CTSO: Standard of Care

Case of the Week

Following further evaluation of CytoSorb technology in additional patients, it is planned to introduce CytoSorb as the standard of care in patients with septic shock.


Use of CytoSorb in osteomyelitis with suspicion of infected grade 4 thrombosis and lung abscesses with septic emboli

Dr. Timo Gentner, Dr. Jürgen Ruf, Dr. Jörg Maurus, Dr. Stefan Locher | Department of Internal Medicine and Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, Westallgäu-Hospital, Wangen, Germany

CoW 24/2018 – This case study reports on a 62-year-old patient (known pre-existing conditions: chronic osteomyelitis with fistulas to the skin surface on the right leg), who was admitted to the hospital via emergency transport after he was found helpless after lying at home for several days.

Case presentation

Clinical condition on admission: conscious, hypotonic (blood pressure 80/60 mmHg), tachycardic (heart rate 113 bpm), hypothermic (temperature 32°C), tachypnoic (sufficient oxygenation with SaO2 97% with 4l O2), hypovolemic, anuric
Extensive cultivation and initiation of a calculated antibiotic therapy with piperacillin/tazobactam due to the clinical picture of sepsis with initially unclear focus Initiation of a guideline-based sepsis therapy with fluid therapy (4 liters in the first 3 hours), start of catecholamine therapy with norepinephrine (1 mg/h) because of persistent circulatory insufficiency
Rapid and serious deterioration of his clinical condition during the following night including worsening of the respiratory situation requiring intubation and mechanical ventilation, as well as development of a shock state refractory to fluids and catecholamines followed by administration of hydrocortisone (200 mg/day)
Installation of an advanced hemodynamic PiCCO monitoring
Over the next 12 hours, the patient developed severe multiple organ failure including septic encephalopathy, circulatory failure, septic cardiomyopathy with severely impaired systolic left ventricular function (EF 25%), ARDS requiring highly invasive ventilation, liver failure, coagulation failure with disseminated intravascular coagulopathy, and acute anuric renal failure requiring the start of hemodiafiltration treatment
Due to his progressive clinical deterioration with maximum standard therapy, a CytoSorb adsorber was additionally installed into the circuit 4 hours after initiation of continuous renal replacement therapy
Microbial analysis later confirmed evidence of Staphylococcus aureus MSSA (blood cultures, tracheal secretions, thigh smear culture), streptococcus dysgalactiae (tracheal secretions, thigh smear culture), pseudomonas aeruginosa (wound smear culture from the thigh). Extension of antibiotic therapy with cefazolin
After clinical stabilization, extended diagnostics were carried out with a CT of the thorax/abdomen/thigh and transesophageal echocardiography (TEE) that confirmed pronounced osteomyelitis of the right thigh and evidence of multiple lung abscesses
No indication of endocarditis confirmed by TEE. In the light of differences in leg circumference, sonography confirmed a grade 4 deep vein thrombosis of the osteomyelitic leg
Final diagnosis: Sepsis due to osteomyelitis with suspicion of infected grade 4 thrombosis in the right leg and lung abscesses with septic embolism
Treatment

Two treatments with CytoSorb for a total treatment time of 45 hours (first treatment 6 hours, second treatment 24 hours, pause interval 15 hours)
Cytosorb was used in combination with CRRT (Prismaflex, Gambro) in CVVHDF mode
Blood flow: 100 ml/min
Anticoagulation: Citrate
CytoSorb Adsorber position: post-hemofilter
Measurements

Catecholamine demand (dobutamine, norepinephrine)
Inflammatory parameters (leucocytes, CRP, PCT)
Coagulation (INR, Quick, aPTT, thrombocytes)
Lung function and invasiveness of ventilation (FiO2, PEEP, Pmax)
Liver function (bilirubin, GPT, GOT)
Renal function (creatinine, urea)
Cardiac function (left ventricular ejection fraction)

Results

Rapid hemodynamic stabilization with a reduction in catecholamine dosages and concomitant stabilization of cardiac function
Significant improvement in lung function and ventilatory invasiveness
Clearly decreasing parameters of infection and inflammation
Stabilization in plasma coagulation with return to normal values 1 day after cessation of CytoSorb therapy, delayed normalization of platelet levels
Slow improvement in liver function
Persistent anuric renal failure
Patient Follow-Up

Further improvement of all organ functions (except for kidneys) over the following days
Extubation 8 days after the last CytoSorb treatment
Persistent renal failure requiring dialysis for several weeks, most recently stabilization at the level of grade 4 renal failure until discharge
Development of critical illness polyneuropathy and myopathy
Bilateral detachment of the retina as part of the acute illness
Ischemic colitis with need for multiple endoscopic interventions due to bleeding episodes
36 days after the last CytoSorb treatment, the patient was awake, responsive and cooperative, and was transferred to an Eye Clinic for treatment of his retinal detachments, before being transferred a few days later to the an Accident Clinic for on-going care of his osteomyelitis

Conclusion

Combined treatment with CRRT, CytoSorb and standard sepsis treatment in this patient with severe septic shock and multiple organ failure resulted in the rapid stabilization of organ functions and hemodynamics with decreasing catecholamine dosages and significant improvement in lung function and ventilatory invasiveness

Following further evaluation of CytoSorb technology in additional patients, it is planned to introduce CytoSorb as the standard of care in patients with septic shock
The application of CytoSorb therapy was simple and safe

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