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Kovacevic P, Dragic S, Jandric M, Momcicevic D, Malesevic V, Kovacevic T, Matejic-Spasic M, Knezevic T, Zlojutro B. Does adjunctive hemoadsorption provide benefit in the management of ischemia-reperfusion syndrome following near-drowning? A case report. Front Med (Lausanne) 2024; 11:1341156. [PMID: 38633302 PMCID: PMC11021721 DOI: 10.3389/fmed.2024.1341156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 03/18/2024] [Indexed: 04/19/2024] Open
Abstract
Drowning remains a significant global health concern, claiming over 300,000 lives annually, with a disproportionate impact on young individuals in low-and middle-income countries. Conventional mechanical ventilation, while common, falls short in addressing the hypoxemia and hypercapnia often observed in severe near-drowning cases. Veno-venous extracorporeal membrane oxygenation (vvECMO) emerges as a critical intervention for cardiopulmonary failure post-drowning. This case report delves into the pivotal role of ischemia-reperfusion injury (IRI) in a near-drowning-related pathology. Following the initial insult, reoxygenation exacerbates the inflammatory cascade, resulting in a surge of pro-inflammatory mediators. In this context, CytoSorb®, a hemoadsorption cartridge, demonstrates promise by effectively removing these mediators from circulation. This report outlines its application in a critically ill adolescent patient who experienced near-drowning, presenting a compelling case for CytoSorb as an adjunctive therapy in managing IRI-induced hyperinflammation.
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Affiliation(s)
- Pedja Kovacevic
- Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, Banja Luka, Bosnia and Herzegovina
- Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Sasa Dragic
- Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, Banja Luka, Bosnia and Herzegovina
- Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Milka Jandric
- Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, Banja Luka, Bosnia and Herzegovina
| | - Danica Momcicevic
- Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, Banja Luka, Bosnia and Herzegovina
- Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Vedrana Malesevic
- Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, Banja Luka, Bosnia and Herzegovina
| | - Tijana Kovacevic
- Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, Banja Luka, Bosnia and Herzegovina
- Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | | | - Tanja Knezevic
- Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, Banja Luka, Bosnia and Herzegovina
| | - Biljana Zlojutro
- Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, Banja Luka, Bosnia and Herzegovina
- Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
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Nemeth E, Soltesz A, Kovacs E, Szakal-Toth Z, Tamaska E, Katona H, Racz K, Csikos G, Berzsenyi V, Fabry S, Ulakcsai Z, Tamas C, Nagy B, Varga M, Merkely B. Use of intraoperative haemoadsorption in patients undergoing heart transplantation: a proof-of-concept randomized trial. ESC Heart Fail 2024; 11:772-782. [PMID: 38111338 DOI: 10.1002/ehf2.14632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 11/18/2023] [Accepted: 11/23/2023] [Indexed: 12/20/2023] Open
Abstract
AIMS The aim of this trial was to compare the clinical effects of intraoperative haemoadsorption versus standard care in patients undergoing orthotopic heart transplantation (OHT). METHODS AND RESULTS In a randomized, controlled trial, OHT recipients were randomized to receive intraoperative haemoadsorption or standard care. Outcomes were vasoactive-inotropic score (VIS), frequency of vasoplegic syndrome (VS) in the first 24 h; post-operative change in procalcitonin (PCT) and C-reactive protein (CRP) levels; intraoperative change in mycophenolic acid (MPA) concentration; frequency of post-operative organ dysfunction, major complications, adverse immunological events and length of in-hospital stay and 1-year survival. Sixty patients were randomized (haemoadsorption group N = 30, control group N = 25 plus 5 exclusions). Patients in the haemoadsorption group had a lower median VIS and rate of VS (VIS: 27.2 [14.6-47.7] vs. 41.9 [22.4-63.2], P = 0.046, and VS: 20.0% vs. 48.0%, P = 0.028, respectively), a 6.4-fold decrease in the odds of early VS (OR: 0.156, CI: 0.029-0.830, P = 0.029), lower PCT levels, shorter median mechanical ventilation (MV: 25 [19-68.8] hours vs. 65 [23-287] hours, P = 0.025, respectively) and intensive care unit stay (ICU stay: 8.5 [8.0-10.3] days vs. 12 [8.5-18.0] days, P = 0.022, respectively) than patients in the control group. Patients in the haemoadsorption versus control group experienced lower rates of acute kidney injury (AKI: 36.7% vs. 76.0%, P = 0.004, respectively), renal replacement therapy (RRT: 0% vs. 16.0%, P = 0.037, respectively) and lower median per cent change in bilirubin level (PCB: 2.5 [-24.6 to 71.1] % vs. 72.1 [11.2-191.4] %, P = 0.009, respectively) during the post-operative period. MPA concentrations measured at pre-defined time points were comparable in the haemoadsorption compared to control groups (MPA pre-cardiopulmonary bypass: 2.4 [1.15-3.60] μg/mL vs. 1.6 [1.20-3.20] μg/mL, P = 0.780, and MPA 120 min after cardiopulmonary bypass start: 1.1 [0.58-2.32] μg/mL vs. 0.9 [0.45-2.10] μg/mL, P = 0.786). The rates of cardiac allograft rejection, 30-day mortality and 1-year survival were similar between the groups. CONCLUSIONS Intraoperative haemoadsorption was associated with better haemodynamic stability, mitigated PCT response, lower rates of post-operative AKI and RRT, more stable hepatic bilirubin excretion, and shorter durations of MV and ICU stay. Intraoperative haemoadsorption did not show any relevant adsorption effect on MPA. There was no increase in the frequency of early cardiac allograft rejection related to intraoperative haemoadsorption use.
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Affiliation(s)
- Endre Nemeth
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Adam Soltesz
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Eniko Kovacs
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | | | - Eszter Tamaska
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Hajna Katona
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Kristof Racz
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Gergely Csikos
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Viktor Berzsenyi
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Szabolcs Fabry
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Zsuzsanna Ulakcsai
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Csilla Tamas
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Beata Nagy
- Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Marina Varga
- Department of Laboratory Medicine, Semmelweis University, Budapest, Hungary
| | - Bela Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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Mehta Y, Ansari AS, Mandal AK, Chatterjee D, Sharma GS, Sathe P, Umraniya PV, Paul R, Gupta S, Singh V, Singh YP. Systematic review with expert consensus on use of extracorporeal hemoadsorption in septic shock: An Indian perspective. World J Crit Care Med 2024; 13:89026. [PMID: 38633478 PMCID: PMC11019629 DOI: 10.5492/wjccm.v13.i1.89026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/05/2023] [Accepted: 01/17/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Septic shock is a severe form of sepsis characterised by deterioration in circulatory and cellular-metabolic parameters. Despite standard therapy, the outcomes are poor. Newer adjuvant therapy, such as CytoSorb® extracorporeal haemoadsorption device, has been investigated and shown promising outcome. However, there is a lack of some guidance to make clinical decisions on the use of CytoSorb® haemoadsorption as an adjuvant therapy in septic shock in Indian Setting. Therefore, this expert consensus was formulated. AIM To formulate/establish specific consensus statements on the use of CytoSorb® haemoadsorption treatment based on the best available evidence and contextualised to the Indian scenario. METHODS We performed a comprehensive literature on CytoSorb® haemoadsorption in sepsis, septic shock in PubMed selecting papers published between January 2011 and March 2023 2021 in English language. The statements for a consensus document were developed based on the summarised literature analysis and identification of knowledge gaps. Using a modified Delphi approach combining evidence appraisal and expert opinion, the following topics related to CytoSorb® in septic shock were addressed: need for adjuvant therapy, initiation timeline, need for Interleukin -6 levels, duration of therapy, change of adsorbers, safety, prerequisite condition, efficacy endpoints and management flowchart. Eleven expert members from critical care, emergency medicine, and the intensive care participated and voted on nine statements and one open-ended question. RESULTS Eleven expert members from critical care, emergency medicine, and the intensive care participated and voted on nine statements and one open-ended question. All 11 experts in the consensus group (100%) participated in the first, second and third round of voting. After three iterative voting rounds and adapting two statements, consensus was achieved on nine statements out of nine statements. The consensus expert panel also recognised the necessity to form an association or society that can keep a registry regarding the use of CytoSorb® for all indications in the open-ended question (Q10) focusing on "future recommendations for CytoSorb® therapy". CONCLUSION This Indian perspective consensus statement supports and provides guidance on the use of CytoSorb® haemoadsorption as an adjuvant treatment in patients with septic shock to achieve optimal outcomes.
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Affiliation(s)
- Yatin Mehta
- Institute of Critical Care and Anesthesiology, Medanta The Medicity, Gurgaon 122001, Haryana, India
| | - Abdul Samad Ansari
- Department of Critical Care, Nanavati Max Super Specialty Hospital, Mumbai 400065, India
| | - Amit Kumar Mandal
- Department of Pulmonology, Sleep and Critical Care, Fortis Hospital, Mohali, Punjab, Mohali 160062, Punjab , India
| | - Dipanjan Chatterjee
- Department of Cardio-Puimonary Critical Care, Medica Superspecialty Hospital, Kolkata 700099, India
| | | | - Prachee Sathe
- Department of Critical Care Medicine, D.Y. Patil Medical College, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad,, Pune 411018, India
| | - Purvesh V Umraniya
- Department of Critical Care Medicine, Bhailal Amin General Hospital, Vadodara 390003, Gujarat, India
| | - Rajib Paul
- Department of Internal Medicine, Apollo Hospitals, Jubilee Hills, Hyderabad 500 033, India
| | - Sachin Gupta
- Department of Anaesthesiology, Narayana Superspeciality Hospital, Gurugram 122002, India
| | - Vinod Singh
- Department of Critical Care Medicine, Institute of Critical Care Medicine, Hospital Name - Sir Ganga Ram Hospital, New Delhi 110001, India
| | - Yogendra Pal Singh
- Department of Critical Care Medicine, Max Super Speciality Hospital, Delhi 110092, India
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Kogelmann K, Hübner T, Drüner M, Jarczak D. Impact of CytoSorb Hemoadsorption Therapy on Fluid Balance in Patients with Septic Shock. J Clin Med 2024; 13:294. [PMID: 38202301 PMCID: PMC10779563 DOI: 10.3390/jcm13010294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/20/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024] Open
Abstract
Recent in vitro studies have investigated the effects of hemoadsorption therapy on endothelial function in sepsis showing a reduction in markers of endothelial dysfunction, but, to this day, there are no clinical studies proving whether this approach could actually positively influence the disturbed vascular barrier function in septic conditions. We retrospectively analyzed data on administered fluid volumes and catecholamines in 124 septic shock patients. We collected catecholamine and volume requirements and calculated the volume balance within different time periods to obtain an assumption on the stability of the vascular barrier. Regarding the entire study cohort, our findings revealed a significant reduction in fluid balance at 72 h (T72) compared to both baseline (T0) and the 24 h mark (T24). Fluid balances from T72-T0 were significantly lower in hospital survivors compared with non-survivors. Patients who received a second catecholamine had a significantly lower in-hospital mortality. Our findings suggest that the applied treatment regimen including hemoadsorption therapy is associated with a reduced positive fluid balance paralleled by reductions in vasopressor needs, suggesting a potential positive effect on endothelial integrity. These results, derived from a large cohort of patients, provide valuable insights on the multiple effects of hemoadsorption treatment in septic shock patients.
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Affiliation(s)
- Klaus Kogelmann
- Department of Anesthesiology and Intensive Care Medicine, Klinikum Leer, Augustenstraße 35-37, 26789 Leer, Germany
| | - Tobias Hübner
- Department of Anesthesiology and Intensive Care, Kantonsspital Münsterlingen, Spitalcampus 1, 8596 Münsterlingen, Switzerland;
| | - Matthias Drüner
- Department of Anesthesiology and Intensive Care Medicine, Klinikum Emden, 26721 Emden, Germany;
| | - Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
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Krakowiak A, Janasik B, Sadowski Ł, Szwabe K, Wiśniewski T, Anna Rak M, Machała W. The use of CytoSorb in acute oral mercuric chloride poisoning at a potentially lethal dose. Int J Artif Organs 2024; 47:67-72. [PMID: 38142295 DOI: 10.1177/03913988231215631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2023]
Abstract
INTRODUCTION The study aims to present a case of acute mercuric chloride poisoning treated successfully with continuous renal replacement therapy using the CytoSorb filter. CASE DESCRIPTION A 21-year-old female patient after a suicide attempt by intentional ingestion of mercuric chloride, was admitted to the hospital with features of multiple organ damage for specific treatment. The performed laboratory tests confirmed high levels of mercury in the blood (1051 μg/L) and urine (22,960 μg/L). Due to acute renal failure, continuous renal replacement therapy (CRRT) CVVHD Ci-Ca was initiated; the procedure was then converted to CVVHDF Ci-Ca with ultrafiltration to optimise therapy, and CytoSorb was added to the artificial kidney system on day 3. Specific antidote therapy (DMPS) was administered concurrently. The ongoing treatment resulted in a reduction in subjective complaints, a decrease in blood mercury levels to 580 μg/L, and an improvement in parenchymal organ function. CONCLUSION In the event of poisoning with inorganic mercury compounds (mercuric chloride), continuous renal replacement therapy using the CytoSorb filter as an extracorporeal blood purification method may be considered.
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Affiliation(s)
- Anna Krakowiak
- Clinic of Anaesthesiology and Intensive Care, Central Clinical Hospital of the Medical University of Łódź, Lodz, Poland
- Centre for Physicians Training in Public Health, Nofer Institute of Occupational Medicine in Łódź, Lodz, Poland
| | - Beata Janasik
- Department of Biological and Enviromental Monitoring, Nofer Institute of Occupational Medicine in Łódź, Lodz, Poland
| | - Łukasz Sadowski
- Clinic of Anaesthesiology and Intensive Care, Central Clinical Hospital of the Medical University of Łódź, Lodz, Poland
| | - Katarzyna Szwabe
- Department of Laboratory Diagnostics and Clinical Biochemistry, Medical University of Łódź, Lodz, Poland
- Medical Diagnostic Laboratory, Central Clinical Hospital of Medical University of Łódź, Lodz, Poland
| | - Tomasz Wiśniewski
- Clinic of Anaesthesiology and Intensive Care, Central Clinical Hospital of the Medical University of Łódź, Lodz, Poland
| | - Małgorzata Anna Rak
- Department of Emergency Medicine, Faculty of Medical Sciences, Academy of Silesia, Katowice, Poland
| | - Waldemar Machała
- Clinic of Anaesthesiology and Intensive Care, Central Clinical Hospital of the Medical University of Łódź, Lodz, Poland
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Tomescu D, Popescu M, Akil A, Nassiri AA, Wunderlich-Sperl F, Kogelmann K, Molnar Z, Alharthy A, Karakitsos D. The potential role of extracorporeal cytokine removal with CytoSorb® as an adjuvant therapy in Acute Respiratory Distress Syndrome. Int J Artif Organs 2023; 46:605-617. [PMID: 38037333 DOI: 10.1177/03913988231211740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Management of acute respiratory distress syndrome (ARDS) represents one of the greatest challenges in intensive care and despite all efforts mortality remains high. One common phenotype of ARDS is that of a secondary injury to a dysregulated inflammatory host response resulting in increased capillary congestion, interstitial lung edema, atelectasis, pulmonary embolism, muscle wasting, recurring infectious episodes, and multiple organ failure. In cases of hyperinflammation, immunomodulation by extracorporeal cytokine removal such as the CytoSorb hemoadsorption cartridge could conceptually enhance lung recovery during the early course of the disease. The aim of this narrative review is to summarize the currently available data in this field and to provide an overview of pathophysiology and rationale for the use of CytoSorb hemoadsorption in patients with hyperinflammatory ARDS.
