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Yu J, Taskén AA, Berg EAR, Tannvik TD, Slagsvold KH, Kirkeby-Garstad I, Grenne B, Kiss G, Aakhus S. Continuous monitoring of left ventricular function in postoperative intensive care patients using artificial intelligence and transesophageal echocardiography. Intensive Care Med Exp 2024; 12:54. [PMID: 38856861 PMCID: PMC11164841 DOI: 10.1186/s40635-024-00640-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 06/04/2024] [Indexed: 06/11/2024] Open
Abstract
BACKGROUND Continuous monitoring of mitral annular plane systolic excursion (MAPSE) using transesophageal echocardiography (TEE) may improve the evaluation of left ventricular (LV) function in postoperative intensive care patients. We aimed to assess the utility of continuous monitoring of LV function using TEE and artificial intelligence (autoMAPSE) in postoperative intensive care patients. METHODS In this prospective observational study, we monitored 50 postoperative intensive care patients for 120 min immediately after cardiac surgery. We recorded a set of two-chamber and four-chamber TEE images every five minutes. We defined monitoring feasibility as how often the same wall from the same patient could be reassessed, and categorized monitoring feasibility as excellent if the same LV wall could be reassessed in ≥ 90% of the total recordings. To compare autoMAPSE with manual measurements, we rapidly recorded three sets of repeated images to assess precision (least significant change), bias, and limits of agreement (LOA). To assess the ability to identify changes (trending ability), we compared changes in autoMAPSE with the changes in manual measurements in images obtained during the initiation of cardiopulmonary bypass as well as before and after surgery. RESULTS Monitoring feasibility was excellent in most patients (88%). Compared with manual measurements, autoMAPSE was more precise (least significant change 2.2 vs 3.1 mm, P < 0.001), had low bias (0.4 mm), and acceptable agreement (LOA - 2.7 to 3.5 mm). AutoMAPSE had excellent trending ability, as its measurements changed in the same direction as manual measurements (concordance rate 96%). CONCLUSION Continuous monitoring of LV function was feasible using autoMAPSE. Compared with manual measurements, autoMAPSE had excellent trending ability, low bias, acceptable agreement, and was more precise.
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Affiliation(s)
- Jinyang Yu
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Postboks 8905, 7491, Trondheim, Norway.
- Clinic of Cardiology St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Anders Austlid Taskén
- Department of Computer Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Erik Andreas Rye Berg
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Postboks 8905, 7491, Trondheim, Norway
- Clinic of Cardiology St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Tomas Dybos Tannvik
- Department of Anesthesia and Intensive Care, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Katrine Hordnes Slagsvold
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Postboks 8905, 7491, Trondheim, Norway
- Clinic of Cardiothoracic Surgery, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Idar Kirkeby-Garstad
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Postboks 8905, 7491, Trondheim, Norway
| | - Bjørnar Grenne
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Postboks 8905, 7491, Trondheim, Norway
- Clinic of Cardiology St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
- Centre of Innovative Ultrasound Solutions, Trondheim, Norway
| | - Gabriel Kiss
- Department of Computer Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Svend Aakhus
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Postboks 8905, 7491, Trondheim, Norway
- Clinic of Cardiology St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
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Forner J, Weidner K, Rusnak J, Dudda J, Behnes M, Akin I, Schupp T. Prognostic Impact of Left Compared to Right Heart Function in Sepsis and Septic Shock. ASAIO J 2024; 70:502-509. [PMID: 38237636 DOI: 10.1097/mat.0000000000002131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024] Open
Abstract
This study investigates the prognostic impact of left ventricular ejection fraction (LVEF) and tricuspid annular plane systolic excursion (TAPSE) in patients with sepsis and septic shock. Consecutive patients with sepsis and septic shock were included from 2019 to 2021. LVEF and TAPSE were assessed during the first 24 hours of intensive care unit (ICU) treatment. Patients were stratified by LVEF of less than 45% and greater than or equal to 45%. The primary endpoint was 30 day all-cause mortality. Two hundred ninety-two consecutive patients were included, of which 26% presented with LVEF of less than 45%. Within the entire study cohort (60% vs. 48%; hazard ratio [HR] = 1.414; 95% confidence interval [CI] = 0.999-2.001; p = 0.050) and specifically in patients with sepsis (58% vs. 36%; HR = 1.919; 95% CI = 1.148-3.208; p = 0.013), LVEF of less than 45% was associated with an increased risk of 30 day all-cause mortality, whereas TAPSE of less than 17 mm was not (56% vs. 52%; log rank p = 0.798). Even after multivariable adjustment, LVEF of less than 45% was accompanied by a worse prognosis in septic patients (HR = 1.944; 95% CI = 1.084-3.485; p = 0.026). Contrarily, LVEF < 45% was not accompanied with increased mortality in septic shock patients (63% vs. 67%; log rank p = 0.847; HR = 0.956; 95% CI 0.596-1.533; p = 0.853). In conclusion, impaired LVEF was associated with increased mortality in septic patients without shock, but not in patients with septic shock. In contrast, impaired right ventricular function was not associated with adverse prognosis in both conditions.
