Case of the Week
Use of CytoSorb in a case of Salmonella typhi–induced gastroenteritis with sepsis associated acute kidney injury
Dr. Abdul Samad Ansari & Dr Mayur Shah | Critical Care Unit, Nanavati Max Super Speciality Hospital, Mumbai, India
04/20/2022
New!Reduction in catecholaminesSafetySeptic ShockAnticoagulation CitrateCase of the weekCase reportCritical CareCRRT post filterInflammatory parameters
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Summary
CoW 16/2022 – This case reports on a 54-year-old female patient with a known medical history of diabetes mellitus, hypertension andacute gastroenteritis, who was admitted to the hospital with tachycardia (145/min), tachypnea (40/min), a SpO2 of 70% on room air, hypovolemia and drowsiness.
Case presentation
Prior to admission, the patient had approximately 15 episodes of diarrhea and vomiting over the previous 2 days, fever since the day before admission with oliguria, increasing breathlessness and giddiness for the previous 12 hours
Laboratory examination revealed leukocytosis (18,100/µl) as well as elevated inflammatory parameters (C-Reactive Protein -CRP 230 mg/dL, procalcitonin – PCT elevated)
She further exhibited signs of severe lactic acidosis with a plasma lactate concentration of 8.8 mmol/L as well as increased serum creatinine levels (2.68 mg/dL) indicating impaired renal function
Initial Sequential Organ Failure Assessment (SOFA) score was 12 and APACHE II score was 25
The 2D echo showed generalized left venticular (LV) hypokinesia with an ejection fraction (EF) of 25%
Early empiric antibiotic therapy with meropenem, doxycycline and metronidazole were initiated while awaiting findings from microbiological examinations
These finally confirmed the presence of Enterococcus fecalis in her stool culture as well as Salmonella enteritidis in her blood culture
Meanwhile, aggressive fluid resuscitation was commenced (7 liters over the first 24 hours) and due to progressive hemodynamic instability, administration of multiple vasoactive substances (epinephrine, norepinephrine, and vasopressin) which had to be started and increased up to extremely high dosages
The patient progressed to septic shock with severe lactic acidosis and anuric renal failure
Due to a progressive deterioration also of the pulmonary situation, she was intubated and put on mechanical ventilation, and continuous renal replacement therapy (CRRT) was initiated along with CytoSorb within 6 hours of admission
Treatment
Two consecutive CytoSorb treatments were performed for a total treatment duration of 12 hours (each session for 6 hours)
CytoSorb was used in conjunction with standard of care and CRRT (Prismaflex) run in continuous veno-venous hemodiafiltration (CVVHDF) mode
Blood flow rate: 150 ml/min
Effluent dose: 25ml/kg/hour
Anticoagulation: Regional Citrate Anticoagulation (RCA)
CytoSorb adsorber position: post dialyzer
Measurements
Hemodynamics and vasopressor requirements
Inflammatory parameters (CRP, leucocytes)
Lactate levels
SOFA score
Results
During and after CytoSorb treatment, hemodynamics improved with a more than 50% reduction in vasopressor requirements within 18 hours of CytoSorb treatment. Vasopressors could be completely tapered off 24 hours following the last CytoSorb treatment
Lactate levels initially increased during the first 24 hours from 8.8 to 14 mmol/L followed by a progressive decrease reaching normal values by the end of day 4
CRP and PCT progressively declined and reached normal values by day 5
Treatment was also associated with a reduction in SOFA score from 12 to 7 points in 24 hours
Patient Follow-up
CRRT was converted to sustained low-efficiency dialysis (SLED) after 10 days. Her renal function was completely restored after one and a half months
The patient was transferred from the ICU to the normal ward after 1 month and was then discharged home after a hospital stay of 2 months having made a complete recovery
Conclusion
In this patient with salmonella typhi–induced gastroenteritis resulting in septic shock and pre-renal acute kidney injury, the use of combined CRRT and CytoSorb treatment led to an improvement in hemodynamics with a concomitant decrease in vasopressor requirements, resolution of lactic acidosis and an improvement in overall organ function
The early use of CytoSorb and CRRT, along with standard of care, appears to be a promising therapy for the treatment of septic shock while helping to restore organ function and prevent sequential organ failure
CytoSorb was safe and easy to use in conjunction with CRRT.
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