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Affiliation(s)
- Dana Tomescu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Fundeni Clinical Institute, Department of Anaesthesia and Intensive Care, Bucharest, Romania
| | - Mihai Popescu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Fundeni Clinical Institute, Department of Anaesthesia and Intensive Care, Bucharest, Romania
| | - Ali Akil
- Department of Thoracic Surgery, Hans Susemihl Hospital Emden, Emden, Germany
| | - Amir Ahmad Nassiri
- Division of Nephrology, Department of Internal Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Florian Wunderlich-Sperl
- Clinical Department of Anesthesiology and Intensive Care Medicine, University Hospital St. Pölten-Lilienfeld, St. Pölten, Austria
| | - Klaus Kogelmann
- Department of Anesthesiology and Intensive Care Medicine, Hans Susemihl Hospital Emden, Emden, Germany
| | - Zsolt Molnar
- CytoSorbents Europe GmbH, Berlin, Germany
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Dimitrios Karakitsos
- Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia
- Critical Care Department, Keck School of Medicine, USC, Los Angeles, CA, USA
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Leber B, Liebchen U, Rohrhofer L, Weber J, Klaus T, Scheier J, Sucher R, Stiegler P. Pharmacokinetics of immunosuppressive agents during hemoperfusion in a sheep model. Front Med (Lausanne) 2023; 10:1258661. [PMID: 37928476 PMCID: PMC10623319 DOI: 10.3389/fmed.2023.1258661] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 10/02/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction Hemoadsorption shows promising signals in organ preservation and post lung transplantation. However, its potential impact on the pharmacokinetics of immunosuppressant drugs (ID) is still unknown. Methods In this interventional study, CytoSorb® hemoperfusion was tested in healthy sheep (n = 5) against a sham extracorporeal circuit (n = 3). Seven different ID (tacrolimus (TAC), cyclosporin A (CYA), mycophenolate mofetil (MMF), everolimus (EVER), basiliximab (BAS), methylprednisolone (MP) and prednisolone (PRED)) were administered in clinically relevant doses and combinations. Their levels were measured repeatedly in blood samples from the extracorporeal circulation over 6 h following administration. Population pharmacokinetic modeling analysis (NONMEM® 7.5) was performed. Results Negligible clearance was observed for PRED and BAS. For all other substances, a saturable adsorption sub-model with linear decrease of the adsorption effect over the adsorbed amount best described the measured concentrations. The maximum absolute adsorbed amounts (95% CI) for TAC, CYA, MMF, EVER, and MP were 0.040 (0.028-0.053), 1.15 (0.39-1.91), 4.17 (2.00-6.35), 0.0163 (0.007-0.026), and 53.4 mg (20.9-85.9), respectively, indicating an adsorption of less than 5% of the daily administered dosages for all investigated substances. Discussion In this large animal model, CytoSorb® hemoperfusion appears to have a limited effect on the clearance of tested ID.
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Affiliation(s)
- Bettina Leber
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Uwe Liebchen
- Department of Anesthesiology, LMU Hospital, Munich, Germany
| | - Lisa Rohrhofer
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Jennifer Weber
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | | | | | - Robert Sucher
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Philipp Stiegler
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
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Kovacevic P, Dragic S, Jandric M, Momcicevic D, Topolovac S, Malesevic V, Kovacevic T, Matejic-Spasic M, Knezevic T, Zlojutro B. Post VV-ECMO Weaning Hyperinflammation-Can Prophylactic Hemoadsorption Treatment Prevent Complications? Medicina (Kaunas) 2023; 59:1818. [PMID: 37893535 PMCID: PMC10607931 DOI: 10.3390/medicina59101818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/23/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023]
Abstract
Acute respiratory distress syndrome (ARDS) is a severe clinical condition characterized by acute respiratory failure and a high mortality risk despite conventional mechanical ventilatory support. Veno-venous extracorporeal membrane oxygenation (vvECMO) has emerged as an effective life-support technology for patients with ARDS. However, complications may arise following the decannulation of vvECMO, with a relatively frequent development of systemic hyperinflammation (SHI). Among the various treatment strategies for SHI, the use of hemoadsorption with CytoSorb® has shown promising results in removing excessive levels of cytokines and attenuating the hyperinflammatory response. In this case series, we present three critically ill patients with ARDS secondary to pneumonia who underwent vvECMO and subsequently received prophylactic hemoadsorption with CytoSorb® following decannulation as a part of our clinical practice. This case series aims to describe the potential positive effects of hemoadsorption in preventing the development of SHI after vvECMO decannulation in ARDS patients.
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Affiliation(s)
- Pedja Kovacevic
- Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, 78000 Banja Luka, Bosnia and Herzegovina; (S.D.); (M.J.); (D.M.); (S.T.); (V.M.); (T.K.); (B.Z.)
- Faculty of Medicine, University of Banja Luka, 78000 Banja Luka, Bosnia and Herzegovina
| | - Sasa Dragic
- Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, 78000 Banja Luka, Bosnia and Herzegovina; (S.D.); (M.J.); (D.M.); (S.T.); (V.M.); (T.K.); (B.Z.)
- Faculty of Medicine, University of Banja Luka, 78000 Banja Luka, Bosnia and Herzegovina
| | - Milka Jandric
- Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, 78000 Banja Luka, Bosnia and Herzegovina; (S.D.); (M.J.); (D.M.); (S.T.); (V.M.); (T.K.); (B.Z.)
| | - Danica Momcicevic
- Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, 78000 Banja Luka, Bosnia and Herzegovina; (S.D.); (M.J.); (D.M.); (S.T.); (V.M.); (T.K.); (B.Z.)
- Faculty of Medicine, University of Banja Luka, 78000 Banja Luka, Bosnia and Herzegovina
| | - Sandra Topolovac
- Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, 78000 Banja Luka, Bosnia and Herzegovina; (S.D.); (M.J.); (D.M.); (S.T.); (V.M.); (T.K.); (B.Z.)
| | - Vedrana Malesevic
- Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, 78000 Banja Luka, Bosnia and Herzegovina; (S.D.); (M.J.); (D.M.); (S.T.); (V.M.); (T.K.); (B.Z.)
| | - Tijana Kovacevic
- Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, 78000 Banja Luka, Bosnia and Herzegovina; (S.D.); (M.J.); (D.M.); (S.T.); (V.M.); (T.K.); (B.Z.)
- Faculty of Medicine, University of Banja Luka, 78000 Banja Luka, Bosnia and Herzegovina
| | | | - Tanja Knezevic
- Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, 78000 Banja Luka, Bosnia and Herzegovina; (S.D.); (M.J.); (D.M.); (S.T.); (V.M.); (T.K.); (B.Z.)
| | - Biljana Zlojutro
- Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, 78000 Banja Luka, Bosnia and Herzegovina; (S.D.); (M.J.); (D.M.); (S.T.); (V.M.); (T.K.); (B.Z.)
- Faculty of Medicine, University of Banja Luka, 78000 Banja Luka, Bosnia and Herzegovina
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Bottari G, Guzzo I, Cappoli A, Labbadia R, Perdichizzi S, Serpe C, Creteur J, Cecchetti C, Taccone FS. Impact of CytoSorb and CKRT on hemodynamics in pediatric patients with septic shock: the PedCyto study. Front Pediatr 2023; 11:1259384. [PMID: 37780052 PMCID: PMC10540853 DOI: 10.3389/fped.2023.1259384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 08/21/2023] [Indexed: 10/03/2023] Open
Abstract
Background There is a lack of data to support the use of hemoadsorption in pediatric septic shock. The aim of our study was to assess the effectiveness and safety of CytoSorb therapy in this setting. Methods Phase II interventional single arm pilot study in which 17 consecutive children admitted with septic shock who required continuous kidney replacement therapy (CKRT) and weighed ≥10 kg were included. A CytoSorb (CytoSorbents Inc, New Jersey, USA) hemoadsorption cartridge was added to the CKRT every 24 h for a maximum of 96 h. A control group of 13 children with septic shock treated with CKRT but not hemoadsorption at Children's Hospital Bambino Gesù and enrolled in the EuroAKId register was selected as an historical cohort. The primary outcome of the study was a reduction in vasopressor or inotrope dose of >50% from baseline by the end of CytoSorb therapy. Secondary outcomes included hemodynamic and biological changes, changes in severity scores, and 28-day mortality. Results There were significant decreases in the Vasoactive Inotropic Score (VIS) and the Pediatric Logistic Organ Dysfunction 2 (PELOD-2) score at 72 and 96 h from the start of the CytoSorb therapy compared to baseline; the reductions were larger in the hemoadsorption group than in the control group (historical cohort). 28-day mortality was lower, although not significantly, in the hemoadsorption group when compared to the control group (5/17 [29%] vs. 8/13 [61%] OR 0.26 [95% CI: 0.05-1.2]; p = 0.08). Conclusions CytoSorb therapy may have some benefits in pediatric patients with septic shock. Future larger randomized trials are needed in this setting. Clinical Trial Registration https://clinicaltrials.gov/ct2/show/NCT05658588, identifier (Clinicaltrials.gov NCT05658588).
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Affiliation(s)
- Gabriella Bottari
- Pediatric Emergency Department, Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Isabella Guzzo
- Department of Pediatrics, Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Andrea Cappoli
- Department of Pediatrics, Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Raffaella Labbadia
- Department of Pediatrics, Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Salvatore Perdichizzi
- Pediatric Emergency Department, Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Carmela Serpe
- Pediatric Emergency Department, Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Jacques Creteur
- Department of Intensive Care, Hopital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Corrado Cecchetti
- Pediatric Emergency Department, Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hopital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
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10
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Pascucci F, Donati T, Tinelli G, Arlotta G, Luparelli A, Tshomba Y. Intraoperative immunomodulation during left heart bypass in open thoracoabdominal aortic aneurysm repair. J Vasc Surg Cases Innov Tech 2023; 9:101276. [PMID: 37662566 PMCID: PMC10470191 DOI: 10.1016/j.jvscit.2023.101276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/02/2023] [Indexed: 09/05/2023] Open
Abstract
Despite the technical innovations introduced in the previous decades, open thoracoabdominal aortic aneurysm repair still represents an enormous challenge for patients and surgeons. Logically, the systemic inflammatory response resulting from these massive operations appears considerable; however, the response has never been thoroughly investigated. In addition, intraoperative adjuncts to modulate the postoperative activation of the immune system have not yet been introduced into clinical practice. We report a case of intraoperative hemadsorption during open repair of a thoracoabdominal aortic aneurysm through the introduction of a CytoSorb device (CytoSorbents Corp) in the left heart bypass circuit. The technique appeared feasible and safe and probably contributed to the good clinical outcomes.
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Affiliation(s)
- Federico Pascucci
- Vascular Surgery Unit, Fondazione Policlinico Universitario A Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Tommaso Donati
- Vascular Surgery Unit, Fondazione Policlinico Universitario A Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Tinelli
- Vascular Surgery Unit, Fondazione Policlinico Universitario A Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gabriella Arlotta
- Cardiac Anesthesia and Intensive Care Unit, Fondazione Policlinico Universitario A Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Luparelli
- Vascular Surgery Unit, Fondazione Policlinico Universitario A Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yamume Tshomba
- Vascular Surgery Unit, Fondazione Policlinico Universitario A Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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11
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Ehrsam JP, Arni S, Weisskopf M, Nowack M, Inci I. Extracorporeal cytokine adsorption reduces systemic cytokine storm and improves graft function in lung transplantation. JTCVS Open 2023; 15:497-507. [PMID: 37808017 PMCID: PMC10556959 DOI: 10.1016/j.xjon.2023.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/10/2023] [Accepted: 06/21/2023] [Indexed: 10/10/2023]
Abstract
Objectives Ischemia-reperfusion injury often coincides with a cytokine storm, which can result in primary graft dysfunction following lung transplantation. Our previous research has demonstrated allograft improvement by cytokine adsorption during ex vivo lung perfusion. The aim of this study was to investigate the effect of in vivo extracorporeal cytokine adsorption in a large animal model. Materials and Methods Pig left lung transplantation was performed following 24 hours of cold ischemic storage. Observation period after transplantation was 24 hours. In the treatment group (n = 6), extracorporeal CytoSorb adsorption was started 30 minutes before reperfusion and continued for 6 hours. A control group (n = 3) did not receive adsorber treatment. Results During adsorption, we consistently noticed a significant decrease in plasma proinflammatory interleukin (IL)-2, trends of less proinflammatory, tumor necrosis factor- α, IL-1α, and granulocyte-macrophage colony-stimulating factor as well as significantly reduced systemic neutrophils. In addition, a significantly lower peak airway pressure was detected during the 6 hours of adsorption. After 24 hours of observation, when evaluating the left lung allograft independently, we observed significantly improved CO2 removal, partial pressure of oxygen/inspired oxygen fraction ratio, and less acidosis in the treatment group. At autopsy, bronchoalveolar lavage results exhibited significantly lower recruitment of cells and less pro-inflammatory IL-1α, IL-1β, IL-6, and IL-8 in the treatment group. Histologically, the treatment group had a strong trend, indicating less neutrophil invasion into the alveolar space. Conclusions Based on our findings, cytokine adsorption during and after reperfusion is a viable approach to reducing posttransplant inflammation following lung transplantation. CytoSorb may increase the acceptance of extended criteria donor lungs, which are more susceptible to ischemia-reperfusion injury.
