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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 8  |  Issue : 3  |  Page : 151-153

CytoSorb in the management of severe septic shock after coronary artery bypass graft surgery


1 Department of Cardiac Anaesthesia, Fortis Hospital, New Delhi, India
2 Department of Cardiothoracic and Vascular Surgery, Fortis Hospital, New Delhi, India

Date of Submission11-Nov-2019
Date of Decision17-Jan-2020
Date of Acceptance13-May-2020
Date of Web Publication26-Nov-2020

Correspondence Address:
Dr. Amit Prakash
Fortis Hospital, A-Block, Shalimar Bagh, New Delhi - 110 088
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/heartindia.heartindia_45_19

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  Abstract 


Achieving sufficient adsorption of increased immune mediators with the help of hemadsorption has been a breakthrough discovery in the field of cardiac sciences. Any surgery, injury, or trauma causes the release of pro-inflammatory mediators, which may trigger a severe systemic inflammatory response syndrome (SIRS) and multiorgan failure. Septic shock after major cardiac surgeries is a feared complication, which increases mortality and morbidity and contributes to prolonged hospitalization. CytoSorb has been widely used worldwide in patients with septic shock as well as in postsurgery SIRS. This is a case of acute septic shock that developed after coronary artery bypass graft and which was efficiently managed using CytoSorb hemoadsorber.

Keywords: Cardiac surgery, CytoSorb, hemoadsorption, sepsis, systemic inflammatory response syndrome


How to cite this article:
Prakash A, Garg V, Mittal DK, Upadhyay AB. CytoSorb in the management of severe septic shock after coronary artery bypass graft surgery. Heart India 2020;8:151-3

How to cite this URL:
Prakash A, Garg V, Mittal DK, Upadhyay AB. CytoSorb in the management of severe septic shock after coronary artery bypass graft surgery. Heart India [serial online] 2020 [cited 2021 Jan 26];8:151-3. Available from: https://www.heartindia.net/text.asp?2020/8/3/151/301598




  Introduction Top


Coronary artery bypass graft (CABG) is the most commonly performed procedure worldwide.[1] As a consequence of the trauma caused by surgery or exposure to the extracorporeal components (cardiopulmonary bypass [CPB]), dysregulation of the immune system can cause an exaggerated inflammatory response called systemic inflammatory response syndrome (SIRS) leading to vasoplegic shock.

The use of an extracorporeal cytokine hemoadsorber (CytoSorb, CytoSorbents Corporation) removes cytokines and other inflammatory mediators restoring the immune system. CytoSorb is a hemoadsorber made of polyvinyl pyrrolidone-coated benzene polymer beads, which are highly porous and biocompatible. It efficiently removes low to middle molecular weight (up to approximately 55 kDa) toxins from the blood. Its application can be lifesaving in patients with SIRS, septic shock, or sepsis.


  Case Report Top


A 58-year-old male was hospitalized with a 2-day history of chest pain and dyspnea on exertion (New York Heart Association Class III). The patient had a history of Type II diabetes mellitus with hypertension and was on medications for the same. Electrocardiogram (ECG) revealed an ST-elevated inferior wall myocardial infarction, and coronary angiography showed triple-vessel disease. Percutaneous balloon angioplasty of the left circumflex artery was performed to restore flow, and CABG was advised considering critical triple-vessel disease. Echocardiogram showed moderate left ventricular dysfunction (ejection fraction [EF]: 40%–45%) and hypokinetic posterolateral area in the basal region.

Total leukocyte count (TLC) was higher, and the patient was started on antibiotics. CABG was planned after the laboratory parameters were within the normal limits. CABGX4 was performed, where the left internal mammary artery was grafted to the left anterior descending artery; reverse saphenous vein grafts were anastomosed to the obtuse marginal branch, the ramus intermediate branch, and the posterior descending artery. Postoperatively, the patient was admitted to the intensive care unit (ICU) on moderate inotropic support.

Within 12–24 h, the patient developed refractory hypotension with signs of multiple organ failure. His hemodynamic condition deteriorated dramatically with TLC of 19.24 cells/cmm, procalcitonin of >100 ng/mL, serum creatinine of 4.6 mg/dL, serum glutamic-oxaloacetic transaminase of 5201 U/L, and serum glutamic-pyruvic transaminase of 1975 U/L. Acute physiology, age, chronic health evaluation II score was 24, and sequential organ failure assessment score was 13 [Table 1]. The progressive deterioration in his hemodynamic state required the administration of epinephrine, norepinephrine, and vasopressin. ECG did not show any new ST-T changes. Echocardiography diagnostics performed in the ICU showed an EF of 35%–40% with no new regional wall motion abnormality. He was immediately started on broad-spectrum antibiotics, and continuous renal replacement therapy (CRRT, multifiltrate CRRT, Fresenius Medical Care) together with CytoSorb was initiated. A single 24-h session (without heparin, blood flow 120 ml/min) of CytoSorb was run to which the patient responded with an improvement in end-organ dysfunction, less requirements of vasopressors, improved urine output, decreased ventilatory requirements, improved liver function, and normal temperature. Hence, inotropic and organ support could be gradually withdrawn. The hemodynamic status remained stable with improvements in the inflammatory and other laboratory parameters. Acute physiology, age, chronic health evaluation II (APACHE II ) and Sequential organ failure assessment (SOFA) scores before and after CytoSorb therapy are shown in [Figure 1].
Table 1: Clinical and laboratory parameters

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Figure 1: APACHE II and SOFA scores before and after CytoSorb therapy. APACHE II: Acute physiology, age, chronic health evaluation II, SOFA: Sequential organ failure assessment

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  Discussion Top


Several factors play a role in causing this systemic inflammatory response, such as surgical trauma, anesthesia, exposure of blood to several nonphysiological components, and ischemia-reperfusion injury.[2] In response to these triggers, the activation of immune cells causes the release of several anti-inflammatory mediators. The high plasma concentration of these inflammatory components leads to a postoperative SIRS, septic shock.

