Case of the Week
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Use of CytoSorb as a stand-alone therapy in a patient suffering from sepsis and multiple organ dysfunction
Dr. Sachin Gupta | Narayana Super Speciality Hospital, Gurgaon, India
05/11/2022
New!Reduction in catecholaminesSafetySeptic ShockStandalone (HP)Improv. resp functionAnticoagulation HeparinARDSCase of the weekCase reportCritical CareInflammatory parametersMOF
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Summary
CoW 19/2022 – This case reports on a 67-year-old male patient, who was admitted to hospital suffering from a severe immunological response following his 2nd COVID-19 vaccination.
Case presentation
After admission, the patient’s vital signs were recorded revealing a reduced blood pressure of 96/52 mmHg as well as increased respiratory rate (30/min), and heart rate (148/min)
A reverse transcription–polymerase chain reaction (RT-PCR) analysis for a current SARS-CoV-2 infection proved negative
The sequential organ failure assessment (SOFA) and acute physiology and chronic health evaluation II (APACHE II) scores on admission were 17 and 29, respectively
He further exhibited severe metabolic acidosis as evidenced by an arterial pH of 7.04 and a lactate plasma concentration of 8 mmol/L
Additionally, oxygenation/lung function were already severely compromised (PaO2/FiO2 ratio of 78 mmHg) suggesting manifest acute respiratory distress syndrome (ARDS)
Consequently, the patient was immediately transferred to the intensive care unit (ICU)
The patient was placed on vasopressor support (baseline norepinephrine at 0.4 µg/kg/min and low dose vasopressin)
Furthermore, there were signs of renal dysfunction as serum creatinine had increased to 2.48 mg/dl
Elevated inflammatory markers such as interleukin – IL-6 (>5500pg/ml) and C-reactive protein (CRP, 212 mg/L) indicated severe hyperinflammation
Bilirubin levels were slightly increased (2.1 mg/dL) pointing towards compromised hepatic function most probably in the context of the ongoing hyperinflammatory response
Establishment of protocol-based volume therapy and administration of antibiotic therapy including meropenem, teicoplanin and colistin was instituted
Given his septic state with multiple organ failure unresponsive to standard therapy, the decision was made to initiate CytoSorb hemoadsorption therapy
Measurements
Hemodynamics and vasopressor requirements
Metabolic status
Inflammatory parameters
Respiratory parameters
Overall clinical condition and organ function
Treatment
Two consecutive treatments with CytoSorb were performed for 32 hours (both treatments for 16 hours each)
CytoSorb therapy was run as a stand-alone treatment
Anticoagulation: Heparin (200 U/h for 12 hours)
Results
After the first CytoSorb session, hemodynamics improved and norepinephrine dosage could be reduced from 0.4 µg/kg/min to 0.12 µg/kg/min after the second therapy session, while MAP was even rising. The patient’s elevated heart rate decreased from 148/min to 96/min
Treatment was accompanied by a normalization of arterial pH from 7.04 to 7.38 and a reduction in serum lactate levels from 6.8 mmol/L to 2.7mmol/L after the second CytoSorb treatment
After the two CytoSorb treatment sessions, there was a marked reduction in IL-6 levels from >5500pg/ml to 216 pg/ml while CRP levels had dropped from 212 mg/l to 178mg/l, indicating a clear control of the hyperinflammatory situation post treatment
Following the first CytoSorb treatment session, there was an improvement in respiratory parameters, as indicated by an increase in PaO2/FiO2 ratio from 78 to 120 mmHg followed by a further increase to 148 mmHg with a concomitant decrease in the respiratory rate to 24/min
The patient’s organ dysfunction and clinical condition also improved as both the APACHE ll and SOFA scores decreased from 29 to 14, and 17 to 9, respectively, during the course of treatment
Patient Follow-Up
The patient was completely weaned off vasopressors over the following days
He was discharged from the ICU to the normal ward after 9 days in a stable condition and was finally discharged from the hospital 16 days post admission
Conclusions
In this patient with sepsis and multiple organ dysfunction syndrome, treatment with CytoSorb in stand-alone mode was associated with stabilization in hemodynamics, resolution of metabolic acidosis, control of the hyperinflammatory response, as well as an improvement in lung function and his overall clinical condition
No complications were observed while using CytoSorb as stand-alone therapy and thetreatment was well tolerated.