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Affiliation(s)
- Jonas Peter Ehrsam
- School of Medicine, University of Zurich, Zurich, Switzerland
- Klinik Hirslanden Zurich, Thoracic Surgery Clinic, Zurich, Switzerland
| | - Stephan Arni
- Center for Surgical Research, University Hospital Zurich, Zurich, Switzerland
| | - Miriam Weisskopf
- Center for Preclinical Development, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Miriam Nowack
- Department of Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Ilhan Inci
- School of Medicine, University of Zurich, Zurich, Switzerland
- Klinik Hirslanden Zurich, Thoracic Surgery Clinic, Zurich, Switzerland
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12
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Bottari G, Goffredo BM, Marano M, Maccarrone C, Simeoli R, Bianco G, Vallesi L, Beetham JCC, Mazzeo AT, Cappoli A, Cairoli S, Labbadia R, Cecchetti C, Bernaschi P, Corsetti T, Morabito S, Taccone FS, Guzzo I. Impact of Continuous Kidney Replacement Therapy and Hemoadsorption with CytoSorb on Antimicrobial Drug Removal in Critically Ill Children with Septic Shock: A Single-Center Prospective Study on a Pediatric Cohort. Antibiotics (Basel) 2023; 12:1395. [PMID: 37760692 PMCID: PMC10525765 DOI: 10.3390/antibiotics12091395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
Background: Extracorporeal therapies (ET) are increasingly used in pediatric settings as adjuvant therapeutic strategies for overwhelming inflammatory conditions. Although these treatments seem to be effective for removing inflammatory mediators, their influence on antimicrobials pharmacokinetic should not be neglected. Methods: A prospective observational study of children admitted to the pediatric intensive care unit (PICU) with a diagnosis of sepsis/septic shock. All critically ill children received hemoadsorption treatment with CytoSorb (CS) in combination with CKRT. Therapeutic drug monitoring has been performed on 10 critically ill children, testing four antimicrobial molecules: meropenem, ceftazidime, amikacin and levofloxacin. In order to evaluate the total and isolated CKRT and CS contributions to antibiotic removal, blood samples at each circuit point (post-hemofilter, post-CS and in the effluent line) were performed. Therefore, the clearance and mass Removal (MR) of the hemofilter and CS were calculated. Results: Our preliminary report describes a different impact of CS on these target drugs removal: CS clearance was low for amikacine (6-12%), moderate for ceftazidime (43%) and moderate to high for levofloxacine (52-72%). Higher MR and clearance were observed with CKRT compared to CS. To the best of our knowledge, this is the first report regarding pharmacokinetic dynamics in critically ill children treated with CKRT and CS for septic shock.
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Affiliation(s)
- Gabriella Bottari
- Pediatric Intensive Care Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.M.); (J.C.C.B.); (C.C.)
| | - Bianca Maria Goffredo
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCSS, 00165 Rome, Italy; (B.M.G.); (R.S.); (S.C.)
| | - Marco Marano
- Pediatric Intensive Care Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.M.); (J.C.C.B.); (C.C.)
| | - Cristina Maccarrone
- Anesthesia and Intensive Care Department of Human Pathology, University of Messina, 98158 Messina, Italy; (C.M.); (A.T.M.)
| | - Raffaele Simeoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCSS, 00165 Rome, Italy; (B.M.G.); (R.S.); (S.C.)
| | - Giuseppe Bianco
- Hospital Pharmacy Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (G.B.); (L.V.); (T.C.)
| | - Leonardo Vallesi
- Hospital Pharmacy Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (G.B.); (L.V.); (T.C.)
| | | | - Anna Teresa Mazzeo
- Anesthesia and Intensive Care Department of Human Pathology, University of Messina, 98158 Messina, Italy; (C.M.); (A.T.M.)
| | - Andrea Cappoli
- Division of Nephrology and Dialysis, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (A.C.); (R.L.); (I.G.)
| | - Sara Cairoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCSS, 00165 Rome, Italy; (B.M.G.); (R.S.); (S.C.)
| | - Raffaella Labbadia
- Division of Nephrology and Dialysis, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (A.C.); (R.L.); (I.G.)
| | - Corrado Cecchetti
- Pediatric Intensive Care Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.M.); (J.C.C.B.); (C.C.)
| | - Paola Bernaschi
- Microbiology and Diagnostic Immunology Unit, Department of Diagnostic and Laboratory Medicine, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Tiziana Corsetti
- Hospital Pharmacy Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (G.B.); (L.V.); (T.C.)
| | - Santo Morabito
- Hemodialysis Unit, Department of Internal Medicine and Medical Specialties, Policlinico Umberto I, 00161 Rome, Italy;
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hopital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium;
| | - Isabella Guzzo
- Division of Nephrology and Dialysis, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (A.C.); (R.L.); (I.G.)
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13
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Göth D, Mahler CF, Kälble F, Speer C, Benning L, Schmitt FCF, Dietrich M, Krautkrämer E, Zeier M, Merle U, Morath C, Fiedler MO, Weigand MA, Nusshag C. Liver-Support Therapies in Critical Illness-A Comparative Analysis of Procedural Characteristics and Safety. J Clin Med 2023; 12:4669. [PMID: 37510784 PMCID: PMC10380554 DOI: 10.3390/jcm12144669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/09/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Extracorporeal liver-support therapies remain controversial in critically ill patients, as most studies have failed to show an improvement in outcomes. However, heterogeneous timing and inclusion criteria, an insufficient number of treatments, and the lack of a situation-dependent selection of available liver-support modalities may have contributed to negative study results. We retrospectively investigated the procedural characteristics and safety of the three liver-support therapies CytoSorb, Molecular Adsorbent Recirculating System (MARS) and therapeutic plasma exchange (TPE). Whereas TPE had its strengths in a shorter treatment duration, in clearing larger molecules, affecting platelet numbers less, and improving systemic coagulation and hemodynamics, CytoSorb and MARS were associated with a superior reduction in particularly small protein-bound and water-soluble substances. The clearance magnitude was concentration-dependent for all three therapies, but additionally related to the molecular weight for CytoSorb and MARS therapy. Severe complications did not appear. In conclusion, a better characterization of disease-driving as well as beneficial molecules in critically ill patients with acute liver dysfunction is crucial to improve the use of liver-support therapy in critically ill patients. TPE may be beneficial in patients at high risk for bleeding complications and impaired liver synthesis and hemodynamics, while CytoSorb and MARS may be considered for patients in whom the elimination of smaller toxic compounds is a primary objective.
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Affiliation(s)
- Daniel Göth
- Department of Nephrology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Christoph F Mahler
- Department of Nephrology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Florian Kälble
- Department of Nephrology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Claudius Speer
- Department of Nephrology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Louise Benning
- Department of Nephrology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Felix C F Schmitt
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Maximilian Dietrich
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Ellen Krautkrämer
- Department of Nephrology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Martin Zeier
- Department of Nephrology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Uta Merle
- Department of Gastroenterology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Christian Morath
- Department of Nephrology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Mascha O Fiedler
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Christian Nusshag
- Department of Nephrology, Heidelberg University Hospital, 69120 Heidelberg, Germany
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14
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Dalmastri V, Angelini A, Minerva V, Ballarini M, Grammatico F, Todeschini P, Pizzini AM, Silingardi M, La Manna G. Extracorporeal hemoadsorption therapy as a potential therapeutic option for rapid removal of Apixaban in high risk-surgical patients: a case report. J Med Case Rep 2023; 17:283. [PMID: 37415195 DOI: 10.1186/s13256-023-03949-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 04/25/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND Apixaban is a non-vitamin K antagonist oral anticoagulant (NOACs) recently emerged as an effective alternative to conventional vitamin K antagonists (VKAs) in the treatment of several thromboembolic disorders. However, in case of overdose or in patients requiring emergency surgery there is a high bleeding rate and severe adverse side effects due to the absence of an antidote. There is promising data from in vitro and clinical studies, that certain antithrombotic agents (that is Rivaroxaban and Ticagrelor) have been successfully removed by the extracorporeal hemoadsorption therapy CytoSorb. Here, we present the case of a patient successfully treated with CytoSorb as a kind of antidote to enable emergency surgery for bilateral nephrostomy. CASE PRESENTATION A 82-year-old Caucasian man was admitted to the Emergency Room with acute kidney injury (AKI) in the context of severe bilateral hydroureteronephrosis. The patient's medical history included chronic obstructive pulmonary disease, arterial hypertension, atrial fibrillation (anticoagulated with Apixaban) and a locally advanced prostate adenocarcinoma treated with trans-ureteral resection of the bladder and radiotherapy in the previous months. The indication for a bilateral nephrostomy could not be considered immediately given the major bleeding risk due to Apixaban, which was discontinued and replaced with calciparin. After 36 hours of continuous renal replacement therapy (CRRT), the Apixaban blood level was still elevated and it was decided to install CytoSorb into the running CRRT to accelerate the drug clearance. After 2 hours 30 minutes, there was good reduction of Apixaban from 139 to 72 ng/ml (reduction rate of 48.2%) registered, and this allowed for an easy placement of bilateral nephrostomies without complications. Four days after surgery renal function parameters further normalized, the patient did not require additional dialysis treatments and Apixaban therapy was prescribed again once the patient returned home. CONCLUSIONS In this case we report the findings of a patient with post-renal AKI requiring emergency nephrostomy placement while on chronic anticoagulation with Apixaban therapy. Combined treatment with CRRT and CytoSorb was associated with the rapid and effective removal of Apixaban allowing for prompt and urgent surgery while simultaneously ensuring the low risk of bleeding as well as an uneventful post-operative course.
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Affiliation(s)
- Vittorio Dalmastri
- Nephrology Dialysis and Renal Transplant Unit IRCCS St, Orsola University Hospital, Bologna, Italy.
| | - Andrea Angelini
- Nephrology Dialysis and Renal Transplant Unit IRCCS St, Orsola University Hospital, Bologna, Italy
| | - Vera Minerva
- Nephrology Dialysis and Renal Transplant Unit IRCCS St, Orsola University Hospital, Bologna, Italy
| | - Melissa Ballarini
- Dialysis Unit, Maggiore General Hospital, National Public Health System, Largo Nigrisoli, 2, 40133, Bologna, BO, Italy
| | - Francesco Grammatico
- Nephrology Dialysis and Renal Transplant Unit IRCCS St, Orsola University Hospital, Bologna, Italy
| | - Paola Todeschini
- Nephrology Dialysis and Renal Transplant Unit IRCCS St, Orsola University Hospital, Bologna, Italy
| | | | - Mauro Silingardi
- Department of Medicine, Maggiore General Hospital, AUSL, Bologna, Italy
| | - Gaetano La Manna
- Nephrology Dialysis and Renal Transplant Unit IRCCS St, Orsola University Hospital, Bologna, Italy
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15
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Hayanga JWA, Song T, Durham L, Garrison L, Smith D, Molnar Z, Scheier J, Deliargyris EN, Moazami N. Extracorporeal hemoadsorption in critically ill COVID-19 patients on VV ECMO: the CytoSorb therapy in COVID-19 (CTC) registry. Crit Care 2023; 27:243. [PMID: 37337243 PMCID: PMC10280833 DOI: 10.1186/s13054-023-04517-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 06/02/2023] [Indexed: 06/21/2023] Open
Abstract
OBJECTIVES The CytoSorb therapy in COVID-19 (CTC) registry evaluated the clinical performance and treatment parameters of extracorporeal hemoadsorption integrated with veno-venous extracorporeal membrane oxygenation (VV ECMO) in critically ill COVID-19 patients with acute respiratory distress syndrome (ARDS) and respiratory failure under US FDA Emergency Use Authorization. DESIGN Multicenter, observational, registry (NCT04391920). SETTING Intensive care units (ICUs) in five major US academic centers between April 2020 and January 2022. PATIENTS A total of 100 critically ill adults with COVID-19-related ARDS requiring VV ECMO support, who were treated with extracorporeal hemoadsorption. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Baseline demographics, clinical characteristics, laboratory values and outcomes were recorded following individual ethics committee approval at each center. Detailed data on organ support utilization parameters and hemoadsorption treatments were also collected. Biomarker data were collected according to the standard practice at each participating site, and available values were compared before and after hemoadsorption. The primary outcome of mortality was evaluated using a time-to-event analysis. A total of 100 patients (63% male; age 44 ± 11 years) were included. Survival rates were 86% at 30 days and 74% at 90 days. Median time from ICU admission to the initiation of hemoadsorption was 87 h and was used to define two post hoc groups: ≤ 87 h (group-early start, GE) and > 87 h (group-late start, GL). After the start of hemoadsorption, patients in the GE versus GL had significantly shorter median duration of mechanical ventilation (7 [2-26] vs. 17 [7-37] days, p = 0.02), ECMO support (13 [8-24] vs. 29 [14-38] days, p = 0.021) and ICU stay (17 [10-40] vs 36 [19-55] days, p = 0.002). Survival at 90 days in GE was 82% compared to 66% in GL (p = 0.14). No device-related adverse events were reported. CONCLUSIONS In critically ill patients with severe COVID-19-related ARDS treated with the combination of VV-ECMO and hemoadsorption, 90-day survival was 74% and earlier intervention was associated with shorter need for organ support and ICU stay. These results lend support to the concept of "enhanced lung rest" with the combined use of VV-ECMO plus hemoadsorption in patients with ARDS.
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Affiliation(s)
- J W Awori Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, 1 Medical Center Drive, Morgantown, WV, 26506, USA.
| | - Tae Song
- University of Chicago Medicine, Chicago, USA
| | | | | | - Deane Smith
- New York University School of Medicine, New York, USA
| | - Zsolt Molnar
- CytoSorbents Europe, Berlin, Germany
- Semmelweis University, Budapest, Hungary
| | | | | | - Nader Moazami
- New York University School of Medicine, New York, USA
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16
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Meagher J, Hendricks J, Eatroff A. Cytokine Adsorption as an Adjunctive Treatment for Patients with Immune-Mediated Hemolytic Anemia Receiving Therapeutic Plasma Exchange: A Case Series of 3 Dogs. Vet Med (Auckl) 2023; 14:103-110. [PMID: 37283630 PMCID: PMC10241178 DOI: 10.2147/vmrr.s407139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/19/2023] [Indexed: 06/08/2023]
Abstract
The use of cytokine adsorption is an emerging treatment for inflammatory diseases in human medicine. There are few reports of this treatment modality in veterinary medicine and no reports of the use of a cytokine adsorbent for immune-mediated hemolytic anemia (IMHA). These case reports illustrate the use of a cytokine adsorbent as an adjunctive treatment during therapeutic plasma exchange (TPE). All dogs were unresponsive to conventional treatment or were severely affected by rapid hemolysis of red blood cells. The aim was to treat all dogs with three sequential TPE sessions; however, one dog died before completion of three sessions and one dog required additional sessions. Preliminary evidence indicates that the use of a cytokine adsorption is well tolerated and can be considered as an adjunct in the management of IMHA that is severe or refractory to traditional treatment.
