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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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Liu J, Hui Q, Lu X, Li W, Li N, Chen Y, Zhang Q. Predictive value of laboratory indicators for in-hospital death in children with community-onset sepsis: a prospective observational study of 266 patients. BMJ Paediatr Open 2024; 8:e002329. [PMID: 38754894 PMCID: PMC11097807 DOI: 10.1136/bmjpo-2023-002329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 05/05/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND AND OBJECTIVES This study aimed to identify predictors of sepsis-associated in-hospital mortality from readily available laboratory biomarkers at onset of illness that include haematological, coagulation, liver and kidney function, blood lipid, cardiac enzymes and arterial blood gas. METHODS Children with sepsis were enrolled consecutively in a prospective observational study involving paediatric intensive care units (PICUs) of two hospitals in Beijing, between November 2016 and January 2020. The data on demographics, laboratory examinations during the first 24 hours after PICU admission, complications and outcomes were collected. We screened baseline laboratory indicators using the Least Absolute Shrinkage and Selection Operator (LASSO) analysis, then we constructed a mortality risk model using Cox proportional hazards regression analysis. The ability of risk factors to predict in-hospital mortality was evaluated by receiver operating characteristic (ROC) curves. RESULTS A total of 266 subjects were enrolled including 44 (16.5%) deaths and 222 (83.5%) survivors. Those who died showed a shorter length of hospitalisation, and a higher proportion of mechanical ventilation, complications and organ failure (p<0.05). LASSO analysis identified 13 clinical parameters related to prognosis, which were included in the final Cox model. An elevated triglyceride (TG) remained the most significant risk factor of death (HR=1.469, 95% CI: 1.010 to 2.136, p=0.044), followed by base excess (BE) (HR=1.131, 95% CI: 1.046 to 1.223, p=0.002) and pH (HR=0.95, 95% CI: 0.93 to 0.97, p<0.001). The results of the ROC curve showed that combined diagnosis of the three indicators-TG+BE+pH-has the best area under the curve (AUC) (AUC=0.77, 95% CI: 0.69 to 0.85, p<0.001), with a 68% sensitivity and 80% specificity. CONCLUSION Laboratory factors of TG, BE and pH during the first 24 hours after intensive care unit admission are associated with in-hospital mortality in PICU patients with sepsis. The combination of the three indices has high diagnostic value.
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Affiliation(s)
- Jing Liu
- Department of Pediatrics, China-Japan Friendship Hospital, Beijing, China
- Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Qin Hui
- Department of Pediatrics, China-Japan Friendship Hospital, Beijing, China
| | - Xiuxiu Lu
- Department of Intensive Care Unit, Capital Institute of Pediatrics, Beijing, China
| | - Wei Li
- Department of Intensive Care Unit, Capital Institute of Pediatrics, Beijing, China
| | - Ning Li
- Department of Intensive Care Unit, Capital Institute of Pediatrics, Beijing, China
| | - Yuanmei Chen
- Department of Pediatrics, China-Japan Friendship Hospital, Beijing, China
| | - Qi Zhang
- Department of Pediatrics, China-Japan Friendship Hospital, Beijing, China
- Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
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Hendrickson KW, Cirulis MM, Burk RE, Lanspa MJ, Peltan ID, Marshall H, Groat D, Jephson A, Beesley SJ, Brown SM. Identifying predictors and determining mortality rates of septic cardiomyopathy and sepsis-related cardiogenic shock: A retrospective, observational study. PLoS One 2024; 19:e0299876. [PMID: 38662672 PMCID: PMC11045062 DOI: 10.1371/journal.pone.0299876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/16/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION Septic shock is a severe form of sepsis that has a high mortality rate, and a substantial proportion of these patients will develop cardiac dysfunction, often termed septic cardiomyopathy (SCM). Some SCM patients may develop frank cardiac failure, termed sepsis-related cardiogenic shock (SeRCS). Little is known of SeRCS. This study describes baseline characteristics of patients with SCM and SeRCS compared to patients with septic shock without cardiac dysfunction. We compare clinical outcomes among SCM, SeRCS, and septic shock, and identify risk factors for the development of SCM and SeRCS. METHODS Septic patients admitted to the ICU with an echocardiogram obtained within 72 hours were included. Left ventricular ejection fraction of ≤55% was used to define SCM, and cardiac index ≤2.1 L/min/m2 among patients with SCM defined SeRCS. Machine learning was used to identify risk factors for development of SCM and SeRCS. Logistic regression was used to compare mortality among groups. RESULTS Among 1229 patients, 977 patients had septic shock without cardiac dysfunction, 207 had SCM, and 45 had SeRCS. In patients with septic shock, the strongest predictor for developing SCM and SeRCs was a prior history of cardiac dysfunction. Mortality did not significantly differ among the three groups. CONCLUSIONS SCM and SeRCS affect a minority of patients with septic shock, disproportionately affecting individuals with a history of cardiac disease. We did not identify a mortality difference associated with SCM or SeRCS. Additional work is needed to define further subtypes and treatment options for this patient population.
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Affiliation(s)
- Kathryn W. Hendrickson
- The Oregon Clinic Department of Pulmonary, Critical Care, and Sleep Medicine East, Portland, OR, United States of America
| | - Meghan M. Cirulis
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, United States of America
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, United States of America
| | - Rebecca E. Burk
- Renown Medical Group Department of Pulmonary and Critical Care Medicine, Reno, NV, United States of America
| | - Michael J. Lanspa
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, United States of America
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, United States of America
| | - Ithan D. Peltan
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, United States of America
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, United States of America
| | - Hunter Marshall
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, United States of America
| | - Danielle Groat
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, United States of America
- Intermountain Healthcare, Information and Analytics, Salt Lake City, UT, United States of America
| | - Al Jephson
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, United States of America
- Intermountain Healthcare, Information and Analytics, Salt Lake City, UT, United States of America
| | - Sarah J. Beesley
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, United States of America
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, United States of America
| | - Samuel M. Brown
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, United States of America
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, United States of America
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Ning XL, Shao M. Analysis of prognostic factors in patients with emergency sepsis. World J Clin Cases 2023; 11:5903-5909. [PMID: 37727482 PMCID: PMC10506019 DOI: 10.12998/wjcc.v11.i25.5903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 07/21/2023] [Accepted: 08/07/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Emergency sepsis is a common and serious infectious disease, and its prognosis is influenced by a number of factors. AIM To analyse the factors influencing the prognosis of patients with emergency sepsis in order to provide a basis for individualised patient treatment and care. By retrospectively analysing the clinical data collected, we conducted a comprehensive analysis of factors such as age, gender, underlying disease, etiology and site of infection, inflammatory indicators, multi-organ failure, cardiovascular function, therapeutic measures, immune status and severity of infection. METHODS Data collection: Clinical data were collected from patients diagnosed with acute sepsis, including basic information, laboratory findings, medical history and treatment options. Variable selection: Variables associated with prognosis were selected, including age, gender, underlying disease, etiology and site of infection, inflammatory indicators, multi-organ failure, cardiovascular function, treatment measures, immune status and severity of infection. Data analysis: The data collected are analysed using appropriate statistical methods such as multiple regression analysis and survival analysis. The impact of each factor on prognosis was assessed according to prognostic indicators, such as survival, length of stay and complication rates. RESULTS Descriptive statistics: Descriptive statistics were performed on the data collected from the patients, including their basic characteristics and clinical presentation. CONCLUSION Type 2 diabetes mellitus were independent factors affecting the prognosis of patients with sepsis.
