 3-vessel coronary disease with percutaneous transluminal coronary angioplasty (PTCA) and 2x stenting in 2005, posterior wall infarction in 2014, mitral valve reconstruction in 2014, persistent atrial fibrillation, heart failure, left bundle branch block, arterial hypertension, hyperlipoproteinemia, obesity, diabetes mellitus type 2, cerebral arteriosclerosis and chronic renal insufficiency G3aA2
On admission to the ICU, he had tachycardic atrial fibrillation with intermittent known left bundle branch block. The subsequent initiation of amiodarone was terminated after 3 days due to bradycardia and pathological QTc prolongation
Chest X-ray examination showed severe bilateral pneumonic infiltrates which was particularly pronounced in the lower lobes
Due to the progressive clinical deterioration with hypoxemia (Horowitz index PaO2:FiO2 ratio of 152 mmHg), he had to be intubated and invasively ventilated on the first day of ICU admission
Hydroxychloroquine therapy was started (for a total of 5 days) following a positive SARS-CoV-2 result. In addition, antibiotic therapy with piperacillin/tazobactam was initiated as a bacterial superinfection was suspected (for a total of 8 days), which was then escalated to meropenem (for a total of 9 days). However, there was no proof of bacterial infection at any time
He subsequently developed an acute anuric renal failure with significantly elevated creatinine levels, resulting in the initiation of continuous renal replacement therapy (CRRT) two days after intubation
Over time, there was no significant improvement in oxygenation. The Horowitz index remained at a level of around 150 mmHg, while there was also no improvement in infiltrates, rather an increase in consolidation. Inflammatory parameters were significantly increased (CRP 25 mg/dl).The patient was predominantly hemodynamically stable and required only moderate doses of norepinephrine (0.5 mg/h)
With the rationale of influencing the persistently high activity of inflammation in the lungs, a CytoSorb adsorber was additionally integrated into the running CRRT circuit 7 days after admission
Treatment
A total of 4 consecutive treatments with CytoSorb for 24 hours each were performed
CytoSorb was used in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) run in CVVHD mode
Blood flow rate: 100 ml/min
Anticoagulation: citrate
CytoSorb adsorber position: pre-dialyzer
Measurements
Hemodynamics and dosage of vasoactive substances
Inflammatory parameters
Ventilation parameters
Results
Combined treatment with CRRT+CytoSorb resulted in stabilization of the hemodynamic situation. The patient was free from catecholamines after 5 days
Inflammatory parameters decreased continuously over the further course of treatment. After 7 days, the CRP plasma concentration was 4.7 mg/dl
Ventilation parameters improved significantly with regard to oxygenation. The Horowitz index increased to approximately 200 mmHg on the 4th day after treatment initiation
Patient Follow-Up
After the treatment, his clinical situation improved further
Weaning from the ventilator was successfully initiated 2 days after the start of CytoSorb therapy. The same day, the patient was breathing spontaneously and could finally be extubated 3 days later. Afterwards, he remained stable on 6 litres of nasal oxygen. Shortly after extubation, the patient was noted to be delirious, which, was treated successfully by the administration of haloperidol
After an unsuccessful CRRT weaning attempt and persistent anuria, CRRT was continued until transfer to the wards
A grade 2 decubitus ulcer was treated by appropriate and regular wound management
At the time of documentation, the patient has already been discharged home and is mostly able to self-care.
Conclusions
In this multi-morbidity patient with ARDS in the context of a COVID-19 infection, the combined treatment with intensive care standard therapy, CRRT and CytoSorb hemoadsorption was associated with hemodynamic stabilization, good control of the inflammatory response and consecutive improvement of the respiratory situation
According to the medical team, the use of CytoSorb in this case showed an immunomodulatory effect which had a positive impact on the clinical course of the disease
CytoSorb was problem-free, safe and easy to use in the context of the combined application together with CRRT