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Affiliation(s)
- John Meagher
- Advanced Critical Care Emergency and Specialty Services, Culver City, CA, USA
| | - Jeanette Hendricks
- Advanced Critical Care Emergency and Specialty Services, Culver City, CA, USA
| | - Adam Eatroff
- Advanced Critical Care Emergency and Specialty Services, Culver City, CA, USA
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17
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Jansen A, Waalders NJB, van Lier DPT, Kox M, Pickkers P. CytoSorb hemoperfusion markedly attenuates circulating cytokine concentrations during systemic inflammation in humans in vivo. Crit Care 2023; 27:117. [PMID: 36945034 PMCID: PMC10029173 DOI: 10.1186/s13054-023-04391-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/03/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND The CytoSorb hemoadsorption device has been demonstrated to be capable of clearing inflammatory cytokines, but has not yet been shown to attenuate plasma cytokine concentrations. We investigated the effects of CytoSorb hemoperfusion on plasma levels of various cytokines using the repeated human experimental endotoxemia model, a highly standardized and reproducible human in vivo model of systemic inflammation and immunological tolerance induced by administration of bacterial lipopolysaccharide (LPS). METHODS Twenty-four healthy male volunteers (age 18-35) were intravenously challenged with LPS (a bolus of 1 ng/kg followed by continuous infusion of 0.5 ng/kg/hr for three hours) twice: on day 0 to quantify the initial cytokine response and on day 7 to quantify the degree of endotoxin tolerance. Subjects either received CytoSorb hemoperfusion during the first LPS challenge (CytoSorb group), or no intervention (control group). Plasma cytokine concentrations and clearance rates were determined serially. This study was registered at ClinicalTrials.gov (NCT04643639, date of registration November 24th 2020). RESULTS LPS administration led to a profound increase in plasma cytokine concentrations during both LPS challenge days. Compared to the control group, significantly lower plasma levels of tumor necrosis factor (TNF, - 58%, p < 0.0001), interleukin (IL)-6 ( - 71%, p = 0.003), IL-8 ( - 48%, p = 0.02) and IL-10 ( - 26%, p = 0.03) were observed in the CytoSorb group during the first LPS challenge. No differences in cytokine responses were observed during the second LPS challenge. CONCLUSIONS CytoSorb hemoperfusion effectively attenuates circulating cytokine concentrations during systemic inflammation in humans in vivo, whereas it does not affect long-term immune function. Therefore, CytoSorb therapy may be of benefit in conditions characterized by excessive cytokine release.
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Affiliation(s)
- Aron Jansen
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences (RIMLS), Nijmegen, The Netherlands.
- Radboud University Medical Center, Radboud Center for Infectious Diseases (RCI), Nijmegen, the Netherlands.
| | - Nicole J B Waalders
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences (RIMLS), Nijmegen, The Netherlands
- Radboud University Medical Center, Radboud Center for Infectious Diseases (RCI), Nijmegen, the Netherlands
| | - Dirk P T van Lier
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences (RIMLS), Nijmegen, The Netherlands
- Radboud University Medical Center, Radboud Center for Infectious Diseases (RCI), Nijmegen, the Netherlands
| | - Matthijs Kox
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences (RIMLS), Nijmegen, The Netherlands
- Radboud University Medical Center, Radboud Center for Infectious Diseases (RCI), Nijmegen, the Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences (RIMLS), Nijmegen, The Netherlands.
- Radboud University Medical Center, Radboud Center for Infectious Diseases (RCI), Nijmegen, the Netherlands.
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18
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Wei S, Zhang Y, Zhai K, Li J, Li M, Yang J, Zhang R, Li Y, Li Z. CytoSorb in patients with coronavirus disease 2019: A rapid evidence review and meta-analysis. Front Immunol 2023; 14:1067214. [PMID: 36798138 PMCID: PMC9927009 DOI: 10.3389/fimmu.2023.1067214] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/17/2023] [Indexed: 02/04/2023] Open
Abstract
Background After its approval by the European Union in 2011, CytoSorb therapy has been applied to control cytokine storm and lower the increased levels of cytokines and other inflammatory mediators in blood. However, the efficiency of this CytoSorb treatment in patients with coronavirus disease (COVID-19) still remains unclear. To elucidate the Cytosorb efficiency, we conducted a systematic review and single-arm proportion meta-analysis to combine all evidence available in the published literature to date, so that this comprehensive knowledge can guide clinical decision-making and future research. Methods The literature published within the period 1 December 2019 to 31 December 2021 and stored in the Cochrane Library, Embase, PubMed, and International Clinical Trials Registry Platform (ICTRP) was searched for all relevant studies including the cases where COVID-19 patients were treated with CytoSorb. We performed random-effects meta-analyses by R software (3.6.1) and used the Joanna Briggs Institute checklist to assess the risk of bias. Both categorical and continuous variables were presented with 95% confidence intervals (CIs) as pooled proportions for categorical variables and pooled means for continuous outcomes. Results We included 14 studies with 241 COVID-19 patients treated with CytoSorb hemadsorption. Our findings reveal that for COVID-19 patients receiving CytoSorb treatment, the combined in-hospital mortality was 42.1% (95% CI 29.5-54.6%, I2 = 74%). The pooled incidence of adjunctive extracorporeal membrane oxygenation (ECMO) support was 73.2%. Both the C-reactive protein (CRP) and interleukin-6 (IL-6) levels decreased after CytoSorb treatment. The pooled mean of the CRP level decreased from 147.55 (95% CI 91.14-203.96) to 92.36 mg/L (95% CI 46.74-137.98), while that of IL-6 decreased from 339.49 (95% CI 164.35-514.63) to 168.83 pg/mL (95% CI 82.22-255.45). Conclusions The majority of the COVID-19 patients treated with CytoSorb received ECMO support. In-hospital mortality was 42.1% for the COVID-19 patients who had CytoSorb treatment. Both CRP and IL-6 levels decreased after Cytosorb treatment.
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Affiliation(s)
- Shilin Wei
- Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China.,Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Yanchun Zhang
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Kerong Zhai
- Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China.,Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Jian Li
- Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Mingming Li
- Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Jianbao Yang
- Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China.,Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Rongzhi Zhang
- Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China.,Department of Anesthesiology, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Yongnan Li
- Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China.,Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Zhenzhen Li
- Department of Extracorporeal Circulation, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
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19
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Hartjes A, Machnik M, Kubasta C, Schrattbauer K. Severe Clozapine Poisoning Treated by Extracorporeal Blood Purification Therapy. Case Rep Nephrol Dial 2023; 13:84-89. [PMID: 37900923 PMCID: PMC10601855 DOI: 10.1159/000531130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 05/09/2023] [Indexed: 10/31/2023] Open
Abstract
Clozapine is a frequently used antipsychotic that, in case of overdose, can cause severe adverse side effects, such as hematological, cardiovascular, and neurological complications. As there is no specific antidote or reversal agent available, extracorporeal techniques such as CytoSorb hemoadsorption might represent a viable option, having already been used in a variety of intoxication scenarios with favorable rates of success. A 56-year-old male was admitted with generalized epileptic seizures and arrhythmias following ingestion of clozapine in a suicide attempt (5,000 mg). Subsequently, conventional supportive care was initiated. To accelerate drug removal, continuous veno-venous hemodiafiltration including the application of CytoSorb hemoadsorption therapy was started. Serial measurements confirmed rapid reduction of clozapine plasma levels. The patient remained hemodynamically stable throughout this period. Furthermore, there were no cardiac arrhythmias detected and liver values were normal. The patient improved and was successfully extubated 3 days after admission with good vigilance and no residual neurological abnormalities. This is the first clinical case report on the use of CytoSorb hemoadsorption in severe clozapine intoxication which helped quickly and efficiently reduce clozapine levels to nontoxic serum levels while preserving organ function. Therefore, CytoSorb might represent an alternative treatment modality to be considered for potentially lethal clozapine intoxications.
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Affiliation(s)
- Andreas Hartjes
- Department for Anesthesia and Intensive Care Medicine, Krankenhaus der Barmherzigen Schwestern Ried, Ried, Austria
| | - Matthäus Machnik
- Department for Anesthesia and Intensive Care Medicine, Krankenhaus der Barmherzigen Schwestern Ried, Ried, Austria
| | - Christa Kubasta
- Institute for Medical and Chemical Laboratory Diagnostics, Blood Depot, Tissue Bank, Kepler University Hospital Linz, Linz, Austria
| | - Karl Schrattbauer
- Institute for Laboratory Diagnostics, Krankenhaus der Barmherzigen Schwestern Ried, Ried, Austria
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20
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Kreutz J, Choukeir M, Chatzis G, Schieffer B, Markus B. Hemoadsorption as part of a multimodal therapy concept to treat Capnocytophaga sepsis with thrombocytopenia and multiple organ failure. Int J Artif Organs 2023; 46:52-57. [PMID: 36401351 DOI: 10.1177/03913988221132575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Capnocytophaga, a bacteria native to the oral flora of canines, in rare cases can lead to severe infections resulting in septic shock, respiratory tract infection, and multiple organ failure. In case of trauma following animal bites with rapidly progressing clinical courses, also adjunctive therapeutic measures such as extracorporeal blood purification therapies might be beneficial. CASE PRESENTATION We report on a 68-year-old male who was hospitalized with fever, oliguria and repeated vomiting after suffering a minor bite by his dog. On admission, he was diagnosed with sepsis. In addition, his coagulation status was markedly deranged resulting in the administration of mass transfusions to stabilize his coagulative status. Following detection of Capnocytophaga canimorsus, anti-infective therapy was initiated. In the context of a progressive respiratory deterioration and an increasing vigilance disorder, he had to be intubated. Due to development of renal failure, dialysis was started in conjunction with CytoSorb hemoadsorption therapy to control the hyperinflammatory condition. All of the applied therapeutic measures led to a rapid clinical stabilization, a control of the hyperinflammatory situation, and an improvement in his neurological status. The therapy was well tolerated with no complications encountered. CONCLUSIONS This case supports the clinical recognition of severe Capnocytophaga infection that can lead to critical conditions even in immunocompetent patients. Combined broad spectrum antibiotic therapy, mass transfusions, CRRT, and CytoSorb hemoadsorption therapy resulted in a control of the critical situation. However, further research is needed to fully elucidate the role of hemoadsorption in this rare but life-threatening setting.
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Affiliation(s)
- Julian Kreutz
- Department of Cardiology, Angiology and Critical Care Medicine, University Hospital (UKGM) Marburg, Philipps University, Marburg, Germany
| | - Maryana Choukeir
- Department of Cardiology, Angiology and Critical Care Medicine, University Hospital (UKGM) Marburg, Philipps University, Marburg, Germany
| | - Georgios Chatzis
- Department of Cardiology, Angiology and Critical Care Medicine, University Hospital (UKGM) Marburg, Philipps University, Marburg, Germany
| | - Bernhard Schieffer
- Department of Cardiology, Angiology and Critical Care Medicine, University Hospital (UKGM) Marburg, Philipps University, Marburg, Germany
| | - Birgit Markus
- Department of Cardiology, Angiology and Critical Care Medicine, University Hospital (UKGM) Marburg, Philipps University, Marburg, Germany
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21
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Buonocore M, Rex S, Degezelle K, Meyns B. CytoSorb haemoadsorption for removal of apixaban-A proof-of-concept pilot case for a randomized controlled trial. J Clin Pharm Ther 2022; 47:2373-2375. [PMID: 36351749 DOI: 10.1111/jcpt.13802] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 09/29/2022] [Accepted: 10/07/2022] [Indexed: 11/11/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Emergent cardiac surgery in patients under anticoagulant therapy is still a major point of concern. Recently approved reversal agents are often not available or not suitable in the cardiac surgery setting, and timely discontinuation of the drug is not always feasible. CytoSorb® haemoadsorption therapy has been approved in Europe for intraoperative ticagrelor and rivaroxaban removal during cardiopulmonary bypass (CPB), but thus far the efficacy of CytoSorb® haemoadsorber on other anticoagulants (apixaban, dabigatran, edoxaban) has only been tested in vitro, and some signals of clinical benefits have reported in a few case reports. CASE SUMMARY We describe a case of CPB implementation with CytoSorb® in a haemodynamic unstable patient with prosthetic aortic valve endocarditis on apixaban therapy. WHAT IS NEW AND CONCLUSION CytoSorb® proved to be effective for removal of apixaban in emergency surgery setting by direct measurements of drug levels before and during CPB circulation.
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Affiliation(s)
- Marianna Buonocore
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Karlien Degezelle
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
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22
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Jerman A, Andonova M, Persic V, Gubensek J. Extracorporeal Removal of Myoglobin in Patients with Rhabdomyolysis and Acute Kidney Injury: Comparison of High and Medium Cut-Off Membrane and an Adsorber Cartridge. Blood Purif 2022; 51:907-911. [PMID: 35340002 PMCID: PMC9808672 DOI: 10.1159/000521923] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 12/27/2021] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The role of extracorporeal myoglobin removal in the treatment of rhabdomyolysis-associated severe acute kidney injury (AKI) is not yet fully established. High cut-off (HCO) and medium cut-off (MCO) dialysis membrane and cytokine adsorber (CytoSorb®) have been used to this purpose in clinical practice. The data on comparative effectiveness of those methods are scarce. METHODS In this single-center retrospective study, we included patients with AKI and concomitant rhabdomyolysis (myoglobin >20,000 μg/L), who underwent at least one extracorporeal myoglobin removal procedure. The main outcome parameter was myoglobin reduction ratio, whereas albumin was assessed as a safety parameter. RESULTS We analyzed data for 15 patients, who underwent 28 procedures (13 HCO, 9 MCO, and 6 adsorber). Pre-treatment serum myoglobin levels were similar between the groups and myoglobin reduction was significant in HCO (p = 0.03) and MCO groups (p < 0.01) and borderline significant in adsorber group (p = 0.06). Reduction ratios were comparable between the groups (median 0.64 (inter-quartile range IQR 0.13-0.72), 0.54 (IQR 0.51-0.61) and 0.50 (IQR 0.37-0.62), respectively, p = 0.83). Both pre- and post-procedure serum albumin levels were significantly lower in the MCO group. However, with routine albumin substitution in the HCO group only, serum albumin remained stable during the procedures in all subgroups. CONCLUSIONS Novel MCO membrane might represent the optimal mode of treatment of severe rhabdomyolysis-associated AKI, as it allows for efficient removal of myoglobin, avoids albumin supplementation and is associated with lower costs. For patients requiring cytokine removal, the adsorption capsule can simultaneously reduce cytokine and myoglobin levels.
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Affiliation(s)
- Alexander Jerman
- Department of Nephrology, Center for Acute and Complicated Dialysis, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Milena Andonova
- Department of Nephrology, Center for Acute and Complicated Dialysis, University Medical Center Ljubljana, Ljubljana, Slovenia,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Vanja Persic
- Department of Nephrology, Center for Acute and Complicated Dialysis, University Medical Center Ljubljana, Ljubljana, Slovenia,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Jakob Gubensek
- Department of Nephrology, Center for Acute and Complicated Dialysis, University Medical Center Ljubljana, Ljubljana, Slovenia,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia,*Jakob Gubensek,
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23
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Mitrovic D, Huntjens DW, de Vos EAJ, van Tellingen M, Franssen EJF. Extracorporeal hemoadsorption with the CytoSorb device as a potential therapeutic option in severe intoxications: Review of the rationale and current clinical experiences. J Clin Pharm Ther 2022; 47:1444-1451. [PMID: 35924306 DOI: 10.1111/jcpt.13724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/01/2022] [Accepted: 06/06/2022] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Many severe intoxications occur with substances with no specific antidote, which is why methods of extracorporeal elimination represent a particularly useful and even critical component in their management. The purpose of this review is to summarize the accumulating evidence and clinical results from the application of CytoSorb hemoadsorption therapy in patients with severe intoxications. COMMENT The technology represents a promising technique with an increasing number of publications in a variety of severe intoxication scenarios suggesting that early intervention might provide rapid substance removal with subsequent overall clinical improvement. WHAT IS NEW AND CONCLUSION Given the tremendous challenges in performing prospective, randomized trials in this field, the strong safety profile of the device and the high acuity of these life-threatening situations, CytoSorb should be considered as a therapeutic option in severe intoxications, particularly when direct antidotes are not available. However, further clinical data are desirable to provide precise recommendations.
