Continuous cytokine haemoadsorption incorporated into a venoarterial ECMO circuit for the management of postcardiotomy cardiogenic and septic shock – a case report

Németh, Endre; Szigeti, Szabolcs; Varga, Tamás; Daróczi, László; Barati, Zoltan; Merkely, Béla; Gál, János

doi:10.1177/0267659118777442

Cited by 14 publications

(13 citation statements)

References 22 publications

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“…Incorporation of the adsorber device into the ECMO circuit as described here is fast and safe and can be easily performed in an intensive care unit setting. This confirms the experiences made at other centers (12, 13, 17). Possible complications such as air embolism that may arise from negative pressure in the pre-pump circuit or abnormalities in blood flow were not observed.…”

Section: Discussionsupporting

confidence: 91%

Cytokine Adsorption in Critically Ill Patients Requiring ECMO Support

Lother

Benk

Staudacher

et al. 2019

Front. Cardiovasc. Med.

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Systemic inflammation is a key characteristic of sepsis but also also in non-infectious conditions such as post-cardiac arrest syndrome. Cytokine adsorption and extracorporeal membrane oxygenation are emerging therapies applied in these critically ill patients, but the experience with their concurrent use is limited. We evaluated cytokine adsorption in critically ill patients requiring support with either veno-venous (vv) or veno-arterial (va) extracorporeal membrane oxygenation (ECMO) support and hypothesized that adsorber incorporation into the ECMO circuit was technically feasible and not associated with imminent risk. We analyzed data from the first six cases of a prospective single-center registry of patients undergoing veno-venous (vv) or veno-arterial (va) ECMO therapy. While in most published cases cytokine adsorbers were inserted into a hemofiltration circuit, we directly incorporated the adsorber into the ECMO circuit without interruption of continuous ECMO support. We observed no relevant side effects attributable to cytokine adsorption. Thirty-day mortality was 83% (predicted mortality 87%), indicating that the decision for adding cytokine adsorption may have been considered as an ultima ratio decision in severe cases with poor prognosis. Vasopressor or inotrope use, lactate level, and fluid balance did not change significantly when comparing pre- vs. post-cytokine adsorption values. Interestingly, the real-time course of the mentioned three surrogate parameters remained unaltered in all but two cases, regardless of cytokine removal. Beneficial effects of cytokine adsorption are plausible in two va-ECMO-treated patient, where increasing lactate began to drop after initiation of cytokine adsorption. Taken together, these data suggest that incorporation of cytokine adsorption into the management of critically ill patients requiring continued ECMO support is feasible and easy to handle. Whether cytokine removal improves clinical outcome in ECMO-treated patients should now be investigated in randomized controlled trials.

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Section: Discussionsupporting

confidence: 91%

Cytokine Adsorption in Critically Ill Patients Requiring ECMO Support

Lother

Benk

Staudacher

et al. 2019

Front. Cardiovasc. Med.

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“…Despite the fact that the patient died from a new onset of fulminant septic shock 2 months after his initial cardiac surgery, this case highlights the feasibility and effectiveness of CytoSorb in such patients with simultane ous postcardiotomy cardiogenic shock and septic shock. 21 In our patients suffering from critical illness, a multi faceted therapeutic approach, including a broad bundle of lifesustaining therapeutic measures, was applied simulta neously. Therefore, it may be debated as to how much sin gle interventions, per se, contributed to the observed clinical course and finally led to an impact on the observed cardiovascular and clinical parameters.…”

Section: Discussionmentioning

confidence: 99%

Hemoadsorption treatment with CytoSorb^® in patients with extracorporeal life support therapy: A case series

et al. 2019

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Introduction: Extracorporeal life support is an increasingly used technique for respiratory and cardiocirculatory support. Besides primary organ dysfunction, an excessive systemic hyperinflammatory response can be the underlying cause for acute organ failure necessitating extracorporeal life support therapy, or it may be associated with the extracorporeal life support itself. Controlling this overwhelming inflammatory response using CytoSorb® hemoadsorption has been shown to be associated with improved hemodynamics and restored metabolic balance resulting in preserved organ functions. Methods: In this retrospective case series, we describe 23 patients undergoing extracorporeal life support therapy and CytoSorb hemoadsorption. Cytokine levels were monitored, hemodynamic and metabolic variables were recorded, and outcome measures such as duration of organ support, intensive care unit mortality, and hospital mortality were noted. Results: CytoSorb treatment was associated with a trend toward a reduction in plasma cytokine levels (first treatment median interleukin-6 pre 595 vs post 350 pg/mL (n.s.); second treatment median interleukin-6 317 vs 108 pg/mL, p < 0.05), a reduced vasoplegic response resulting in a reduction in vasopressor requirements (first treatment median norepinephrine pre 0.15 vs post 0.02 µg/kg/min (n.s.); second treatment median norepinephrine 0.1 vs 0.02 µg/kg/min, p < 0.05) as well as rebalancing of deranged metabolic parameters (first treatment median lactate pre-treatment 6 vs post-treatment median lactate 2 mmol/L, p < 0.05). The hemoperfusion treatment was well tolerated and safe, without the occurrence of any CytoSorb device-related adverse events. Conclusion: Hemoadsorption may offer a potentially promising therapeutic option for critically ill patients undergoing extracorporeal life support therapy, with cytokine reduction and a consecutively mitigated inflammatory response, decreased vasoplegia, and improved organ function as seen in our patients.

