MO675HEMOADSORPTION WITH CYTOSORB® CARTRIDGE IN PEDIATRIC INTENSIVE CARE UNIT – A SERIES OF FOUR CASES
Authors: Bezeljak Neva , Peršič Vanja , Krevh Golubić Darja , Vidmar Igor , Andonova Milena , Jerman Alexander , Vajdič Trampuž Barbara , Zupunski Cede Ana , Premru Vladimir , Gubensek Jakob 
Published: May 2021

Abstract

Background and Aims
Hemoadsorption with Cytosorb® cartridge is one of extracorporeal blood purification therapies increasingly used in adult intensive care units in conditions with elevated inflammatory mediators. Many positive experiences of hemodynamic improvement of patients treated with hemoadsorption have resulted in attempts of its application also in critically ill pediatric patients. Here we present a case series of four children treated with hemoadsorption in pediatric intensive care unit (PICU) of University Medical Centre Ljubljana from September 2018 to January 2019.

Method
All patients were mechanically ventilated and required vasopressor and inotropic support. Hemoadsorption was used as a rescue therapy after all standard treatments for their underlying condition had been insufficient. CytoSorb® cartridge was coupled with continuous veno-venous hemodialysis (CVVHD, Prismaflex system, Gambro) in pre-filter (ST60 set, Gambro) position. In children &lt;10 kg body weight (2 infants), the extracorporeal circuit was prefilled with a 1:1 mixture of packed red blood cells and saline, with heparin added. Automated regional citrate anticoagulation was used, blood flow was 30-100 ml/min and dialysate flow 500 ml/h.

Results
The youngest child was 10 days old 1.9 kg premature female with acute liver failure due to gestational alloimmune liver disease. CVVHD was started for hyperammonemia and concomitant CytoSorb® for severe hyperbilirubinemia (335 umol/l). Procedure was discontinued after 6 hours due to uncontrollable sepsis and hemodynamic collapse. We managed to normalize ammonia values and reduce bilirubin concentration (116 umol/l). Further treatment was withdrawn as a result of irreversible multiorgan failure.
One month old 2.5 kg female patient was treated in PICU due to necrotizing enterocolitis and refractory septic shock with multiorgan failure. Oliguric acute kidney injury (AKI) required CVVHD and later on Cytosorb ® was added as an attempt to limit severe hyperinflammatory condition. During 19 hours of treatment the need for vasopressor support was increasing and metabolic acidosis was deepening. The patient required a short resuscitation a couple of hours into the procedure due to bradycardia which resulted in catheter and CVVHD circuit thrombosis. Dialysis was discontinued as urgent surgery was necessary. The patient later died of uncontrolled septic shock.
Three years old 17 kg male was admitted with meningococcal septic shock, requiring initiation of veno-arterial ECMO. Cytosorb® with CVVHD was started and attached to the ECMO circuit. A significant decline of interleukine-6 (IL-6) was achieved without any procedure-related side effect and treatment was discontinued after 68 hours as patient's clinical status notably improved. The patient survived.
Five years old 20 kg female patient, actively treated for acute lymphoblastic leukemia, was admitted with E. coli sepsis. Septic shock was unresponsive to conventional treatment therefore she was started on Cytosorb® with CVVHD as oliguric AKI also developed. Two consecutive procedures were preformed, the first for 31 and the second for 37 hours. Level of IL-6 decreased (from &gt; 5000 ng/L to 1000 ng/L) and lactate level normalized. We achieved reduction in vasopressors and oxygen need during both procedures and patient's overall status greatly improved.

Conclusion
Although significantly increasing the volume of extracorporeal circuit, the use of Cytosorb® cartridge within CVVHD circuit is technically feasible even in critically ill children with low body weight, if principles of pediatric renal replacement therapy are considered. More efficacy and safety data on Cytosorb® utilization are necessary before inclusion in routine clinical practice. Treatment outcome is highly dependent on primary disease and severity of patient condition.