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Affiliation(s)
- Jan Forner
- From the Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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You JY, Sato R, Chawla S, Kapoor A, Wang X, Collier P, Auzinger G, Duggal A, Dugar S. Hemodynamic profile of cirrhotic patients with sepsis and septic shock: A propensity score matched case-control study. J Crit Care 2024; 81:154532. [PMID: 38330737 DOI: 10.1016/j.jcrc.2024.154532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/15/2024] [Accepted: 02/01/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE Our understanding of hemodynamics in cirrhotic patients with sepsis remains limited. Our study aims to investigate differences in hemodynamic profiles using echocardiography between septic patients with and without cirrhosis. MATERIALS AND METHODS This is a single-center, retrospective study of septic patients with echocardiogram within 3 days of ICU admission. We compared baseline characteristics, echocardiographic markers of LV systolic function arterial load between patients with and without cirrhosis. A propensity score-matched case-control model was developed to describe the differences in those echocardiography derived parameters between the groups. RESULTS 3151 patients with sepsis were included of which 422 (13%) had cirrhosis. In the propensity score matched group with 828 patients, cirrhotic patients had significantly higher left ventricular ejection fraction (64 vs.56%, p < 0.001) and stroke volume (72 vs.48 ml, p < 0.001) along with lower arterial elastance (Ea) (1.35 1vs.20.3, p < 0.001) and systemic vascular resistance (SVR) (851 vs.1209 dynes/s/m-5, p = 0.001). The left ventricular elastance (Ees) (2.83 vs 2.45, p = 0.002) was higher and ventricular-arterial coupling (Ea/Ees) (0.48 vs. 0.86, p < 0.001) lower in cirrhotic compared to non-cirrhotic. CONCLUSIONS Septic patients with cirrhosis had higher LVEF with lower Ea and SVR with higher Ees and significantly lower Ea/Ees suggesting vasodilation as the principal driver of the hyperdynamic profile in cirrhosis.
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Affiliation(s)
- Jee Young You
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Ryota Sato
- Division of Critical Care Medicine, Department of Medicine, The Queen's Medical Center, Honolulu, HI, USA.
| | - Sanchit Chawla
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Aanchal Kapoor
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Xiaofeng Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA.
| | - Patrick Collier
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Georg Auzinger
- Department of Critical Care, Cleveland Clinic London, London, UK; Reader in Critical Care King's College London, London, UK; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH, USA.
| | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH, USA.
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH, USA.
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Persaud P, Rudoni MA, Duggal A, Miyashita S, Lanspa M, Dugar S. Validity of International Classification of Diseases, Tenth Revision, codes for atrial fibrillation/flutter in critically ill patients with sepsis. Anaesth Crit Care Pain Med 2024; 43:101398. [PMID: 38821159 DOI: 10.1016/j.accpm.2024.101398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 03/09/2024] [Accepted: 03/26/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) and atrial flutter (AFL) are frequently seen in critically ill sepsis patients and are associated with poor outcomes. There is a need for further research, however, studies are limited due to challenges in identifying patient cohorts. Administrative data using the International Classification of Diseases, Tenth Revision (ICD-10) are routinely used for identifying disease cohorts in large datasets. However, the validity of ICD-10 for AF/AFL remains unexplored in these populations. METHODS This validation study included 6554 adults with sepsis and septic shock admitted to the intensive care unit. We sought to determine whether ICD-10 coding could accurately identify patients with and without AF/AFL compared to manual chart review. We also evaluated whether the date of ICD-10 code entry could distinguish prevalent from incident AF/AFL, presuming codes dated during the index admission to be incident AF/AFL. A manual chart review was performed on 400 randomly selected patients for confirmation of AF/AFL, and validity was measured using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS Among the 400 randomly selected patients, 293 lacked ICD-10 codes for AF/AFL. The manual chart review confirmed the absence of AF/AFL in 286 patients (NPV 97.3%, specificity 99.7%). Among the 107 patients with ICD-10 codes for AF/AFL, 106 were confirmed to have AF/AFL by manual chart review (PPV 99.1%, sensitivity 93.0%). Out of the 114 patients with confirmed AF/AFL, 44 had ICD-10 codes dated during the index admission. All 44 were confirmed to have AF/AFL, however, 18 patients had prior documentation of AF/AFL (incident AF/AFL: PPV 59.1%). Specificity for incident (95.1%) and prevalent (99.7%) AF/AFL were high; however, sensitivity was 76.5% and 77.5%, respectively. DISCUSSION/CONCLUSION ICD-10 codes perform well in identifying clinical AF/AFL in critically ill sepsis. However, their temporal specificity in distinguishing incidents from prevalent AF/AFL is limited.
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Affiliation(s)
| | | | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH, USA
| | - Sotoshi Miyashita
- Department of Cardiovascular Medicine Heart, Vascular, and Thoracic Institute Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Michael Lanspa
- Critical Care Echocardiography Service, Intermountain Medical Center, UT, USA; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH, USA.
