Case of the Week
Literature Database
Cytokine adsorption in a patient with severe coronavirus disease 2019 related acute respiratory distress syndrome requiring extracorporeal membrane oxygenation therapy: A case report
Marina Rieder, Timm Zahn, Christoph Benk, Achim Lother, Christoph Bode, Dawid Staudacher, Daniel Duerschmied, Alexander Supady | University of Freiburg, Freiburg, Germany, University of Heidelberg, Heidelberg, Germany
10/28/2020
New!Peer Reviewed Published DataReduction in catecholaminesARDSCase of the weekCase reportCOVID-19Critical CareECMO-VVInflammatory parametersInfluenza
Download documentDownload documentLink to source
Summary
CoW 44/2020 – This case reports on a 59-year-old woman, who was hospitalized with fever (38.8°C) and severe respiratory insufficiency requiring immediate noninvasive ventilation, after she had developed increasing dyspnea one day before.
Case presentation
One week previously, she had presented to a family doctor who diagnosed a urinary tract infection after urine chemistry and prescribed nitrofurantoin and metamizole. Despite antibiotic therapy, symptoms did not improve adequately
Apart from a history of breast cancer with ongoing hormone therapy and glaucoma, there were no other relevant preexisting conditions
Following admission, contrast-enhanced computed tomography images depicted multiple subsegmental pulmonary arterial emboli on both sides and signs of atypical pneumonia
Abnormalities in blood chemistry were elevated D-dimers, lymphopenia, and neutrophilia as well as increased levels of lactate dehydrogenase, C-reactive protein (CRP), and elevated cardiac biomarkers (troponin I hs, NT-proBNP); interleukin (IL)-6 was also altered
Renal and liver function parameters were only mildly elevated
A polymerase chain reaction test for respiratory viruses finally revealed an infection with SARS-CoV-2
Hydroxychloroquine was administered for estimated antiviral effects according to an internal treatment standard for COVID-19 at that time and empiric antibiotic therapy (piperacillin/tazobactam and clarithromycin) was started for suspected bacterial superinfection
Additionally, she received anticoagulation therapy with unfractionated heparin monitored by partial thromboplastin time (PTT), aiming at a PTT of 60-80 seconds
However, the patient developed progressive hypoxemia (pO2 62 mmHg under FiO2 100% on noninvasive ventilation) requiring intubation and invasive mechanical ventilation including prone positioning later that day
Echocardiography revealed mild to medium grade reduced ejection fraction
Norepinephrine (0.2 µg/kg/min) was started, and dobutamine was applied according to the Pulse Contour Cardiac Output-measurements
Over the next days, CRP further increased. D-dimers and IL-6 decreased at first, but then showed a remarkable increment
Hypoxic respiratory failure worsened despite prone positioning and soon highly invasive ventilation was necessary (FiO2 100%, positive end-expiratory pressure [PEEP] 17 cmH2O, pmax 32 cmH2O)
Due to her continuous deterioration, the patient was finally transferred to our center for initiation of veno-venous (V-V) ECMO support 5 days after initial hospital admission
Additionally, antiviral therapy was escalated by adding ritonavir and lopinavir (following an internal treatment standard at that time)
Laboratory findings immediately before implantation of V-V ECMO showed elevated IL-6 levels (540 pg/mL) and the decision was made to integrate a CytoSorb cartridge into the ECMO circuit
Treatment
CytoSorb therapy was performed for a total of 72 hours according to internal standards (3 adsorbers in total)
The CytoSorb adsorber was connected in a recirculating bypass starting behind the oxygenator and going back into the system at a pre-pump-luer-lock connection (ECMO circuit from SCPC Sorin, Munich, Germany)
Blood flow rates through the adsorber: 350-450 mL/min with ECMO blood flow rates around 4 L/min.
Anticoagulation: PTT-monitored anticoagulation with heparin or argatroban within the target range (PTT 60 seconds)
Measurements
Overall clinical status
Hemodynamics and catecholamine requirements
Inflammatory parameters
Lung function/ventilation invasiveness
Coagulation parameters
Results
Following initiation of ECMO support and cytokine adsorption, prompt clinical stabilization of the patient was observed
The need for vasopressors decreased significantly. Dobutamine could be stopped shortly after initiation of ECMO and norepinephrine could be reduced step-wise and was no longer required after 4 days
Also, CRP and IL-6 dropped within a few hours after the start of ECMO and cytokine adsorption
ECMO support with blood flow rates around 4 L/min allowed the medical staff to perform lung-protective low-tidal-volume ventilation as suggested by guidelines for ARDS treatment; to achieve PaO2 values between 55 and 65 mmHg a PEEP of 15 cm H2O and a fraction of inspired oxygen of 40%-60% was required
There was abnormal clotting in the ECMO circuit and various parts of the system and the cytokine adsorber needed to be replaced during the treatment. D-dimers increased after the onset of combined therapy with ECMO and cytokine adsorption, whereas platelet count decreased. Suspecting heparin-induced thrombocytopenia, argatroban anticoagulation was used instead, however a test for heparin-antibodies proved negative
Patient Follow-Up
During the further course of treatment, the patient developed septic shock with multi-organ failure, most likely due to bacterial superinfection of the lung. Procalcitonin levels ranged between 0.41 and 0.76 ng/mL during the first days after ECMO implantation and then climbed to a maximum of 18.4 ng/mL on day 6 after ECMO implantation and remained markedly increased
According to the presumed will of the patient, the therapy was, therefore, terminated 12 days after initiation of ECMO and 17 days after initial hospital admission
Conclusions
In this patient with severe ARDS due to COVID-19, treatment with V-V ECMO and cytokine adsorption resulted in short-term hemodynamic stabilization with a significant decrease in vasopressor needs and levels of inflammatory parameters
Of note, hypercoagulability in COVID-19 has been described previously, and therefore, this complication is most probably not a consequence of cytokine adsorption or ECMO, but rather explained by the underlying disease
This case suggests that cytokine adsorption may help initial stabilization of patients with severe COVID-19 disease requiring V-V ECMO support. The combination of V-V ECMO and cytokine adsorption may be feasible.
Market Data 
Markets 
AI
