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CytoSorb as adjuvant therapy in refractory ARDS and ECMO support in COVID-19
Dr. med. Martin Schmölz, Dr. med. T. Gröbl, Dr. med. A. Schirner, Dr. med. L. Wagner | Department for Anesthesiology, Intensive Care and Emergency Medicine, Immenstadt Clinic - Klinikverbund Allgäu gGmbH, Germany
06/29/2022
New!Reduction in catecholaminesSafetyViral infectionImprov. resp functionAnticoagulation OthersARDSCase of the weekCase reportCOVID-19Critical CareECMO (VV or VA)
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Summary
CoW 26/2022 – This case reports on a 55-year-old male patient who was transferred from an external hospital to Immenstadt hospital due to progressive respiratory deterioration with confirmed COVID-19 pneumonia.
Case presentation
Prior to this, he was admitted to a peripheral hospital following a deterioration in his general condition including fever. At this hospital he initially received oxygen therapy via nasal cannula and dexamethasone therapy for a total of 16 days. However, respiratory wise he continued to deteriorate with subsequent transfer to the intensive care unit (ICU). Hence, high-flow oxygen/non-invasive ventilation therapy was started, but there was a continuous clinical deterioration with O2 requirements of 90-100% via non-invasive ventilation. Finally, endotracheal intubation was performed and the patient was subsequently transferred to Immenstadt hospital
His vaccination status was as follows: vaccinated 3x COVID-19 (2x Biontech, 1x Moderna), but no titer response to the first two vaccinations, but only to the 3rd vaccination
The patient’s medical history further included follicular lymphoma, post-radiotherapy, current chemotherapy, nicotine abuse, hypercholesterolaemia and obesity
On admission to Immenstadt hospital, the patient was intubated with the following settings: paO2 59 mmHg, paCO2 46 mmHg, FiO2 of 1.0, positive end-expiratory pressure (PEEP) 14 cmH2O; his blood pressure was 89/52 mmHg under ongoing norepinephrine therapy (2.2 mg/h)
Due to the highly critical acute situation of refractory acute respiratory distress syndrome (ARDS) and the rapid dynamics of deterioration, veno-venous (vv) extracorporeal membrane oxygenation (ECMO) therapy was implanted immediately after admission. Given a difficult puncture attempt of the right internal jugular vein and status after port implantation in the right subclavian vein, a bifemoral insertion technique was chosen, with the reflow cannula via the femoral vein on the left side
After initiation of the extracorporeal circuit, lung-protective ventilation could be performed. The patient was then prone-positioned several times. Subsequently, FiO2 could be reduced to 0.5. PaO2/FiO2 at that time was 133 mmHg
To measure the transpulmonary pressure, a PESO catheter was placed and the PEEP was adjusted according to the measured values which varied considerably with positioning
Computed tomography showed severe COVID changes, but also pneumonic consolidations. Calculated antibiotic therapy was started with meropenem; in addition, voriconazole was administered in a calculated manner due to radiological suspicion of COVID-19-associated pulmonary aspergillosis. This was later confirmed in the bronchoalveolar lavage. Over time, the patient developed recurrent severe infections, partly with multi-resistant pathogens and also with herpes simplex Virus
Due to a pronounced hyperinflammatory state with markedly elevated plasma concentrations of C-reactive protein (CRP 347 mg/l), a CytoSorb hemoadsorber was additionally integrated into the vvECMO circuit with the aim of controlling the hyperinflammatory situation
Treatment
One treatment with CytoSorb was performed for a total treatment duration of 24 hours
The CytoSorb adsorber was directly integrated into the vvECMO circuit as a bypass
Anticoagulation was performed according to internal standard with Argatroban controlled via PTT and ECA-test
Measurements
Hemodynamics and norepinephrine requirements
Inflammatory parameters
Results
The catecholamine dose (norepinephrine 2.1 mg/h) initially required to maintain an adequate mean arterial pressure could be significantly reduced under adsorber therapy and fluid substitution. After 24 h, norepinephrine requirement was 0.5 mg/h with subsequent further decreasing values
A decrease in the elevated CRP levels (347 mg/l) was not observed during the treatment period
Patient Follow-Up
Over time, continuous renal replacement therapy (CRRT) using continuous veno-venous hemodialysis (CVVHD) was indicated due to the development of acute renal failure
Initially, the patient had a protracted course with septic multi-organ failure and a difficult sedation regime (inhalative sedation)
He also suffered from diffuse hemorrhages and microthrombi in his extremities with severe necrosis of all fingers of the left hand as a result of severe disseminated intravascular coagulation
Repeated initiation of broad-spectrum antibiotic therapy with evidence of partly multi-resistant pathogens in the bronchial secretions as well as in the bloodstream
Weaning was difficult and prolonged in the context of the underlying disease
A CT scan performed because of ongoing drowsiness that showed acute subdural bilateral hematomas with a slight midline shift. Anticoagulation in the context of the extracorporeal ECMO circuit was immediately discontinued and vvECMO therapy had to be stopped
Initially, pulmonary stabilization was only partially successful without ECMO and ventilation pressures outside the lung-protective range had to be tolerated for a short time
After infection control though, there was a steady improvement in compliance with consecutive pulmonary stabilization, and the patient could be switched to discontinuous weaning
Ventilation intervals via the nasal cannula with intermittent relief could be steadily increased
After 8 weeks of intensive therapy, the patient could be decannulated with good vigilance, respiratory mechanics and good pulmonary gas exchange
Unfortunately, the patient was still COVID-19 positive after several months. A mutation analysis revealed the virus type to be Omicron (BA.2-like). Antiviral triple therapy with Remdesivir, Paxlovir and Sotrovimab was therefore initiated
Early neurological rehabilitation has been organised and is expected to start soon
Conclusions
In this patient with COVID-19, refractory ARDS and vvECMO support, the combination of extracorporeal oxygenation, adsorber therapy and volume/catecholamine therapy resulted in clear clinical stabilization both in regards to his hemodynamic and respiratory parameters during the highly critical phase
A hyperinflammatory state could be controlled initially, but severe septic episodes occurred repeatedly later on
Treatment with CytoSorb was safe and use of the adsorber together with vvECMO therapy was feasible without technical problems.