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“…He was young, had no underlying comorbidities, and the source for his sepsis was localized to a single source which could be treated. Based on the reversibility of myocardial depression, ECMO could be a bridge to restore adequate perfusion to vital organs [22,23], to reverse the failures of multiple organs and to gain time for control of sepsis. However, the timing of VA-ECMO introduction is also controversial: we decided to introduce VA-ECMO based on high possibility of falling into cardiopulmonary arrest by prolongation of shock.…”

Section: Venoarterial Extracorporeal Membrane Oxygenationmentioning

confidence: 99%

Sequential Extracorporeal Therapy Collaborative Device and Timely Support for Endotoxic, Septic, and Cardiac Shock: A Case Report

Rosa¹,

Samoni²,

Ronco³

2019

Blood Purif

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We report a 49-year-old man, without prior medical history, consulted in the emergency department with a 5 day history of cough, fever, and dysuria. He was admitted to the intensive care unit due to septic shock. Critical care management was initiated, including mechanical ventilation and vasopressors. Endotoxic shock was suspected (endotoxin activity assay [EAA] 0.75), and 2 treatments with Polymyxin B hemoperfusion (Toraymyxin ® , Toray Medical Co., Ltd., Tokyo, Japan) were performed in 48 h, alternate with high-volume hemofiltration sessions. Initial blood cultures were positive for Neisseria meningitidis (serogroup B), and a lumbar puncture was deferred because of the coagulopathy and a bleeding risk. The circulatory efficiency significantly improved after the second procedure of hemoperfusion, and the treatment resulted in a marked decrease in the serum endotoxin level (EAA < 0.4). However, after 48 h, tachycardia did not improve, left ventricular ejection fraction was 20%, and circulatory insufficiency progressed. Therefore, considering the involvement of septic cardiomyopathy and cardiogenic shock, venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated for circulation assistance on day 3 from admission. Continuous cytokine hemoadsorption (Cytosorb ® , Cytosorbent Corporation, Monmouth Junction, NJ, USA) was incorporated into a VA-ECMO circuit for 48 h without a considerable improvement. For this reason, a 72-h continuous veno-venous hemodialysis session was started in which a high cutoff filter was used. Tachycardia and myocardial dysfunction improved by day 6, and VA-ECMO was withdrawn on the tenth day. Subsequently, nutrition management and rehabilitation were performed, and the patient was transferred to the department of respiratory medicine on day 80, he was discharged from our hospital on day 113. Sequential extracorporeal therapy may be beneficial when concomitant with circulatory assistance in uncontrollable cases of septic shock using catecholamines and blockers.

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Continuous cytokine haemoadsorption incorporated into a venoarterial ECMO circuit for the management of postcardiotomy cardiogenic and septic shock – a case report

Abstract: This specific application of CytoSorb was safe, feasible and contributed to the optimal management of simultaneous shocks.

Cited by 14 publications

References 22 publications

Cytokine Adsorption in Critically Ill Patients Requiring ECMO Support

Cytokine Adsorption in Critically Ill Patients Requiring ECMO Support

Hemoadsorption treatment with CytoSorb^® in patients with extracorporeal life support therapy: A case series

Sequential Extracorporeal Therapy Collaborative Device and Timely Support for Endotoxic, Septic, and Cardiac Shock: A Case Report

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Continuous cytokine haemoadsorption incorporated into a venoarterial ECMO circuit for the management of postcardiotomy cardiogenic and septic shock – a case report

Abstract: This specific application of CytoSorb was safe, feasible and contributed to the optimal management of simultaneous shocks.

Cited by 14 publications

References 22 publications

Cytokine Adsorption in Critically Ill Patients Requiring ECMO Support

Cytokine Adsorption in Critically Ill Patients Requiring ECMO Support

Hemoadsorption treatment with CytoSorb® in patients with extracorporeal life support therapy: A case series

Sequential Extracorporeal Therapy Collaborative Device and Timely Support for Endotoxic, Septic, and Cardiac Shock: A Case Report

Contact Info

Product

Resources

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Hemoadsorption treatment with CytoSorb^® in patients with extracorporeal life support therapy: A case series