Clinical experience of using a novel extracorporeal cytokine adsorption column for treatment of septic shock with multiorgan failure

Introduction

Severe sepsis and multiorgan failure (MOF) are major causes of death in the ICU. The extracorporeal cytokine adsorption column (ECAC; Cytosorb®, CytoSorbents Corporation, USA), a critical care focused therapeutic device, results in rapid in vitro and in vivo elimination of several key cytokines and prevents organ failure. Use of ECAC in patients with sepsis is a new area of research with insufficient data to promote large prospective RCTs. Studies published to date have shown promising results. We report our clinical experience with ECAC for severe sepsis/septic shock/MOF patients.

Methods

A retrospective evaluation of ECAC in patients admitted to a tertiary ICU from November 13 to October 14 to analyze: clinical safety; selection of a subgroup of patients where it could be used; selection of timing for initiation; number of device filters required per patient; and selective markers to identify above initiation. Patients were managed with standard of care (SOC; antibiotics, vasopressors, i.v. fluids, sepsis dosed steroids) and ECAC as adjuvant therapy. Vitals, APACHE II and SOFA scores were measured.

Results

Nineteen ICU patients (14 men, five women; 24 to 72 years; average ICU stay 10 days; average ventilator days 9) with APACHE II >17 (except one with dengue shock syndrome), SOFA score ≥11 (n = 16) and the majority having infection largely in the lung (n = 8; alone or with UTI and blood infection) followed by the abdomen (n = 4), UTI (n = 3) and others (n = 4) were given ECAC (total ECAC = 31). Predicted mortality (PM) was >40% in 16, >30% in two and <30% in two (tropical infections) patients. Duration of therapy was 6 hours (no. of ECAC = 18) and 8 hours (n = 4; no. of ECAC = 5) for the majority of patients. Overall, four patients (two with tropical infections and two with PM >40%) survived; three of them had were ECAC early (<24 hours of admission). The majority of patients (n = 11) who died could be given ECAC only once. Of patients who died, seven were given ECAC late (>24 hours). APACHE scores before and after ECAC therapy were available for eight patients who died; APACHE score decreased >5 points in five patients after single application of ECAC.

Conclusion

ECAC can be used as adjuvant therapy in treatment of severe sepsis/septic shock/MOF. Our patients had high PM and four could be saved with use of ECAC. We could expect a better outcome if ECAC was used early (<24 hours) during treatment. However, future well-designed studies are needed to clarify the role of ECAC in patients with MOF/septic shock.