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Early Cytokine Removal in Critical COVID-19 Patients with Extracorporeal Therapies (HA-380 plus High Volume Hemofiltration) May Prevent Progression of Acute Respiratory Distress Syndrome: Case Report

We present the case of a patient who suffered from acute respiratory distress syndrome caused by pneumonia associated with COVID-19 and cytokine release syndrome. This patient received a high-volume hemofiltration plus adsorption, solving the hemodynamic deterioration, pulmonary infiltrates, and gas exchange. Our clinical case proposes that the extracorporeal therapies can have a role in the management of severe COVID-19.


Introduction
The extracorporeal therapies for COVID-19 have the role of removing the proinflammatory molecules for patients that suffer from severe pulmonary involvement and cytokine release syndrome (CRS) [1,2]. Clinical studies in different scenarios and HVHF plus adsorption have shown that its premature use is associated with a decrease of cytokines, improvement of PaO 2 /FiO 2 , better result in severity scores (APACHE II and SOFA), accomplishing the reduction of the sepsis's incidence, days of mechanical ventilation, and mortality [3][4][5]. Our group proposes that the premature use of extracorporeal therapies for immunomodulation could have a role, modifying the natural history of severe COVID-19.

Case Presentation
A 59-year-old man presented without comorbidities and 15 days of respiratory symptoms. The chest CT is shown in Figure 1. Upon admission, the data were as follows: PaO 2/ FIO2 134, C-reactive protein 132 mg/dL, ferritin 1,278 µg/L, LDH 632 UI/L, and absolute lymphocyte count 376 cel/µL.
A hemoperfusion (HP) of 10 h (HA-380 cartridge, Jafron Biomedical Co.) was performed combined with HVHF in Prismaflex monitor (Baxter) with 250 mL/min blood flow and 70 mL/kg/h effluent dose, with prefilter replacement and heparin. The HP cartridge was installed postfilter. According to local protocol, after 24 h, an 8 h HVHF was performed, maintaining parameters. There were no adverse events associated with the performed process.
Normalization of the temperature and discontinuation of vasoactive drugs during the first hour was accomplished. After that, we can highlight the significant improvement of the ventilatory mechanics and gas exchange in supine position (PaO 2 /FiO 2 192) (Fig. 1), without making any changes in the parameters of the mechanical ventilator. Significant regression of CT images was observed. After the described procedure, it was maintained in the intensive unit, evolving with an infection caused by Enterococcus faecalis, dying weeks later.

Discussion and Conclusion
The hemadsorption was proposed as a rescue therapy in a COVID-19 patient with severe ARDS in spite of the protective mechanical ventilation according to the mod- ern concepts and in which we demonstrated the regression of pulmonary images associated to the improvement in gas exchange and ventilatory mechanics. Unfortunately, it evolves unfavorably due to complications not associated with the procedure. The CRS and ARDS are phenomena that are related in their pathophysiology, contributing to increase in CO-VID-19 mortality. Recently a case was reported, in which the intubation's prevention through extracorporeal therapies was achieved [2]. Our team presented this case in which we could avoid the progression of ADRS with HVHF/HP as adjuvant therapy [6].