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Affiliation(s)
- Darko Mitrovic
- Hospital Pharmacy, Tjongerschans Hospital Heerenveen, Heerenveen, The Netherlands
| | - Daan W Huntjens
- Department of Clinical Pharmacy, OLVG Hospital, Amsterdam, The Netherlands
| | | | | | - Eric J F Franssen
- Department of Clinical Pharmacy, OLVG Hospital, Amsterdam, The Netherlands
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24
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Alarie M, Savelberg M, Vautour D, Ribeiro IB. Use of CytoSorb® hemoadsorption column during prolonged cardiopulmonary bypass in complex cardiac surgery patient. J Cardiothorac Surg 2022; 17:172. [PMID: 35799205 PMCID: PMC9261011 DOI: 10.1186/s13019-022-01922-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 05/19/2022] [Indexed: 11/24/2022] Open
Abstract
Background Complex cardiac surgery and prolonged cardiopulmonary bypass are associated with significant activation of the systemic inflammatory response system. Pro-inflammatory cytokines, oxygen free radicals and complement activation products contribute to postoperative complications and multiorgan injury. CytoSorb® hemoadsorption therapy has been suggested to alleviate the hyperinflammatory response triggered by cardiopulmonary bypass during cardiac surgery. Case presentation We describe the use of CytoSorb® hemoadsorption therapy in a 61-year-old male presenting for aortic valve replacement, mitral valve replacement, tricuspid valve repair, coronary artery bypass grafting and left atrial appendage clip. Conclusion We were able to demonstrate that CytoSorb® use during cardiopulmonary bypass may be a safe and feasible adjunct therapy that may contribute to improved postoperative outcomes in a patient with complex cardiac disease.
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Affiliation(s)
| | | | | | - Igo B Ribeiro
- Kingston Health Sciences Centre, Kingston, ON, Canada
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25
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Heymann M, Schorer R, Putzu A. Mortality and adverse events of hemoadsorption with CytoSorb® in critically ill patients: a systematic review and meta-analysis of randomized controlled trials. Acta Anaesthesiol Scand 2022; 66:1037-1050. [PMID: 35788557 PMCID: PMC9541789 DOI: 10.1111/aas.14115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 05/08/2022] [Accepted: 06/20/2022] [Indexed: 11/28/2022]
Abstract
Background The effects and safety of extracorporeal hemoadsorption with CytoSorb® in critically ill patients with inflammatory conditions are controversial. Methods We performed a systematic review with meta‐analysis and trial sequential analysis (TSA) of randomized‐controlled trials to assess the mortality and safety of CytoSorb® therapy in critically ill patients with inflammatory conditions. Electronic databases were searched up to April 2022. The primary outcome was mortality at longest follow‐up and secondary outcomes included various adverse event (AE) outcomes. Conflict of interest and funding of each trial were assessed. We calculated relative risk (RR) and 95% confidence interval (CI). Results Fourteen published (n = 764) and 4 unpublished (n = 111) trials were included. Eight trials were performed in medical ICU patients and 10 in complex cardiac surgery. Ten trials had significant industrial funding or an author conflict of interest. Hemoadsorption with CytoSorb® was associated with higher mortality at latest follow‐up (16 trials, n = 807, 120 of 402 [29.85%] patients in the CytoSorb® group vs. 98 of 405 [24.20%] patients in the control group, RR = 1.24 [95% CI, 1.04–1.49], p = .02, [TSA‐adjusted CI, 0.92–1.68]) and at 30‐days or in‐hospital (11 trials, n = 727; RR = 1.41 [95% CI, 1.06–1.88], p = .02, [TSA‐adjusted CI, 0.44–4.62]). Only one trial reported the definition of adverse event, while detailed results were reported in 3 trials; the risk of adverse events was not higher with CytoSorb®. Certainty of evidence ranged from low to very low. Conclusion Low certainty of evidence showed that the use of CytoSorb® might increase mortality in critically ill patients with inflammatory conditions. Adverse events were frequent but underreported and not systematically evaluated. Industrial funding and conflict of interest were common. Considerable uncertainty about the findings does not allow firm conclusions and suggests a need for high‐quality randomized trials to clarify mortality and adverse events related to CytoSorb®. Editorial Comment Hemoadsorption with CytoSorb® have been used in critically ill patients despite lack of high quality data from RCTs suggesting any patient‐important benefits. The findings from this systematic review and meta‐analysis suggests an increased risk of adverse events including mortality. With no apparent benefits and at the same time risk of harm, use of hemoadsorption with CytoSorb® in daily clinical practice cannot be recommended at this time.
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Affiliation(s)
- Marc Heymann
- Division of Anesthesiology, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Raoul Schorer
- Division of Anesthesiology, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Alessandro Putzu
- Division of Anesthesiology, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
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26
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Akil A, Ziegeler S, Rehers S, Ernst EC, Fischer S. Blood purification therapy in patients with severe COVID-19 requiring veno-venous ECMO therapy: A retrospective study. Int J Artif Organs 2022; 45:615-622. [PMID: 35695200 DOI: 10.1177/03913988221103287] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Patients with severe manifestations of COVID-19 might exhibit characteristics of a sepsis-like syndrome that can progress to multiple organ failure and ultimately death. Underlying mechanism have been explored and suggest a profound dysregulation of the immune system associated with hyperinflammation, hemodynamic instability and respiratory failure. Besides standard intensive care treatment, approaches modulating the dysregulated immune response, such as CytoSorb hemoadsorption, have been used. However, data of ECMO-dependent patients in comparison to a control cohort remain scarce. METHODS Included were 26 critically ill COVID-19 patients requiring high-flow veno-venous extracorporeal membrane oxygenation (high-flow VV ECMO) therapy due to severe acute respiratory distress syndrome (ARDS), of whom 16 were additionally treated with an extracorporeal hemoadsorption device, and compared to a control group of 10 patients. Assessed were levels of inflammatory markers, vasopressor requirements, oxygenation parameters, as well as clinically relevant outcome variables. Data were prospectively recorded and retrospectively analyzed. RESULTS Treatment with the applied multimodal therapy approach resulted in a stabilization in hemodynamics, a control of the hyperinflammatory response as evidenced by a significant reduction in inflammatory mediators, as well as a marked improvement in lung function. No device related adverse events were observed while treatment appeared safe and feasible. CONCLUSION Treatment of a critically ill COVID-19 ARDS patients with combined VV ECMO support and hemoadsorption therapy led to a rapid and sustained hemodynamic stabilization, a control of the uncontrolled inflammatory response and an improvement in oxygenation. Given these signals pointing toward a patient-oriented benefit of extracorporeal hemoadsorption therapy in those patients, future controlled, randomized studies should focus on the investigation of the appropriate timing and dosing of this promising treatment modality.
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Affiliation(s)
- Ali Akil
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Stephan Ziegeler
- Department of Anesthesiology, Intensive Care Medicine and Pain Management, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Stephanie Rehers
- Department of Anesthesiology, Intensive Care Medicine and Pain Management, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Erik Christian Ernst
- Department of Respiratory Medicine and Pulmonary Rehabilitation, Karl-Hansen-Hospital, Bad Lippspringe, Germany
| | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
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Røed-Undlien H, Schultz NH, Lunnan A, Husebråten IM, Wollmann BM, Molden E, Bjørnstad JL. In Vitro Apixaban Removal By CytoSorb Whole Blood Adsorber: An Experimental Study. J Cardiothorac Vasc Anesth 2022; 36:1636-1644. [PMID: 35272914 DOI: 10.1053/j.jvca.2022.01.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/13/2022] [Accepted: 01/21/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The use of unopposed oral anticoagulants while undergoing cardiothoracic surgery is associated with severe bleeding and increased morbidity. The aim of this experimental study was to examine if the apixaban concentration in reconstituted blood could be reduced in an in vitro setup by the use of CytoSorb whole blood adsorber, and to study how this affected global coagulation assays. DESIGN AND SETTING An experimental study performed in a laboratory. PARTICIPANTS An in vitro setup with reconstituted whole blood. INTERVENTIONS Reconstituted whole blood spiked with apixaban circulated in an in vitro circuit with the CytoSorb 300 mL device connected. MEASUREMENTS AND MAIN RESULTS Blood samples were drawn at 0, 5, 15, 30, 60, and 120 minutes of adsorption. The apixaban concentration was measured at each time point. In addition, the global coagulation assays, thromboelastometry clotting time and thrombin generation, were performed, and the results were compared with baseline values obtained before spiking blood with apixaban. After 30 minutes of adsorption, the mean apixaban concentration was reduced from 414.3 (±69.1) ng/mL to 33 (±11.4) ng/mL. Thrombin generation showed maximum effect after 60 minutes, and the thromboelastometry clotting time was close to baseline values after 120 minutes. CONCLUSIONS In this in vitro study, apixaban concentrations were effectively reduced, and the clotting time and thrombin generation assays were normalized by the use of CytoSorb whole blood adsorber.
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Affiliation(s)
| | - Nina Haagenrud Schultz
- Research Institute for Internal Medicine, Oslo University Hospital, Oslo, Norway; Department of Haematology, Akershus University Hospital, Lørenskog, Norway; Department of Haematology, Oslo University Hospital, Oslo, Norway
| | - Asbjørn Lunnan
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway
| | | | | | - Espen Molden
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway; Department of Pharmacy, University of Oslo, Norway
| | - Johannes Lagethon Bjørnstad
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway.
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28
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Reuchsel C, Gonnert FA. Successful treatment of severe quetiapine intoxication with CytoSorb hemoadsorption. J Clin Pharm Ther 2022; 47:1471-1474. [PMID: 35537706 DOI: 10.1111/jcpt.13668] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/23/2022] [Accepted: 03/31/2022] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE While many drug poisonings are successfully treated with specific antidotes, intoxications with tricyclic antidepressants and/or atypical neuroleptics still represent a major challenge. Besides conventional approaches, a new hemoadsorption device might represent an opportunity for therapeutic detoxification. CASE SUMMARY We report a 64-year-old female patient who attempted suicide by ingesting an unknown dose of quetiapine. Following application of all available standard diagnostic and therapeutic measures, she was admitted to the intensive care in a deeply somnolent state. Gastroscopy was performed necessitating analgo-sedation, intubation, and mechanical ventilation. Since quetiapine is in principle not dialysable, CytoSorb hemoadsorption was commenced resulting in a clear and rapid decrease in plasma levels of quetiapine and its metabolite norquetiapine over the next few hours. The next day, analgesia was stopped, the patient became alert, and cooperative so that she could be extubated without issues. CytoSorb blood purification therapy was discontinued after 2 days. One day later, the patient was transferred to a psychiatric clinic. WHAT IS NEW AND CONCLUSION We were able to quickly and efficiently reduce quetiapine and norquetiapine to non-toxic serum levels and to stabilize a critical situation using CytoSorb. Therefore, in the absence of a proven beneficial treatment regimen, the use of CytoSorb might represent an alternative for life-threatening complications of quetiapine intoxication. In particular, intoxications caused by lipophilic agents should be further evaluated.
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Affiliation(s)
- Caterina Reuchsel
- Department of Anesthesiology and Intensive Care Medicine, SRH Klinikum Gera, Gera, Germany
| | - Falk A Gonnert
- Department of Anesthesiology and Intensive Care Medicine, SRH Klinikum Gera, Gera, Germany
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Kumar A, Joshi RK, Aggarwal N, Ray M, Joshi R. Strategies to mitigate inflammation in management of complex congenital heart disease complicated by "multisystem inflammatory syndrome in children". Ann Pediatr Cardiol 2022; 15:276-279. [PMID: 36589656 PMCID: PMC9802620 DOI: 10.4103/apc.apc_16_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/28/2022] [Accepted: 06/08/2022] [Indexed: 11/17/2022] Open
Abstract
A 6-month-old boy, a case of Shone's complex, presented in decompensated state was found to have severe mitral stenosis along with multisystem inflammatory syndrome in children (MISC) warranting urgent surgical intervention. Various modalities including cytokine-adsorbing hemofilter were used to target inflammation. Postoperatively, the child recovered from low cardiac output accompanied by decrease in the levels of inflammatory markers, inopressors, and ventilatory requirements. Open heart surgery in itself is a proinflammatory process and is best avoided during the active inflammatory phase of MISC. In the rare and unavoidable circumstance exemplified by this index case, multipronged strategy targeting inflammation as described can be successfully implemented.
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Affiliation(s)
- Anil Kumar
- Department of Pediatric Cardiac Sciences, Sir Gangaram Hospital, New Delhi, India
| | - Reena K. Joshi
- Department of Pediatric Cardiac Sciences, Sir Gangaram Hospital, New Delhi, India
| | - Neeraj Aggarwal
- Department of Pediatric Cardiac Sciences, Sir Gangaram Hospital, New Delhi, India
| | - Mily Ray
- Department of Pediatric Cardiology, Max Super Speciality Hospital, Patparganj, New Delhi, India
| | - Raja Joshi
- Department of Pediatric Cardiac Sciences, Sir Gangaram Hospital, New Delhi, India
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Sekandarzad A, Weber E, Prager EP, Graf E, Bettinger D, Wengenmayer T, Supady A. Cytokine adsorption in patients with acute-on-chronic liver failure (CYTOHEP)-a single center, open-label, three-arm, randomized, controlled intervention trial. Trials 2022; 23:222. [PMID: 35303938 PMCID: PMC8931566 DOI: 10.1186/s13063-022-06139-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 03/02/2022] [Indexed: 12/21/2022] Open
Abstract
Background Liver cirrhosis is a major healthcare problem and the mortality rate is high. During recent years, systemic inflammation has been recognized as a major driver of hepatic decompensation and progression of liver cirrhosis to acute-on-chronic liver failure (ACLF). The aim of the CYTOHEP study is to assess the impact of extracorporeal hemoadsorption with the CytoSorb adsorber on serum bilirubin concentrations, humoral inflammation parameters, liver function parameters, and patient survival in patients with ACLF and acute kidney injury (AKI). Methods The CYTOHEP study is a prospective, single-center, open-label, three-arm, randomized, controlled intervention trial. Patients with ACLF and AKI stage 3 according to Kidney Disease: Improving Global Outcome (KDIGO) criteria will be randomized into three groups to be treated with (1) continuous renal replacement therapy (CRRT) and CytoSorb, (2) CRRT without CytoSorb, and (3) without both, CRRT and CytoSorb. In the hemoadsorption group, CytoSorb will be used for 72 h. The other groups receive standard of care with early or late initiation of CRRT, respectively. Primary endpoint of the study is serum bilirubin concentration after 72 h, important secondary endpoints are 30-day survival and a panel of inflammatory parameters. Discussion The CYTOHEP study is designed to evaluate the benefit of extracorporeal hemoadsorption in patients with ACLF. The results of this study will help to better understand the potential role of hemoadsorption for the treatment of ACLF and its impact on bilirubin levels, inflammatory parameters, and survival. Trial registration ClinicalTrials.gov NCT05019352. Registered on August 24, 2021. Deutsches Register Klinischer Studien (DRKS) DRKS00026082.
