Introduction: CytoSorb is a novel sorbent hemoadsorption device for cytokine removal and has been used as adjunctive therapy in management of patients with septic shock. This overview reports on 7 patients with septic shock with multiorgan failure admitted to ICU in General Hospital Varazdin from November 2015 to June 2016 and treated with CytoSorb as adjunctive therapy. The aim was to evaluate the effect of CytoSorb on clinical outcomes, mean arterial pressure (MAP), catecholamine needs and C-reactive protein and blood lactate levels.

Methods: The initial therapy of these patients followed the Surviving Sepsis guidelines and focused on adequate volume and catecholamine therapy, administering antibiotics not later than 1 hour after detection of septic shock and lung-protective ventilation, if needed (1). If the patients had been non-responding despite adequate conventional treatment of severe sepsis/septic shock over a 24 hour period, blood purification with Cytosorb hemoadsorbant was initiated. CytoSorb was installed in a series connection after the dialyzer in the continuous renal replacement therapy (CRRT) circuit and was applied in combination with standard CVVHD on Prismaflex System in 6 patients. In 1 patient, CRRT with Diapact System was initiated with a CytoSorb adsorber with the only goal to remove cytokines, despite absence of acute kidney injury and no need for renal replacement therapy. Duration of therapy was predefined to be between 24 and 48 hours and the adsorber was changed every 24 hours. Clinical parameters were collected before and after CytoSorb treatment and the demand of norepinephrine (norepinephrine µg/h vs. thereby achieved mmHg MAP) was calculated.

Results: A total of 7 ICU patients (5 male/2 female) were included in the study and overall survival was 57.1%. Mean age was 68.9±10.2 years, with range from 54 to 81 years. SAPS II score was 51.1±12.7 with range from 21 to 81 and SOFA score 11.4±2.1, with range from 9 to 14. The focus of infection was abdominal in 4 patients, mediastinal in 1, urinary tract in 1 and surgical wound progressing to necrotizing fasciitis in 1 patient. Average ICU stay was 6 days, with range from 1 to 9 days and average hospital stay 21 days with range from 1 to 50 days. Four patients were treated over a 48-hour period and survival rate was 50%, 2 patients were treated over a 24-hour period with 100% survival rate and 1 patient was treated only over a 4-hour period due to irreversible hypotension following cardiac arrest. In all 4 patients who survived, hemodynamic stabilization with an overall MAP improvement was observed and MAP before treatment increased from 57.8± 5.2 mmHg to 96.3±17.9 mmHg after CytoSorb treatment. This was paralleled by a reduction in norepinephrine dosages, from 0.48±0.18 to 0.13±0.11 µg/kg/min, as well as by a decrease of norepinephrine demands, from 37.3±17.2 to 2.6±1.6 µg/h* mmHg. C-reactive protein levels were 295±81 and 220±90 mg/L and lactate blood levels 2.76±1.41 and 2.29±1.46 mmol/L before and after CytoSorb therapy, respectively. In 1 patient who was treated with CytoSorb over a 48-hour period, but did not survive, hemodynamics also improved significantly, with an increase of MAP from 55 mmHg to 85 mmHg, a decrease of norepinephrine dose from 0.45 to 0.05 µg/kg/min, a decrease of norepinephrine demands from 32.7 to 2.4 µg/h* mmHg and a decrease of C-reactive protein and blood lactate level from 215 to 168 mg/L and 1.88 to 1.53 mmol/L, before and after CytoSorb treatment, respectively. However, despite the clear hemodynamic stabilization after CytoSorb treatment over next 48 hours, the patient’s condition deteriorated thereafter and he died 2 days later due to multiorgan failure. In the other patient who was treated with CytoSorb over a 48-hour period and did not survive, hemodynamic stabilization was not achieved after CytoSorb therapy and the patient died 24 hours later due to irreversible hypotension and multiorgan failure. In all 7 patients, treatment with CytoSorb adsorption filters was safe and without any noticed side effects.

Conclusion: The use of CytoSorb as adjunctive therapy in 7 patients with septic multiorgan failure facilitated hemodynamic stabilization and resulted in pronounced reduction of vasopressor needs and decrease of C-reactive protein and lactate blood levels in 4 surviving patients, with an overall survival rate of 57.1%. However, more randomized controlled studies using CytoSorb adsorber are necessary to confirm the true benefit of this therapy.

Reference:

1. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock. 2012. Crit Care Med 2013; 41:580-637.

Renata Krobot
Department of Anesthesiology, reanimatology and intensive care medicine
General Hospital Varazdin, Varazdin, Croatia

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