In addition, diabetes mellitus can contribute to an environment in which any additional stress/trauma favors the early development of SIRS. Hypoinsulinemia causes increased hepatic glucose production with increased peripheral insulin resistance and circulatory free fatty acids. These changes cause oxidative stress and imbalance in the endothelial cell functioning with the liberation of pro-inflammatory cytokines and mediators, predisposing the development of SIRS.[3]

The management of SIRS/septic shock requires high doses of vasopressors, appropriate fluid, and antibiotic therapy. Elimination of inflammatory mediators from the circulation by adjunctive hemoadsorption treatment may also be beneficial, helping rebalancing of the immune system with subsequent restoration of organ functions.

CytoSorb can help by removing the low-to-middle molecular range pro- and anti-inflammatory mediators and chemokines. CytoSorb can be used with any dialysis machine for treating vasoplegic shock postcardiac surgery, facilitating its use in several major cardiac surgeries, both intra- and postoperatively, in patients with a higher risk of SIRS. CytoSorb is also compatible with extracorporeal membrane oxygenation or heart–lung machine as well.

Studies have reported the usefulness of CytoSorb in septic shock along with a decreased use of vasopressors.[4] Using CytoSorb during cardiac surgery reduces the level of circulating cytokines, minimizing the inflammatory response, and reducing the risk of multiple organ failure. In a study, patients undergoing CPB were treated with CytoSorb during cardiac surgery, and the clinical and laboratory parameters demonstrated that there was a balanced control of the inflammatory response evidenced by a significant reduction of interleukin (IL)-6 and IL-8 concentrations.[5] This was paralleled by consistent hemodynamic stability during and postsurgery. In another study, treatment with CytoSorb improved vascular barrier function, which might have potentially led to early recovery from organ dysfunction caused by hyperinflammation.[6]

The majority of reported cases have shown the efficacy of CytoSorb during cardiac surgery, whereas very few cases have emphasized its effectiveness post-CABG. The above-mentioned case is one such rare occurrence. The patient's septic shock after CABG was efficiently managed by a single session with CytoSorb. This resulted in a marked improvement in the laboratory parameters as well as a stabilization of hemodynamics with a concomitant reduction in vasopressor dosages.

The CytoSorb technique is novel and seems to be a promising tool in stabilizing hemodynamics in refractory vasoplegia. In patients with known risk factors, CytoSorb therapy during surgery could be used. In addition, septic shock not only poses an increased risk of multiple organ failure but also adds to financial burden by increasing hospitalization and other expenses, and the use of CytoSorb may reduce this burden.[7]


  Conclusion Top


CytoSorb was an effective, safe, and easy option in the management of severe septic shock that developed after CABG. No associated complications were observed in this case. Septic shock increases the risk of multiple organ failure and also adds to the financial burden, which was reduced by CytoSorb therapy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors would like to acknowledge Ms. Babita Kumari and Mr. Shishir Agarwal for end to end coordination to conclude this case report under the guidance of Mr. Pradeep Yanamala.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Ethical Approval

Ethical clearance is not required as proper consent was taken from the patient and no personal details of the patient were revealed.



 
  References Top

1.
Holsworth RE Jr., Shecterle LM, St. Cyr JA, Sloop GD. Importance of monitoring blood viscosity during cardiopulmonary bypass. Perfusion 2013;28:91-2.  Back to cited text no. 1
    
2.
Elahi MM, Khan JS, Matata BM. Deleterious effects of cardiopulmonary bypass in coronary artery surgery and scientific interpretation of off-pump's logic. Acute Card Care 2006;8:196-209.  Back to cited text no. 2
    
3.
Kaplan L. What is the Pathogenesis of Hyperglycemia in Systemic Inflammatory Response Syndrome (SIRS) and What are its Effects? Available from: https://www.medscape.com/answers/168943-41433/what-is-the-pathogenesis-of-hypergycemia-in-systemic-inflammatory-response-syndrome-sirs-and-what-are-its-effects. [Last updated on 2018 May 07; Last accessed on 2019 Oct 14].  Back to cited text no. 3
    
4.
Friesecke S, Stecher SS, Gross S, Felix SB, Nierhaus A. Extracorporeal cytokine elimination as rescue therapy in refractory septic shock: A prospective single-center study. J Artif Organs 2017;20:252-9.  Back to cited text no. 4
    
5.
Träger K, Skrabal C, Fischer G, Datzmann T, Schroeder J, Fritzler D, et al. Hemoadsorption treatment of patients with acute infective endocarditis during surgery with cardiopulmonary bypass – A case series. Int J Artif Organs 2017;40:240-9.  Back to cited text no. 5
    
6.
David S, Thamm K, Schmidt BM, Falk CS, Kielstein JT. Effect of extracorporeal cytokine removal on vascular barrier function in a septic shock patient. J Intensive Care 2017;5:12.  Back to cited text no. 6
    
7.
Javanbakht M, Trevor M, Rezaei Hemami M, Rahimi K, Branagan-Harris M, Degener F, et al. Ticagrelor Removal by CytoSorb ® in patients requiring emergent or urgent cardiac surgery: A UK-based cost-utility analysis. Pharmacoecon Open 2020;4:307-19.  Back to cited text no. 7
    


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