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Affiliation(s)
- Asieb Sekandarzad
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany
| | - Enya Weber
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Eric Peter Prager
- Department of Medicine IV (Nephrology and General Medicine), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Erika Graf
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Dominik Bettinger
- Department of Medicine II (Gastroenterology), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Wengenmayer
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany
| | - Alexander Supady
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany. .,Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany. .,Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany.
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Hakemi MS, Nassiri AA, Nobakht A, Mardani M, Darazam IA, Parsa M, Miri MM, Shahrami R, Koomleh AA, Entezarmahdi K, Karimi A. Benefit of Hemoadsorption Therapy in Patients Suffering Sepsis-Associated Acute Kidney Injury: A Case Series. Blood Purif 2022; 51:823-830. [PMID: 35108714 DOI: 10.1159/000521228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/15/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Sepsis is defined as life-threatening organ dysfunction in result of the host's dysregulated response to infection and septic shock. Sepsis-associated kidney injury is usually defined as concurrent presence of acute kidney injury (AKI) and sepsis without other significant causative factors. METHOD The current retrospective study was conducted to elucidate beneficial and side effects of CytoSorb®. A total of 17 patients were primarily treated with continuous renal replacement therapy in combination with CytoSorb. The demand for norepinephrine, mean arterial pressure, lactate, and procalcitonin (PCT) levels, as well as ICU length of stay, was measured. RESULT The blood lactate levels decreased by 32.30% when comparing mean levels before and after treatment. All patients who survived (n = 14) had reduction in vasopressor demand to 68.96% of their initial dose before the start of treatment. Hospital survival was greater in patients who initially had higher vasopressor demand compared to their nonsurviving counterparts, but in whom vasopressor dosages were reduced significantly during their treatments. Mortality as predicted by APACHE II score in the overall patient population was 79.9%, whereas, the observed ICU mortality was 31%. The baseline PCT levels on patients received 1, 2, and 3 CytoSorbs were 27.08 ± 5.81 ng/mL, 13.28 ± 2.62 ng/mL, and 21.03 ± 6.56 ng/mL, respectively. Observed PCT levels at 24 h after the last treatment on patients received 1, 2, and 3 CytoSorb were 31.55 ± 15.70 ng/mL, 5.61 ± 1.77 ng/mL, and 8.11 ± 3.62 ng/mL, respectively. CONCLUSION In conclusion, it seems that applying the CytoSorb in combination with CRRT in ICU septic patients with AKI, is related to a significant decrease in mortality, if the integrity and continuity of the treatment be kept, as much as possible. This study presented an effectively positive outcome with cytokine adsorber treatment as an adjuvant along with standard treatment in a high-risk mortality case of septic shock with organ failure.
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Affiliation(s)
- Monir Sadat Hakemi
- Department of Nephrology, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Ahmad Nassiri
- Division of Nephrology, Department of Internal Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Nobakht
- Professor of Internal Medicine Nephrology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoud Mardani
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ilad Alavi Darazam
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maziyar Parsa
- Infectious Specialist of Jam General Hospital, Tehran, Iran
| | - Mir Mohammmad Miri
- Department Anesthesiology and Critical Care, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Azadeh Ahmadi Koomleh
- Division of Nephrology, Department of Internal Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Anita Karimi
- Research Institute of Internal Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Song T, Hayanga J, Durham L, Garrison L, McCarthy P, Barksdale A, Smith D, Bartlett R, Jaros M, Nelson P, Molnar Z, Deliargyris E, Moazami N. CytoSorb Therapy in COVID-19 (CTC) Patients Requiring Extracorporeal Membrane Oxygenation: A Multicenter, Retrospective Registry. Front Med (Lausanne) 2022; 8:773461. [PMID: 34988092 PMCID: PMC8720923 DOI: 10.3389/fmed.2021.773461] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 11/30/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction: CytoSorb extracorporeal blood purification therapy received FDA Emergency Use Authorization (EUA) to suppress hyperinflammation in critically ill COVID-19 patients. The multicenter CTC Registry was established to systematically collect patient-level data, outcomes, and utilization patterns of CytoSorb under the EUA. Methods: Patient-level data was entered retrospectively at participating centers. The primary outcome of the registry was ICU mortality. Patient disposition of death, continuing ICU care, or ICU discharge was analyzed up to Day 90 after start of CytoSorb therapy. Demographics, comorbidities, COVID-19 medications, inflammatory biomarkers, and details on CytoSorb use were compared between survivors and non-survivors in the veno-venous extracorporeal membrane oxygenation (ECMO) cohort. Results: Between April 2020 and April 2021, 52 patients received veno-venous ECMO plus CytoSorb therapy at 5 U.S. centers. ICU mortality was 17.3% (9/52) on day 30, 26.9% (14/52) on day 90, and 30.8% (16/52) at final follow-up of 153 days. Survivors had a trend toward lower baseline D-Dimer levels (2.3 ± 2.5 vs. 19.8 ± 32.2 μg/mL, p = 0.056) compared to non-survivors. A logistic regression analysis suggested a borderline association between baseline D-Dimer levels and mortality with a 32% increase in the risk of death per 1 μg/mL increase (p = 0.055). CytoSorb was well-tolerated without any device-related adverse events reported. Conclusions: CytoSorb therapy for critically ill COVID-19 patients on ECMO was associated with high survival rates suggesting potential therapeutic benefit. Elevated baseline D-Dimer levels may suggest increased risk of mortality. Prospective controlled studies are warranted to substantiate these results. Clinical Trial Registration:https://clinicaltrials.gov/ct2/show/NCT0439192, identifier: NCT04391920.
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Affiliation(s)
- Tae Song
- University of Chicago Medicine, Chicago, IL, United States
| | - Jeremiah Hayanga
- West Virginia University School of Medicine, Morgantown, WV, United States
| | - Lucian Durham
- Medical College of Wisconsin, Milwaukee, WI, United States
| | | | - Paul McCarthy
- West Virginia University School of Medicine, Morgantown, WV, United States
| | - Andy Barksdale
- Franciscan Health Indianapolis, Indianapolis, IN, United States
| | - Deane Smith
- New York University Grossman School of Medicine, New York, NY, United States
| | - Robert Bartlett
- University of Michigan School of Medicine, Ann Arbor, MI, United States
| | - Mark Jaros
- Summit Analytical LLC, Denver, CO, United States
| | - Peter Nelson
- CytoSorbents Corporation, Princeton, NJ, United States
| | - Zsolt Molnar
- CytoSorbents Europe, Berlin, Germany.,Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary.,Department of Anesthesiology and Intensive Therapy, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Nader Moazami
- New York University Grossman School of Medicine, New York, NY, United States
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Rachunek K, Krause M, Thiel JT, Kolbenschlag J, Daigeler A, Bury A. Technical Note: Novel Use of CytoSorb™ Haemadsorption to Provide Wound Healing Support in Case of Severe Burn Trauma via Reduction of Hyperbilirubinaemia. Front Surg 2022; 8:743571. [PMID: 34977137 PMCID: PMC8718512 DOI: 10.3389/fsurg.2021.743571] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 11/29/2021] [Indexed: 11/21/2022] Open
Abstract
Hyperbilirubinaemia has been shown to compromise wound healing in severely burned patients. The therapy options for patients with impairment of wound healing and subsequent severe liver dysfunction are limited. A novel extracorporeal treatment, CytoSorb® (CytoSorbents Corp, USA), is a whole blood adsorber composed of highly biocompatible and porous polystyrene divinylbenzene copolymer beads covered in a polyvinylpyrrolidone coating. It is capable of extracting mainly hydrophobic middle-sized (up to 55 kDa) molecules from blood via size exclusion, including cytokines and bilirubin. We performed therapy with CytoSorb® on a severely burned (48% Total Body Surface Area-TBSA) patient with secondary sclerosing cholangitis (SCC) to promote the wound healing process by reducing bilirubin concentrations and to bridge the time to spontaneous liver regeneration or eventually to liver transplantation after two skin transplantations had failed to provide wound closure. In the first 6 days the cartridge was changed on a daily basis and later after every 2–4 days. The therapy with six adsorbers decreased a total bilirubin concentration from 14.02 to 4.29 mg/dl. By maintaining a stable bilirubin concentration under 5 mg/dl, debridement of abdomen and upper extremities with autologous skin grafting and, 4 weeks later, autologous skin grafting of the back from scrotum and lower extremities were performed successfully. After wound healing had been achieved, the CytoSorb therapy was discontinued after 57 days and 27 adsorber changes. CytoSorb therapy can be a promising support of wound and skin graft healing in patients with severe burns and liver dysfunction due to a significant reduction of total bilirubin concentration.
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Affiliation(s)
- Katarzyna Rachunek
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Maja Krause
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Johannes Tobias Thiel
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Jonas Kolbenschlag
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Adrien Daigeler
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Andreas Bury
- Department of Anesthesiology and Intensive Care Medicine, BG Trauma Center, Eberhard Karls University of Tuebingen, Tuebingen, Germany
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Tampe D, Korsten P, Bremer SCB, Winkler MS, Tampe B. Kinetics of Bilirubin and Ammonia Elimination during Hemadsorption Therapy in Secondary Sclerosing Cholangitis Following ECMO Therapy and Severe COVID-19. Biomedicines 2021; 9:biomedicines9121841. [PMID: 34944657 PMCID: PMC8698542 DOI: 10.3390/biomedicines9121841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/03/2021] [Accepted: 12/04/2021] [Indexed: 12/14/2022] Open
Abstract
In critically ill patients, liver dysfunction often results in coagulopathy and encephalopathy and is associated with high mortality. Extracorporeal clearance of hepatotoxic metabolites, including bilirubin and ammonia, aims to attenuate further hepatocyte damage and liver injury, resulting in decreased mortality. The efficacy of hemadsorption combined with conventional hemodialysis to eliminate bilirubin and ammonia to support the liver's excretory function in acute liver injury has been described previously. However, the optimal use of liver support systems in chronic liver dysfunction due to secondary sclerosing cholangitis in critically ill patients (SSC-CIP) has not been defined yet. We herein describe the kinetics of successful bilirubin and ammonia elimination by hemadsorption in a patient with SSC-CIP after extracorporeal membrane oxygenation (ECMO) therapy for severe acute respiratory distress syndrome (ARDS) in a patient with coronavirus disease 2019 (COVID-19). During the course of the disease, the patient developed laboratory signs of liver injury during ECMO therapy before clinically detectable jaundice or elevated bilirubin levels. A diagnosis of SSC-CIP was confirmed by endoscopic retrograde cholangiopancreatography (ERCP) based on intraductal filling defects in the intrahepatic bile ducts due to biliary casts. The patient showed stable elevations of bilirubin and ammonia levels thereafter, but presented with progressive nausea, vomiting, weakness, and exhaustion. Based on these laboratory findings, hemadsorption was combined with hemodialysis treatment and successfully eliminated bilirubin and ammonia. Moreover, direct comparison revealed that ammonia is more efficiently eliminated by hemadsorption than bilirubin levels. Clinical symptoms of nausea, vomiting, weakness, and exhaustion improved. In summary, bilirubin and ammonia were successfully eliminated by hemadsorption combined with hemodialysis treatment in SSC-CIP following ECMO therapy and severe COVID-19. This observation is particularly relevant since it has been reported that a considerable subset of critically ill patients with COVID-19 suffer from liver dysfunction associated with high mortality.
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Affiliation(s)
- Désirée Tampe
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, 37075 Göttingen, Germany; (D.T.); (P.K.)
| | - Peter Korsten
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, 37075 Göttingen, Germany; (D.T.); (P.K.)
| | - Sebastian C. B. Bremer
- Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Göttingen, 37075 Göttingen, Germany;
| | - Martin S. Winkler
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Göttingen, 37075 Göttingen, Germany;
| | - Björn Tampe
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, 37075 Göttingen, Germany; (D.T.); (P.K.)
- Correspondence: ; Tel.: +49-551-39-10575
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Ocskay K, Tomescu D, Faltlhauser A, Jacob D, Friesecke S, Malbrain M, Kogelmann K, Bogdanski R, Bach F, Fritz H, Hartjes A, Kortgen A, Soukup J, Utzolino S, van Tellingen M, Träger K, Schumacher U, Brunkhorst FM, Molnar Z. Hemoadsorption in 'Liver Indication'-Analysis of 109 Patients' Data from the CytoSorb International Registry. J Clin Med 2021; 10:5182. [PMID: 34768702 DOI: 10.3390/jcm10215182] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/01/2021] [Accepted: 11/03/2021] [Indexed: 12/26/2022] Open
Abstract
Background: Our aim is to report the results of the ‘liver indication’ subset of patients in the CytoSorb International Registry. Methods: Structured data were recorded. Treatment characteristics and changes from T1 (start of hemoadsorption) to T2 (termination) were evaluated with a special focus on bilirubin, C-reactive protein, procalcitonin, interleukin-6, platelet levels, SOFA scores, mortality, and subjective assessment by the attending physicians. Results: Until January 2021, from the total 1434 patients, 109 (age: 49.2 ± 17.1 years, 57.8% males) received treatment for hyperbilirubinemia. APACHE II-predicted mortality was 49.6 ± 26.8%. In the study, 91% of patients were alive at the termination of hemoadsorption and improvement was observed by the physicians in 75 cases. Overall, 65 (59.6%) patients died in the hospital, and 60 (55.0%) died in the ICU. Patients received a median of two treatments for a median of 43 h (interquartile range: 24–72 h) in total. Serum bilirubin levels reduced significantly to −4.6 (95% CI: −6.329 to −2.8) mg/dL. Thrombocytopenia was reported in four patients as an adverse event. Conclusions: We report the largest case series on hemoadsorption for ‘liver indication’ from the CytoSorb International Registry. The finding of significant bilirubin removal observed in our study could have substantial impact in designing and executing further studies on the effects of hemoadsorption in liver dysfunction, which are certainly warranted.
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Reuchsel C, Gonnert FA. Successful Treatment of Severe Lamotrigine Intoxication with CytoSorb Hemoadsorption. Blood Purif 2021; 51:679-682. [PMID: 34736249 DOI: 10.1159/000519167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 08/22/2021] [Indexed: 11/19/2022]
Abstract
Severe intoxication with the anti-epileptic drug, lamotrigine can cause cardiovascular collapse, neurotoxicity - expressed as intractable seizures, and even death. As there is currently no known specific antidote, extracorporeal removal therapies such as CytoSorb hemoadsorption might represent a promising therapeutic option. We report on a deeply comatosed 60-year-old woman who was treated in our intensive care unit with severe lamotrigine intoxication. To support removal from the blood, combined treatment with continuous veno-venous hemodialysis and CytoSorb hemoadsorption was started. Pre- and post-adsorber drug level measurements showed the rapid elimination of lamotrigine accompanied by an impressive clinical improvement in the patient. Two days after treatment discontinuation, there were no more clinical signs of intoxication and the patient could be extubated, followed by transfer to the stroke unit in a stable condition the following day. In the absence of a viable antidote, for the efficient short-term removal of lamotrigine, hemoadsorption with the CytoSorb device could represent a feasible treatment option for patients with severe lamotrigine intoxication.
