Take control in Critical Care
Whether as a result of infection or of a sterile trigger such as severe injury or major surgery, systemic hyperinflammation with increased levels of cytokines can cause significant hemodynamic instability and other organ dysfunction.
Use the CytoScore calculator to determine the optimal time to initiate CytoSorb Therapy.
The Challenge
The cause
Infections or non-infective triggers like severe injury or major surgery can induce an unwanted excessive immune response.
Immune response
Overwhelming levels of inflammatory mediators can lead to a cytokine storm.
Hemodynamic instability
The cytokine storm can cause significant hemodynamic instability and vasoplegic shock, triggering multi-organ dysfunction.
Restore the balance
CytoSorb® helps to restore the balance by removal of excessive levels of cytokines, and to stabilize the patient’s hemodynamics, so you can focus on the treatment your patient needs to recover.
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The cause
Infections or non-infective triggers like severe injury or major surgery can induce an unwanted excessive immune response.
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Immune response
Overwhelming levels of inflammatory mediators can lead to a cytokine storm.
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Hemodynamic instability
The cytokine storm can cause significant hemodynamic instability and vasoplegic shock, triggering multi-organ dysfunction.
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Restore the balance
CytoSorb® helps to restore the balance by removal of excessive levels of cytokines, and to stabilize the patient’s hemodynamics, so you can focus on the treatment your patient needs to recover.
CytoSorb can be applied across critical care challenges
Reversing shock – restoring balance
Excessive cytokine release during systemic hyperinflammation can lead to vasoplegia and circulatory shock, posing acute and life-threatening consequences for patients. CytoSorb can help.
Stabilize hemodynamics
CytoSorb, with its unique adsorptive bead technology, has been demonstrated to effectively achieve reversal of vasoplegic shock, e.g. in sepsis.
In intensive care units (ICU), systemic hyperinflammation as in sepsis is the most common cause of death, particularly when it progresses to refractory vasoplegic shock, where the mortality rate increases significantly despite improvements in the standard of care.
Vasoplegic or distributive shock caused by non-infectious triggers can look like septic shock and be just as dangerous with high morbidity and mortality.
By removal of excessive cytokines, CytoSorb Therapy can help to stabilize hemodynamics through:
Attenuation of hyperinflammation
Reduction in vasopressor needs
Norepinephrine requirements
In septic-shock patients, following initiation of CytoSorb Therapy, vasopressor needs halved within 24 hours. In the control group, unlike the CytoSorb group, no significant difference can be seen within the first 48 hrs.
Improvement in macro- and microcirculation
Promotion of shock reversal
Reduction in lactate
Hyperinflammatory shock
Treatment Rationale & Guidance
Break the vicious cycle of massive systemic inflammation. Prevent and reverse capillary leak. Stabilize micro- and macro-hemodynamics. Enable early active removal of excess fluids. Preserve and restore organ function.
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Break the cycle of massive systemic inflammation
Jansen et al.Removes excessive cytokines and inflammatory mediators
A large proportion of ICU patients are prone to develop a refractory vasoplegic shock condition with high corresponding mortality, often due to sepsis. Underlying excessive cytokine release represents a major hyperinflammatory problem, driving a vicious, self-amplifying circle and is difficult to treat directly with Standard of Care measures.
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Reduce capillary leakage
Papp et al.Removes endothelial damaging proteins. Promotes endothelial integrity.
A major problem in hyperinflammatory shock is the “leaky bucket” phenomenon on tissue level: the endothelial firewall is disrupted, resulting in fluid loss into the interstitium with subsequent tissue edema. Circulating cytokines and certain proteins drive this process through damaging endothelial tight junctions.
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Stabilize micro- and macro-circulation
Hawchar et al.Allows shock reversal/vasopressor reduction
Founded on the capillary leakage problem, micro- and also macro circulation issues arise, leading to impaired tissue perfusion and oxygenation, as well as extensive need for support from vasoactive vasopressor medication. Mastering these crises in micro- and microcirculatory stability is the essential prerequisite for patient recovery.
