Case of the Week 28
Literature Database
Use of CytoSorb in splenic abscessand septic shock due to intestinal ischemia following portal vein thrombosis and extensive small bowel resection
Dr. Klaus Kogelmann | Interdisciplinary Intensive Care Medicine, Emden Hospital, Germany
07/13/2022
New!Case of the week
Download documentDownload document
Summary
CoW 28/2022 – This case reports on a 37-year-old male patient with known type 1 diabetes mellitus, who was admitted to the hospital with nausea, multiple vomiting and abdominal pain.
Case presentation
The patient had already complained of nausea, vomiting, abdominal pain and multiple loose bowel movements about 10-12 days previously. After initial improvement after taking ibuprofen (1-2 times daily), the patient’s condition worsened again, leading to the current hospital admission
Initially, the patient presented with limited vigilance, tachycardia, tachypnoea, pale skin and cold sweats
On rectal digital examination pale blood was found
Additionally, sonography revealed dilated loops of the small intestine, which was clinically compatible with the diagnosis of peritonism
Consequently, there was an immediate indication for emergency surgery including median laparotomy, opening and draining of a splenic abscess found intraoperatively and application of a vacuum dressing to the open abdomen
Postoperatively, the patient was now in septic shock and transferred to the intensive care intubated and ventilated
Due to pronounced hemodynamic instability, a differentiated, protocol-based sepsis therapy (volume, catecholamines and calculated antibiotic therapy – with piperacillin/sulbactam as well as lung-protective ventilation) was started immediately
In addition, high-dose hydrocortisone administration (10 mg/h for 7 days) was initiated
On the following day and in the context of increasing intra-abdominal pressure and protracted septic shock, which was most likely due to the splenic abscess with consecutive portosplenomesenteric thrombosis and circulatory disturbances of the jejunum (mesenteric infarction), the patient underwent a re-operation and resection of the entire small intestine up to 10 cm from the oral and aboral ending, with creation of a jejunostoma and blind closure of the terminal ileum
Given a postoperative increase in catecholamine requirements (initial norepinephrine 0.22 µg/kg/min), infection markers (procalcitonin [PCT] 2 pg/ml, C-reactive protein [CRP] 145.9 mg/l), lactate levels (4.2 mmol/L), leukocytosis (42.5 thousand/µl) and anuria, combined continuous renal replacement therapy (CRRT) and adjunctive CytoSorb therapy were initiated with a CytoScore of 7 points
Behandlung
A total of 3 consecutive treatments with CytoSorb were performed over the following 3 days (each treatment for 24 hours)
CytoSorb was used in combination with CRRT (Multifiltrate, Fresenius Medical Care) run in continuous veno-venous hemodialylis (CVVHD) mode
Blood flow rate: 100 ml/min
Anticoagulation: Citrate
CytoSorb adsorber position: pre-hemofilter
Measurements
Hemodynamics and catecholamine requirements
Inflammatory parameters
Lactate
Results
Catecholamine therapy could already be discontinued after the 2nd treatment cycle
Treatment was further associated with a control of the hyperinflammatory response with clear reductions in inflammatory parameters (leukocytes 16.2/nl and PCT 0.47 pg/ml 24 h after the last treatment)
Lactate also returned to normal values (1.3 mmol/L) 24 h after the last treatment
Patient Follow-up
Discontinuation of dialysis and CytoSorb treatment on day 3
Invasive ventilation was also terminated after 3 days and the patient could be successfully extubated
Transfer from intensive care to the normal ward after a total of 7 days
Discharge from the hospital into his home environment after 21 days of total hospital stay
Currently the patient is permanently dependent on a daily parenteral fluid and nutrient supply. Thus, the patient appears to be a possible candidate for a small bowel transplant and has been referred to an appropriate centre
Conclusions
In this patient with septic shock, the combined treatment consisting of standard therapy, CytoSorb hemoadsorption and renal replacement therapy resulted in a marked stabilization in hemodynamics with rapid reduction of norepinephrine requirements as well as control of the hyperinflammatory situation
According to the authors, CytoSorb quickly and effectively helped to stabilize a critical condition
A CytoScore above 6 points represents a refractory shock state. The score may therefore help in the initiation of CytoSorb therapy
Treatment with CytoSorb was safe and feasible without technical problems.
