Resident Fundación Santa Fe de Bogotá Universidad del Rosario Bogota, Distrito Capital de Bogota, Colombia
Disclosure(s):
Jorge A. Herrera, MD: No financial relationships to disclose
Background: Cytokine storm (CS) is defined as a life threating systemic syndrome of augmented release of proinflammatory cytokines and immune cell activation that can trigger organ dysfunction including cardiomyopathy (1)
Methods A 26-year-old woman with a pregnancy of 20.5 weeks presented to a low complexity hospital with urinary sepsis and suspicious
Methods: of pulmonary embolism receiving systemic thrombolysis with alteplase 100 mg, referred to our hospital due to multiorgan disfunction secondary to septic and obstructive shock. An unstable patient with inotropic and vasopressors therapy, negative angiotomography, evidence in point of care ultrasound (POCUS) of severe biventricular failure with left ventricular dilatation and general hypokinesia, ejection fraction (LVEF) 16% and fractional area change (FAC) 17% and tricuspid annular plane systolic excursion (TAPSE) 8 mm; chest X-ray with pulmonary edema conditioning sever hypoxemia fulfilling acute distress respiratory syndrome definition and a positive urine culture for Escherichia coli wild type complicated with right pyelonephritis. At arrival, no fetal heart was observed during ultrasound (US) examination, spontaneous stillbirth on the same day.
After initial reanimation and persistence of refractory cardiogenic shock SCAI C secondary to septic cardiomyopathy (SCm), cytokine storm was diagnosed associated with hemophagocytic syndrome (H-score 205) and progression of multiorgan disfunction, levosimendan was initiated with no response showed in POCUS with persistent severe biventricular disfunction and left ventricular velocity-time integral 10 cm/s, veno-arterial extracorporeal membrane oxygenation (V-A ECMO) was considered and initiated as a bridge for recovery with an intra-aortic ballon (IABP) as venting strategy requiring isoproterenol infusion, ventilation with ultraprotective parameters and renal
Outcome: replacement therapy was required due to acute kidney injury associated with hemoperfusion therapy with cartridge HA380 (Jafron Biomedical Co. Guangdong, China). Follow-up was made with interleukin-6, C-reactive protein, ferritin and procalcitonin with marked decrease after fist hemoperfusion cartridge and the tendency continued after it; VA-ECMO and IABP were both titrated and retired after 4 days. The next day POCUS measurements were: LVEF 35%, CAF 29% and TAPSE 11mm.
On day 18, patient presented sudden desaturation and pulseless electrical activity requiring cardiopulmonary resuscitation. After 4 minutes with return of spontaneous circulation, cause was determined to be hypoxemia due to new onset of pulmonary edema requiring diuretic and PEEP titration. No neurological sequelae observed after.
Outcomes: Patient was discharged with no sequalae and tracheostomy canula after 35 days with optimal medical therapy for heart failure with reduced ejection fraction.
Conclusion: Septic cardiomyopathy (SCm) is a serious and life threatening condition with an incidence of 10-70% and a median of 28.2% (2) with mortality between 14-65% but with no consensus of an increase in mortality between patients with and without the condition (3). Cytokine storm is one of the main triggers in SCm due to a downregulation in the clearance of cytokines secondary
Conclusion: to augmented circulating Pathogen-Associated Molecular Patterns (PAMPs) leading to an increase in interleukin-1, Interleukin-6 and tumor necrosis factor-α (4). V-A ECMO is one of the strategies for support with an indication of bridge to recovery even though it has been associated as a risk factor for increased mortality (5).