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Affiliation(s)
- Xian-Li Ning
- Department of Emergency, Anqing Municipal Hospital, Anqing 246000, Anhui Province, China
| | - Min Shao
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei 230031, Anhui Province, China
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Ullah K, Li Y, Lin Q, Pan K, Nguyen T, Aniruddhsingh S, Su Q, Sharp W, Wu R. Comparative Analysis of Whole Transcriptome Profiles in Septic Cardiomyopathy: Insights from CLP- and LPS-Induced Mouse Models. Genes (Basel) 2023; 14:1366. [PMID: 37510271 PMCID: PMC10379808 DOI: 10.3390/genes14071366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 06/15/2023] [Accepted: 06/20/2023] [Indexed: 07/30/2023] Open
Abstract
Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection, with septic cardiomyopathy being a common and severe complication. Despite its significant clinical impact, the molecular mechanisms underlying sepsis-induced cardiomyopathy (SICM) remain incompletely understood. In this study, we performed a comparative analysis of whole transcriptome profiles using RNA sequencing in mouse hearts in two widely used mouse models of septic cardiomyopathy. CLP-induced sepsis was achieved by surgical cecal ligation and puncture, while LPS-induced sepsis was induced using a 5 mg/kg intraperitoneal (IP) injection of lipopolysaccharide (LPS). For consistency, we utilized sham-operated mice as the control for septic models. Our aim was to identify key genes and pathways involved in the development of septic cardiomyopathy and to evaluate the similarities and differences between the two models. Our findings demonstrated that both the CLP and lipopolysaccharide LPS methods could induce septic heart dysfunction within 24 h. We identified common transcriptional regulatory regions in the septic hearts of both models, such as Nfkb1, Sp1, and Jun. Moreover, differentially expressed genes (DEGs) in comparison to control were involved in shared pathways, including regulation of inflammatory response, regulation of reactive oxygen species metabolic process, and the JAK-STAT signaling pathway. However, each model presented distinctive whole transcriptome expression profiles and potentially diverse pathways contributing to sepsis-induced heart failure. This extensive comparison enhances our understanding of the molecular basis of septic cardiomyopathy, providing invaluable insights. Accordingly, our study also contributes to the pursuit of effective and personalized treatment strategies for SICM, highlighting the importance of considering the specific causative factors.
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Affiliation(s)
- Karim Ullah
- Section of Cardiology, Department of Medicine, Biological Sciences Division, University of Chicago, Chicago, IL 60637, USA (T.N.)
| | - Yan Li
- Center for Research Informatics, University of Chicago, Chicago, IL 60637, USA; (Y.L.); (Q.L.)
| | - Qiaoshan Lin
- Center for Research Informatics, University of Chicago, Chicago, IL 60637, USA; (Y.L.); (Q.L.)
| | - Kaichao Pan
- Section of Cardiology, Department of Medicine, Biological Sciences Division, University of Chicago, Chicago, IL 60637, USA (T.N.)
| | - Tu Nguyen
- Section of Cardiology, Department of Medicine, Biological Sciences Division, University of Chicago, Chicago, IL 60637, USA (T.N.)
| | | | - Qiaozhu Su
- Institute for Global Food Security, School of Biological Sciences, Queen’s University Belfast, Belfast BT9 5DL, UK;
| | - Willard Sharp
- Emergency Medicine, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Rongxue Wu
- Section of Cardiology, Department of Medicine, Biological Sciences Division, University of Chicago, Chicago, IL 60637, USA (T.N.)
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Dugar S, Sato R, Chawla S, You JY, Wang X, Grimm R, Collier P, Lanspa M, Duggal A. Is Left Ventricular Systolic Dysfunction Associated With Increased Mortality Among Patients With Sepsis and Septic Shock? Chest 2023; 163:1437-1447. [PMID: 36646415 DOI: 10.1016/j.chest.2023.01.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/13/2022] [Accepted: 01/05/2023] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The impact of left ventricular (LV) systolic function on outcomes in patients with sepsis and septic shock remains uncertain. The association, if any, may be nonlinear. RESEARCH QUESTION Is LV systolic dysfunction associated with increased mortality among patients with sepsis and septic shock? STUDY DESIGN AND METHODS Retrospective cohort study comprising all adult patients admitted to the medical ICU from January 1, 2011, through December 31, 2020, with sepsis and septic shock as defined by the Third International Consensus Definitions for Sepsis and Septic Shock guidelines. All adult patients with sepsis or septic shock who underwent transthoracic echocardiography within 3 days from admission to the medical ICU were included. We divided patients into five groups based on LV ejection fraction (LVEF). In addition to univariate analysis, we also performed multivariate logistic regression analysis adjusting for patients' baseline characteristics and severity of illness. The primary outcome was the association between each classification of LVEF and in-hospital mortality. RESULTS A total of 3,151 patients were included in this study (LVEF < 25%, 133 patients; 25% ≤ LVEF < 40%, 305 patients; 40% ≤ LVEF < 55%, 568 patients; 55% ≤ LVEF < 70%, 1,792 patients; and LVEF ≥ 70%, 353 patients). In-hospital mortalities in each LVEF category were 51.1%, 34.8%, 26.6%, 26.2%, and 41.9%, respectively. In the multivariate logistic regression analysis, LVEF of < 25% (OR, 2.75; 95% CI, 1.82-4.17; P < .001) and LVEF of ≥ 70% (OR, 1.70; 95% CI, 1.09-1.88; P = .010) were associated independently with significantly higher in-hospital mortality compared with the reference LVEF category of 55% to 70%. INTERPRETATION The association of LVEF to in-hospital mortality in sepsis and septic shock was U-shaped. Both severe LV systolic dysfunction (LVEF < 25%) and hyperdynamic LVEF (LVEF ≥ 70%) were associated independently with significantly higher in-hospital mortality.
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Affiliation(s)
- Siddharth Dugar
- Respiratory Institute, Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH.
| | - Ryota Sato
- Respiratory Institute, Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH
| | - Sanchit Chawla
- Respiratory Institute, Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH
| | - Jee Young You
- Respiratory Institute, Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH
| | - Xiaofeng Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Richard Grimm
- Heart, Vascular, and Thoracic Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Patrick Collier
- Heart, Vascular, and Thoracic Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Michael Lanspa
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, Salt Lake City, UT; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT
| | - Abhijit Duggal
- Respiratory Institute, Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH
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Lima MR, Silva D. Septic cardiomyopathy: A narrative review. Rev Port Cardiol 2023; 42:471-481. [PMID: 36893835 DOI: 10.1016/j.repc.2021.05.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 03/03/2021] [Accepted: 05/01/2021] [Indexed: 03/09/2023] Open
Abstract
Sepsis is a systemic inflammatory response syndrome of suspected or documented infectious origin, whose outcome is multiorgan failure. Sepsis-induced myocardial dysfunction (SIMD), present in more than 50% of septic patients, is characterized by (i) left ventricular (LV) dilatation with normal or low filling pressure, (ii) right and/or LV (systolic and/or diastolic) dysfunction and (iii) reversibility. Since the first definition proposed by Parker et al. in 1984, attempts have been made to define SIMD. Many parameters are used to assess cardiac function in septic patients, sometimes making it more difficult to measure due to the intrinsic hemodynamical changes in this condition. Nevertheless, with advanced echocardiographic techniques, such as speckle tracking analysis, it is possible to diagnose and assess systolic and diastolic dysfunction, even in the earliest stages of sepsis. Cardiac magnetic resonance imaging brings new insights into the reversibility of this condition. Many uncertainties still remain regarding the mechanisms, characteristics, treatment and even prognosis of this condition. There are also inconsistent conclusions from studies, therefore this review attempts to summarize our current knowledge of SIMD.