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Sato R, Hasegawa D, Guo SC, Nishida K, Dugar S. INVASIVE HEMODYNAMIC MONITORING WITH PULMONARY ARTERY CATHETER IN SEPSIS-ASSOCIATED CARDIOGENIC SHOCK. Shock 2024; 61:712-717. [PMID: 38150363 DOI: 10.1097/shk.0000000000002290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
ABSTRACT Background: Both sepsis-induced cardiomyopathy and worsening of preexisting cardiac disease can contribute to circulatory shock in septic patients. The early use of pulmonary artery catheter (PAC) could play a pivotal role in the management of sepsis-associated cardiogenic shock. In this study, we aimed to evaluate the impact of early invasive hemodynamic monitoring with PAC in patients with sepsis-associated cardiogenic shock. Method: We performed a retrospective study using the National Inpatient Sample data from January 2017 to December 2019. The early use of PAC was defined as the use of PAC within 2 days from the admission. We performed the multivariable logistic regression analysis to investigate the association between the early use of PAC and in-hospital mortality in patients with sepsis-associated cardiogenic shock and sepsis without cardiogenic shock, respectively. Results: There was no difference in in-hospital mortality between PAC and no PAC groups in sepsis without cardiogenic shock (adjusted odds ratio [aOR] = 1.05, 95% confidence interval [CI] = 0.82-1.35, P = 691). On the other hand, the early use of PAC was independently associated with lower in-hospital mortality in patients with sepsis-associated cardiogenic shock (aOR = 0.58, 95% confidence interval [CI] = 0.46-0.72, P < 0.001). The use of PAC was also associated with increased use of mechanical circulatory support in those with sepsis-associated cardiogenic shock (aOR = 12.26, 95% CI = 9.37-16.03, P < 0.001). For patients with sepsis-associated cardiogenic shock, the use of PAC after 2 days of admission was associated with significantly higher in-hospital mortality and decreased use of mechanical circulatory support. Conclusion: The use of pulmonary artery catheters in sepsis-associated cardiogenic shock was associated with significantly lower in-hospital mortality and increased use of mechanical circulatory supports in patients with sepsis-associated cardiogenic shock.
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Affiliation(s)
- Ryota Sato
- Division of Critical Care Medicine, Department of Medicine, The Queen's Medical Center, Hawaii
| | | | | | - Kazuki Nishida
- Department of Biostatistics, Graduate School of Medicine, Nagoya University, Nagoya, Aichi, Japan
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Santonocito C, Dugar S, Sanfilippo F. Positive end-expiratory pressure and left ventricular function are key factors affecting right ventricular to pulmonary arterial coupling. Ann Intensive Care 2024; 14:50. [PMID: 38563888 PMCID: PMC10987446 DOI: 10.1186/s13613-024-01284-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 03/27/2024] [Indexed: 04/04/2024] Open
Affiliation(s)
- Cristina Santonocito
- Department of Anaesthesia and Intensive Care, A.O.U. Policlinico-San Marco, site "Policlinico G. Rodolico", Via S. Sofia N 78, Catania, 95123, Italy
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. Policlinico-San Marco, site "Policlinico G. Rodolico", Via S. Sofia N 78, Catania, 95123, Italy.
- Department of General Surgery and Medical-Surgical Specialties, Section of Anesthesia and Intensive Care, University of Catania, Catania, Italy.
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Pruszczyk A, Zawadka M, Andruszkiewicz P, LaVia L, Herpain A, Sato R, Dugar S, Chew MS, Sanfilippo F. Mortality in patients with septic cardiomyopathy identified by longitudinal strain by speckle tracking echocardiography: An updated systematic review and meta-analysis with trial sequential analysis. Anaesth Crit Care Pain Med 2024; 43:101339. [PMID: 38128732 DOI: 10.1016/j.accpm.2023.101339] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 11/27/2023] [Accepted: 12/04/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Septic cardiomyopathy is associated with poor outcomes but its definition remains unclear. In a previous meta-analysis, left ventricular (LV) longitudinal strain (LS) showed significant prognostic value in septic patients, but findings were not robust due to a limited number of studies, differences in effect size and no adjustment for confounders. METHODS We conducted an updated systematic review (PubMed and Scopus up to 14.02.2023) and meta-analysis to investigate the association between LS and survival in septic patients. We included studies reporting global (from three apical views) or regional LS (one or two apical windows). A secondary analysis evaluated the association between LV ejection fraction (EF) and survival using data from the selected studies. RESULTS We included fourteen studies (1678 patients, survival 69.6%) and demonstrated an association between better performance (more negative LS) and survival with a mean difference (MD) of -1.45%[-2.10, -0.80] (p < 0.0001;I2 = 42%). No subgroup differences were found stratifying studies according to number of views used to calculate LS (p = 0.31;I2 = 16%), severity of sepsis (p = 0.42;I2 = 0%), and sepsis criteria (p = 0.59;I2 = 0%). Trial sequential analysis and sensitivity analyses confirmed the primary findings. Grade of evidence was low. In the included studies, thirteen reported LVEF and we found an association between higher LVEF and survival (MD = 2.44% [0.44,4.45]; p = 0.02;I2 = 42%). CONCLUSIONS We confirmed that more negative LS values are associated with higher survival in septic patients. The clinical relevance of this difference and whether the use of LS may improve understanding of septic cardiomyopathy and prognostication deserve further investigation. The association found between LVEF and survival is of unlikely clinical meaning. REGISTRATION PROSPERO number CRD42023432354.
