Cytokine Release Syndrome (CRS)

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Salient features:

This article focuses on:

  • Grades of Cytokine Release Syndrome (CRS)
  • Clinical assessment
  • Treatment

Detailed summary :

Cytokine Release Syndrome (CRS)

  • Grade 1

Clinical assessment :

  • Mild reaction:  low grade fever, No oxygen requirement or need for IVF

            Treatment : no treatment

  • Grade 2

Clinical assessment :

  • Moderate reaction:

High grade fever (> 103 F) need for IVF ( not hypo tension ), mild oxygen requirement ( <6L/min)

-Grade 2 AKI

-Grade 3 LFT ( Raised liver enzymes and S Bilirubin ≥ 2.5 gm/dl)

  • Grade 3 

Clinical assessment :

  • Severe reaction:

-Rapidly worsening respiratory status with radiographic infiltrates and SPO2 ≤ 93% in room air or on supplemental oxygen (>6L/min, high flow BiPAP, CPAP)

-Grade 4 Liver Function Test ( raised liver enzymes, S Bilirubin > 2.5gm/dl and INR >1.5, encephalopathy)

-Grade 3 AKI

-IVF for resuscitation

-Coagulopathy requiring correction with FFP or cryoprecipitate

-Low dose vasopressor (Noradrenaline < 0.5 mcg/kg/min or Adrenaline < 0.3mcg/kg/min)

          Treatment:

  • Send for Serum IL-6 or CRP, Ferritin.
  • Consider Tocilizumab >18 years: 8 mg/kg IV ( Max 400 mg)
  • < 18 years
  • <30 kg: 12 mg/kg IV over 60 minutes
  • >30 kg: 8 mg/kg ( max 800 mg) IV over 60 minutes if no effect can repeat X 2 more doses Q8H apart;
  • If no response, consider low dose corticosteroids especially in case of concomitant septic shock.
  • Send for serum IL-6 or CRP
  • Tocilizumab in Grade 3 should be considered.
  • Corticosteroids should be considered.
  1. Grade 4

Clinical assesment :

  • Life threatening multi organ dysfunction
  • Hypoxia requiring mechanical ventilation 
  • Hypotension requiring high dose vasopressors. 

           Treatment:

  • Send for serum IL-6 or CRP
  • Consider Tocilizumab in Grade 3
  • Consider Corticosteroids

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