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Use of CytoSorb in a patient with septic shock and multiple organ dysfunction syndrome following recurrent acute necrotizing pancreatitis
Dr. Manik Chhabra, Max Hospital, Patparganj, New Delhi, India
08/12/2020
Case reportSeptic ShockCase of the weekCritical CareReduction in catecholaminesSafetyMOFPancreatitisCRRT post filterNew!
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Summary
CoW 33/2020 – This case reports on a 32-year-old male patient admitted to the Max Hospital, Patparganj with upper abdominal pain associated with vomiting.
Case presentation
The patient had a known history of chronic alcohol abuse and pancreatitis
Physical examination revealed abdominal distention and tenderness, while cardiovascular and neurological evaluations were unremarkable
Treatment was started with intravenous antibiotics (meropenem and amikacin) and fluid therapy
He exhibited severe metabolic acidosis with a pH of 6.86, pCO2 25 mmHg, and a pO2 of 90 mmHg
Chest X-ray confirmed lower zone consolidations in the lungs
The patient had difficulties breathing along with drowsiness and high blood sugar levels and was therefore transferred to the medical ICU
Working diagnosis at this time was acute pancreatitis with concomitant diabetic ketoacidosis, bilateral pneumonia and metabolic acidosis
Laboratory parameters revealed severe leucocytopenia (3.6*10³/µl), decreased platelet count 90*10³/µl and significantly elevated PCT levels (17.3 ng/ml), indicating a severe ongoing systemic hyperinflammatory response
He also decompensated hemodynamically, necessitating the start of a norepinephrine infusion, which had to be increased to up to 0.3 µg/kg/min over time, and was further supplemented by the additional application of vasopression (3 IU/h)
APACHE II score was 19 and SOFA score 12
Due to respiratory deterioration, the patient was intubated and put on invasive mechanical ventilation
Additionally, continuous renal replacement therapy (CRRT) was initiated due to development of acute renal failure
As the patient was not responding to standard therapy and his clinical condition was continuing to deteriorate, the decision was made to install a CytoSorb hemoadsorber into the already running CRRT circuit
Treatment
Three CytoSorb sessions were run in total, each treatment was performed for 24 hours with pause intervals of 2 hours between each session
CytoSorb was used in conjunction with CRRT (Prismaflex, Gambro) run in CVVHDF mode
Blood flow: 180 ml/min
Anticoagulation: none
Measurements
Hemodynamics and vasopressor requirement
Inflammatory status
Metabolic acidosis
Parameters of pancreatitis
Severity scores
Results
Treatment resulted in a significant improvement in hemodynamics as evidenced by a stable mean arterial pressure (MAP) above 65 mmHg with decreasing vasopressor dosages. Norepinephrine dosages could be reduced to 0.1 µg/kg/min after the first CytoSorb+CRRT therapy session. Vasopressor support could be completely stopped after the 2nd CytoSorb treatment
During the course of treatment, PCT decreased from 17.3 ng/ml to 1.01 ng/ml while platelet and leucocyte count initially remained low but recovered over time
Metabolic acidosis resolved as shown by a normalization in pH with the first 24 hours of treatment
Also parameters pointing towards a severe pancreatitis could be efficiently reduced during treatment (pre CytoSorb therapy serum amylase 740.6 U/L and lipase 152.0 U/L, post 2nd CytoSorb therapy session serum amylase 148.2 U/L and lipase 33.1 U/L)
The combined treatment was also associated with a reduction in SOFA score from 12 to 5 throughout the therapy interval
Patient Follow-Up
The patient could be extubated on day 8 after admission with continuous improvement thereafter
Alcoholic pancreatitis further improved with amylase and lipase plasma levels showing a declining trend
On day 13 he was discharged from the hospital in a clinically stable condition
Conclusion
In this patient with septic shock and multiple organ dysfunction syndrome the combined treatment of standard therapy, CRRT and CytoSorb resulted in rapid stabilization in hemodynamics with simultaneous resolution of metabolic acidosis, control of the overshooting inflammatory response and improvement in organ functions
This case highlights that early initiation of CytoSorb therapy and sustaining the therapy helped in regaining control of the inflammatory process in this patient
The use of CytoSorb together with CRRT proved to be safe with no signs of adverse events.
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