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Affiliation(s)
- Andrzej Pruszczyk
- 2nd Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Poland
| | - Mateusz Zawadka
- 2nd Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Poland
| | - Pawel Andruszkiewicz
- 2nd Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Poland
| | - Luigi LaVia
- Department of Anesthesia and Intensive Care, "Policlinico-San Marco" University Hospital, Catania, Italy
| | - Antoine Herpain
- Department of Intensive Care, St.-Pierre University Hospital, Université Libre de Bruxelles, 1050 Brussels, Belgium; Experimental Laboratory of Intensive Care, Université Libre de Bruxelles, 1050 Brussels, Belgium
| | - Ryota Sato
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, "Policlinico-San Marco" University Hospital, Catania, Italy; Department of General Surgery and Medico-Surgical Specialties, School of Anaesthesia and Intensive Care, University of Catania, Catania, Italy.
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Millington SJ, Narasimhan M, Mayo PH, Vieillard-Baron A. Ten Influential Point-of-Care Ultrasound Papers: 2023 in Review. J Intensive Care Med 2024:8850666241233556. [PMID: 38374613 DOI: 10.1177/08850666241233556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
In an effort to help keep busy clinicians up to date with the latest ultrasound research, our group of experts has selected 10 influential papers from the past 12 months and provided a short summary of each. We hope to provide emergency physicians, intensivists, and other acute care providers with a succinct update concerning some key areas of ultrasound interest.
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Affiliation(s)
- Scott J Millington
- Critical Care, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Mangala Narasimhan
- Critical Care, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Paul H Mayo
- Critical Care, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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Sato R, Sanfilippo F, Hasegawa D, Prasitlumkum N, Duggal A, Dugar S. Prevalence and prognosis of hyperdynamic left ventricular systolic function in septic patients: a systematic review and meta-analysis. Ann Intensive Care 2024; 14:22. [PMID: 38308701 PMCID: PMC10838258 DOI: 10.1186/s13613-024-01255-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 01/21/2024] [Indexed: 02/05/2024] Open
Abstract
PURPOSE The prevalence of hyperdynamic left ventricular (LV) systolic function in septic patients and its impact on mortality remain controversial. In this systematic review and meta-analysis, we investigated the prevalence and association of hyperdynamic LV systolic function with mortality in patients with sepsis. METHODS We searched MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. Primary outcomes were the prevalence of hyperdynamic LV systolic function in adult septic patients and the associated short-term mortality as compared to normal LV systolic function. Hyperdynamic LV systolic function was defined using LV ejection fraction (LVEF) of 70% as cutoff. Secondary outcomes were heart rate, LV end-diastolic diameter (LVEDD), and E/e' ratio. RESULTS Four studies were included, and the pooled prevalence of hyperdynamic LV systolic function was 18.2% ([95% confidence interval (CI) 12.5, 25.8]; I2 = 7.0%, P < 0.0001). Hyperdynamic LV systolic function was associated with higher mortality: odds ratio of 2.37 [95%CI 1.47, 3.80]; I2 = 79%, P < 0.01. No difference was found in E/e' (P = 0.43) between normal and hyperdynamic LV systolic function, while higher values of heart rate (mean difference: 6.14 beats/min [95%CI 3.59, 8.69]; I2 = 51%, P < 0.0001) and LVEDD (mean difference: - 0.21 cm [95%CI - 0.33, - 0.09]; I2 = 73%, P < 0.001) were detected in patients with hyperdynamic LV systolic function. CONCLUSION The prevalence of hyperdynamic LV systolic function is not negligible in septic patients. Such a finding is associated with significantly higher short-term mortality as compared to normal LV systolic function.
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Affiliation(s)
- Ryota Sato
- Division of Critical Care Medicine, Department of Medicine, The Queen's Medical Center, Honolulu, HI, USA
| | - Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. Policlinico-San Marco, Site "Policlinico G. Rodolico", Via S. Sofia N 78, 95123, Catania, Italy
| | - Daisuke Hasegawa
- Department of Internal Medicine, Mount Sinai Beth Israel, New York, NY, USA
| | | | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA.
