Case of the Month
Use of CytoSorb in a patient with urosepsis and septic shock
Dr. Zsolt Rausch Department for Anesthesia, Surgical Intensive Care Medicine, Emergency Medicine and Pain Therapy, SLK Clinics Heilbronn, Heilbronn, Germany
03/01/2023
New!Reduction in catecholaminesSafetySeptic ShockAnticoagulation CitrateCase of the Week / MonthCase reportCRRT pre filterInflammatory parameters
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Summary
CoM 03/2023 – This case reports on a 56-year-old female patient who was admitted to hospital by ambulance with fever (up to 42°C) that had been persisting for 4 days, lower abdominal pain and progressive deterioration of her general condition.
Case presentation
Pre-existing medical conditions included morbid obesity (body mass index 46), arterial hypertension and chronic back pain
On admission, her vital signs were as follows: blood pressure 90/70 mmHg, tachycardia up to 180/min, SpO291%, respiratory rate 28/min and a Glasgow Coma Scale (GCS) score of 7
While still in the shock room, a FAST sonography, blood gas analysis and a CT from head to abdomen were performed. In addition, the patient was intubated and ventilated, and an arterial line inserted
The CT showed a grade II renal obstruction with an inflamed imbibed ureter on the right side as the only pathological findings
With the working diagnosis of urosepsis and septic shock, urine status and blood cultures were taken
Following admission to the intensive care unit (ICU), the patient was analgosedated (propofol, sufentanil), tachycardic up to 110/min with high catecholamine requirements
Advanced hemodynamic PiCCO monitoring was established. Septic shock was treated according to guidelines including volume resuscitation, catecholamine administration and initiation of empiric anti-infective therapy with piperacillin/tazobactam (for 5 days). After the detection of Klebsiella bacteria in blood cultures, urine and tracheal secretions, antibiotic therapy was changed to cefotaxime in accordance with the antibiogram
Over time, the patient’s right leg and left arm became cold following increasing doses of catecholamines and vasopressin (norepinephrine 0.67 µg/kg/min, argipressin 2.1 IU), accompanied by livid marbling of her toes and fingers. Consequently, administration of argipressin was stopped
Initially, urine was sterile and the focus of the infection not clear. However, a cerebrospinal fluid (CSF) puncture was performed to exclude meningitis in the presence of neck stiffness
Later that day, ultrasound-guided Shaldon catheter insertion was performed into the left internal jugular vein without any problems. Given the sepsis-associated hyperinflammatory picture and in order to stabilize the hemodynamic situation, renal replacement therapy in combination with CytoSorb hemoadsorption was started. At that time, the patient was anuric despite massive volume substitution
During the night of the second day, spasticity and a drop in blood pressure to 30 mmHg occurred during repositioning, most likely due to a leakage of the catecholamine line. After administration of epinephrine, she developed ventricular fibrillation, followed by 1x defibrillation and brief period of cardiopulmonary resuscitation (30 s) and return of spontaneous circulation. After subsequent administration of amiodarone 300 mg i.v., sinus rhythm was restored.
Treatment
CytoSorb treatment was started 14 hours after hospital admission and a total of 3 consecutive treatments with CytoSorb were performed over a period of 54 hours (change of the 1st adsorber after 12 hours, the 2nd and 3rdtreatment were performed for 27 and 18 hours, respectively)
CytoSorb was used in combination with CRRT (Fresenius, Mulitfiltrate CiCa) run in continuous veno-venous hemodialysis (CVVHD) mode
Blood flow rate: 170 ml/min, with a calculated blood purification volume of 6.12 L/kgBW*
Anticoagulation: citrate
CytoSorb adsorber position: pre-hemofilter
Measurements
Hemodynamics and need for vasoactive substances
Inflammatory parameters (interleukin 6, C-reactive protein, procalcitonin, leukocytes)
Lactate
Fluid balance
Renal function
Results
Following initially stable catecholamine requirements, vasoactive therapy with norepinephrine and vasopressin could be significantly reduced on the second day (from 0.67 µg/kg/min to 0.3 µg/kg/min) and both were completely discontinued on the fourth day. At the end of CytoSorb treatment (after 54 hours, on the third day), norepinephrine dosage was 0.05 µg/kg/min. Due to a recurring septic event (bilateral pneumonia), catecholamine requirements had to be increased again for a short time, but could be completely discontinued after 24 hours
The hyperinflammatory situation could also be well controlled during the use of CytoSorb therapy, as evidenced by a reduction in interleukin 6 levels from 344 to 66 pg/ml within 32 hours, with subsequently decreasing values thereafter. Plasma concentrations of procalcitonin and C-reactive protein also decreased significantly during and after hemoadsorption therapy. Leukocytes initially remained at normal levels during the course of CytoSorb therapy, rose progressively after the end, before spontaneously turning back to normal values in the following 2 weeks under appropriate therapy
Lactate levels significantly decreased under volume resuscitation and CytoSorb therapy and were back within the normal range (4.6 vs 1.05 mmol/L) at cessation of hemoadsorption therapy after 54 hours
After stabilization of the hemodynamic situation and a cumulative positive fluid balance of 30 litres, consistent negative balancing could be achieved from day 6 onwards
Furthermore, combined treatment with CRRT and CytoSorb was associated with a significant improvement in renal function with good diuresis as of day 4
Patient Follow-Up
Tracheotomy was performed 12 days after admission given the ongoing need for invasive ventilation and difficult weaning (morbid obesity, bilateral pneumonia and massive positive fluid balance)
The patient was successfully weaned off ventilation and decannulation was performed 21 days after her initial admission
Sonography confirmed that the right kidney was no longer congested and according to the urological consultation, urological intervention was not necessary at this time
The patient could be transferred to the normal ward after 24 days of intensive care in a good general clinical condition, awake, oriented, mobile and hemodynamically stable
The bladder catheter as well as the central venous cannula were removed due to the patient’s significantly improved laboratory results and favorable clinical condition
The patient was given physiotherapy for muscle weakness and fatigue, and after consultation with a neurologist, mild critical illness polyneuropathy and myopathy was diagnosed, and neurological rehabilitation was organized.
32 days after admission, the patient could finally be discharged from the hospital
Conclusions
In this patient with hyperinflammatory syndrome due to urosepsis with septic shock, combined treatment consisting of guideline-based sepsis therapy, CRRT and CytoSorb resulted in hemodynamic stabilization, control of the hyperinflammation and rapid recovery in renal function
According to the treating physicians, in this case CytoSorb therapy contributed to faster hemodynamic stabilization, shortened catecholamine therapy and faster improvement of renal function
Application of CytoSorb in combination with CRRT was safe and easy to perform
* Footnote
ABP = (CD × BF)/BW × 0,001
ABP = amount of blood purified (l/kg), CD = duration of treatment with CytoSorb® (min), BF = blood flow through the extra-corporeal circuit (ml/min) and BW = actual body weight (kg)
Reference: Schultz P, Schwier E, Eickmeyer C, Henzler D, Köhler T. High-dose CytoSorb hemoadsorption is associated with improved survival in patients with septic shock: A retrospective cohort study. J Crit Care. 2021 Aug;64:184-192.