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Affiliation(s)
- Maria Rita Lima
- Internal Medicine Department, Egas Moniz Hospital, Lisbon Ocidental Hospital Center, Lisbon, Portugal.
| | - Doroteia Silva
- Intensive Care Department, Santa Maria University Hospital, Lisbon North Hospital Center, Lisbon, Portugal; CCUL, Lisbon Academic Medical Center, Faculty of Medicine of Lisbon, Lisbon, Portugal
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La Via L, Merola F, Schembari G, Liotta C, Sanfilippo F. The interplay between left ventricular diastolic and right ventricular dysfunction: challenges in the interpretation of critical care echocardiography studies. Egypt Heart J 2023; 75:7. [PMID: 36692697 PMCID: PMC9872744 DOI: 10.1186/s43044-023-00333-w] [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: 12/06/2022] [Accepted: 01/17/2023] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Sepsis is a leading cause of death and it is characterized not only by profound vasoplegia but also by myocardial dysfunction. Critical care echocardiography is the preferred modality for the initial assessment of the cause of shock. Moreover, it can be extremely helpful in the identification of progressing myocardial dysfunction during the course of sepsis, also known as septic cardiomyopathy. MAIN BODY One of the issues in the identification of septic cardiomyopathy is that it can be manifest with different clinical phenotypes, from overt biventricular dysfunction to isolated left ventricular (LV) systolic and/or diastolic dysfunction, from right ventricular (RV) systolic dysfunction to RV failure and dilatation. However, the commonly used echocardiography parameters for the assessment of LV and/or RV function are not always entirely reliable. Indeed, these are influenced by variable preload and afterload conditions imposed by critical illness such as fluid shifts, sedation level and mechanical ventilation with positive pressure. CONCLUSIONS Strain echocardiography is a promising tool for the early identification of myocardial dysfunction in the context of sepsis. Studies reporting data on strain echocardiography should be particularly detailed in order to increase the reproducibility of results and to favor comparison with future studies.
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Affiliation(s)
- Luigi La Via
- grid.412844.f0000 0004 1766 6239Department of Anesthesia and Intensive Care, “Policlinico-San Marco” University Hospital, Catania, Italy ,grid.8158.40000 0004 1757 1969School of Anesthesia and Intensive Care, University of Catania, Catania, Italy
| | - Federica Merola
- grid.8158.40000 0004 1757 1969School of Anesthesia and Intensive Care, University of Catania, Catania, Italy
| | - Giovanni Schembari
- grid.411489.10000 0001 2168 2547School of Anesthesia and Intensive Care, University “Magna Graecia”, Catanzaro, Italy
| | - Calogero Liotta
- grid.411489.10000 0001 2168 2547School of Anesthesia and Intensive Care, University “Magna Graecia”, Catanzaro, Italy
| | - Filippo Sanfilippo
- grid.412844.f0000 0004 1766 6239Department of Anesthesia and Intensive Care, “Policlinico-San Marco” University Hospital, Catania, Italy ,grid.8158.40000 0004 1757 1969Department of Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
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Ehrman RR, Bredell BX, Harrison NE, Favot MJ, Haber BD, Welch RD, Levy PD, Sherwin RL. Increasing illness severity is associated with global myocardial dysfunction in the first 24 hours of sepsis admission. Ultrasound J 2022; 14:32. [PMID: 35900610 PMCID: PMC9334514 DOI: 10.1186/s13089-022-00282-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 07/19/2022] [Indexed: 11/11/2022] Open
Abstract
Background Septic cardiomyopathy was recognized more than 30 years ago, but the early phase remains uncharacterized as no existing studies captured patients at the time of Emergency Department (ED) presentation, prior to resuscitation. Therapeutic interventions alter cardiac function, thereby distorting the relationship with disease severity and outcomes. The goal of this study was to assess the impact of illness severity on cardiac function during the first 24 h of sepsis admission. Methods This was a pre-planned secondary analysis of a prospective observational study of adults presenting to the ED with suspected sepsis (treatment for infection plus either lactate > 2 mmol/liter or systolic blood pressure < 90 mm/Hg) who received < 1L IV fluid before enrollment. Patients had 3 echocardiograms performed (presentation, 3, and 24 h). The primary outcome was the effect of increasing sepsis illness severity, defined by ED Sequential Organ Failure Assessment (SOFA) score, on parameters of cardiac function, assessed using linear mixed-effects models. The secondary goal was to determine whether cardiac function differed between survivors and non-survivors, also using mixed-effects models. Results We enrolled 73 patients with a mean age of 60 (SD 16.1) years and in-hospital mortality of 23%. For the primary analysis, we found that increasing ED SOFA score was associated with worse cardiac function over the first 24 h across all assessed parameters of left-ventricular systolic and diastolic function as well as right-ventricular systolic function. While baseline strain and E/e' were better in survivors, in the mixed models analysis, the trajectory of Global Longitudinal Strain and septal E/e′ over the first 24 h of illness differed between survivors and non-survivors, with improved function at 24 h in non-survivors. Conclusions In the first study to capture patients prior to the initiation of resuscitation, we found a direct relationship between sepsis severity and global myocardial dysfunction. Future studies are needed to confirm these results, to identify myocardial depressants, and to investigate the link with adverse outcomes so that therapeutic interventions can be developed. Supplementary Information The online version contains supplementary material available at 10.1186/s13089-022-00282-6.
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Formenti P, Coppola S, Massironi L, Annibali G, Mazza F, Gilardi L, Pozzi T, Chiumello D. Left Ventricular Diastolic Dysfunction in ARDS Patients. J Clin Med 2022; 11:jcm11205998. [PMID: 36294319 PMCID: PMC9604741 DOI: 10.3390/jcm11205998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/26/2022] [Accepted: 10/07/2022] [Indexed: 12/16/2022] Open
Abstract
Background: The aim of this study was to evaluate the possible presence of diastolic dysfunction and its possible effects in terms of respiratory mechanics, gas exchange and lung recruitability in mechanically ventilated ARDS. Methods: Consecutive patients admitted in intensive care unit (ICU) with ARDS were enrolled. Echocardiographic evaluation was acquired at clinical PEEP level. Lung CT-scan was performed at 5 and 45 cmH2O. In the study, 2 levels of PEEP (5 and 15 cmH2O) were randomly applied. Results: A total of 30 patients were enrolled with a mean PaO2/FiO2 and a median PEEP of 137 ± 52 and 10 [9–10] cmH2O, respectively. Of those, 9 patients (30%) had a diastolic dysfunction of grade 1, 2 and 3 in 33%, 45% and 22%, respectively, without any difference in gas exchange and respiratory mechanics. The total lung weight was significantly higher in patients with diastolic dysfunction (1669 [1354–1909] versus 1554 [1146–1942] g) but the lung recruitability was similar between groups (33.3 [27.3–41.4] versus 30.6 [20.0–38.8] %). Left ventricular ejection fraction (57 [39–62] versus 60 [57–60]%) and TAPSE (20.0 [17.0–24.0] versus 24.0 [20.0–27.0] mL) were similar between the two groups. The response to changes of PEEP from 5 to 15 cmH2O in terms of oxygenation and respiratory mechanics was not affected by the presence of diastolic dysfunction. Conclusions: ARDS patients with left ventricular diastolic dysfunction presented a higher amount of lung edema and worse outcome.