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10
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Gonzalez FA, Santonocito C, Maybauer MO, Lopes LR, Almeida AG, Sanfilippo F. Diastology in the intensive care unit: Challenges for the assessment and future directions. Echocardiography 2024; 41:e15773. [PMID: 38380688 DOI: 10.1111/echo.15773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/19/2024] [Accepted: 01/20/2024] [Indexed: 02/22/2024] Open
Abstract
Myocardial dysfunction is common in patients admitted to the intensive care unit (ICU). Septic disease frequently results in cardiac dysfunction, and sepsis represents the most common cause of admission and death in the ICU. The association between left ventricular (LV) systolic dysfunction and mortality is not clear for critically ill patients. Conversely, LV diastolic dysfunction (DD) seems increasingly recognized as a factor associated with poor outcomes, not only in sepsis but also more generally in critically ill patients. Despite recent attempts to simplify the diagnosis and grading of DD, this remains relatively complex, with the need to use several echocardiographic parameters. Furthermore, the current guidelines have several intrinsic limitations when applied to the ICU setting. In this manuscript, we discuss the challenges in DD classification when applied to critically ill patients, the importance of left atrial pressure estimates for the management of patients in ICU, and whether the study of cardiac dysfunction spectrum during critical illness may benefit from the integration of left ventricular and left atrial strain data to improve diagnostic accuracy and implications for the treatment and prognosis.
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Affiliation(s)
- Filipe A Gonzalez
- Intensive Care Department of Hospital Garcia de Orta, Almada, Portugal
- Centro Cardiovascular da Universidade de Lisboa, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Cristina Santonocito
- Department of Anesthesia and Intensive Care, "Policlinico-San Marco" University Hospital, Catania, Italy
| | - Marc O Maybauer
- Department of Anesthesiology, Division of Critical Care Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Luís Rocha Lopes
- Inherited Cardiac Disease Unit, Bart's Heart Centre St Bartholomew's Hospital London, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Ana G Almeida
- Centro Cardiovascular da Universidade de Lisboa, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, "Policlinico-San Marco" University Hospital, Catania, Italy
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
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Gong S, Lian H, Ding X, Wang X. High Respiratory and Cardiac Drive Exacerbate Secondary Lung Injury in Patients With Critical Illness. J Intensive Care Med 2024:8850666231222220. [PMID: 38173252 DOI: 10.1177/08850666231222220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
The high respiratory and cardiac drive is essential to the host-organ unregulated response. When a primary disease and an unregulated secondary response are uncontrolled, the patient may present in a high respiratory and cardiac drive state. High respiratory drive can cause damage to the lungs, pulmonary circulation, and diaphragm, while high cardiac drive can lead to fluid leakage and infiltration as well as pulmonary interstitial edema. A "respiratory and cardiac dual high drive" state may be a sign of an unregulated response and can lead to secondary lung injury through the increase of transvascular pressure and pulmonary microcirculation injury. Ultrasound examination of the lung, heart, and diaphragm is important when evaluating the phenotype of high respiratory drive in critically ill patients. Ultrasound assessment can guide sedation, analgesia, and antistress treatment and reduce the risk of high respiratory and cardiac drive-induced lung injury in these patients.
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Affiliation(s)
- Shiyi Gong
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Hui Lian
- Department of Health Care, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xin Ding
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Xia JD, Hua LW, Kang DW, Liu C, Su Z, Zhao KF. The association between higher cardiac troponin levels and the development of left ventricular diastolic dysfunction in septic patients with diabetes mellitus. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024; 40:27-34. [PMID: 37843758 DOI: 10.1007/s10554-023-02963-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/18/2023] [Indexed: 10/17/2023]
Abstract
This study was designed to retrospectively analyze the relationship between the levels of cardiac troponin T (cTnT) and cardiac troponin I (cTnI) and the development of left ventricular diastolic dysfunction (LVDD) in septic patients with diabetes mellitus. Furthermore, the predictive value of cTnT and cTnI in the LVDD development in those patients was investigated. The clinical information of 159 septic patients with diabetes mellitus treated in the intensive care unit of Affiliated Hospital of Chengde Medical University from June 2016 to January 2023 were retrospectively analyzed. These patients were separated into LVDD group (LVFP > 15 mmHg) and non-LVDD group (LVFP ≤ 15 mmHg) based on left ventricular filling pressure (LVFP). The differences in clinical data, echocardiographic parameters, as well as cTnT and cTnI levels between the LVDD and non-LVDD groups were compared. The relationship between the cTnT and cTnI levels and the echocardiographic parameters was studied using Pearson correlation analysis. Logistic regression analysis was conducted to explore the factors that influenced the LVDD development in septic patients with diabetes. Receiver operator characteristic (ROC) curves were created to evaluate the predictive value of cTnT and cTnI levels for the LVDD development in septic patients with diabetes. Totally 159 septic patients with diabetes were included in this study, with 97 patients in the LVDD group and 62 in the non-LVDD group. Compared with the non-LVDD group, patients in the LVDD group had much lower left ventricular (LV) early diastolic peak inflow velocity (E), LV advanced diastolic peak inflow velocity (A), E/A, and early diastolic mitral annular velocity (Em) while significantly higher E/Em. The LVDD group showed much higher levels of cTnI and cTnT than the non-LVDD group (P < 0.05). Significant positive correlation between log10cTnI level and E/Em ratio (r = 0.425, P < 0.001) was revealed by the Pearson correlation analysis. Multivariate analysis showed that E/A, E/Em, cTnI and cTnT were independent risk factors for the LVDD development in septic patients with diabetes (P < 0.05). As for ROC curve results, the area under the curve (AUC) of cTnT to predict the development of LVDD in septic patients with diabetes was 0.849 (95% CI 0.788-0.910, P < 0.001); the AUC of cTnI was 0.742 (95% CI 0.666-0.817, P < 0.001). Both cTnT and cTnI are independent risk factors and have predictive value for the LVDD development in septic patients with diabetes mellitus.
