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Use of Cytosorb in persistent hyperinflammation associated with lung infiltrates and pleural effusion
Maria Ting Ting SINN | Intensive Care Unit, Tseung Kwan O Hospital, Tseung Kwan O, Hong Kong, SAR
06/01/2022
New!Other indicationsReduction in catecholaminesSafetyShock reversalImprov. resp functionAnticoagulation CitrateCase of the weekCase reportCritical CareCRRT post filterInflammatory parameters
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Summary
CoW 22/2022 – This case reports on a 63-year-old male, who was admitted to the hospital with a 2-month history of exertional shortness of breath, a periodic cough with purulent sputum and right pleuritic chest pain.
Case presentation
The patient was a chronic smoker and drinker. Past medical history included hypertension and hyperlipidemia
He had no documented fever and was TOCC-negative (travel, occupation, contact, and cluster history) i.e. had no risk of COVID-19 infection
While still in the accident and emergency department, the patient developed signs of severe hypotension with a drop in blood pressure to 79/58 mmHg requiring initiation of a dopamine infusion
Moreover, the patient was put on oxygen supplementation (through nasal cannula, 4 liters) to maintainarterial oxygen saturation (SpO2) of 94%
Subsequent chest X-ray revealed lung infiltrates and pleural effusion in the right lung
Blood test results on admission showed a white cell count of 42,900/µl, hyperlactatemia (3.51 mmol/l) as well as increased retention parameters
Initiation of empirical anti-infective therapy with piperacillin/tazobactam and doxycycline
The same day the patient was then transferred to intensive care unit (ICU) for close monitoring
On admission to the ICU, oxygen supplementation had to be increased to 6 liters to maintain an SpO2 of 94 % with a respiratory rate of 30/min
Due to progressive hemodynamic instability, norepinephrine administration had to be commenced at a dose of 1.6 mg/hour
Pigtail catheter insertion for drainage of the right pleural effusion
Over the next 2 days, the patient showed desaturation events, resulting in the start of high-flow oxygen therapy
Another chest X-ray revealed a decrease in the right pleural effusion, however a simultaneous increase in left upper zone infiltrates, so that the patient had to be electively intubated later that day
His condition continued to deteriorate, accompanied by progressive development of anuric renal failure one day later
Meanwhile, his hemodynamic instability had drastically worsened with increasing norepinephrine requirements up to 4.8 mg/hour. At that time the FiO2 was 1.0
The next day, continuous renal replacement (CRRT) was initiated and run with an oXiris hemofilter (two sessions) over the next three days, resulting in only a very minor improvement in hemodynamics (norepinephrine still 4.5 mg/hour) and oxygenation (FiO28)
In addition, two more mini-chest drains were inserted for the pleural effusion and a subsequent chest X-ray showed a decrease in right pleural effusion, but an increase in pulmonal infiltrates
Due to the persistent hyperinflammatory state, empirical vancomycin and hydrocortisone therapy was prescribed and sedation was intensified
With the rationale to control the hyperinflammation, CRRT was re-initiated and a CytoSorb hemoadsorber was additionally integrated into the circuit
Treatment
Two CytoSorb treatment sessions were performed with a pause interval between both sessions of 3 days (1st session for 22 hours, 2nd session for 10 hours). Importantly, both CytoSorb therapy session had to be terminated prematurely due to filter clotting issues – which, however, was verified as not related to the adsorber
CytoSorb was used in conjunction with CRRT run in CVVHD mode
Blood flow rate: 100-120 ml/min
Anticoagulation: regional citrate
CytoSorb adsorber position in the system: post-hemofilter
Measurements
Hemodynamics and catecholamine demand
Inflammatory status
Oxygenation
Results
After the start of CytoSorb therapy, the patient’s hemodynamic condition improved significantly with a decrease in norepinephrine requirements down to 2.4 mg/h. Two days after the cessation of the first adsorber, norepinephrine demand had further decreased to 0.8 mg/h while epinephrine had been weaned off from an initial dose of 0.8 mg/h two days previously. The second treatment cycle again resulted in further hemodynamic stabilization
C-reactive protein (CRP) decreased from 292 mg/L to 199 mg/L during the first treatment and to 88.5 mg/L two days later. At the same time, leukocytes also decreased to 27,000/µl. During the second treatment, CRP levels decreased further to 24.3 mg/L and leukocytes to 22,800/µl
Under combined CRRT/CytoSorb therapy, the oxygen demand also improved culminative with an FiO2of only 0.5 two days after termination of the first therapy session. During the second therapy session, FiO2 could be kept stable
Patient Follow-Up
Between the two treatment sessions (i.e. the pause interval), the patient again developed hypotension and type II (hypercapnic) respiratory failure. Muscle relaxant cisatracurium was prescribed for ventilator-patient desynchrony and a stress dose of hydrocortisone was given for potential relative adrenal insufficiency, while chest X-ray showed a decrease in the right pleural effusion and a decrease in infiltrates
Vancomycin and hydrocortisone therapy were gradually weaned while there was no more sedation needed after the end of CytoSorb therapy
Also doxycycline treatment was stopped one day after the second treatment cycle due to consistently negative microbiological findings
CRRT was discontinued after 10 days including three CRRT sessions with a total ultrafiltration volume of ~10 liters
However, the patient’s clinical condition gradually deteriorated over time and he died a few months after the initial event
Conclusion
In this case of a patient with persistent hyperinflammation associated with lung infiltrates and pleural effusion, combined therapy consisting of standard of care, CRRT and CytoSorb hemoadsorption was associated with hemodynamic stabilization, control of the hyperinflammatory response and an improvement in oxygenation
According to the authors, the use of CytoSorb successfully managed the hyperinflammation, leading to an improved clinical condition and shock reversal in this patient
CytoSorb was safe and easy to use.
