My Special Cytosorb Case. Fabio Silvio TACCONE Dpt of Intensive Care Hôpital Erasme ULB Brussels (BE)

Transcription

1 My Special Cytosorb Case Fabio Silvio TACCONE Dpt of Intensive Care Hôpital Erasme ULB Brussels (BE)

2 Conflicts of Interest

3 Clinical Case - 1! 27 yo woman, 45 Kgs (Belgian Vietnam origin)! Blank medical history! Admitted to the ED of another hospital in Brussels because of intoxication! Disco with some friends (Sunday evening)! Found on the floor! Agitated and obtunded! Rigor! Tachycardia! Hypertension (190/100 mmhg)! Hyperthermia (41.6 C)

4 Clinical Case - 2! Intubated on site! Suspected drug: ECTASY! Unknown dose! Unknown association with other drugs! No other people were intoxicated! Concomitant alcohol intake! First episode according to her friends

5 ! On ED admission:! Sedated and paralyzed! Dilated pupils Clinical Case - 3! HR 130 bpm BP 75/35 mmhg BT 41.8 C! No signs of cyanosis or hypoperfusion! FAST echo = negative! Echo-cardio: LVEF 50%

6 Chest X-Ray Clinical Case - 4

7 ECG on ED Admission Clinical Case - 5

8 ! Initial Blood Sample: Clinical Case - 6! ph 7.28 PaCO 2 32 mmhg PaO mmhg (FiO 2 100%)! Lactate 3.0 meq/l, sbe meq/l, methb 1.1%! WBC: 8,000/mm 3 ; Hb: 13.1 g/dl; PLT: 317,000/mm 3! aptt: 19 secs; INR 0.98; Fibrinogen: 215 mg/dl! Na + : 139 meq/l; K + : 4.9 meq/l; Alb 4.8 g/l;! Urea: 29 mg/dl; Creat 1.6 mg/dl, CK 220 IU/L! Glucose 55 mg/dl, CRP 4.9 mg/l! Ethanol: <0.1 g/l

9 Clinical Case - 7! Evolution:! Severe shock start Noradrenaline (NA) / Lactate 8.5 meq/l! Diffuse bleeding in the throat, on puncture sites and bladder probe rectal bleeding! PaO mmhg (FiO 2 100%)! WBC: 2,000/mm 3 ; Hb: 11.1 g/dl; PLT: 47,000/mm 3! aptt: 85 secs; INR 8.8; Fibrinogen: 45 mg/dl! K + : 5.9 meq/l; Creat 2.1 mg/dl, CK 3220 IU/L! Glucose 15 mg/dl; ALT/AST >200 IU/L; NH µg/dl

10 ! Initial Therapy:! Fluids: 6000 ml (crystalloids)! Noradrenaline: 0.4 µg/kg.min! IV Glucose Clinical Case - 8! Fresh Frozen Plasma: 600 ml! Prothrombin complex concentrates: 400 ml! Tranexamic Acid: 2g! Fibrinogen: 2g! Midazolam: 8 mg/h! Morphine: 5 mg/h

11 Clinical Case - 9! DIAGNOSIS:! Hepatic Failure < MDMA! Distributive shock! Hypoglycemia! AKI < Rhabdomyolysis! ARDS < inhalation

12 Clinical Case - 10

13 Clinical Case - 11! Toxicology:! Methamphetamine: +! Paracetamol: -! Benzodiazepines: -! Cannabis: -! Opiates: -! Antidepressants: -! Barbiturates: -! Cocaine: -! Methadone: -! Phencyclidine: -

14 Clinical Case - 12! MDMA Toxicity Catecholamine release 5-HT release! CNS (Euphoria Hallucinations - Dizziness Seizures - Bleeding)! Cardiovascular (Tachycardia Hypertension Arrhythmias)! Gastrointestinal! Hyponatremia (ADH sweating)! Serotonin syndrome (hyperthermia, autonomic instability, and altered muscle tone and/or rigidity)! AKI (interstitial nephritis, myoglobinuria)! CIVD (microvascular)! Hepatitis (centrolobular necrosis microvascular steatosis)

15 Clinical Case - 12! MDMA Toxicity Catecholamine release 5-HT release! CNS! Cardiovascular! Gastrointestinal! Hyponatremia! Serotonin syndrome! AKI! CIVD! Hepatitis

16 Clinical Case - 13! Therapy:! Supportive! B1 (1500mg)! Protective lung ventilation! Gastrointestinal decontamination (activated charcoal)! Cooling measures! 5-HT antagonists??