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Affiliation(s)
- Caterina Reuchsel
- Department of Anesthesiology and Intensive Care Medicine, SRH Klinikum Gera, Gera, Germany
| | - Falk Alexander Gonnert
- Department of Anesthesiology and Intensive Care Medicine, SRH Klinikum Gera, Gera, Germany
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Mehta Y, Mehta C, Nanda S, Kochar G, George JV, Singh MK. Use of CytoSorb therapy to treat critically ill coronavirus disease 2019 patients: a case series. J Med Case Rep 2021; 15:476. [PMID: 34535189 DOI: 10.1186/s13256-021-03021-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/21/2021] [Indexed: 02/06/2023] Open
Abstract
Background Acute respiratory distress syndrome is an important clinical presentation of respiratory complications caused by severe acute respiratory syndrome coronavirus 2, a novel coronavirus responsible for the ongoing pandemic. The disease is poorly understood, and immunopathogenesis is constantly evolving. Cytokine release syndrome remains central to pathology of coronavirus disease 2019. Antivirals, anticytokine treatment, and other pharmacological approaches have failed to treat it. CytoSorb, an extracorporeal cytokine adsorber that reduces the cytokine storm and other inflammatory mediators in the blood, seems promising in treating severely ill patients with coronavirus disease 2019. Case presentation This article presents three cases of Asian ethnicity of severely ill adult patients with coronavirus disease 2019 admitted to intensive care unit who were treated with CytoSorb therapy. All patients used single CytoSorb device. During their clinical course, all patients were prescribed tocilizumab (an interleukin-6 receptor blocker), antivirals, hydroxychloroquine, azithromycin, and other antibiotics and general antipyretic drugs. No vasopressor treatment was required. The patients’ average duration of stay in intensive care unit was 30 days; the average duration of stay in hospital was 31 days. All three patients showed significant improvement in biochemical parameters and clinical outcomes post CytoSorb therapy. C-reactive protein levels decreased by 91.5%, 97.4%, and 55.75 %, and mean arterial pressure improved by 18%, 23%, and 17 % in patient 1, 2, and 3, respectively, on day 7 post-therapy. Conclusions All three patients improved clinically and survived. Supplementary Information The online version contains supplementary material available at 10.1186/s13256-021-03021-y.
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Duran S, Miedema D, Ergin B, Ince C. Sublingual Microcirculatory Evaluation of Extracorporeal Hemoadsorption with CytoSorb® in Abdominal Sepsis: A Case Report. Blood Purif 2021; 51:634-638. [PMID: 34535603 PMCID: PMC9393819 DOI: 10.1159/000518903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 07/24/2021] [Indexed: 11/19/2022]
Abstract
Cytokemia is associated with microcirculatory alterations often with persistent loss of coherence between the micro- and macrocirculation, linked to organ failure and poor outcome of septic patients. Addition of a hemoadsorbant filter to an extracorporeal circuit next to conventional treatment of septic shock results in the hematological clearance of cytokines, hypothetically leading to normalization of the microcirculation and thus organ perfusion. Bedside sublingual microcirculatory assessment using handheld vital microscopy allows real-time direct visualization of the microcirculation and its response to therapy. This is demonstrated in the present case report of an 83-year-old man admitted to our intensive care unit after surgical repair of a colonic perforation for fecal soiling after a low anterior resection for a rectum carcinoma, with leakage of bowel content at the resection site. The clinical course of this patient can be described as having undergone adequate surgical treatment taking away the source of the disease, followed by optimal support including antibiotic treatment in the ICU. However, during the course of his stay in the ICU, his condition deteriorated with symptoms consistent with septic shock. Our report shows that the addition of a hemoadsorbent (CytoSorb) to the continuous renal replacement therapy circuit was associated with an improvement in the condition of our severely ill patient with abdominal sepsis. Parallel to the clinical improvement of our patient, the functional parameters of the microcirculation also showed improvement suggesting that such a noninvasive real-time evaluation of the status of the microcirculation may be a sensitive diagnostic tool to monitor the effectiveness of hemoadsorbent therapy.
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Affiliation(s)
- Servet Duran
- Intensive Care Units, Wilhelmina Gasthuis Assen, Groningen, The Netherlands
| | - Dietske Miedema
- Department of Intensive Care Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bülent Ergin
- Department of Intensive Care Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Steurer LM, Schlager G, Sadeghi K, Golej J, Wiedemann D, Hermon M. Hemadsorption as rescue therapy for patients with multisystem organ failure in pediatric intensive care-Two case reports and review of the literature. Artif Organs 2021; 45:1582-1593. [PMID: 34331775 PMCID: PMC9291205 DOI: 10.1111/aor.14047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 07/04/2021] [Accepted: 07/14/2021] [Indexed: 12/13/2022]
Abstract
Hemadsorption via the cytokine‐adsorber CytoSorb (CytoSorbents Europe, Berlin, Germany) has successfully been used as an adjunctive method in adults, mainly for the purpose of immunomodulation under acute inflammatory conditions such as sepsis and cardiac surgery. In recent years, there has been growing interest in its use in pediatric intensive care to improve outcomes in patients with multiple organ failure following an inflammatory illness. Literature on the application of CytoSorb in neonatal and pediatric patients is scarce, though the implication is that it could be an effective last‐resort treatment option in critically ill pediatric patients. Herein we present the clinical cases of two pediatric patients successfully treated with a combination of the CytoSorb hemadsorber, continuous renal replacement therapy, and extracorporeal membrane oxygenation due to multiple organ failure following different underlying medical conditions. Patient 1 was a 7‐month‐old male child with Down's syndrome admitted to the Pediatric Intensive Care Unit (PICU) after congenital heart surgery, who developed antimicrobial‐resistant septic shock and severe acute respiratory distress syndrome. Patient 2 was a 2‐year‐old male child admitted to the PICU with influenza A‐associated acute liver failure resulting in hyperammonemia, lactate acidosis, hemodynamic instability, and acute kidney failure. In both patients, hemadsorption with CytoSorb was initiated as an adjunctive rescue therapy to treat refractory multisystem organ failure. Improvement of laboratory and clinical parameters was observed within hours of treatment initiation. The application of the hemadsorber—developed for use in adults—proved simple and safe for use in both of our low‐weight pediatric patients.
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Affiliation(s)
- Lisa-Maria Steurer
- Division of Neonatology, Pediatric Intensive Care & Neuropediatrics, Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Gerald Schlager
- Division of Neonatology, Pediatric Intensive Care & Neuropediatrics, Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Kambis Sadeghi
- Division of Neonatology, Pediatric Intensive Care & Neuropediatrics, Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Johann Golej
- Division of Neonatology, Pediatric Intensive Care & Neuropediatrics, Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Michael Hermon
- Division of Neonatology, Pediatric Intensive Care & Neuropediatrics, Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
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Wunderlich-Sperl F, Kautzky S, Pickem C, Hörmann C. Adjuvant hemoadsorption therapy in patients with severe COVID-19 and related organ failure requiring CRRT or ECMO therapy: A case series. Int J Artif Organs 2021; 44:694-702. [PMID: 34256643 DOI: 10.1177/03913988211030517] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Severe cases of the COVID-19 are often associated with the development of a fulminant sepsis-like state with a concomitant cytokine release syndrome. Recently, immunomodulating approaches to treat such a hyperinflammation have come into focus, including the use of new extracorporeal organ support therapies such as CytoSorb hemoadsorption designed to remove cytokines and other circulating mediators from blood. PATIENTS AND METHODS Thirteen critically ill COVID-19 patients with ARDS who received either ECMO therapy and/or CRRT with concomitant multiple organ failure were included. Hemoadsorption therapy was initiated once the patient had established-or was at high risk of developing-a hyperinflammatory state with marked hemodynamic instability or progressive lung failure. Levels of inflammatory markers, vasopressor requirements, oxygenation, and ventilation parameters were measured, as well as clinically relevant outcome measures. RESULTS Combined therapy was associated with a significant reduction in inflammatory mediators, hemodynamic stabilization with a concomitant decrease in requirements for vasoactive substances, and a pronounced improvement in lung function and the need for ventilatory support. Treatment appeared safe and well-tolerated. CONCLUSIONS In this case series of SARS-CoV-2 infected patients admitted to the intensive care unit with ARDS, we report effective interleukin (IL)-6 removal, reduced norepinephrine requirement, and improved lung function while receiving adjuvant, extracorporeal hemoadsorption therapy in the context of a multimodal treatment approach. The presented protocol for CytoSorb initiation may be a good foundation for the development of further prospective studies in the field and may eventually also be applied to other forms of hyperinflammatory ARDS.
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Affiliation(s)
- Florian Wunderlich-Sperl
- Clinical Department of Anesthesiology and Intensive Care Medicine, University Hospital St. Pölten-Lilienfeld, St. Pölten, Austria
| | - Sebastian Kautzky
- Clinical Department of Anesthesiology and Intensive Care Medicine, University Hospital St. Pölten-Lilienfeld, St. Pölten, Austria
| | - Christian Pickem
- Clinical Department of Anesthesiology and Intensive Care Medicine, University Hospital St. Pölten-Lilienfeld, St. Pölten, Austria
| | - Christoph Hörmann
- Clinical Department of Anesthesiology and Intensive Care Medicine, University Hospital St. Pölten-Lilienfeld, St. Pölten, Austria
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Kogelmann K, Hübner T, Schwameis F, Drüner M, Scheller M, Jarczak D. First Evaluation of a New Dynamic Scoring System Intended to Support Prescription of Adjuvant CytoSorb Hemoadsorption Therapy in Patients with Septic Shock. J Clin Med 2021; 10:jcm10132939. [PMID: 34209001 PMCID: PMC8268021 DOI: 10.3390/jcm10132939] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/27/2021] [Accepted: 06/28/2021] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Despite advances in critical care medicine, adjunctive approaches in sepsis therapy have failed to prove their efficacy. Notwithstanding promising results using hemoadsorption (CytoSorb), questions remain concerning timing and dosing. We created a dynamic scoring system (DSS) to assess patients with early septic shock and performed a first evaluation of the system in this patient population. METHODS Data from 502 patients with septic shock according to Sepsis-3 criteria were retrospectively analyzed. Score parameters were documented at the time of diagnosis (T0) and 6 h later (T6) to calculate a dynamic score. Survival on day 7 and 56 as well as ICU and hospital mortality were analyzed in regard to the score as well as the delay of hemoadsorption therapy. RESULTS Of the 502 patients analyzed, 198 received adjunctive CytoSorb treatment and 304 received standard therapy. Septic shock was typically represented by 5 points, while >6 points indicated a situation refractory to standard therapy with the worst outcome in patients shown by >8 points. The differences in mortality between the score groups (<6, 6-8, >8 points) were significant. Analysis further showed a significant 56-day, ICU and hospital survival advantage in CytoSorb patients when therapy was started early. CONCLUSION We created a scoring system allowing for the assessment of the clinical development of patients in the early phase of septic shock. Applying this approach, we were able to detect populations with a distinct mortality pattern. The data also showed that an early start of CytoSorb therapy was associated with significantly improved survival. As a next step, this easy-to-apply scoring system would require validation in a prospective manner to learn whether patients to be treated with hemoadsorption therapy in the course of septic shock could thereby be identified.
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Affiliation(s)
- Klaus Kogelmann
- Department of Anesthesiology and Intensive Care Medicine, Klinikum Emden, Bolardusstr. 20, 26721 Emden, Germany; (M.D.); (M.S.)
- Correspondence: ; Tel.: +49-(0)-4921-98-3508
| | - Tobias Hübner
- Department of Anesthesiology and Intensive Care, Kantonsspital Münsterlingen, Spitalcampus 1, 8596 Münsterlingen, Switzerland;
| | - Franz Schwameis
- Department of Anesthesiology and Intensive Care, Landesklinikum Baden-Mödling, Sr. M. Restituta-Gasse 12, 2340 Mödling, Austria;
| | - Matthias Drüner
- Department of Anesthesiology and Intensive Care Medicine, Klinikum Emden, Bolardusstr. 20, 26721 Emden, Germany; (M.D.); (M.S.)
| | - Morten Scheller
- Department of Anesthesiology and Intensive Care Medicine, Klinikum Emden, Bolardusstr. 20, 26721 Emden, Germany; (M.D.); (M.S.)
| | - Dominik Jarczak
- Department of Intensive Care, Universitätsklinikum Hamburg Eppendorf, Martinistr. 52, 20251 Hamburg, Germany;
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Nassiri AA, Hakemi MS, Miri MM, Shahrami R, Koomleh AA, Sabaghian T. Blood purification with CytoSorb in critically ill COVID-19 patients: A case series of 26 patients. Artif Organs 2021; 45:1338-1347. [PMID: 34152629 PMCID: PMC8444787 DOI: 10.1111/aor.14024] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/08/2021] [Accepted: 06/09/2021] [Indexed: 11/30/2022]
Abstract
Severe forms of the coronavirus disease 2019 (COVID‐19) can progress to sepsis‐like complications accompanied by “cytokine storm” for which the most effective treatment has not yet been established. Our study describes the results of CytoSorb hemoadsorption in COVID‐19 patients treated on the intensive care unit (ICU). In this retrospective study, 26 patients with COVID‐19 and acute respiratory distress syndrome (ARDS) were treated with hemoadsorption therapy. Pre‐, and post‐treatment values (clinical and laboratory) were compared. Data are expressed as mean (confidence intervals, CI), or median [interquartile ranges, IQR], as appropriate. Patients received 2 hemoadsorption treatments. This resulted in a significant decrease in norepinephrine requirements, and inflammatory marker plasma concentrations (procalcitonin, C‐reactive protein, ferritin) when comparing pre versus post treatment levels. The PaO2/FiO2 and overall organ function (ie, Sequential Organ Failure Assessment—SOFA score) also improved significantly. Patients stayed on the ICU for 9 days and 21 of them survived. To the best of our knowledge, this is one of the largest case series to date reporting early experiences on extracorporeal hemoadsorption therapy in SARS‐CoV‐2 positive patients with hyperinflammation and moderate ARDS. Treatment proved to be effective, technically feasible and well‐tolerated.
