Case of the Week
Use of CytoSorb in a patient with severe polytrauma and ARDS following a motorbike accident
Dr. med. Christoph Busjahn Clinic and Polyclinic for Anesthesiology and Intensive Care, Rostock University Medical Centre, Rostock, Germany
01/04/2023
MyoglobinNew!Reduction in catecholaminesSafetyTraumaImprov. fluid balanceAnticoagulation HeparinARDSCase of the Week / MonthCase reportCritical CareECMO-VVInflammatory parameters
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Summary
CoM 01/2023 – This case reports on a 20-year-old patient with no relevant medical history, who was admitted to the emergency room with severe polytrauma after hitting a stationary car whilst on his motorbike.
Case presentation
In the shock room, while he was still breathing spontaneously, rapid pulmonary deterioration occurred so that emergency intubation was performed immediately
The main injuries diagnosed in the course of the initial assessment included: avulsion of the left main bronchus with bilateral hemato-pneumothorax, extensive pulmonary contusions with hemorrhages, cervical soft tissue emphysema and soft tissue hematoma, various rib fractures, right clavicle fracture, left scapula fracture, fracture of the manubrium sterni, left tripod fracture, dislocated multi-fragmentary fractures of the left maxillary sinus walls, right petrous bone longitudinal fracture, fractures of the left proc. transversi, non-displaced fracture of the proc. spinosus, multi-fragmentary fractures of the left pelvic scapula, left distal ulnar shaft fracture, suspected rupture of the anterior cruciate ligament and medial collateral ligament of the left knee joint, contusio cordis (contusion of the heart in the context of the thoracic trauma), splenic laceration (grade II), a craniocerebral trauma as well as a subcapsularly dorsal liver contusion/hematoma in the right liver lobe and also diffuse intraparenchymal hematoma in the right liver lobe
Subsequently, veno-venous extracorporeal membrane oxygenation (vv-ECMO) therapy was commenced due to his actively bleeding bronchus injury and the patient was transferred to the perioperative intensive care unit (ICU) intubated and ventilated in a controlled ventilation mode, already requiring high catecholamines (0.6 µg/kg/min)
The bronchus injury was treated with a thoracotomy with resection of the left upper lobe by colleagues from the thoracic surgical team
Diagnostic laparoscopy and gastroscopy were performed in the same time without further therapeutic consequences
In addition, mass transfusions were necessary in the context of his hemorrhagic shock with anemia (a total of 19 red cell concentrates, 19 units of fresh frozen plasma, 9 platelet concentrates)
Already intraoperatively, increased lactate levels were noted. Postoperatively, the patient then exhibited increased volume and catecholamine requirements with ongoing increases in lactate levels
Due to pronounced acute respiratory distress syndrome (ARDS), proning therapy was required and maintained for 4 days
After postoperative transfer to the ICU, CytoSorb therapy was started to control the hyperinflammatory situation, to achieve hemodynamic stabilization and to potentially avoid pulmonary hyperhydration and edema through reduced volume requirements
Treatment
Consecutive use of 2 CytoSorb adsorbers over a period of 41 hours (1st adsorber 15 hours, 2nd adsorber 26 hours)
Integration of the adsorber as bypass into the vv-ECMO circuit (Xenios console, Fesenius Medical Care) via the ECMO connections offered by CytoSorbents
Anticoagulation: initially without, then in the second treatment 200 IU/h heparin, with a target pTT of 40 – 45 sec
Measurements
Hemodynamics and catecholamine requirements
Inflammatory parameters
Metabolic parameters
Fluid balance
Myoglobin
Results
Under combined CytoSorb and vv-ECMO therapy, catecholamine requirements could be clearly reduced. Within 24 hours, norepinephrine demand was lowered to 0.09 µg/kg/min and could be stopped already on the first post op day
Treatment also led to a control of the hyperinflammatory situation as evidenced by a rapid reduction in interleukin-6 plasma levels and a normalization in leukocyte levels after the start of the hemoadsorption therapy
Already 5 hours after initiation of CytoSorb therapy, serum lactate had decreased from 9.8 to 4.8 mmol/l. Levels trended downwards over time reaching normal values 26 hours after the start of Cytosorb therapy
In parallel, the pH value normalized already during the first CytoSorb treatment
In addition, total fluid balance for the first 24 hours was only 1.5 litres and 2.6 litres for the first 48 hours. On day 3, this increased again by 2.3 litres. Afterwards, a negative fluid balance could be achieved throughout
Furthermore, therapy was associated with a rapid and sustained reduction in myoglobin and creatine kinase plasma levels
Patient Follow-Up
Bronchoscopies were repeatedly required due to viscous secretions and diffuse bleeding tendencies. HSV-1 was detected in the tracheal secretions, so that anti-viral therapy with aciclovir was started
Due to wide-complex tachycardia following contusio cordis, continuous amiodarone therapy was started, which was terminated after he converted back to sinus rhythm
As the duration of ventilation was expected to be long, a dilatative tracheotomy was performed on day 5 in the ICU. During the subsequent weaning period, the patient could tolerate spontaneous breathing trials and was able to breath adequately with stable gas exchange on Continuous Positive Airway Pressure (CPAP)
With sufficient improvement of pulmonary gas exchange and an increasing bleeding tendency in the context of an acquired von Willebrand syndrome, vv-ECMO therapy was discontinued after a total of 8 days
The last tracheal cannula change was performed on day 10 after admission to the ICU
Surgical treatment of the ulna fracture was performed by the trauma surgery team one week later
Given his pronounced stress reaction and agitation, sedation was extended until the patient could finally be weaned
At the time of transfer, the patient was awake, fully oriented, normotensive, catecholamine-free and breathing 3 x 2 hours a days using a heat and moisture exchanger
Conclusions
In this patient with severe polytrauma, hemorrhagic shock, traumatic brain injury and ARDS, the use of CytoSorb in combination with other therapeutic measures was associated with hemodynamic stabilization, control of the hyperinflammatory response, resolution of metabolic acidosis and reduction in myoglobin and creatine kinase levels
According to the authors, CytoSorb was helpful in this particular case for rapid control of the hyperinflammation in the setting of trauma and for achieving hemodynamic stability without massive volume overload. Contrary to all expectations, the use of CytoSorb prevented a significant positive fluid balance and thus an additional burden, especially to the lungs
The use of CytoSorb in combination with vv-ECMO proved to be safe and simple.
