Müslüm ÇİÇEK, ENDER GEDİK, Zafer DOĞAN, Nurçin GÜLHAŞ, M. Özcan ERSOY

Septik şok ve akut böbrek yetmezliği tedavisinde eş zamanlı devamlı veno-venöz hemodiyafiltrasyon ve aktive protein C kullanımı (olgu sunumu)

Amaç: Ağır sepsis ve septik şokun mortalitesi oldukça yüksektir. Septik şok ve akut böbrek yetmezliği tedavisi için, devamlı veno-venöz hemodiyafiltrasyon ve aktive protein C uygulanan bir olguyu sunmayı amaçladık. Olgu Sunumu: Kırk iki yaşında erkek, ateşli silah yaralanması nedeniyle acil serviste değerlendirildiğinde; Glasgow Koma Skoru 3, pupiller izokorik, ışık refleksi (+/+), cilt soğuk ve soluk, solunum sayısı 38 dk'1, kan basıncı 64/42 mmHg, kalp atım hızı 174 dk'1 olarak saptandı. Acil olarak ameliyata alınan hastaya; karaciğer laserasyonu ve diyafragma rüptürüne primer onarım, kolesistektomi, çekum rezeksiyonu ve ileokolostomi, femoral artere greft, bilateral göğüs tüpü takılması, orşiektomi, tibia kırığına debridman yapıldı. Ameliyattan sonra yoğun bakım ünitesinde mekanik ventilasyon destek tedavisi başlandı. İlk gün APACHE II skoru 34 olarak belirlendi. Antibiyoterapi ve destek tedavilerine rağmen 9. gün septik şok ve akut böbrek yetmezliği gelişti. Hasta tekrar ameliyata alınarak subhepatik apse drenajı, ileokolik anastomoz tamiri ve ileostomi yapıldı. Ameliyat sonrası aktive protein C ve devamlı veno-venöz hemodiyafiltrasyon başlandı. Aktive protein C tedavisine iki saat ara verilerek perkütan trakeotomi açıldı. Trakeotomiden bir saat sonra tekrar aktive protein C başlanarak 96 saate tamamlandı. Yatışının 47. gününde tibia kırığı sekeli dışında sağlıklı olarak taburcu edildi. Sonuç: Karın içi enfeksiyon sonucu septik şok ve akut böbrek yetmezliği gelişen hastada, standart bakım tedavilerine ek olarak sepsis odağı ortadan kaldırıldıktan sonra, eş zamanlı devamlı veno-venöz hemodiyafiltrasyon ve aktive protein C uygulamasının hayat kurtarıcı olabileceği kanısına varıldı.

Anahtar Kelimeler:

Böbrek yetmezliği, akut, Hemodiyafiltrasyon, Şok, septik, Protein C

Simultaneous use of continuous veno-venous hemodiafiltration and activated protein C for treatment of septic shock and acute renal failure (case report)

Objective: The mortality of severe sepsis and septic shock is extremely high. We aimed to present a case to which we applicated continuous veno-venous hemodiafiltration and activated protein Cfor treatment of septic shock and acute renal failure. Case report: Assessment of the 42-year old male with gun-shot wound in the emergency service revealed that Glasgow Coma Scale 3, isochoric pupils, bilateral positive light reflex, cold and pale skin, spontaneous ventilation rate (38 mirî1), blood pressure (64142 mmHg), and heart rate (174 min'1). In urgent operation, primary repair of liver laceration and diaphragm rupture, cholecystectomy, caecum resection and ileocolostomy, greft to femoral artery, thorax drainage with bilateral tubes, orchiectomy and debridment of tibia fracture were performed. After the operation, he was mechanically ventilated in intensive care unit. In first day, APACHE II score was determined as 34. In the 9th day, septic shock and acute renal failure developed in spite of antibacterial and supportive treatments. In another operation, subhepatic abscess drainage, repair of ileocolic anastomosis and ileostomy were performed. Activated protein C and continuous veno-venous hemodiafiltration were started following the operation. Activated protein C treatment was stopped for 2 hours and than percutaneous tracheotomy was performed. Activated protein C was started again one hour after the tracheotomy and than administered totally 96 hours. Patient was discharged with tibia fracture sequel in the 47th day. Conclusion: In a case with septic shock and acute renal failure due to abdominal infection, in addition to standard care and treatment of cause of sepsis, simultaneous continuous veno-venous hemodiafiltration application and activated protein C administration may be life-saving.

Keywords:

Kidney Failure, Acute, Hemodiafiltration, Shock, Septic, Protein C,

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