Clinical impact of visually assessed right ventricular dysfunction in patients with septic shock

Clinical implications of septic cardiomyopathy: A narrative review

Sepsis is caused by the body's dysregulated response to infection, which can lead to multiorgan injury and death. Patients with sepsis may develop acute cardiac dysfunction, termed septic cardiomyopathy, which is a global but reversible dysfunction of both sides of the heart. This narrative review discusses the mechanistic changes in the heart during septic cardiomyopathy, its diagnosis, existing treatment options regarding severity and course, and emerging treatment approaches. Although no standardized definition for septic cardiomyopathy exists, it is described as a reversible myocardial dysfunction that typically resolves within 7 to 10 days. Septic cardiomyopathy is often diagnosed based on electrocardiography, cardiac magnetic resonance imaging, biomarkers, and direct invasive and noninvasive measures of cardiac output. Presently, the treatment of septic cardiomyopathy is similar to that of sepsis, primarily focusing on acute interventions. Treatments for cardiomyopathy often include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and diuretics. However, because of profound hypotension in sepsis, many cardiomyopathy treatments are contraindicated in patients with septic cardiomyopathy. Substantial efforts have been made to study the pathophysiological mechanisms and diagnostic options; however, the lack of a uniform definition for septic cardiomyopathy is challenging for physicians when considering treatments. Another challenge for physicians is that the treatment for septic cardiomyopathy has only focused on acute intervention, whereas the treatment for other cardiomyopathies has been provided on a long-term basis. A better understanding of the underlying mechanisms of septic cardiomyopathy may contribute to the development of a unified definition of the condition and novel treatment options.

Diagnostic Adjunct Techniques in the Assessment of Hypovolemia: A Prospective Pilot Project

INTRODUCTION

Measuring the hypovolemic resuscitation end point remains a critical care challenge. Our project compared clinical hypovolemia (CH) with three diagnostic adjuncts: 1) noninvasive cardiac output monitoring (NICOM), 2) ultrasound (US) static IVC collapsibility (US-IVC), and 3) US dynamic carotid upstroke velocity (US-C). We hypothesized US measures would correlate more closely to CH than NICOM.

METHODS

Adult trauma/surgical intensive care unit patients were prospectively screened for suspected hypovolemia after acute resuscitation, excluding patients with burns, known heart failure, or severe liver/kidney disease. Adjunct measurements were assessed up to twice a day until clinical improvement. Hypovolemia was defined as: 1) NICOM: ≥10% stroke volume variation with passive leg raise, 2) US-IVC: <2.1 cm and >50% collapsibility (nonventilated) or >18% collapsibility (ventilated), 3) US-C: peak systolic velocity increase 15 cm/s with passive leg raise. Previously unknown cardiac dysfunction seen on US was noted. Observation-level data were analyzed with a Cohen's kappa (κ).

RESULTS

44 patients (62% male, median age 60) yielded 65 measures. Positive agreement with CH was 47% for NICOM, 37% for US-IVC and 10% for US-C. None of the three adjuncts correlated with CH (κ -0.045 to 0.029). After adjusting for previously unknown cardiac dysfunction present in 10 patients, no adjuncts correlated with CH (κ -0.036 to 0.031). No technique correlated with any other (κ -0.118 to 0.083).

CONCLUSIONS

None of the adjunct measurements correlated with CH or each other, highlighting that fluid status assessment remains challenging in critical care. US should assess for right ventricular dysfunction prior to resuscitation.

Impact of heart failure on outcomes in patients with sepsis: A systematic review and meta-analysis

BACKGROUND

Heart failure (HF) often affects the progress of sepsis patients, although its impact on outcomes is inconsistent and inconclusive.

AIM

To conduct a systematic review and meta-analysis of the impact of HF on mortality in patients with sepsis.

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library databases were searched to compare the outcomes of sepsis patients with HF. A random effect model was used to summarize the mortality data, and the odds ratio (OR) and 95% confidence interval (CI) were calculated as effect indicators.

RESULTS

Among 18001 records retrieved in the literature search, 35712 patients from 10 separate studies were included. The results showed that sepsis patients with HF were associated with increased total mortality (OR = 1.80, 95%CI: 1.34-2.43; I² = 92.1%), with high heterogeneity between studies. Significant subgroup differences according to age, geographical location, and HF patient sample were observed. HF did not increase the 1-year mortality of patients (OR = 1.11, 95%CI: 0.75-1.62; I² = 93.2%), and the mortality of patients with isolated right ventricular dysfunction (OR=2.32, 95%CI: 1.29-4.14; I² = 91.5%) increased significantly.

CONCLUSION

In patients with sepsis, HF is often associated with adverse outcomes and mortality. Our results call for more high-quality research and strategies to improve outcomes for sepsis patients with HF.

Factors associated with left ventricular diastolic dysfunction in patients with septic shock

Purpose

To investigate risk factors associated with left ventricular diastolic dysfunction (LVDD) of patients with septic shock.

Materials and methods

Patients with septic shock concomitant with or without LVDD were retrospectively enrolled and divided into the LVDD group (n = 17) and control without LVDD (n = 85). The clinical and ultrasound data were analyzed.

Results

A significant (P < 0.05) difference existed between the two groups in serum creatinine, APACHE II score, serum glucose, triglyceride, BUN, FT4, LAVI, mitral E, average e’, E/average e’, septal e’, septal e’/septal s’, E/septal e’, lateral s’, lateral e’, and E/lateral e’. LAVI > 37 mL/m², septal e’ < 7 cm/s (OR 11.04, 95% CI 3.38–36.05), septal e’/septal s’ < 0.8 (OR 4.09, 95% CI 1.37–12.25), E/septal e’ > 15 (OR 22.86, 95% CI 6.09–85.79), lateral e’ < 8 cm/s (OR 9.16, 95% CI 2.70–31.07), E/lateral e’ > 13 (OR 52, 95% CI 11.99- 225.55), lateral s’ < 10 (OR 3.36, 95% CI 1.13–9.99), average e’ > 10, E/average e’ > 10 (OR 9.53, 95% CI 2.49–36.46), APACHE II score > 16 (OR 3.33, 95% CI 1.00–11.03), SOFA > 5 (or 3.43, 95% CI 1.11–10.60), BUN > 12 mmol/L (OR 3.37, 95% CI 1.15–9.87), serum creatinine > 146 μmol/L (OR 5.08, 95% CI 1.69–15.23), serum glucose > 8 mmol/L (OR 3.36, 95% CI 1.09–10.40), and triglyceride > 1.8 mmol/L were significant (P < 0.05) risk factors for LVDD. LAVI > 37 ml/m², lateral e’ < 8 cm/s, E/lateral e’ > 13, and SOFA > 5 were significant (P < 0.05) independent risk factors for LVDD. ROC curve analysis demonstrated that the cut-off value and AUC were 37.09 mL/m² and 0.85 for LAVI, 8.00 cm/s and 0.89 for lateral e’, 12.86 and 0.82 for E/lateral e’, and 5.00 and 0.69 for SOFA, respectively.

Conclusion

Left atrial volume index, mitral lateral e’, E/lateral e’, and SOFA score are significant independent risk factors for predicting left ventricular diastolic dysfunction in patients with septic shock.