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Affiliation(s)
- Paolo Formenti
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, 20142 Milan, Italy
| | - Silvia Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, 20142 Milan, Italy
| | - Laura Massironi
- Division of Cardiology, Department of Health Sciences, San Paolo Hospital, University of Milan, 20142 Milan, Italy
| | - Giacomo Annibali
- Department of Health Sciences, University of Milan, 20142 Milan, Italy
| | - Francesco Mazza
- Department of Health Sciences, University of Milan, 20142 Milan, Italy
| | - Lisa Gilardi
- Department of Health Sciences, University of Milan, 20142 Milan, Italy
| | - Tommaso Pozzi
- Department of Health Sciences, University of Milan, 20142 Milan, Italy
| | - Davide Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, 20142 Milan, Italy
- Department of Health Sciences, University of Milan, 20142 Milan, Italy
- Coordinated Research Center on Respiratory Failure, University of Milan, 2014 Milan, Italy
- Correspondence:
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11
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Greenstein YY, Guevarra K. Point-of-Care Ultrasound in the Intensive Care Unit: Applications, Limitations, and the Evolution of Clinical Practice. Clin Chest Med 2022; 43:373-384. [PMID: 36116807 DOI: 10.1016/j.ccm.2022.04.001] [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: 11/03/2022]
Abstract
The use of point-of-care ultrasonography in the intensive care unit has been rapidly advancing over the past 20 years. This review will provide a broad overview of the discipline spanning lung ultrasonography to advanced critical care echocardiography. It will highlight new research that questions the utility of the inferior vena cava for determining volume responsiveness and will introduce the reader to cutting-edge technology including artificial intelligence, which is likely to revolutionize ultrasound teaching and image interpretation, increasing the reach of this modality for the frontline clinician.
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Affiliation(s)
- Yonatan Y Greenstein
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Rutgers - New Jersey Medical School, University Hospital Building, Room I-354, 150 Bergen Street, Newark, NJ 07103, USA.
| | - Keith Guevarra
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Rutgers - New Jersey Medical School, University Hospital Building, Room I-354, 150 Bergen Street, Newark, NJ 07103, USA
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Jentzer JC, Tabi M, Wiley BM, Lanspa MJ, Anavekar NS, Oh JK. Doppler-derived haemodynamics performed during admission echocardiography predict in-hospital mortality in cardiac intensive care unit patients. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:640-650. [PMID: 35851395 DOI: 10.1093/ehjacc/zuac084] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 06/20/2022] [Accepted: 06/28/2022] [Indexed: 06/15/2023]
Abstract
AIMS Cardiac point-of-care ultrasound (CV-POCUS) has become a fundamental part for the assessment of patients admitted to cardiac intensive care units (CICU). We sought to refine the practice of CV-POCUS by identifying 2D and Doppler-derived measurements from bedside transthoracic echocardiograms (TTEs) performed in the CICU that are associated with mortality. METHODS AND RESULTS We retrospectively included Mayo Clinic CICU patients admitted from 2007 to 2018 and assessed the TTEs performed within 1 day of CICU admission, including Doppler and 2D measurements of left and right ventricular function. Logistic regression and classification and regression tree (CART) analysis were used to determine the association between TTE variables with in-hospital mortality. A total of 6957 patients were included with a mean age of 68.0 ± 14.9 years (37.0% females). A total of 609 (8.8%) patients died in the hospital. Inpatient deaths group had worse biventricular systolic function [left ventricular ejection fraction (LVEF) 48.2 ± 16.0% vs. 38.7 ± 18.2%, P < 0.0001], higher filling pressures, and lower forward flow. The strongest TTE predictors of hospital mortality were left ventricular outflow tract velocity-time integral [LVOT VTI, adjusted OR 0.912 per 1 cm higher, 95% confidence interval (CI) 0.883-0.942, P < 0.0001] followed by medial mitral E/e' ratio (adjusted OR 1.024 per 1 unit higher, 95% CI 1.010-1.039, P = 0.0011). Classification and regression tree analysis identified LVOT VTI <16 cm as the most important TTE predictor of mortality. CONCLUSIONS Doppler-derived haemodynamic TTE parameters have a strong association with mortality in the CICU, particularly LVOT VTI <16 cm or mitral E/e' ratio >15. The incorporation of these simplified Doppler-derived haemodynamics into admission CV-POCUS facilitates early risk stratification and strengthens the clinical yield of the ultrasound exam.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN 55905, USA
| | - Meir Tabi
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
| | - Brandon M Wiley
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
| | - Michael J Lanspa
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, University of Utah, Murray, UT 84132, USA
| | - Nandan S Anavekar
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
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Ge WD, Li FZ, Hu BC, Wang LH, Ren DY. Factors associated with left ventricular diastolic dysfunction in patients with septic shock. Eur J Med Res 2022; 27:134. [PMID: 35897043 PMCID: PMC9327319 DOI: 10.1186/s40001-022-00761-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 07/10/2022] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Wei-Dong Ge
- Department of Ultrasonography, Zhejiang Provincial People's Hospital and People's Hospital of Hangzhou Medical College, Hangzhou, 310000, Zhejiang, China
| | - Feng-Zhi Li
- Department of Ultrasonography, Zhejiang Provincial People's Hospital and People's Hospital of Hangzhou Medical College, Hangzhou, 310000, Zhejiang, China.,Department of Ultrasonography, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Bang-Chuan Hu
- Department of Ultrasonography, Zhejiang Provincial People's Hospital and People's Hospital of Hangzhou Medical College, Hangzhou, 310000, Zhejiang, China
| | - Li-Hong Wang
- Department of Ultrasonography, Zhejiang Provincial People's Hospital and People's Hospital of Hangzhou Medical College, Hangzhou, 310000, Zhejiang, China
| | - Ding-Yuan Ren
- Department of Ultrasonography, Zhejiang Provincial People's Hospital and People's Hospital of Hangzhou Medical College, Hangzhou, 310000, Zhejiang, China.
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14
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Zhang H, Wang X, Yin W, Zhang H, Liu L, Pan P, Zhu Y, Huang W, Xing Z, Yao B, Wang C, Lin T, Yu R, Shang X. A multicenter prospective cohort study of cardiac ultrasound phenotypes in patients with sepsis: Study protocol for a multicenter prospective cohort trial. Front Med (Lausanne) 2022; 9:938536. [PMID: 35966841 PMCID: PMC9363883 DOI: 10.3389/fmed.2022.938536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 07/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background Sepsis-induced cardiomyopathy significantly increased the mortality of patients with sepsis. The diagnostic criteria for septic cardiomyopathy has not been unified, which brings serious difficulties to clinical treatment. This study aimed to provide evidence for the early identification and intervention in patients with sepsis by clarifying the relationship between the ultrasound phenotype of septic cardiomyopathy and the prognosis of patients with sepsis. Methods This was a multicenter, prospective cohort study. The study population will consist of all eligible consecutive patients with sepsis or septic shock who meet the Sepsis 3.0 diagnostic criteria and were aged ≥18 years. Clinical data and echocardiographic measurements will be recorded within 2 h, at the 24th hour, at the 72nd hour, and on the 7th day after admission. The prevalence of each phenotype will be described as well, and their association with prognosis will be analyzed statistically. Discussion To achieve early recognition, prevent reinjury, achieve precise treatment, and reduce mortality in patients with sepsis, it is important to identify septic cardiac alterations and classify the phenotypes at all stages of sepsis. First, there is a lack of studies on the prevalence of each phenotype in Chinese populations. Second, each phenotype and its corresponding prognosis are not clear. In addition, the prognosis of patients with normal cardiac ultrasound phenotypes vs. those with suppressed or hyperdynamic cardiac phenotypes is unclear. Finally, this study was designed to collect data at four specific timing, then the timing of occurrence, duration, changes over time, impact to outcomes of each phenotype will probably be found. This study is expected to establish a standard and objective method to assess the ultrasound phenotype of septic cardiomyopathy due to its advantages of visualization, non-invasiveness and reproducibility, and to provide more precise information for the hemodynamic management of septic patients. In addition, this research will promote the clinical application of critical care ultrasound, which will play an important role in medical education and make ultrasound the best method to assess cardiac changes in sepsis. Trial registration https://clinicaltrials.gov/ct2/show/NCT05161104, identifier NCT05161104.
