Case of the Week
Combined Application of CytoSorb and Sustained Low Efficiency Dialysis (SLED) in Critical Patients
Jose Lucas Daza1, Yaroslad De la Cruz1, Gerardo Gutierrez1, Hernan Sarzuri1, Nestor Guarnizo2, Alexander Ariza3, Leonardo Marin4 | 1Nephrology, University of Buenos Aires, Argentina, |2Intensive Care Unit, Tolima University, Colombia, | 3Hematology, University of Buenos Aires, Argentina, | 4Nephrology, University del Valle - Cali, Colombia | Annals of Case Reports 2022; 7(2):807
05/03/2022
New!Peer Reviewed Published DataReduction in catecholaminesSeptic ShockImprov. resp functionAnticoagulation HeparinCase of the weekCase reportCritical CareIHD / SLEDInflammatory parameters
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Summary
CoW 18/2022 – A 41- year-old male patient with no pathological history presented to the hospital with colic-type abdominal pain in the right hypochondrium associated with a history of fever over a few days.
Summary
In this case report a 41 yr old patient with refractory septic shock and acute kidney injury (AKIN III) secondary to pancreatitis requiring pancreatectomy, colectomy and ileostomy, was given sustained low efficiency dialysis (SLED) plus CytoSorb. Two consecutive SLED & CytoSorb sessions were performed for 12 hrs each with a Genius 90 machine and blood flow rates around 120 ml/min. Over the following 48 hours, norepinephrine was able to be reduced from 1.2 µg/kg/min to 0.3 µg/kg/min after the first session and 0 after the second session. There was also a notable improvement in ventilatory parameters (paO2/FiO2 ratio up from 120 to 230 after the first session and up even further to 290 after the second session. Unfortunately, the patient presented with various complications over the following days including a massive pulmonary thromboembolism on day 29 from which he died. The authors then discuss the SLED modality which combines the benefits of continuous renal replacement therapy (CRRT) and intermittent hemodialysis (IHD) and present some comparative studies in this regard. They conclude by stating that, to date, no dialysis therapy modality shows clear superiority over others in terms of survival and recovery of renal function. For clinical cases with multi-organ systemic involvement associated with acute renal dysfunction requiring dialysis therapy in the context of anuria, they propose the use of SLED modality daily, combined with CytoSorb, pre-filter.
Case presentation
An ultrasound showed a lithiasis and obstruction in the bile duct
Subsequently, an endoscopic retrograde cholangiopancreatography (ERCP) was performed
Over the next 48 hours, his abdominal pain continued accompanied by persistent fever
Blood sample analysis revealed leukocytosis and increased pancreatic enzymes
Additionally, the patient developed arterial hypotension resulting in the diagnosis of distributive shock secondary to severe pancreatitis and he was admitted to the intensive care unit (ICU)
Here, fever persisted while blood cultures showed growth of Gram-negative bacteria followed by the initiation of wide spectrum antibiotic therapy
Another 48 hours later the patient had developed multiple organ failure with signs of peritonitis
Subsequent contrast-enhanced CT diagnostics showed diffuse pancreatic necrosis and intestinal ischemia, and an operation was scheduled
Following combined pancreatectomy, colectomy and ileostomy the patient developed refractory septic shock, cytokine release syndrome and acute anuric kidney injury AKIN III requiring initiation of sustained low efficiency dialysis (SLED)
With the rationale to control the excessive inflammatory response, a CytoSorb hemoadsorber was additionally integrated into the SLED circuit
Treatment
Two CytoSorb hemoadsorption sessions were applied for 12 hours each
CytoSorb was used in combination with SLED (Genius 90, Fresenius Medical Care)
Blood flow rate: 120-125 ml/min
Anticoagulation: sodium heparin bolus 5000 (1st session) and 5500 (2nd session) units
CytoSorb adsorber position: pre-hemofilter
Measurements
Hemodynamics and dosages of vasoactive substances
Inflammatory response
Oxygenation/lung function
Metabolic status
Renal function
Results
Over the following 48 hours, norepinephrine could be reduced from 1.2 µg/kg/min to 0.3 µg/kg/min after the first session and could be completely stopped after the second session. Vasopressin could be already tapered out during the first treatment session
Combined SLED & CytoSorb therapy was further associated with a control of the hyperinflammatory response (leucocytes from 26,000/µl to 9300/µl, C-reactive protein from 145 to 21 mg/dl)
Additionally, there was a notable improvement in oxygenation/lung function (PaO2/FiO2 ratio up from 120 to 230 mmHg after the first session and up even further to 290 mmHg after the second session)
Treatment also resulted in a resolution of metabolic acidosis (pH from 7.19 to 7.39, lactate from 5.6 to 1.1 mmol/l, HCO3 from 13 to 24 mmol/l)
Also renal retention parameters could be reduced to normal levels throughout the combined SLED & CytoSorb treatment period
Patient Follow-up
Following cessation of therapy, the patient developed several infectious and non-infectious complications resulting in a prolonged stay in the ICU
Additionally, a tracheostomy was performed
Unfortunately, over time the patient went on to develop a massive pulmonary thromboembolism on day 29 from which he finally died
Conclusion
In this patient with refractory septic shock and acute kidney injury (AKIN III) secondary to pancreatitis requiring pancreatectomy, colectomy and ileostomy, combined SLED & CytoSorb treatment resulted in hemodynamic stabilization, a control of the hyperinflammatory response, improvement in ventilatory parameters as well as resolution of metabolic acidosis and improvement in renal function
For clinical cases with multi-organ systemic involvement associated with acute renal dysfunction requiring dialysis therapy in the context of anuria, the authors propose the use of SLED modality daily, combined with a pre-filter set-up of CytoSorb.
