Cytokine hemoadsorption with CytoSorb® in post-cardiac arrest syndrome, a pilot randomized controlled trial

BACKGROUND

Hemoadsorption (HA) might mitigate the systemic inflammatory response associated with post-cardiac arrest syndrome (PCAS) and improve outcomes. Here, we investigated the feasibility, safety and efficacy of HA with CytoSorb® in cardiac arrest (CA) survivors at risk of PCAS.

METHODS

In this pilot randomized controlled trial, we included patients admitted to our intensive care unit following CA and likely to develop PCAS: required norepinephrine (> 0.2 µg/kg/min), and/or had serum lactate > 6 mmol/l and/or a time-to-return of spontaneous circulation (ROSC) > 25 min. Those requiring ECMO or renal replacement therapy were excluded. Eligible patients were randomly allocated to either receive standard of care (SOC) or SOC plus HA. Hemoadsorption was performed as stand-alone therapy for 24 h, using CytoSorb® and regional heparin-protamine anticoagulation. We collected feasibility, safety and clinical data as well as serial plasma cytokines levels within 72 h of randomization.

RESULTS

We enrolled 21 patients, of whom 16 (76%) had out-of-hospital CA. Median (IQR) time-to-ROSC was 30 (20, 45) minutes. Ten were assigned to the HA group and 11 to the SOC group. Hemoadsorption was initiated in all patients allocated to the HA group within 18 (11, 23) h of ICU admission and conducted for a median duration of 21 (14, 24) h. The intervention was well tolerated except for a trend for a higher rate of aPTT elevation (5 (50%) vs 2 (18%) p = 0.18) and mild (100-150 G/L) thrombocytopenia at day 1 (5 (50%) vs 2 (18%) p = 0.18). Interleukin (IL)-6 plasma levels at randomization were low (< 100 pg/mL) in 10 (48%) patients and elevated (> 1000 pg/mL) in 6 (29%). The median relative reduction in IL-6 at 48 h was 75% (60, 94) in the HA group versus 5% (- 47, 70) in the SOC group (p = 0.06).

CONCLUSIONS

In CA survivors at risk of PCAS, HA was feasible, safe and was associated with a nonsignificant reduction in cytokine plasma levels. Future trials are needed to further define the role of HA after CA. Those studies should include cytokine assessment to enrich the study population.

TRIAL REGISTRATION

NCT03523039, registered 14 May 2018.

Cytokine Hemoadsorption in the Management of a Pregnant Woman with COVID-19 Pneumonia: Case Report

Here, we discussed a 22-year-old pregnant woman (gestational age: 32 weeks) infected with COVID-19 who presented with fever (39.1 °C) and respiratory symptoms. Thoracic computed tomography could not be obtained due to pregnancy. PCR testing was positive. The patient was treated with supportive care and anti-viral and anti-inflammatory agents; however, general health status deteriorated and patient was admitted to intensive care unit on day 3. After admission to COVID-19 ICU, clinical picture was rapidly worsened with development of respiratory failure and acute respiratory distress syndrome (ARDS). Thus, “extracorporeal cytokine hemoadsorption” (CytoSorb®, Cytosorbents Corporation, Monmouth Junction, NJ, USA) was planned and performed with regular intervals in order to remove inflammatory cytokines from circulation and to relieve systemic inflammatory response. The fever response and CRP elevation were controlled by hemoadsorption and cytokine filter performed in alternate days. On day 7 of ICU admission, it was decided to terminate pregnancy due to worsening hypoxemia and a healthy, premature infant was born. On day 2 after cesarean section, the patient was intubated and mechanical ventilation support was initiated. However, the patient showed an increasingly complicated clinical course and died on day 22 after ICU admission. It is seen that COVID-19 positivity carries an important risk for both mother and fetus, particularly in those at advanced stages of gestation, by physiological changes in the mother during pregnancy. We believe that, in the treatment of COVID-19 and its complications during pregnancy, cytokine filter treatment can give time to patient for hemodynamic and metabolic stabilization.

Clinical Utility of Extracorporeal Cytokine Hemoadsorption Therapy: A Literature Review

Cytokines play a critical role in coordinating and amplifying a host immune response to infection. The normal pattern of localized and systemic release of proinflammatory and anti-inflammatory cytokines varies on the basis of the disease process. A dysregulated cytokine response can lead to a hyper-inflammatory condition called a cytokine storm. This is believed to contribute to the pathophysiology of sepsis and septic shock, a condition carrying high morbidity and mortality in critically ill patients. Extracorporeal cytokine hemoadsorption is an emerging technology utilized in the treatment of dysregulated inflammatory states such as sepsis, although there is a paucity of clinical evidence supporting its outcomes benefits. We assess the peer-reviewed literature relating to cytokine hemoadsorption in the context of sepsis and suggest areas of future research incorporating this novel technology.