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Affiliation(s)
- Jia-Ding Xia
- Department of Intensive Care, Affiliated Hospital of Chengde Medical University, Chengde, 067000, Hebei, China
| | - Li-Wei Hua
- Department of Intensive Care, Affiliated Hospital of Chengde Medical University, Chengde, 067000, Hebei, China
| | - Da-Wei Kang
- Department of Emergency, Affiliated Hospital of Chengde Medical University, Chengde, 067000, Hebei, China
| | - Chang Liu
- Department of Intensive Care, Affiliated Hospital of Chengde Medical University, Chengde, 067000, Hebei, China
| | - Zhen Su
- Department of Intensive Care, Affiliated Hospital of Chengde Medical University, Chengde, 067000, Hebei, China
| | - Kai-Feng Zhao
- Department of Intensive Care, Affiliated Hospital of Chengde Medical University, Chengde, 067000, Hebei, China.
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Sato R, Hasegawa D, Guo SC, Nishida K, Dugar S. Temporary Mechanical Circulatory Support in Sepsis-Associated Cardiogenic Shock With and Without Acute Myocardial Infarction. J Cardiothorac Vasc Anesth 2024; 38:207-213. [PMID: 37852913 DOI: 10.1053/j.jvca.2023.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/08/2023] [Accepted: 09/21/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVES To describe the current use and outcomes of temporary mechanical circulatory support (MCS) in patients with sepsis-associated cardiogenic shocks with and without acute myocardial infarction (AMI) in the United States. DESIGN Retrospective cohort study. SETTING The National Inpatient Sample database from 2017 to 2019. PARTICIPANTS Adult patients with sepsis-associated cardiogenic shock with and without AMI. INTERVENTIONS Temporary MCSs, including intra-aortic balloon pump (IABP), percutaneous left ventricular assist device (pLVAD), and extracorporeal membrane oxygenation (ECMO). MEASUREMENTS AND MAIN RESULTS Multivariate logistic regression analyses adjusting for patient characteristics, organ failures, and socioeconomic status. Although the uses of IABP and pLVAD were associated with significantly lower odds of in-hospital mortality in patients with sepsis-associated cardiogenic shock (IABP: adjusted odds ratio [aOR] 0.57, 95% CI 0.44-0.73, p < .001; pLVAD: aOR 0.66, 95% CI 0.45-0.98, p = .037), ECMO was not (aOR 1.51, 95% CI 0.93-2.45, p = 0.096). In the subgroup with AMI, temporary MCSs were not associated with significantly lower or higher odds of in-hospital mortality. In the subgroup without AMI, IABP was associated with significantly lower odds of in-hospital mortality (aOR 0.43, 95% CI 0.28-0.65, p < 0.001). CONCLUSIONS Although temporary MCS is deemed to be a feasible option in sepsis-associated cardiogenic shock, the selection of the right patients whose shock is driven mainly by cardiogenic shock rather than septic shock, as represented by low cardiac output and high systemic vascular resistance, plays a critical role in the feasibility of this approach in the absence of clinical trials.
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Affiliation(s)
- Ryota Sato
- Division of Critical Care Medicine, Department of Medicine, The Queen's Medical Center, Honolulu, HI.
| | | | - Stephanie C Guo
- Division of Critical Care Medicine, Department of Medicine, The Queen's Medical Center, Honolulu, HI
| | - Kazuki Nishida
- Department of Biostatistics, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Cleveland, OH
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Sanfilippo F, Messina A, Scolletta S, Bignami E, Morelli A, Cecconi M, Landoni G, Romagnoli S. The "CHEOPS" bundle for the management of Left Ventricular Diastolic Dysfunction in critically ill patients: an experts' opinion. Anaesth Crit Care Pain Med 2023; 42:101283. [PMID: 37516408 DOI: 10.1016/j.accpm.2023.101283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 07/31/2023]
Abstract
The impact of left ventricular (LV) diastolic dysfunction (DD) on the outcome of patients with heart failure was established over three decades ago. Nevertheless, the relevance of LVDD for critically ill patients admitted to the intensive care unit has seen growing interest recently, and LVDD is associated with poor prognosis. Whilst an assessment of LV diastolic function is desirable in critically ill patients, treatment options for LVDD are very limited, and pharmacological possibilities to rapidly optimize diastolic function have not been found yet. Hence, a proactive approach might have a substantial role in improving the outcomes of these patients. Recalling historical Egyptian parallelism suggesting that Doppler echocardiography has been the "Rosetta stone" to decipher the study of LV diastolic function, we developed a potentially useful acronym for physicians at the bedside to optimize the management of critically ill patients with LVDD with the application of the bundle. We summarized the bundle under the acronym of the famous ancient Egyptian pharaoh CHEOPS: Chest Ultrasound, combining information from echocardiography and lung ultrasound; HEmodynamics assessment, with careful evaluation of heart rate and rhythm, as well as afterload and vasoactive drugs; OPtimization of mechanical ventilation and pulmonary circulation, considering the effects of positive end-expiratory pressure on both right and left heart function; Stabilization, with cautious fluid administration and prompt fluid removal whenever judged safe and valuable. Notably, the CHEOPS bundle represents experts' opinion and are not targeted at the initial resuscitation phase but rather for the optimization and subsequent period of critical illness.