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Reduce fluid balance / Edema
Kogelmann et al.Improves prerequistes for early active fluid removal
With hemodynamic stability achieved and endothelial walls ”healed”, further fluid administration can be reduced/stopped and removal via dialysis and/or diuretics proactively addressed to reverse tissue edema.
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Preserve and restore organ function
Szigetvary et al.Lung: shorter diffusion distance improves gas exchange
Kidney: decompression supports urine production. Liver: direct detoxification support and recovery of synthesis functions. The rebalancing effects of CytoSorb on peaking cytokines and other damaging proteins support the preservation and/or restoration of organ tissue integrity and function during vasoplegic shock conditions. This can lead to better outcome perspectives.
Support your decision with CytoScore
This dynamic scoring system is intended to provide support in the decision to initiate CytoSorb Therapy in refractory septic/vasoplegic shock. The score can be calculated 6 hours after initiation of standard therapy for shock. For this purpose, various categories that are meaningful for the hemodynamic condition of the patient are rated with 0, 1 or 2 points in order to arrive at a total score. If the total score is >6 clinical data suggests that initiation CytoSorb Therapy within the next 6 hours might lead to positive outcome effects.
Kogelmann et al., J Clin Med 2021; 10: 2939
Diagnosis of septic shock
Start of standard therapy
Evaluation using CytoScore
Start treatment with CytoSorb
if >6 points after 6 hours, consider starting CytoSorb
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Diagnosis of septic shock
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Start of standard therapy
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Evaluation using CytoScore
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Start treatment with CytoSorb
if >6 points after 6 hours, consider starting CytoSorb
Postoperative hyperinflammation management
Major surgeries can trigger temporary systemic hyperinflammation. CytoSorb can help maintain the inflammatory balance crucial for patient stability.
Control postoperative hyperinflammation
Help control post-surgical hyperinflammation and multi-organ dysfunction. When undergoing major surgical procedures, patients often experience a transient inflammatory response that should be considered physiological.
An uncontrolled systemic inflammatory response, however, can contribute to multi-organ dysfunction, which plays a significant role in postoperative morbidity or mortality.
By removal of excessive cytokines, CytoSorb Therapy can help to stabilize hemodynamics through:
Attenuation of hyperinflammation
Reduction in vasopressor needs
Noradrenaline and adrenaline requirements
CytoSorb demonstrates substantial and statistically significant reduced catecholamine needs, together with a restoration of hemodynamic stability.
Improvement in micro- and microcirculation
Promotion of shock reversal
Best practice therapy management
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Therapy goal
Promotion of shock reversal through:
- Attenuation of hyperinflammation
- Reduction in vasopressor needs
- Improvement of micro and macro circulation
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Patient selection
- Refractory septic/vasoplegic shock
- High (and increasing) need for vasopressors
- No (proper) response to standard of care
- Biomarkers (if available):
- IL-6 > 500 pg/ml,
- PCT > 3 μg/l,
- Ferritin > 1000 μg/l
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Timing
- Ideally < 12 hours after diagnosis of shock/start of standard therapy
- Don’t wait until lactate is > 6.5/7 mmol/L
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Dosing
- For severely unstable and hyper-inflamed patients, device changes every 8-12 hours at the beginning of treatment is recommended. Otherwise, daily device changes will suffice.
- Continue until sufficient hemodynamic stabilization is achieved
Support your ECMO patients
Reduce elevated levels of cytokines to promote organ recovery for Extracorporeal Membrane Oxygenation (ECMO) patients.
Applications
With two main applications — Venoarterial (VA) ECMO for cardiac and pulmonary support, and venovenous (VV) ECMO for pulmonary support — ECMO is increasingly used in acute respiratory distress syndrome (ARDS) and cardiogenic shock, but morbidity and mortality rates remain high.
Treatment options to enhance the clinical benefits of ECMO support and prevent complications, such as ongoing hyperinflammation, are currently limited.
Enhanced lung rest: improve VV-ECMO outcomes
Viral or bacterial infections, such as pneumonia, influenza, COVID, and non-infectious insults, such as aspiration, trauma, pancreatitis, smoke, and ventilator-induced lung injury, can lead to acute respiratory distress syndrome (ARDS) and respiratory failure, requiring VV-ECMO intervention.
