Download Case report of a patient with multiorgan failure due to

Case of
the week
21/2016
Case report of a patient with multiorgan failure
due to severe SIRS in cardiac failure additionally
treated with CytoSorbents haemadsorption as an
adjunctive therapy
Klaus Kogelmann, Matthias Drüner, Dominik Jarczak, Department of Anaesthesiology and Intensive Care Medicine,
Hospital Emden
This case study reports on a female patient who was admitted to hospital after she collapsed several times at home
Case presentation
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Patients medical history included peripheral arterial obstructive disease, arterial hypertension and a previous
minor stroke
Glasgow Coma scale was 11, heart rate 20 bpm, hypothermia 30 °C, metabolic acidosis with pH 7.2, no
measurable blood pressure
After immediate resuscitation the patient developed severe SIRS and multiple organ failure with cardiogenic shock
due to refractory cardiac arrhythmia
Initial ultrasound of heart function showed diffuse hypokinesia and an ejection fraction (EF) of around 45 %, with a
heart rate of 36 bpm
24 hours of conventional treatment (differentiated catecholamine therapy with combined norepinephrine and
adrenaline, ultrasound guided volume therapy, lung-protective ventilation, temporary cardiac pacemaker)
Following this, ultrasound showed diffuse dysfunction and hypokinesia with an EF of 50 %
Laboratory tests and electrocardiography on admission showed neither myocardial infarction nor evidence of
infection but highly elevated liver enzymes and creatinine
Due to high and stable catecholamine support associated with persistent renal failure, CytoSorb therapy and
CRRT were initiated
Treatment
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Duration of therapy with CytoSorb was 72 hours
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CytoSorb was used in conjunction with citrate dialysis (Multifiltrate; Fresenius Medical Care) in CVVHD mode
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Three CytoSorb treatment sessions for 24 hours each
Blood flow rate: 100 ml/min
Anticoagulation: citrate
CytoSorb adsorber position: pre-hemofilter
Messungen
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Before, during and after treatment
oSAPS II-Score, SOFA-Score
oMean Arterial Pressure
oRequirement for norepinephrine
oBlood lactate level
During therapy
oDemand of norepinephrine (µg/h vs. mmHg MAP)
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Case of
the week
21/2016
Results
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During CytoSorb therapy the authors observed a decrease in catecholamine demand of more than 95 %, and 72 h
after therapy the patient was free of catecholamines
SOFA Score did not change; SAPS II-Score decreased to 50 % of its initial value
Blood lactate decreased from 46.9 to 21.4 mg/dl
Liver function tests improved, AST decreased from 5355 U/L to 431 U/L 3 days later; ALT decreased from 4858
U/L to 888 U/L and LDH decreased from 6859 to 242 U/L
Patienten Follow-Up
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12 days after treatment the liver enzymes had returned to normal values
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During therapy, blood natriuretic peptide level showed a tenfold increase to 1.959 pg/ml as a marker of left
ventricular dysfunction
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Chest X-ray 10 days after admission showed only slight effusions, 6 days later she could be weaned from
ventilation, the patient was alert, vigilant and stable clinically without the requirement for catecholamines
Coronary angiography showed three vessel coronary artery disease with ischemic cardiomyopathy as the reason
for the patients cardiac arrhythmia which had led to pump failure and the severe SIRS
CONCLUSIONS
• Treatment using CytoSorb adsorption in this patient with severe cardiac failure
due to ischemic cardiomyopathy was associated with significant clinical
improvement, was safe and without apparent side effects
• The authors note that CytoSorb therapy was helpful even in a patient with
marked cardiac failure leading to severe SIRS
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