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Affiliation(s)
- Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. Policlinico-San Marco, Catania, Italy; Department of General Surgery and Medico-Surgical Specialties, School of Anaesthesia and Intensive Care, University of Catania, Catania, Italy.
| | - Antonio Messina
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center IRCCS, 20089, Rozzano, Milan, Italy.
| | - Sabino Scolletta
- Anesthesia and Intensive Care Unit, University Hospital of Siena, University of Siena, Siena, Italy.
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Andrea Morelli
- Department Clinical Internal, Anesthesiological and Cardiovascular Sciences, University of Rome, "La Sapienza", Policlinico Umberto Primo, Roma, Italy.
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center IRCCS, 20089, Rozzano, Milan, Italy.
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
| | - Stefano Romagnoli
- Department of Health Science, Section of Anaesthesia and Intensive Care, University of Florence, Department of Anetshesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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Havaldar AA, Kumar MV, Kumar R, Yarramalle SP, Khan MS, Misra KC, Kamble S, Sangale A, Prakash J, Kartik M, Selvam S. Echocardiographic parameters in COVID-19 patients and their association with ICU mortality: a prospective multicenter observational study. Ultrasound J 2023; 15:38. [PMID: 37702930 PMCID: PMC10499708 DOI: 10.1186/s13089-023-00336-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/21/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Echocardiography has become an integral part of the management of critically ill patients. It helps to diagnose and treat various conditions. COVID-19 patients can develop cardiac dysfunction. We planned to study the echocardiographic parameters in COVID-19 patients. METHODS We conducted a prospective observational multicenter study after institutional ethical committee approval. COVID-19 pneumonia patients admitted to the intensive care unit (ICU) were enrolled. The echocardiographic evaluation was done within 24-48 hours of admission. Assessment of the left and right heart with systolic and left ventricular diastolic function evaluation was done. The primary outcome was ICU mortality. The secondary outcomes were the length of ICU stay and duration of mechanical ventilation. RESULTS Among 573 patients mean age was 57.17 (14.67) with 68.60% being males. On day 1 of ICU, invasive mechanical ventilation was used in 257 (45%) patients. One hundred and forty-eight (25.83%) patients were on vasopressors when echocardiography was performed. Severe left ventricle (LV) systolic dysfunction was seen in 8.7% of patients and had higher odds of mortality [2.48(1.058-5.807), p = 0.037] followed by E and e' with odds ratio of [0.984(0.971-0.998), p = 0.021] and 0.897 (0.805-0.998), p = 0.046], respectively. E/e' indicative of filling pressure of the LV was not found to be significant. Troponin I, E/A, and RV dilatation were similar among survivors and non-survivors. CONCLUSION Echocardiographic evaluation in COVID-19 patients showed severe LV systolic dysfunction was associated with ICU mortality. E/e' was not found to be significant but lower e' was associated with higher mortality. Trial registration IEC 131/2020, CTRI/2020/06/025858 date 13th June 2020.
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Affiliation(s)
- Amarja Ashok Havaldar
- Department of Critical Care Medicine, St John's Medical College Hospital, 1st floor, MICU, Bangalore, 560034, India.
