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CytoSorb in septic shock after perforated Ulcus ventriculi Dr. Markus Teipel,head physician, Interdisciplinary Intensive Care, Nordwest-Krankenhaus Sanderbusch GmbH This case study reports on a 43-year-old male patient, who was transferred to hospital via emergency boat and ambulance service from Langeoog island with initially belt-shaped and then diffuse radiating acute pain in the upper abdomen, dark vomitus, diarrhea and dyspnea. Case presentation
• Diagnosis: perforated ulcus ventriculi at the small curvature
• Immediate emergency laparoscopy and laparotomy within 2 hours after admission followed by surgical suturing and covering of the perforation
• The patient was transferred to ICU intubated and ventilated
• At this time the patient was hemodynamically unstable, hypotonic, tachycardic with high requirement for catecholamines (noradrenaline 0.5 ug / kg / min)
• Significantly increased inflammatory parameters: PCT> 200 ng/ml, leukocytes 6.900/µL, CRP >27 mg/dl
• Advanced hemodynamic monitoring showed septic shock with high volume requirements (SVRI 1500 dyn*s*cm-5*m², ELWI 5.6 ml/kg, GEDI 496 ml/m²)
• High loading volumes (positive fluid balance 12 liters) with poor and further decreasing spontaneous diuresis (200 ml/day), creatinine 5.8 mg/dl, GFR 11.3 ml/min, urea 95 mg/dl
• Initiation of antibiotic therapy with ertapenem followed by additional calculated antifungal treatment with caspofungin
• Hydrocortisone 200 mg/day, continuous Amiodarone with 300 mg loading dose (maintenance dose 900 mg/d)
• Insertion of a Shaldon catheter and initiation of continuous veno-venous hemodiafiltration (CVVHDF)
• Due to acute renal failure, sharp increase in inflammatory markers, progressive need for vasopressors and septic shock, CytoSorb was started 24 hours after initiation of CVVHDF
Treatment
• Two consecutive CytoSorb treatment sessions for 24 hours each
• CytoSorb was used in conjunction with citrate dialysis (Prismaflex; Gambro) in CVVHDF mode
• Blood flow rate: 150 ml/min
• Anticoagulation: citrate
• CytoSorb adsorber position: post-hemofilter Measurements
• Demand for catecholamines
• Advanced hemodynamic monitoring parameters (SVRI, GEDI)
• Lactate clearance
• Inflammatory parameters (PCT, CRP)
• Renal function (excretion)
Case of the week
23/2016
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Results
• Clear stabilization of hemodynamics during the course of the two CytoSorb treatments (GEDI 840 ml/m², SVRI 2600 dyn*s*cm-5*m²)
• With installation of the adsorber the norepinephrine dose could be reduced significantly to around 1/5 of the initial dose after completion of the first CytoSorb treatment and a further reduction to 0.08µg/kg/min after completion of the second treatment. Five days after the first treatment norepinephrine could be completely tapered off
• Reduction of inflammatory parameters during the two treatments: PCT to 45 ng/ml after the first and to 23 ng/ml after the second treatment, CRP at >27 mg/dl after the first treatment and 7.4 mg/dl after the second treatment
• Two days after completion of CytoSorb therapy increasing spontaneous diuresis
• Antibiotic dosages did not have to be adjusted at any time Patient Follow-Up
• Cessation of renal replacement therapy 5 days after last CytoSorb treatment
• Extubation on postoperative day 11
• Antibiotic treatment with ertapenem could be discontinued 10 days and the antifungal treatment 14 days after admission
• After extubation, patient had ongoing delirium which normalized over the next 4 days
• No neuropathic sequelae
• Transfer to IMC 16 days after initial admission and 4 days later to the normal ward
Conclusions
• Clear stabilization and consolidation of hemodynamic and inflammatory
mediators with CytoSorb within 48 hours
• Conventional therapy using the sepsis bundle was not enough to
hemodynamically stabilize the patient during his acute septic phase,
however, after using the CytoSorb adsorber this could be achieved in a
short period of time
• The application of CytoSorb therapy was simple, safe with no problems
installing the adsorber in a post-hemofilter position
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