While VV-ECMO addresses hypoxemia and helps prevent ventilator-induced lung injury (VILI), it does not address the underlying hyperinflammation, which can have serious consequences, including endothelial and epithelial damage, capillary leakage, and loss of surfactant.
CytoSorb helps manage this concomitant hyperinflammation and, when used in combination with VV-ECMO to rest the lungs, can enhance lung rest and promote organ recovery — both crucial to improved survival.
Earlier intervention with CytoSorb and VV-ECMO allows for “Enhanced lung rest” in severe-ARDS patients and was associated with shorter need for ECMO therapy, mechanical ventilation (MV) and ICU stay, compared to patients with late treatment start.
Substantial and statistically significant increase in PaO₂/FiO₂ ratio and concomitant substantial and statistically significant decrease of C-Reactive Protein (CRP), Lactate and norepinephrine (NE) were observed in ARDS patients treated with hemoadsorption.
Best practice therapy management
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Therapeutic goal
Promotion of lung function recovery through the concept of “enhanced lung rest”:
- Lung rest by ECMO and concomitant treatment of hyperinflammation by CytoSorb
- Improvement in oxygenation
- Faster weaning from ECMO
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Patient selection
- ARDS with respiratory failure requiring ECMO therapy
- Clinical signs of severe hyperinflammation and/or elevated biomarkers:
- IL-6 > 500 pg/mL
- PCT > 3 μg/L
- Ferritin > 1000 μg/L
- CRP > 50 mg/L
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Timing
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Consider simultaneous integration of CytoSorb at the start of ECMO as a protocolized “enhanced lung rest” approach
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Early intervention with CytoSorb is associated with better outcomes
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Dosing
Depending on the individual clinical course:
- For patients with severe ARDS, changing the device every 12 hours for the first day is recommended, followed by daily device changes for the next 2 days, for a total of 4 devices over 72 hours. Treatment can be extended beyond 72 hours if needed.
- Change each adsorber after a maximum use time of 24 hrs
- Consider changing CytoSorb every 12 hrs if there is ongoing cardiopulmonary instability
- Re-evaluate every 12-24 hrs and continue treatment as clinically indicated
Enhance VA-ECMO Outcomes
Additional Information
- Kogelmann et al., J Clin Med 2021; 10(13):2939
- Rugg et al., Biomedicines 2020; 8(12):539
- Brouwer et al., Crit Care. 2019; 23(1):317
- Akil et al., Thorac Cardiovasc Surg 2021; 69(3):246-251
- Boss et al., PLoS One 2021; 16(2):e0246299
- Rasch S et al., Artif Org 2022; 46(6):1019-1026
- Traeger et al., Int J Artif Organs 2016; 39(3):141-146
- Leonardis et al., Case Rep Crit Care 2018:1205613
- Bottari et al., Front in Pediatrics 2023; 11:1259384
- Friesecke et al., J Artif Organs 2017; 20(3):242-259
- David et al., J Int Care 2017; 5:12
- Akil et al., J Clinical Med 2022; 11(20):5990
- Hayanga et al., Crit Care 2023; 27(1):243
- Calabrò et al., Artif Organs 2019; 43(2):189-194
- Hawchar et al., J Crit Care 2019; 49;172-178
- Kogelmann et al., J Clin Med 2024; 13(1):294
- Zuccari et al., Blood Purif 2020; 49(1-2):110 -113
- Szigetvary et al., Biomedicines 2023; 11(11):3068
- Piskovatska et al., Healthcare 2023; 11(3):310
- Kogelmann et al., J Int Care Soc 2020; 21(2):183-190
- Song, T et al., Front. Med. 2021; 8:773461
- Hayanga J et al., Crit. Care 2023; 27:243
Voices around the world
Access Healthcare Professionals Area
This area is for Health Care Professionals only and provides reports about clinical experiences gained during the use of CytoSorbents products. The information presented reflects the opinions and procedural techniques of individual physicians and is not intended as medical advice. Physician experience, risks, patient outcomes and results may vary. This content is intended for Health Care Professionals outside the United States and Canada as CytoSorb has not yet been approved or cleared in the United States or Canada for any indication, except under an Emergency Use Authorization (EUA) by the US FDA.