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Affiliation(s)
- Hongxuan Zhang
- The Third Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Xiaoting Wang
| | - Wanhong Yin
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Hongmin Zhang
- Department of Critical Care Medicine, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Lixia Liu
- Department of Critical Care Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Pan Pan
- Department of Respiratory and Critical Care Medicine, Chinese PLA General Hospital, Beijing, China
| | - Ying Zhu
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Huang
- Department of Critical Care Medicine, School of Medicine, First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Zhiqun Xing
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Bo Yao
- Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Cui Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Tianlai Lin
- Department of Critical Care Medicine, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, China
| | - Rongguo Yu
- The Third Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou, China
- Rongguo Yu
| | - Xiuling Shang
- The Third Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou, China
- Xiuling Shang
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15
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Kahl U, Schirren L, Yu Y, Lezius S, Fischer M, Menke M, Sinning C, Nierhaus A, Vens M, Zöllner C, Kluge S, Goepfert MS, Roeher K. Left Ventricular Diastolic Dysfunction Is Not Associated With Pulmonary Edema in Septic Patients. A Prospective Observational Cohort Study. Front Cardiovasc Med 2022; 9:900850. [PMID: 35845063 PMCID: PMC9283750 DOI: 10.3389/fcvm.2022.900850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 06/06/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose We aimed to investigate whether left ventricular diastolic dysfunction (LVDD) is associated with pulmonary edema in septic patients. Methods We conducted a prospective cohort study in adult septic patients between October 2018 and May 2019. We performed repeated echocardiography and lung ultrasound examinations within the first 7 days after diagnosis of sepsis. We defined LVDD according to the 2016 recommendations of the American Society of Echocardiography and—for sensitivity analysis—according to an algorithm which has been validated in septic patients. We quantified pulmonary edema using the lung ultrasound score (LUSS), counting B-lines in four intercostal spaces. Results We included 54 patients. LVDD was present in 51 (42%) of 122 echocardiography examinations. The mean (±SD) LUSS was 11 ± 6. There was no clinically meaningful association of LVDD with LUSS (B = 0.55 [95%CI: −1.38; 2.47]; p = 0.571). Pneumonia was significantly associated with higher LUSS (B = 4.42 [95%CI: 0.38; 8.5]; p = 0.033). Conclusion The lack of a clinically meaningful association of LVDD with LUSS suggests that LVDD is not a major contributor to pulmonary edema in septic patients. Trial Registration NCT03768752, ClinicalTrials.gov, November 30th, 2018 - retrospectively registered.
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Affiliation(s)
- Ursula Kahl
- Klinik und Poliklinik für Anästhesiologie Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
- *Correspondence: Ursula Kahl ; orcid.org/0000-0003-2096-9647
| | - Leah Schirren
- Klinik und Poliklinik für Anästhesiologie Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Yuanyuan Yu
- Klinik und Poliklinik für Anästhesiologie Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Lezius
- Institut für Medizinische Biometrie und Epidemiologie Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Marlene Fischer
- Klinik und Poliklinik für Anästhesiologie Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
- Klinik für Intensivmedizin Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Maja Menke
- Klinik und Poliklinik für Anästhesiologie Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Sinning
- Klinik und Poliklinik für Kardiologie Universitäres Herz- und Gefäßzentrum Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Axel Nierhaus
- Klinik für Intensivmedizin Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Maren Vens
- Institut für Medizinische Biometrie und Epidemiologie Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
- Institut für Medizinische Biometrie und Statistik Universität zu Lübeck, Universitätsklinikum Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Christian Zöllner
- Klinik und Poliklinik für Anästhesiologie Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Klinik für Intensivmedizin Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias S. Goepfert
- Klinik und Poliklinik für Anästhesiologie Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
- Klinik für Anästhesie und Intensivmedizin Alexianer St. Hedwigkliniken Berlin, Berlin, Germany
| | - Katharina Roeher
- Klinik und Poliklinik für Anästhesiologie Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
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Khalid N, Patel PD, Alghareeb R, Hussain A, Maheshwari MV. The Effect of Sepsis on Myocardial Function: A Review of Pathophysiology, Diagnostic Criteria, and Treatment. Cureus 2022; 14:e26178. [PMID: 35891864 PMCID: PMC9306401 DOI: 10.7759/cureus.26178] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 12/29/2022] Open
Abstract
Sepsis remains a worldwide challenge for physicians with many patients admitted to ICUs with septic shock. Septic shock management involves targeted treatment to control infections, reduce end-organ damage, and reverse the injury. Sepsis-induced myocardial dysfunction or septic cardiomyopathy remains an avenue to be explored with regard to underlying pathophysiology and definite treatment guidelines. This article has compiled various studies to explain the possible mechanisms involved in the development of septic cardiomyopathy and the existing diagnostic criteria including radiological and laboratory tests to assess septic cardiomyopathy. Furthermore, the article highlights management options currently available for physicians dealing with myocardial dysfunction secondary to sepsis.
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Affiliation(s)
- Nabeeha Khalid
- Cardiology, Omar Hospital and Cardiac Centre, Lahore, PAK
| | - Pragnesh D Patel
- Research, St. George's University School of Medicine, St. George's, GRD
| | | | - Afshan Hussain
- Research, Dow Medical College and Dr. Ruth K. M. Pfau Civil Hospital Karachi, Karachi, PAK
| | - Marvi V Maheshwari
- Research, Our Lady of Fatima University College of Medicine, Valenzuela, PHL
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17
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Krantz MJ, Rudo T, Horvath B, Gregory E, Farasat M, Gore O, Mehler PS. The E/e' Ratio: As "Critical" As the Left Ventricular Ejection Fraction? Crit Pathw Cardiol 2022; 21:93-95. [PMID: 35604775 DOI: 10.1097/hpc.0000000000000288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Ascertainment of the left ventricular ejection fraction is the primary reason for ordering echocardiography in the acute care setting; however, this parameter does not provide information regarding a patient's volume status. As such, it cannot be reliably used to inform decisions regarding intravenous fluid resuscitation or diuresis, particularly in undifferentiated dyspnea and hypotension. This is relevant given a national quality improvement exhortation to provide aggressive fluid resuscitation as part of a "sepsis bundle." This initiative must be tempered by the well-established increase in hospital mortality from providing intravenous fluid to patients with unrecognized heart failure, which may occur if sepsis is misdiagnosed. We describe herein, what is to our knowledge, the first description of a critically elevated Doppler ratio of mitral inflow peak E-wave velocity to the mean mitral annular velocity as a harbinger of sudden death from pulmonary edema in a patient treated with aggressive intravenous fluids as part of the "sepsis bundle." This is utilized as a springboard for proposing a clinical algorithm focused on expedited echocardiography. It emphasized the potential value of advancing markedly the diastolic assessment of filling pressure (ratio of mitral inflow peak E-wave velocity to the mean mitral annular velocity) in the acute care setting to a level of import comparable to the left ventricular ejection fraction.
