Heat Stroke With Multiple Organ Failure Treated With Cold Hemodialysis and Cold Continuous Hemodiafiltration: A Case Report

Abstract

A 23-year-old comatose man was presented in the emergency room. He had been working inside a building under construction on a hot summer's day. His core body temperature was 42.1 degrees C and he was diagnosed with heat stroke. Urgent cooling procedures, including applying cold vapor to the patient's skin, a gastric lavage with cold water and an intravenous cold saline infusion, were not completely successful and his body temperature remained above 40 degrees C. Because his high temperature was refractory to conventional cooling procedures and we suspected that acute renal failure (ARF) by rhabdomyolysis would develop, we applied hemodialysis (HD) using cold dialysate (initially 30 degrees C and later 35 degrees C), followed by continuous hemodiafiltration (CHDF) with cold dialysate (35 degrees C) at a high flow rate of 18,000 mL per hour. The patient's body temperature fell below 38.0 degrees C within 3 h and was kept below 38.0 degrees C. Continuous hemodiafiltration was continued for one week. During the first week, the patient suffered from multiple organ failure (MOF) involving renal failure, as well as the failure of heart, liver, lung, and central nervous systems. Disseminated intravascular coagulation also developed. However, by virtue of cold CHDF, he almost recovered 3 weeks after the onset, except for remaining mild liver and renal dysfunction. In severe heat stroke, cold HD and high flow, cold CHDF should be a therapeutic choice for cooling and treatment of MOF. Considering mild liver and renal dysfunction still remained, this case suggested these procedures should be initiated at the very beginning of the treatment of severe heat stroke.

Expert consensus on the diagnosis and treatment of heat stroke in China

“…Continuous veno-venous hemodialysis (CVVHD) should be avoided because it cannot effectively clear myoglobin. For patients with adequate urine output, preventive blood purification or blood purification for simply removing myoglobin is not recommended [120].…”

A Case of Exertional Heat Stroke Complicated by Hypoxic Hepatitis

“…In addition, numerous animal models show that blockage of the release pathways for the cytokines IL-1β, IL-6, TNF-α, CD11b, CD68, IκBα, and NF-κB p65 and microRNA-155 [3][4][5]. Successful treatments with emergency liver transplantation [6][7][8][9][10][11][12][13][14][15], MARS [16], plasma exchange alone [17,18], and hemofiltration [19] as well as cold dialysis and hemofiltration [20] have been published. ere is growing evidence that conservative management seems to be sufficient for the management of most cases, and a delayed transplant strategy is reasonable [8,12,[21][22][23][24][25][26][27][28][29][30][31], with cases reporting successful transplant after delaying transplantation in favour of spontaneous recovery [8,12].…”

“…Most reported cases survived, but fatalities have been reported due to liver failure [8,[32][33][34] or transplant complications [35][36][37]. Nevertheless, early induction of cooling treatment, ideally reaching <38.9°C within 30 minutes, seems to be paramount [20,38,39]. Also, the administration of N-acetyl-cysteine was shown to improve transplant-free survival [40,41] and has been reported in acute liver failure secondary to heat stroke [8,21,22].…”

Heat stroke presented with disseminated intravascular coagulation and bilateral intracerebral bleed

“…There are cases of heat stroke with MOF with DIC and patients have survived with meticulous management5 6 but otherwise outcomes are fatal 7. However, such case of intracerebral haemorrhage resulting from heat stroke and their outcome is rare.…”