Abstract
BackgroundWe describe a combinatorial intensive care approach and discuss the critical factors that allowed us to successfully manage a life-threatening case of acute anaerobic septic shock triggered by descending necrotizing mediastinitis.Case presentationWe admitted a 38-year-old critically ill Kosovar Albanian man to our intensive care unit because of clinical manifestations of severe sepsis. His condition had worsened in the previous 2 weeks following unsuccessful antibiotic therapy for tonsillitis complicated by retropharyngeal abscesses. Computed tomography and intraoperative observations identified abscesses in the anterior and middle mediastinum regions and the distal part of the neck, directly on the border with the left lobe of the thyroid gland. Cultures indicated infections with α-hemolytic Streptococcus and Clostridium species: High procalcitonin and lactate levels, blood gas analysis, poor peripheral capillary oxygen saturation, and severe hemodynamic instability pointed to a case of acute septic shock. The entire treatment consisted of an aggressive antibiotic regimen, transthoracic and mediastinal surgical evacuation of the abscess, vacuum sealing drainage with a pleural chest tube, continuous venovenous hemodiafiltration using cytokine-adsorbing hemofilters, and extracorporeal blood hyperoxygenation.ConclusionsEfficient treatment of severe anaerobic sepsis resulting from descending necrotizing mediastinitis should build on a multidisciplinary approach. In support of first-line therapies with targeted antibiotics and surgical debridement, clinicians should consider alternative therapies such as continuous venovenous hemodiafiltration with cytokine-adsorbing hemofilters and hyperoxygenation.
Highlights
Descending necrotizing mediastinitis (DNM) is an acute, life-threatening disease caused by infections originating in the head and neck area
Our work highlights the importance of multidisciplinary intensive care in the Popevski et al Journal of Medical Case Reports (2019) 13:205 successful management of a 38-year-old man with acute anaerobic septic shock due to DNM
In this report, we describe a novel treatment approach for mediastinitis and anaerobic sepsis that includes our early initiation of a CVVHDF-CAH protocol, adjuvant blood purification using the modified AN69ST high-permeability membrane, and the use of intermittent extracorporeal blood hyperoxygenation
Summary
Adjuvant therapy should be considered when first-line treatment regimens fail to control sepsis progression and organ failure. Initiation of CVVHDF-CAH may be critical to control systemic infection and provide adequate renal support. Extracorporeal hyperoxygenation could overturn tissue hypoxia by optimizing peripheral vascularization. In the absence of established guidelines advocating the use of CVVHDF-CAH and extracorporeal hyperoxygenation, we conclude that well-designed randomized controlled trials are warranted to guide clinical decision making. Perhaps the ongoing NCT02600312, NCT02398019, and NCT01779635 trials will provide a definitive answer on the clinical benefit of the oXiris® system. Effective management of DNM-induced anaerobic septic shock benefits from a multidisciplinary approach that builds on the timely administration of antibiotics, skilled surgical intervention, and the use of adjuvant treatment modalities to support renal, pulmonary, and hemodynamic functioning.
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