17 Clinical Case - 13! Therapy:! Supportive! B1 (1500mg)! Protective lung ventilation! Gastrointestinal decontamination (activated charcoal)! Cooling measures! 5-HT antagonists??

18 Clinical Case - 14! Clinical status:! HR 125 bpm BP mmhg BT 39.7 C! ph 7.15 PaCO 2 41 mmhg PaO 2 61 mmhg Lactate 8.9 meq/l! 290 T V PEEP 12 cmh 2 0 FiO 2 80% - ΔP 18cmH 2 0! NA 1.3 µg/kg.min! Capillary leakage +++! Hb 10.8 g/dl; Alb 29 g/l; CK IU/L! Start Amoxi-clav 2g q8h! Start CRRT

19 Clinical Case - 15 Chest X-Ray VV-ECMO

20 Idiopathic Drug-induced (Chemotherapy) Retinoic acid syndrome Ovarian hyperstimulation syndrome Hemophagocytic lymphohistiocytosis Hemorrhagic fever Snakebite Sepsis (OPSI) Autoimmune Kawasaki disease Antiphospholipid syndrome Sjögren syndrome Systemic sclerosis Polymyositis Clinical Case - 16

21 Clinical Case - 17 Colloids IV Vasopressin Hydrocortisone IV β 2 -agonists IVIG Methylene Blue

22 Clinical Case - 17 Colloids IV Vasopressin Hydrocortisone IV β 2 -agonists IVIG Methylene Blue (2mg/kg)

23 Clinical Case - 18

24 Clinical Case - 19 SpO 2 75%

25 Clinical Case - 20! Clinical status:! HR 135 bpm BP mmhg BT 38.5 C (CRRT)! ph 7.23 PaCO 2 41 mmhg PaO 2 54 mmhg SpO2 72%! Lactate 6.9 meq/l! 290 T V PEEP 12 cmh 2 0 FiO 2 100% - ΔP 18cmH 2 0! NA 1.1 µg/kg.min! MetHb 21%

26 Clinical Case - 21! Methaemoglobinemia - CAUSES: % % - > 70%

27 Clinical Case - 22! Methaemoglobinemia - THERAPY:! Remove etiology! Methylene Blue!!!! Vitamine C! Hyperbaric Oxygen! Hemodialysis / Plasmapheresis! Cimetidine (DAPSONE)! NAC

28 Clinical Case - 23

29 Clinical Case - 24 PATENT BLUE:! Used in used in lymphangiography and sentinel node biopsy as a dye to color lymph vessels (1-2 mg)! Skin sensitivity, rash, itching, nausea! Urticaria, Hypotension, Bronchospasm! Inhibitory effects on mitochondrial respiration of human cells! Highly protein-bound (Albumin)! Excreted in the urines within hours but also into the bile

30 Clinical Case - 25

31 NA (mg/kg.min) Clinical Case - 26

32 Clinical Case 27

33 Clinical Case 28 NA (mg/kg.min)

34 Clinical Case 29 NA (mg/kg.min)

35 Clinical Case 30! Weaned from ECMO on day 5! VAP and ICU-AW! Tracheostomy on day 19! Weaned from MV on day 26! Discharged from ICU on day 30! Weaned from tracheostomy on day 41! Discharged rehabilitation on day 56! Back home on day 75

36 Conclusions! Severe intoxication to MDMA with MOF! Iatrogenic intoxication to Patent Blue! Cytosorb use was associated with reduced MetHb and Lactate levels and improved hemodynamics! Potential role for Cytosorb in drug intoxication

37 THANKS