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Use of CytoSorb in a patient with hyperinflammatory syndrome following extensive 3-vessel coronary surgery
Dr. Angelika Oblin | Department of Cardiology, Cardiological Intensive Care Unit, Floridsdorf Hospital, Vienna, Austria
02/01/2023
New!Post-OpReduction in catecholaminesSafetyImprov. fluid balanceAortic SurgeryAnticoagulation CitrateCardiac surgeryCase of the Week / MonthCase reportCritical CareCRRT pre filterInflammatory parameters
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Summary
CoM 02/2023 – This case reports on a 60-year-old male patient who presented to hospital for elective aortocoronary bypass surgery.
Case presentation
His extensive cardiac medical history included chronic ischemic (3-vessel) heart disease, post-aortocoronary bypass, post-endovascular aortic repair for abdominal aortic aneurysm, peripheral arterial occlusive disease with serial high-grade stenosis of the left femoral artery, cerebral arterial occlusive disease, left ventricular hypertrophy, arterial hypertension, post-nephrectomy left, chronic nicotine abuse and hyperlipidemia
The operation was initially performed without complications and included a triple LIMA and LAD, RIMA and CX and vein [brachial left] and RCA. Repeated administration of low doses of norepinephrine was required for hemodynamic stabilization. The intraoperative cumulative fluid balance was +7400 ml (8800 in, 1400 out)
On postoperative transfer to the intensive care unit (ICU), the patient was deeply sedated (Richmond Agitation Sedation Scale [RASS] -5) and hemodynamically stable with still only low catecholamine requirements
During the night, however, catecholamine requirement increased (norepinephrine >1 µg/kg/min, additional administration of vasopressin) with simultaneously increasing lactate values (3.7 mmol/l). Hydrocortisone therapy was also started
Continuous renal replacement therapy (CRRT) was initiated 18 hours after postoperative transfer to the ICU because of progressively increasing retention parameters and to compensate for the metabolic acidosis (pH 7.3)
Given the simultaneously increasing inflammatory parameters (leukocytes 13.6×10³/µl, C-reactive protein [CRP] 37.45 mg/dl, interleukin-6 [IL-6] 16,586 pg/ml) in the context of a hyperinflammatory post-cardiopulmonary bypass syndrome and with the aim to hemodynamically stabilize the patient, a CytoSorb hemoadsorber was additionally integrated into the CRRT circuit
Treatment
A total of 10 treatments with CytoSorb were performed over a period of 96 hours (change of adsorber every 8 hours on day 1, and every 12 hours thereafter)
CytoSorb was used in combination with CRRT (Fresenius, Mulitfiltrate CiCa) run in continuous veno-venous hemodialysis (CVVHD) mode
Blood flow rate: 100 ml/min
Anticoagulation: Citrate
Position of the CytoSorb adsorber: pre-hemofilter
Measurements
Hemodynamics and norepinephrine requirements
Inflammatory parameters (leukocytes, CRP, IL-6)
Lactate
Fluid balance
Renal function
Results
Initially, blood pressure values fluctuated and he exhibited intermittent tachycardia as well as slightly increasing norepinephrine values (as part of the attempt to reduce volume). Catecholamine therapy with norepinephrine and vasopressin could then be significantly reduced from the second day onwards while vasopressin was discontinued after only 48 hours. Norepinephrine dosage was 0.43 µg/kg/min (under generous volume administration) on postoperative day 3. On the 4th postoperative day, only a low maintenance dose of norepinephrine (0.1 µg/kg/min) was required, which could be discontinued over the following days
In addition, the hyperinflammatory situation was well controlled during treatment, as evidenced by a reduction in IL-6 plasma levels to 360 pg/ml within 48 hours and further decreases thereafter. Leukocytes and CRP initially remained at an elevated level, but progressively decreased over time
Lactate values also reached normal ranges on the 4th postoperative day
After stabilization of his hemodynamic condition and a cumulative positive fluid balance of 18 litres, continuous negative fluid balancing could be achieved from day 3 onwards
Furthermore, the combined treatment with CRRT and CytoSorb was associated with a significant improvement in renal function with good diuresis from day 5 onwards
Patient Follow-Up
Successful extubation on postoperative day 5, initially without problems. However, over time he became tachypneic and stressed. This was followed by the start of a non-invasive high-flow ventilation regime
Removal of pleural drains on postoperative day 6
Also, discontinuation of renal replacement therapy after 2 therapy cycles 6 days after surgery
Transfer of the patient with non-invasive O2 application to the general ward after a total of 12 days of intensive care
Conclusions
In this patient with profound cardiac history with hyperinflammatory syndrome secondary to extensive 3-vessel coronary surgery, the postoperative combined use of CRRT and CytoSorb resulted in hemodynamic stabilization, control of hyperinflammation, resolution of metabolic acidosis, improvement in renal function and the possibility of a negative fluid balance
According to the authors, CytoSorb therapy helped to rapidly reduce the inflammatory parameters and thus stabilize the hyperinflammatory situation in this complex case
In this challenging setting, application of CytoSorb in combination with CRRT was safe and easy.