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Affiliation(s)
- Mori J Krantz
- From the Clario CV imaging and Cardiac Safety, Philadelphia, PA
| | - Todd Rudo
- From the Clario CV imaging and Cardiac Safety, Philadelphia, PA
| | - Blaine Horvath
- From the Clario CV imaging and Cardiac Safety, Philadelphia, PA
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Abstract
Sepsis is the life-threatening organ dysfunction caused by a dysregulated host response to infection and is the leading cause of death in intensive care units. Cardiac dysfunction caused by sepsis, usually termed sepsis-induced cardiomyopathy, is common and has long been a subject of interest. In this Review, we explore the definition, epidemiology, diagnosis and pathophysiology of septic cardiomyopathy, with an emphasis on how best to interpret this condition in the clinical context. Advances in diagnostic techniques have increased the sensitivity of detection of myocardial abnormalities but have posed challenges in linking those abnormalities to therapeutic strategies and relevant clinical outcomes. Sophisticated methodologies have elucidated various pathophysiological mechanisms but the extent to which these are adaptive responses is yet to be definitively answered. Although the indications for monitoring and treating septic cardiomyopathy are clinical and directed towards restoring tissue perfusion, a better understanding of the course and implications of septic cardiomyopathy can help to optimize interventions and improve clinical outcomes.
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Estimation of Pulmonary Artery Occlusion Pressure Using Doppler Echocardiography in Mechanically Ventilated Patients. Crit Care Med 2021; 48:e943-e950. [PMID: 32885942 DOI: 10.1097/ccm.0000000000004512] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Evaluation of left atrial pressure is frequently required for mechanically ventilated critically ill patients. The objective of the present study was to evaluate the 2016 American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines for assessment of the pulmonary artery occlusion pressure (a frequent surrogate of left atrial pressure) in this population. DESIGN A pooled analysis of three prospective cohorts of patients simultaneously assessed with a pulmonary artery catheter and echocardiography. SETTINGS Medical-surgical intensive care department of two university hospitals in France. PATIENTS Mechanically ventilated critically ill patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 98 included patients (males: 67%; mean ± SD age: 59 ± 16; and mean Simplified Acute Physiology Score 2: 54 ± 20), 53 (54%) experienced septic shock. Using the 2016 American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines, the predicted pulmonary artery occlusion pressure was indeterminate in 48 of the 98 patients (49%). Of the 24 patients with an elevated predicted left atrial pressure (grade II/III diastolic dysfunction), only 17 (71%) had a pulmonary artery occlusion pressure greater than or equal to 18 mm Hg. Similarly, 20 of the 26 patients (77%) with a normal predicted left atrial pressure (grade I diastolic dysfunction) had a measured pulmonary artery occlusion pressure less than 18 mm Hg. The sensitivity and specificity of American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines for predicting elevated pulmonary artery occlusion pressure were both 74%. The agreement between echocardiography and the pulmonary artery catheter was moderate (Cohen's Kappa, 0.48; 95% CI, 0.39-0.70). In a proposed alternative algorithm, the best echocardiographic predictors of a normal pulmonary artery occlusion pressure were a lateral e'-wave greater than 8 (for a left ventricular ejection fraction ≥ 45%) or an E/A ratio less than or equal to 1.5 (for a left ventricular ejection fraction < 45%). CONCLUSIONS The American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines do not accurately assess pulmonary artery occlusion pressure in ventilated critically ill patients. Simple Doppler measurements gave a similar level of diagnostic performance with less uncertainly.
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Abstract
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. The heart is one of the most important oxygen delivery organs, and dysfunction significantly increases the mortality of the body. Hence, the heart has been studied in sepsis for over half a century. However, the definition of sepsis-induced cardiomyopathy is not unified yet, and the conventional conception seems outdated: left ventricular systolic dysfunction (LVSD) along with enlargement of the left ventricle, recovering in 7 to 10 days. With the application of echocardiography in intensive care units, not only LVSD but also left ventricular diastolic dysfunction, right ventricular dysfunction, and even diffuse ventricular dysfunction have been seen. The recognition of sepsis-induced cardiomyopathy is gradually becoming complete, although our understanding of it is not deep, which has made the diagnosis and treatment stagnate. In this review, we summarize the research on sepsis-induced cardiomyopathy. Women and young people with septic cardiomyopathy are more likely to have LVSD, which may have the same mechanism as stress cardiomyopathy. Elderly people with ischemic cardiomyopathy and hypertension tend to have left ventricular diastolic dysfunction. Patients with mechanical ventilation, acute respiratory distress syndrome or other complications of increased right ventricular afterload mostly have right ventricular dysfunction. Diffuse cardiac dysfunction has also been shown in some studies; patients with mixed or co-existing cardiac dysfunction are more common, theoretically. Thus, understanding the pathophysiology of sepsis-induced cardiomyopathy from the perspective of critical care echocardiography is essential.
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21
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Yu G, Cheng K, Liu Q, Lin X, Lin F, Wu W. Association between left ventricular diastolic dysfunction and septic acute kidney injury in severe sepsis and septic shock: A multicenter retrospective study. Perfusion 2021; 37:175-187. [PMID: 33475032 DOI: 10.1177/0267659121988969] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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).
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Affiliation(s)
- Guangwei Yu
- Department of Emergency, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Kun Cheng
- Department of Intensive Care Unit, Fujian Provincial Hospital, Fuzhou, Fujian Province, China.,Fujian Critical Care Medicine Center, Fuzhou, Fujian Province, China.,Fujian Provincial Clinical College of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Qing Liu
- Department of Emergency, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Xiaohong Lin
- Department of Emergency, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.,Fujian Key Laboratory of Vascular Aging, Fuzhou, Fujian Province, China
| | - Fenghui Lin
- Department of Intensive Care Unit, Fujian Provincial Hospital, Fuzhou, Fujian Province, China.,Fujian Critical Care Medicine Center, Fuzhou, Fujian Province, China.,Fujian Provincial Clinical College of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Wenwei Wu
- Department of Emergency, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
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Bagate F, Masi P, d'Humières T, Al-Assaad L, Chakra LA, Razazi K, de Prost N, Carteaux G, Derumeaux G, Mekontso Dessap A. Advanced echocardiographic phenotyping of critically ill patients with coronavirus-19 sepsis: a prospective cohort study. J Intensive Care 2021; 9:12. [PMID: 33472693 PMCID: PMC7816136 DOI: 10.1186/s40560-020-00516-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 12/17/2020] [Indexed: 12/27/2022] Open
Abstract
Background Sepsis is characterized by various hemodynamic alterations which could happen concomitantly in the heart, pulmonary and systemic circulations. A comprehensive demonstration of their interactions in the clinical setting of COVID-19 sepsis is lacking. This study aimed at evaluating the feasibility, clinical implications, and physiological coherence of the various indices of hemodynamic function and acute myocardial injury (AMI) in COVID-19 sepsis. Methods Hemodynamic and echocardiographic data of septic critically ill COVID-19 patients were prospectively recorded. A dozen hemodynamic indices exploring contractility and loading conditions were assessed. Several cardiac biomarkers were measured, and AMI was considered if serum concentration of high-sensitive troponin T (hs-TNT) was above the 99th percentile, upper reference. Results Sixty-seven patients were assessed (55 males), with a median age of 61 [50–70] years. Overall, the feasibility of echocardiographic parameters was very good, ranging from 93 to 100%. Hierarchical clustering method identified four coherent clusters involving cardiac preload, left ventricle (LV) contractility, LV afterload, and right ventricle (RV) function. LV contractility indices were not associated with preload indices, but some of them were positively correlated with RV function parameters and negatively correlated with a single LV afterload parameter. In most cases (n = 36, 54%), echocardiography results prompted therapeutic changes. Mortality was not influenced by the echocardiographic variables in multivariable analysis. Cardiac biomarkers’ concentrations were most often increased with high incidence of AMI reaching 72%. hs-TNT was associated with mortality and inversely correlated with most of LV and RV contractility indices. Conclusions In this comprehensive hemodynamic evaluation in critically ill COVID-19 septic patients, we identified four homogeneous and coherent clusters with a good feasibility. AMI was common and associated with alteration of LV and RV functions. Echocardiographic assessment had a clinical impact on patient management in most cases. Supplementary Information The online version contains supplementary material available at 10.1186/s40560-020-00516-6.
