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An event is serious (based on the ICH definition) when the patient outcome is:
* death
* life-threatening
* hospitalisation
* disability
* congenital anomaly
* other medically important event
A 75-year-old man exhibited lack of efficacy during treatment with norepinephrine for hemodynamic instability, septic shock and hypotension.
The man, who had Parkinson's disease, chronic obstructive pulmonary disease, severe psychosis and noninsulin-dependent diabetes mellitus, was diagnosed with COVID-19 in May 2020. He was transferred to ICU due to severe respiratory failure. He received two doses of off-label tocilizumab 8 mg/kg for COVID-19 during hospitalisation. After admission to the ICU, he was found to be hypotensive and was diagnosed with secondary septic shock due to sacral decubitus lesion with perineal, scrotal, and upper limb oedema. Further analyses revealed hypoxaemic respiratory failure with metabolic acidosis and mild leucocytosis along with Proteus Mirabilis, Providencia Stuartii, and Klebsiella Pneumoniae infections. He was intubated and received piperacillin/tazobactam alongside norepinephrine infusion at 0.6 µg/kg/min. His haemodynamics remained unstable despite the maximum norepinephrine dose of 1.4 µg/kg/min (lack of efficacy), and he was started on terlipressin. Thereafter, he underwent three cycles of CytoSorb treatment initially in haemoperfusion-mode and then in combination with continuous venovenous haemodiafiltration with heparin [sodium heparin] as anticoagulant. His metabolic acidosis improved 24h after the initiation of CytoSorb treatment. He was continued on haemodynamic support with high-dose norepinephrine and terlipressin. His sacral decubitus worsened and vacuum assisted closure therapy was performed. Thereafter, his inflammation indexes, lactate, and IL-6 reduced significantly. The norepinephrine dose was reduced to 0.25 µg/kg/min, and terlipressin therapy was stopped. His diuresis restored and haemodynamics stabilised. He was extubated after 7 days of admission.