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Use of Cytosorb in a patient with septic shock and acute liver failure
Dr. med. Stephan Klösel | Department for Anesthesiology, Intensive Care Medicine and Perioperative Pain Therapy, GPR-Hospital Rüsselsheim, Germany
07/28/2021
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Summary
CoW 30/2021 – This case reports on a 66-year-old female patient who presented to hospital for elective surgical treatment of a large right-sided renal pelvic stone.
Case presentation
The patient’s medical history included a known, medically controlled depression, arterial hypertension and morbid obesity (BMI 37)
On the following day, an open nephrotomy with nephron-pyelocalicotomy was performed without complications, as well as the insertion of a ureteral catheter and percutaneous trans-renal nephrostomy
Direct postoperative care was initially possible without problems on the urological ward
However, ten days after surgery, the patient presented with markedly reduced vigilance (Glasgow Coma Scale [GCS] score 5), hyperpyrexia (up to 41°C), acute renal failure, compromised coagulation parameters and laboratory signs of hyperinflammation (C- Reactive Protein -CRP: 9.4 mg/dl, leukocytes: 27.4*10³/µl, procalcitonin PCT: >100 µg/l, interleukin – IL-6: 351 pg/ml)
An abdominal CT showed a strong perfusion mismatch in the right kidney with partly blurred hypodensity, pointing towards an infected hematoma
Immediate surgical intervention for the hypodensia was not considered possible by the urology department after weighing risks and benefits
As a result, the patient was transferred to the intensive care unit in fulminant septic shock
Due to the decreased GCS, she had to be intubated, sedated and mechanically ventilated (using lung protective parameters)
Advanced hemodynamic monitoring (Trans Esophageal Echo – TEE and PiCCO) were established accompanied by initiation of catecholamine therapy (norepinephrine up to 2.7 µg/kg/min, dobutamine up to 3.4 µg/kg/min) and volume management with balanced electrolyte solution (5500 ml) and 200 ml human albumin (20%) over the following 24 hours
Administration of 100 mg methylene blue, 100 mg hydrocortisone and 6 g vitamin C as well as 2×200 mg vitamin B6 complemented the adjunctive sepsis therapy
Anuria developed with elevated renal retention parameters (creatinine: 1.96 mg/dl, urea: 43.9 mg/dl), resulting in the placement of a Shaldon catheter and initiation of continuous renal replacement therapy (CRRT)
In addition, calculated anti-infective therapy (meropenem, linezolid, caspofungin) was prescribed
Eight hours after implementation of the first intensive care measures, a Cytosorb adsorber was additionally installed in the running CRRT circuit as the course of septic shock continued to progress and there were also laboratory signs of acute liver failure (ATIII: 42%, bilirubin: 1.66 mg/dl, Quick: 57%, INR: 1.29)
Treatment
Two consecutive CytoSorb treatments for a treatment time of approximately 50 hours (treatment 1 for 24 hours, treatment 2 for 26 hours)
CytoSorb was used in combination with a CRRT run in CVVHDF mode (Prismaflex, Baxter, M100 membrane)
Blood flow rate: 100 ml/min
Dialysate flow: 1000 ml/h
Substituate flow: 1000 ml/h, post-dilution
Ultrafiltration: 100 ml/h
Anticoagulation: citrate
CytoSorb adsorber position: post-hemofilter
Measurements
Hemodynamics and catecholamine requirements
Inflammatory parameters
Respiratory situation
Results
The applied complex and differentiated sepsis therapy measures including CytoSorb resulted in the rapid stabilization of the patients’ cardio-circulatory situation. Norepinephrine infusion could be completely stopped within three days
Treatment was also associated with control of the inflammatory response as measured by a reduction in CRP to 4.36 mg/dl, leukocytes to 5.0*10³/µl, PCT to 1.32 µg/l and subsequently below the detection level, and IL-6 to 14.8 pg/ml within 4 days
The respiratory situation also improved noticeably. Only a few hours after the initiation of combined CytoSorb/renal replacement therapy, invasive ventilation therapy could be changed to a spontaneous-assisted mode. Arterial blood gases improved with a concomitant reduction in the inspiratory oxygen concentration. During the course of CytoSorb therapy, the Horovitz index increased from 112 to 232 mmHg. After cessation of renal replacement therapy after a total of 5 days, the patient was already completely weaned off the ventilator
Patient Follow-Up
The only remaining symptom was a marked decrease in vigilance, which was probably caused by depression as known from the patient’s medical history, which was treated with medication. Due to ongoing concerns re her respiratory condition, the patient underwent a dilated tracheotomy
Staphylococcus epidermidis was detected several times in blood cultures. Anti-infective therapy was completely stopped after seven days
Plasma levels of CPR, leukocytes and PCT completely normalized at the time of discharge from the ICU and laboratory parameters indicative of liver failure had also completely recovered
After a total of 13 days in intensive care, the patient could be transferred in a stable condition to a specialized neurological clinic for further targeted treatment
Conclusion
In this patient with septic shock and acute liver failure, the early initiation of CytoSorb therapy together with continuous renal replacement therapy resulted in a rapid and sustained stabilization of the hemodynamic, inflammatory, pulmonary and renal situation
CytoSorb is routinely used at the Klinikum Rüsselsheim for patients with septic shock requiring renal replacement therapy due to acute renal failure. In combination with acute liver failure, the intensive care physicians at the Klinikum see a clear clinical and technical advantage towards the use of a CytoSorb adsorber compared to alternative procedures
The change of the adsorber during ongoing therapy could be performed quickly and without complications. In combination with regional anticoagulation using citrate during renal replacement therapy, no laboratory or clinical disadvantages could be detected by using the CytoSorb adsorber.
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