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Affiliation(s)
- François Bagate
- AP-HP, Hôpitaux universitaires Henri Mondor, Service de Médecine Intensive Réanimation, 94010, Créteil, France.,Université Paris Est Créteil, Faculté de Santé de Créteil, IMRB, Groupe de recherche clinique CARMAS, 94010, Créteil, France
| | - Paul Masi
- AP-HP, Hôpitaux universitaires Henri Mondor, Service de Médecine Intensive Réanimation, 94010, Créteil, France.,Université Paris Est Créteil, Faculté de Santé de Créteil, IMRB, Groupe de recherche clinique CARMAS, 94010, Créteil, France
| | - Thomas d'Humières
- AP-HP, Hôpitaux universitaires Henri Mondor, Service de Physiologie, 94010, Créteil, France.,INSERM IMRB U955, Université Paris Est Créteil, Créteil, 94010, France
| | - Lara Al-Assaad
- AP-HP, Hôpitaux universitaires Henri Mondor, Service de Physiologie, 94010, Créteil, France.,INSERM IMRB U955, Université Paris Est Créteil, Créteil, 94010, France
| | - Laure Abou Chakra
- AP-HP, Hôpitaux universitaires Henri Mondor, Service de Physiologie, 94010, Créteil, France.,INSERM IMRB U955, Université Paris Est Créteil, Créteil, 94010, France
| | - Keyvan Razazi
- AP-HP, Hôpitaux universitaires Henri Mondor, Service de Médecine Intensive Réanimation, 94010, Créteil, France.,Université Paris Est Créteil, Faculté de Santé de Créteil, IMRB, Groupe de recherche clinique CARMAS, 94010, Créteil, France
| | - Nicolas de Prost
- AP-HP, Hôpitaux universitaires Henri Mondor, Service de Médecine Intensive Réanimation, 94010, Créteil, France.,Université Paris Est Créteil, Faculté de Santé de Créteil, IMRB, Groupe de recherche clinique CARMAS, 94010, Créteil, France
| | - Guillaume Carteaux
- AP-HP, Hôpitaux universitaires Henri Mondor, Service de Médecine Intensive Réanimation, 94010, Créteil, France.,Université Paris Est Créteil, Faculté de Santé de Créteil, IMRB, Groupe de recherche clinique CARMAS, 94010, Créteil, France
| | - Genevieve Derumeaux
- AP-HP, Hôpitaux universitaires Henri Mondor, Service de Physiologie, 94010, Créteil, France.,INSERM IMRB U955, Université Paris Est Créteil, Créteil, 94010, France
| | - Armand Mekontso Dessap
- AP-HP, Hôpitaux universitaires Henri Mondor, Service de Médecine Intensive Réanimation, 94010, Créteil, France. .,Université Paris Est Créteil, Faculté de Santé de Créteil, IMRB, Groupe de recherche clinique CARMAS, 94010, Créteil, France. .,INSERM IMRB U955, Université Paris Est Créteil, Créteil, 94010, France.
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23
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Abstract
Purpose of Review This article summarizes the utility and evidence supporting the use of ultrasound exams in the intensive care unit. Recent Findings Point-of-care ultrasonography (POCUS) is widely used by intensivists managing critically ill patients whereby they can accurately and rapidly assess for many pathologies such as pneumothorax, pulmonary edema, hydronephrosis, hemoperitoneum, and deep vein thrombosis among others. Basic and advanced critical care echocardiography, including transesophageal echocardiography, are routinely performed to determine the etiology of hemodynamic instability in undifferentiated shock and to guide subsequent therapy. The use of POCUS in the assessment of volume status is controversial with studies demonstrating that respiratory variation of the IVC is not reliable and with analysis of aortic blood flow velocity after passive leg raising maneuvers being the most promising. Summary Point-of-care ultrasonography allows frontline clinicians to make real-time diagnoses and treatment decisions. This article will provide the reader with a broad overview of this important topic. Electronic supplementary material The online version of this article (10.1007/s11886-020-01393-z) contains supplementary material, which is available to authorized users.
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24
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Kim JS, Kim YJ, Kim M, Ryoo SM, Kim WY. Association between right ventricle dysfunction and poor outcome in patients with septic shock. Heart 2020; 106:1665-1671. [PMID: 32641318 DOI: 10.1136/heartjnl-2020-316889] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/23/2020] [Accepted: 05/28/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Sepsis-induced myocardial dysfunction (SIMD) can involve both the left and right ventricles. However, the characteristics and outcomes across various manifestations of SIMD remain unknown. METHODS This was a retrospective cohort study using a prospective registry of septic shock from January 2011 and April 2017. Patients with clinically presumed cardiac dysfunction underwent echocardiography within 72 hours after admission and were enrolled (n=778). SIMD was classified as left ventricle (LV) systolic/diastolic and right ventricle (RV) dysfunction, which were defined based on the American Society of Echocardiography criteria. The primary outcome was 28-day mortality. RESULTS Of the 778 septic shock patients who underwent echocardiography, 270 (34.7%) showed SIMD. The median age was 67.0 years old, and the male was predominant (57.3%). Among them, 67.3% had LV systolic dysfunction, 40.7% had RV dysfunction and 39.3% had LV diastolic dysfunction. Although serum lactate level and sequential organ failure assessment score were not significantly different between groups, SIMD group showed higher troponin I (0.1 vs 0.1 ng/mL; p=0.02) and poor clinical outcomes, including higher 28-day mortality (35.9 vs 26.8%; p<0.01), longer intensive care unit length of stay (5 vs 2 days; p<0.01) and prolonged mechanical ventilation (9 vs 4 days; p<0.01). Multivariate analysis showed that isolated RV dysfunction was an independent risk factor of 28-day mortality (OR 2.26, 95% CI 1.04 to 4.91). CONCLUSIONS One-third of patients with septic shock showed various myocardial dysfunctions. LV systolic dysfunction was common; however, only RV dysfunction was associated with short-term mortality.
