Impact of left ventricular dysfunction and fluid balance on the outcomes of patients with sepsis

The association between higher cardiac troponin levels and the development of left ventricular diastolic dysfunction in septic patients with diabetes mellitus

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.

Influence of fluid balance on postoperative outcomes after hepatic resection in patients with left ventricular diastolic dysfunction

OBJECTIVE

The maintenance of low central venous pressure (CVP) during hepatic resection is associated with a reduction in estimated blood loss. After completion of the hepatic parenchymal transection, fluid is rapidly administered to replace the surgical blood loss and fluid deficit to prevent subsequent organ injury risk. However, this perioperative fluid strategy may influence on the postoperative outcomes of patients with left ventricular diastolic dysfunction (LVDD) who cannot tolerate volume adjustment.

METHOD

A total of 206 patients with who underwent hepatic resection between March 2015 and February 2021 were evaluated. LVDD was defined according to the American Society of Echocardiography and the European Association of Cardiovascular Imaging 2016 recommendations as LVDD (group A, n = 39), or normal LV diastolic function and indeterminate decision (group B, n = 153). We compared the clinical outcomes of patients between two groups, and then analyzed the risk factors for postoperative complications.

RESULT

Postoperative acute kidney injury (AKI, 10.3% vs. 1.3%, P = 0.004) and pleural effusion or edema (51.3% vs. 30.1%, P = 0.013) were more common in group A than in group B. Further, creatinine levels from postoperative day 1 to day 7 were significantly higher and daily urine outputs at postoperative day 1 (P = 0.038) and day 2 (P = 0.025) were significantly lower in group A than in group B. LVDD was the only significant risk factor for postoperative AKI after hepatic resection (odds ratio, 10.181; 95% confidence interval, 1.570-66.011, P = 0.015).

CONCLUSIONS

The rates of renal dysfunction and pulmonary complications after hepatic resection are higher in patients with LVDD than in those with normal LV diastolic function. Thus, these patients require individualized fluid management.

Clinical outcomes of severe sepsis and septic shock patients with left ventricular dysfunction undergoing continuous renal replacement therapy

Baseline left ventricular (LV) dysfunction is associated with subsequent risks of acute kidney injury (AKI) and mortality in patients with sepsis. This study investigated the therapeutic effects of continuous renal replacement therapy (CRRT) in hemodynamically unstable patients with severe sepsis and septic shock combined with LV dysfunction. In this multicenter retrospective study, severe sepsis and septic shock patients with LV dysfunction were classified into one of two groups according to the timing of CRRT: the early group (before AKI was detected) or the control group (patients with AKI). Patients from the control group received an accelerated strategy or a standard strategy of CRRT. The primary outcome was all-cause intensive care unit (ICU) mortality. Patients were weighted by stabilized inverse probability of treatment weights (sIPTW) to overcome differences in baseline characteristics. After sIPTW analysis, the ICU mortality was significantly lower in the early group than the control group (27.7% vs. 63.5%, p < 0.001). Weighted multivariable analysis showed that early CRRT initiation was a protective factor for the risk of ICU mortality (OR 0.149; 95% CI 0.051–0.434; p < 0.001). The ICU mortality was not different between the accelerated- and standard-strategy group (52.5% vs. 52.9%, p = 0.970). Early CRRT in the absence of AKI is suggested for hemodynamically unstable patients with severe sepsis and septic shock combined with LV dysfunction since it benefits survival outcomes.

Association between left ventricular diastolic dysfunction and septic acute kidney injury in severe sepsis and septic shock: A multicenter retrospective study

INTRODUCTION

Left ventricular diastolic dysfunction (LVDD) adversely impacts renal function, and E/e' is a significant predictor of adverse kidney events under different clinical conditions. However, no studies have evaluated the association between LVDD and septic acute kidney injury (AKI) among patients with severe sepsis and septic shock.

METHODS

This multicenter retrospective study evaluated adult patients with severe sepsis or septic shock between January 1, 2013, and December 31, 2019, who underwent echocardiography within 24 hours after admission to an intensive care unit.

RESULTS

A total of 495 adult patients were enrolled in the study. LVDD grades II and III were associated with severe (stage 3) AKI (p < 0.001, p for trend < 0.001). E/e' and e' were risk factors for septic AKI (OR, 1.155; 95% CI, 1.088-1.226, p < 0.001; and OR, 7.218; 95% CI, 2.942-17.712, p < 0.001, respectively) in the multivariate logistic regression analysis. The area under the receiver operating characteristic curve of E/e' and e' was 0.728 (95% CI, 0.680-0.777, p < 0.001) and 0.715 (95% CI, 0.665-0.764, p < 0.001), respectively.

CONCLUSIONS

LVDD was associated with septic AKI, and E/e' and e' are useful predictors of septic AKI among patients with severe sepsis or septic shock.

TRIAL REGISTRATION

The study was registered at the Chinese Clinical Trial Registry (Protocol No. ChiCTR2000033083).