| | - Merugu Vinay Kumar
- Department of Critical Care Medicine, St John's Medical College Hospital, 1st floor, MICU, Bangalore, 560034, India
| | - Raman Kumar
- Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, 834009, India
| | | | - Mohammad Saif Khan
- Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, 834009, India
| | - Krushna Chandra Misra
- Department of Critical Care Medicine, Yashoda Hospital, Somajiguda, 500082, Hyderabad, India
| | - Shubhangi Kamble
- Department of Critical Care, Apollo Hospital, Nashik, 422003, India
| | - Atul Sangale
- Department of Critical Care, Apollo Hospital, Nashik, 422003, India
| | - Jay Prakash
- Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, 834009, India
| | - Munta Kartik
- Department of Critical Care Medicine, Yashoda Hospital, Somajiguda, 500082, Hyderabad, India
| | - Sumithra Selvam
- Department of Epidemiology and Biostatistics, St Johns Research Institute, Bangalore, India, 560034
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Chawla S, Sato R, Duggal A, Alwakeel M, Hasegawa D, Alayan D, Collier P, Sanfilippo F, Lanspa M, Dugar S. Correlation between tissue Doppler-derived left ventricular systolic velocity (S') and left ventricle ejection fraction in sepsis and septic shock: a retrospective cohort study. J Intensive Care 2023; 11:28. [PMID: 37400918 DOI: 10.1186/s40560-023-00678-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/25/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Tissue Doppler-derived left ventricular systolic velocity (mitral S') has shown excellent correlation to left ventricular ejection fraction (LVEF) in non-critically patients. However, their correlation in septic patients remains poorly understood and its impact on mortality is undetermined. We investigated the relationship between mitral S' and LVEF in a large cohort of critically-ill septic patients. METHODS We conducted a retrospective cohort study between 01/2011 and 12/2020. All adult patients (≥ 18 years) who were admitted to the medical intensive care unit (MICU) with sepsis and septic shock that underwent a transthoracic echocardiogram (TTE) within 72 h were included. Pearson correlation test was used to assess correlation between average mitral S' and LVEF. Pearson correlation was used to assess correlation between average mitral S' and LVEF. We also assessed the association between mitral S', LVEF and 28-day mortality. RESULTS 2519 patients met the inclusion criteria. The study population included 1216 (48.3%) males with a median age of 64 (IQR: 53-73), and a median APACHE III score of 85 (IQR: 67, 108). The median septal, lateral, and average mitral S' were 8 cm/s (IQR): 6.0, 10.0], 9 cm/s (IQR: 6.0, 10.0), and 8.5 cm/s (IQR: 6.5, 10.5), respectively. Mitral S' was noted to have moderate correlation with LVEF (r = 0.46). In multivariable logistic regression analysis, average mitral S' was associated with an increase in both 28-day ICU and in-hospital mortality with odds ratio (OR) 1.04 (95% CI 1.01-1.08, p = 0.02) and OR 1.04 (95% CI 1.01-1.07, p = 0.02), respectively. CONCLUSIONS Even though mitral S' and LVEF may be related, they are not exchangeable and were only found to have moderate correlation in this study. LVEF is U-shaped, while mitral S' has a linear relation with 28-day ICU mortality. An increase in average mitral S' was associated with higher 28-day mortality.
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Affiliation(s)
- Sanchit Chawla
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ryota Sato
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH, USA
| | - Mahmoud Alwakeel
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daisuke Hasegawa
- Department of Internal Medicine, Mount Sinai Beth Israel, New York, NY, USA
| | - Dina Alayan
- Department of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Patrick Collier
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Filippo Sanfilippo
- Anaesthesiology and Intensive Care, University of Catania, Catania, Italy
- Policlinico-San Marco University Hospital, Catania, Italy
| | - Michael Lanspa
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT, USA
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
- Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH, USA.
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Dugar S, Siuba MT, Sacha GL, Sato R, Moghekar A, Collier P, Grimm RA, Vachharajani V, Bauer SR. Echocardiographic profiles and hemodynamic response after vasopressin initiation in septic shock: A cross-sectional study. J Crit Care 2023; 76:154298. [PMID: 37030157 DOI: 10.1016/j.jcrc.2023.154298] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/10/2023]
Abstract
PURPOSE Vasopressin, used as a catecholamine adjunct, is a vasoconstrictor that may be detrimental in some hemodynamic profiles, particularly left ventricular (LV) systolic dysfunction. This study tested the hypothesis that echocardiographic parameters differ between patients with a hemodynamic response after vasopressin initiation and those without a response. METHODS This retrospective, single-center, cross-sectional study included adults with septic shock receiving catecholamines and vasopressin with an echocardiogram performed after shock onset but before vasopressin initiation. Patients were grouped by hemodynamic response, defined as decreased catecholamine dosage with mean arterial pressure ≥ 65 mmHg six hours after vasopressin initiation, with echocardiographic parameters compared. LV systolic dysfunction was defined as LV ejection fraction (LVEF) <45%. RESULTS Of 129 included patients, 72 (56%) were hemodynamic responders. Hemodynamic responders, versus non-responders, had higher LVEF (61% [55%,68%] vs. 55% [40%,65%]; p = 0.02) and less-frequent LV systolic dysfunction (absolute difference -16%; 95% CI -30%,-2%). Higher LVEF was associated with higher odds of hemodynamic response (for each LVEF 10%, response OR 1.32; 95% CI 1.04-1.68). Patients with LV systolic dysfunction, versus without LV systolic dysfunction, had higher mortality risk (HR(t) = e[0.81-0.1*t]; at t = 0, HR 2.24; 95% CI 1.08-4.64). CONCLUSIONS Pre-drug echocardiographic profiles differed in hemodynamic responders after vasopressin initiation versus non-responders.
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Affiliation(s)
- Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Matthew T Siuba
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | | | - Ryota Sato
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ajit Moghekar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Patrick Collier
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA; Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, USA
| | - Richard A Grimm
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA; Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, USA
| | - Vidula Vachharajani
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA; Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, USA
| | - Seth R Bauer
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA; Department of Pharmacy, Cleveland Clinic, USA.
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