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Affiliation(s)
- Amir Ahmad Nassiri
- Division of Nephrology, Department of Internal Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Monir Sadat Hakemi
- Nephrology ward, Shariati Hospital, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Mir Mohammad Miri
- Anesthesiology and Critical Care Department, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Shahrami
- Intensive Care Department, NIOC Tehran Hospital, Tehran, Iran
| | - Azadeh Ahmadi Koomleh
- Division of Nephrology, Department of Internal Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Tahereh Sabaghian
- Division of Nephrology, Department of Internal Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Napp LC, Lebreton G, De Somer F, Supady A, Pappalardo F. Opportunities, controversies, and challenges of extracorporeal hemoadsorption with CytoSorb during ECMO. Artif Organs 2021; 45:1240-1249. [PMID: 34152637 DOI: 10.1111/aor.14025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/07/2021] [Accepted: 06/09/2021] [Indexed: 11/28/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is frequently used in many centers around the globe for various indications. However, prognosis is often poor even with all supportive therapies, and in many cases, clinical deterioration is associated with inflammation. Hemoadsorption with CytoSorb is a novel approach to limit the inflammatory response, and the device can be safely and easily installed into ECMO circuits. CytoSorb has been used more than 130.000 times to date, but because randomized controlled trials are largely lacking, there is substantial debate on its use. Here, experts from critical care medicine, cardiology, cardiac surgery, and perfusion technology discuss the pros and cons of this novel therapy and outline the future aspects for its clinical application and research.
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Affiliation(s)
- L Christian Napp
- Cardiac Arrest Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Guillaume Lebreton
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, La Pitié-Salpêtrière Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
| | - Filip De Somer
- Heart Centre 5K12, University Hospital Ghent, Ghent, Belgium
| | - Alexander Supady
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany.,Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
| | - Federico Pappalardo
- Department of Anesthesia and Intensive Care, IRCCS ISMETT, UPMC Italy, Palermo, Italy
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Damiani M, Gandini L, Landi F, Borleri G, Fabretti F, Gritti G, Riva I. Extracorporeal cytokine hemadsorption in severe COVID-19 respiratory failure. Respir Med 2021; 185:106477. [PMID: 34102594 DOI: 10.1016/j.rmed.2021.106477] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 05/15/2021] [Accepted: 05/18/2021] [Indexed: 01/08/2023]
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Pancani F, Pavani R, Quacquarelli A, Feri M. Successful use of CytoSorb in a Covid-19 patient with secondary septic shock due to a sacral decubitus infection. Int J Artif Organs 2021; 44:1034-1038. [PMID: 33998306 DOI: 10.1177/03913988211016473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Septic shock is a clinical condition with high mortality (40%-70%) and morbidity. During septic shock, there is a significant release of cytokines and other inflammatory mediators that can cause damage to different organs, known as a "cytokine storm." The cytokine storm can cause hypotension, tissue damage, metabolic acidosis, and renal failure. This clinical picture also seems to be confirmed in the context of Covid-19 patients. Hemoadsorption with CytoSorb represents an adjunctive therapy to attenuate the systemic inflammatory process and helps restore a balanced immune response. We present the clinical case of a 75-year-old man, admitted to our hospital with respiratory failure due to Sars-CoV-2 infection and secondary septic shock due to a sacral decubitus. On admission the patient presented with a clinical picture of mixed acidosis with high levels of lactate and inflammatory indexes. Simultaneously along with antibiotic therapy, we started hemoadsorption treatment with CytoSorb in combination with continuous venous-venous hemodiafiltration. At the end of the treatment the patient had recovered his vital functions and the infection was successfully treated. Use of the CytoSorb device in a Covid-19 positive patient was safe and well-tolerated. Early treatment with CytoSorb decreased interleukin 6 plasma levels and inflammatory indexes, resulting in earlier stabilization of homeostasis. This case report suggests that the use of CytoSorb could be a possible adjuvant therapy in patients with septic shock even when affected by Covid-19.
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Affiliation(s)
- Flavia Pancani
- Department of Emergency, Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Raffaella Pavani
- Department of Emergency, Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Antonio Quacquarelli
- Department of Emergency, Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Marco Feri
- Department of Emergency, Intensive Care Unit, San Donato Hospital, Arezzo, Italy
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Scandroglio AM, Pieri M, Nardelli P, Fominskiy E, Calabrò MG, Melisurgo G, Ajello S, Pappalardo F. Impact of CytoSorb on kinetics of vancomycin and bivalirudin in critically ill patients. Artif Organs 2021; 45:1097-1103. [PMID: 33686696 DOI: 10.1111/aor.13952] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/05/2021] [Accepted: 02/28/2021] [Indexed: 12/19/2022]
Abstract
CytoSorb is a promising tool to treat severe inflammatory status with multiple mechanisms in the acute care setting. Its effect on drugs is, however, poorly documented in vivo, although removal of small molecules might translate into decreased blood levels of life-saving medications. The aim of this study was to assess the impact of CytoSorb on vancomycin and bivalirudin clearance in a large population of critically ill patients. We performed a single-center analysis of CytoSorb treatments performed between January 2018 and March 2019 in critically ill patients admitted to our intensive care unit. A total of 109 CytoSorb treatments were performed in 89 patients. A decrease in lactate dehydrogenase (P = .007), troponin T (P = .022), and creatine phosphokinase (P = .013) was reported during treatment. Vancomycin dose required significant adjustments during treatment (P < .001), but no significant change was necessary after the first 3 days. Similarly, the requirements of bivalirudin significantly changed over days (P < .001), but no dose adjustment was needed after the first 3 days of treatment. No differences in terms of vancomycin and bivalirudin dose need was observed between patients on extracorporeal membrane oxygenation and those who were not (P = .6 and P = .6, respectively), between patients with and without continuous veno-venous hemofiltration (P = .9 and P = .9, respectively), and between CytoSorb responders or not (P = .4 and P = .7, respectively). CytoSorb is effective in mitigating the systemic inflammatory response and safe with respect to vancomycin and bivalirudin administration. These preliminary data further support the use of CytoSorb as adjunct therapy in critically ill patients.
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Affiliation(s)
- Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Pasquale Nardelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Grazia Calabrò
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Melisurgo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Ajello
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federico Pappalardo
- Department of Anesthesia and Intensive Care, IRCCS ISMETT, UPMC Italy, Palermo, Italy
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Bottari G, Lorenzetti G, Severini F, Cappoli A, Cecchetti C, Guzzo I. Role of Hemoperfusion With CytoSorb Associated With Continuous Kidney Replacement Therapy on Renal Outcome in Critically III Children With Septic Shock. Front Pediatr 2021; 9:718049. [PMID: 34504817 PMCID: PMC8423368 DOI: 10.3389/fped.2021.718049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/02/2021] [Indexed: 12/29/2022] Open
Abstract
Introduction: Sepsis-associated acute kidney injury (SA-AKI) represents a relevant cause of mortality and morbidity in critically ill children. Since with the "inflammatory theory" the authors have been witnessed an important role of inflammatory mediators in the pathophysiology and in the prognosis of SA-AKI, making the need of adjunctive therapies in association with kidney replacement therapies mandatory. Hemoperfusion with CytoSorb is a safe and well-tolerated therapy in septic shock: the very high surface area of the absorber means it is able to efficiently remove cytokines and other medium size molecules involved in cytokine storm, thus playing a synergistic effect with Continuous Kidney Replacement Therapy (CKRT). Materials and Methods: We retrospectively analyzed data from a cohort of eight critically ill children treated from January 2018 to March 2020 describing the impact of CKRT plus hemoperfusion with CytoSorb on renal outcome in critically ill children with septic shock. Results: We evidenced a significant reduction in interleukin (IL)-6 an IL-10 after hemoperfusion with CytoSorb in our pediatric population. Furthermore, we were able to show a significant improvement of creatinine and blood urea nitrogen (BUN) after blood purification and at pediatric intensive care units (PICU) discharge. We have observed a median of 2.5 CKRT days after stop of hemoperfusion (Q1 0.25; Q3 18.75). None of our patients required CKRT 30 days after PICU discharge (PICU-D). None of them developed CKD. Conclusion: Hemoperfusion with CytoSorb is a valuable therapeutic option in combination with CKRT in SA-AKI. More studies are warranted to confirm our results and in particular to define the role of this adjuvant therapy as a preemptive strategy to protect renal function in pediatric septic shock.
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Affiliation(s)
- Gabriella Bottari
- Pediatric Emergency Department, Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Giulia Lorenzetti
- Department of Pediatrics, University of Rome Tor Vergata, Residency School of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Flavia Severini
- Department of Pediatrics, University of Rome Tor Vergata, Residency School of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Andrea Cappoli
- Department of Pediatrics, Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Corrado Cecchetti
- Pediatric Emergency Department, Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Isabella Guzzo
- Department of Pediatrics, Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Bottari G, Confalone V, Cotugno N, Guzzo I, Perdichizzi S, Manno EC, Stoppa F, Cecchetti C. Efficacy of CytoSorb in a Pediatric Case of Severe Multisystem Infammatory Syndrome (MIS-C): A Clinical Case Report. Front Pediatr 2021; 9:676298. [PMID: 34178891 PMCID: PMC8232055 DOI: 10.3389/fped.2021.676298] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/27/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Multisystem inflammatory syndrome in children (MIS-C) has emerged during the COVID-19 pandemic as a new SARS-CoV-2-related entity, potentially responsible for a life-threatening clinical condition associated with myocardial dysfunction and refractory shock. Case: We describe for the first time in a 14-year-old girl with severe MIS-C the potential benefit of an adjuvant therapy based on CytoSorb hemoperfusion and continuous renal replacement therapy with immunomodulatory drugs. Conclusions: We show in our case that, from the start of extracorporeal blood purification, there was a rapid and progressive restoration in cardiac function and hemodynamic parameters in association with a reduction in the most important inflammatory biomarkers (interleukin 6, interleukin 10, C-reactive protein, ferritin, and D-dimers). Additionally, for the first time, we were able to show with analysis of the sublingual microcirculation a delayed improvement in most of the important microcirculation parameters in this clinical case of MIS-C.
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Affiliation(s)
- Gabriella Bottari
- Pediatric Emergency Department Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, Institute for Research and Health Care (IRCCS), Rome, Italy
| | - Valerio Confalone
- Pediatric Emergency Department Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, Institute for Research and Health Care (IRCCS), Rome, Italy
| | - Nicola Cotugno
- Clinical Immunology and Vaccinology Unit, Pediatric Academic Department (DPUO), Bambino Gesù Children's Hospital, IRCSS, Rome, Italy
| | - Isabella Guzzo
- Division of Nephrology and Dialysis, Department of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Salvatore Perdichizzi
- Pediatric Emergency Department Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, Institute for Research and Health Care (IRCCS), Rome, Italy
| | - Emma C Manno
- Clinical Immunology and Vaccinology Unit, Pediatric Academic Department (DPUO), Bambino Gesù Children's Hospital, IRCSS, Rome, Italy
| | - Francesca Stoppa
- Pediatric Emergency Department Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, Institute for Research and Health Care (IRCCS), Rome, Italy
| | - Corrado Cecchetti
- Pediatric Emergency Department Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, Institute for Research and Health Care (IRCCS), Rome, Italy
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Brouwer WP, Duran S, Ince C. Improved Survival beyond 28 Days up to 1 Year after CytoSorb Treatment for Refractory Septic Shock: A Propensity-Weighted Retrospective Survival Analysis. Blood Purif 2020; 50:539-545. [PMID: 33352555 DOI: 10.1159/000512309] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 10/02/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND AIMS It is currently unknown whether CytoSorb treatment for septic shock improves long-term survival beyond 28 days from intensive care unit (ICU) admission and which factors determine outcome. METHODS This was a long-term follow-up retrospective analysis of patients with septic shock who were treated with continuous renal replacement therapy (CRRT) + CytoSorb (n = 67) or CRRT alone (n = 49). These patients were previously analyzed for 28-day mortality. The primary outcome was the time to long-term all-cause mortality. Factors associated with time to event were analyzed both weighted by stabilized inverse probability of treatment weights (sIPTW) as well as unweighted stratified by therapy received. RESULTS The median follow-up for the total cohort was 30 days (interquartile range [IQR]: 5-334, maximum 1,059 days) after ICU admission and 333 days (IQR: 170-583) for those who survived beyond 28 days (n = 59). Survival beyond 28 days was sustained up to 1 year after ICU admission for both treatment regimens: 80% (standard error [SE] 7%) vs. 87% (SE 7%), for CytoSorb vs. CRRT, respectively, p = 0.853. By sIPTW, CytoSorb was significantly associated with long-term outcome compared to CRRT (adjusted hazard ratio [aHR] 0.59, 95% confidence interval [CI] 0.37-0.93, p = 0.025). Independent factors associated with long-term outcome in CytoSorb-treated patients were baseline log10 lactate levels (aHR 5.1, p = 0.002), age in the presence of comorbidity (aHR 2.60, p = 0.013), and presence of abdominal sepsis (aHR 0.34, p = 0.004). A lactate level above 6.0 mmol/L at the start of CytoSorb therapy had a positive predictive value of 79% for mortality (p = 0.013). CONCLUSIONS Survival is achieved with CytoSorb and CRRT for patients with septic shock beyond 28 days from ICU admission and may be improved for CytoSorb treatment. Lactate levels above 6.0 mmol/L at the start of CytoSorb therapy are predictive of worse outcome with high specificity and positive predictive value.
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Affiliation(s)
- Willem P Brouwer
- Department of Gastroenterology & Hepatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands, .,Department of Internal Medicine, Maasstad Ziekenhuis, Rotterdam, The Netherlands,
| | - Servet Duran
- Department of Intensive Care Medicine, Maasstad Ziekenhuis, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Rugg C, Klose R, Hornung R, Innerhofer N, Bachler M, Schmid S, Fries D, Ströhle M. Hemoadsorption with CytoSorb in Septic Shock Reduces Catecholamine Requirements and In-Hospital Mortality: A Single-Center Retrospective 'Genetic' Matched Analysis. Biomedicines 2020; 8:E539. [PMID: 33255912 DOI: 10.3390/biomedicines8120539] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 12/14/2022] Open
Abstract
Septic shock is a major burden to healthcare with mortality rates remaining high. Blood purification techniques aim to reduce cytokine levels and resultant organ failure. Regarding septic shock, hemoadsorption via CytoSorb seems promising, but the main effects on organ failure and mortality remain unclear. In this retrospective single-center study, septic shock patients receiving CytoSorb in addition to renal replacement therapy (n = 42) were analyzed and compared to matched controls (n = 42). A generalized propensity-score and Mahalanobis distance matching method (‘genetic’ matching) was applied. Baseline comparability was high. Differences were merely present in higher initial Sequential Organ Failure Assessment (SOFA) scores (median and interquartile range: 13.0 (12.0–14.75) vs. 12.0 (9.0–14.0)) and requirements of norepinephrine equivalents (0.54 (0.25–0.81) vs. 0.25 (0.05–0.54) µg/kg/min) in the CytoSorb group. While remaining fairly constant in the controls, the catecholamines decreased to 0.26 (0.11–0.40) µg/kg/min within 24 h after initiation of CytoSorb therapy. In-hospital mortality was significantly lower in the CytoSorb group (35.7% vs. 61.9%; p = 0.015). Risk factors for mortality within the CytoSorb group were high lactate levels and low thrombocyte counts prior to initiation. Hereby, a cut-off value of 7.5 mmol/L lactate predicted mortality with high specificity (88.9%). Thus, high lactate levels may indicate absent benefits when confronted with septic shock patients considered eligible for CytoSorb therapy.
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