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Affiliation(s)
- June-Sung Kim
- Department of Emergency Medicine, Asan Medical Center, Songpa-gu, Seoul, Republic of Korea
| | - Youn-Jung Kim
- Department of Emergency Medicine, Asan Medical Center, Songpa-gu, Seoul, Republic of Korea
| | - Muyeol Kim
- Department of Emergency Medicine, Asan Medical Center, Songpa-gu, Seoul, Republic of Korea
| | - Seung Mok Ryoo
- Department of Emergency Medicine, Asan Medical Center, Songpa-gu, Seoul, Republic of Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, Songpa-gu, Seoul, Republic of Korea
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25
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Dong J, White S, Nielsen K, Banchs J, Wang J, Botz GH, Nates JL. Tricuspid Annular Plane Systolic Excursion is a Predictor of Mortality for Septic Shock. Intern Med J 2020; 51:1854-1861. [PMID: 32618101 DOI: 10.1111/imj.14957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Cardiac dysfunction is a common sequela in patients with sepsis and multi-organ dysfunction. Echocardiography is commonly used in the investigation of circulatory failure. We aimed to evaluate the prognostic value of echocardiographic parameters in patients with septic shock. METHODS This study was a retrospective trial. We included patients who were admitted to ICU with septic shock. The patients' echocardiograms, clinical data, and outcomes were obtained from their medical records. Associations between echo-cardiogram variables and mortality were assessed using logistic regression, controlled for age, sex, BMI, and the interval between the ICU admission and echocardiogram. The utility of statistically significant echocardiogram variables to predict mortality were assessed using receiver operating characteristic (ROC) curves. RESULTS The outcomes presented that Tricuspid Annular Plane Systolic Excursion(TAPSE) was statistically significantly associated with both ICU (p = 0.02) and 90-day (p = 0.001) mortality. From the ROC curves, TAPSE emerged a significant and moderate predictor for 90-day (area under curve (AUC) = 0.69, 95% CI = 0.565-0.814) and in-ICU mortality (AUC = 0.762, 95% CI = 0.652-0.871). The optimal cut-off for TAPSE was 2.1 cm for both 90-day mortality (sensitivity of 80% and specificity and 58%) and in-ICU mortality (sensitivity of 69% and specificity of 77%). CONCLUSION TAPSE was associated with increased mortality in those with sepsis and suspicion of cardiac dysfunction. This is a hypothesis generating paper that an association may be present and requires significant more work with expansion to the entire population base. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jun Dong
- Department of Critical Care Medicine, Division of Anesthesiology and Critical Care, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit #112, Houston, Texas, 77030, USA.,Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Intensive Care Unit department, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Seth White
- Department of Critical Care Medicine, Division of Anesthesiology and Critical Care, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit #112, Houston, Texas, 77030, USA
| | - Kirsten Nielsen
- Department of Critical Care Medicine, Division of Anesthesiology and Critical Care, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit #112, Houston, Texas, 77030, USA.,Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Blvd 99, 8200, Aarhus N, Denmark
| | - Jose Banchs
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit #112, Houston, Texas, 77030, USA
| | - Jian Wang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit #112, Houston, Texas, 77030, USA
| | - Gregory H Botz
- Department of Critical Care Medicine, Division of Anesthesiology and Critical Care, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit #112, Houston, Texas, 77030, USA
| | - Joseph L Nates
- Department of Critical Care Medicine, Division of Anesthesiology and Critical Care, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit #112, Houston, Texas, 77030, USA
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26
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Lan P, Wang TT, Li HY, Yan RS, Liao WC, Yu BW, Wang QQ, Lin L, Pan KH, Yu YS, Zhou JC. Utilization of echocardiography during septic shock was associated with a decreased 28-day mortality: a propensity score-matched analysis of the MIMIC-III database. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:662. [PMID: 31930063 DOI: 10.21037/atm.2019.10.79] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Hemodynamic management is of paramount importance in patients with septic shock. Echocardiography has been increasingly used in assessing volume status and cardiac function. However, whether the utilization of echocardiography has an impact on prognosis is unknown. Thus, we intended to explore its effect on the outcomes of patients with septic shock. Methods The study was based on the Medical Information Mart for Intensive Care (MIMIC) III database. Septic shock patients were divided into two groups according to the usage of echocardiography during the onset of septic shock. The primary outcome was 28-day mortality. Secondary outcomes included the usage of inotropes, ventilation-free and norepinephrine-free time, and fluids input. Propensity-score matching was used to reduce the imbalance. Results Among 3,291 eligible patients, 1,289 patients who underwent echocardiography (Echo), and 1,289 who did not receive the Echo, had similar propensity scores and were included in the analyses. After matching, the Echo group had a significantly lower 28-day mortality (33.2% vs. 37.7%, P=0.019). More patients in the Echo group received pulmonary artery catheter (PAC) (4.2% vs. 0.2%, P<0.001) and inotropes (17.8% vs. 7.1%, P<0.001). In the survival analysis, Echo utilization was associated with improved 28-day mortality [hazard ratio (HR): 0.83; 95% confidence interval (CI), 0.73-0.95, P=0.005]. A reduced likelihood of 28-day mortality in patients with Echo vs. those without Echo was maintained either when excluding patients receiving multiple echocardiography scans (HR, 0.82; 95% CI, 0.72-0.94; P=0.004) or when excluding patients undergoing PAC or pulse index continuous cardiac output (PiCCO) (HR, 0.87; 95% CI, 0.76-0.99; P=0.034). Conclusions Utilization of echocardiography was associated with improved 28-day outcomes in patients with septic shock.
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Affiliation(s)
- Peng Lan
- Department of Infectious Diseases Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou 310016, China.,Department of Critical Care Medicine, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Ting-Ting Wang
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Hang-Yang Li
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Ru-Shuang Yan
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Wei-Chao Liao
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Bu-Wen Yu
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Qian-Qian Wang
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Ling Lin
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Kong-Han Pan
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Yun-Song Yu
- Department of Infectious Diseases Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Jian-Cang Zhou
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou 310016, China
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27
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Duan M, Yuan Y, Liu C, Cai Z, Xie Q, Hu T, Tang Q, Wu Q. Indigo Fruits Ingredient, Aucubin, Protects against LPS-Induced Cardiac Dysfunction in Mice. J Pharmacol Exp Ther 2019; 371:348-359. [PMID: 31467086 DOI: 10.1124/jpet.119.259069] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 08/12/2019] [Indexed: 12/13/2022] Open
Abstract
Aucubin (AUB), which is extracted from Eucommia ulmoides Oliver seeds, has been found to possess anti-inflammatory and antiapoptotic properties. Recent studies have indicated that inflammation, oxidative stress, and apoptosis are involved in the pathophysiology of lipopolysaccharide (LPS)-induced cardiac dysfunction. Our study aimed to investigate the effect of AUB on LPS-induced acute cardiac injury. Male C57BL/6 mice were injected with LPS (one 6 mg/kg injection) to induce cardiac dysfunction without or with AUB pretreatment (20 or 80 mg/kg per day) for 1 week. We found that AUB ameliorated cardiac dysfunction, inflammation, oxidative stress, and apoptosis induced by LPS stimulation. Mechanistically, AUB inhibited LPS-induced oxidative stress by decreasing reactive oxygen species and thioredoxin interaction protein (TXNIP) levels. Moreover, AUB suppressed LPS-induced inflammation and apoptosis by reducing nucleotide-binding oligomerization domain-like receptor family pyrin domain-containing 3 (NLRP3)/apoptosis-associated speck-like protein containing a caspase recruitment domain (ASC)/caspase-1 inflammasome formation. Overexpression of NLRP3 in cardiomyocytes attenuated the protective effects of AUB. Interestingly, NLRP3 deficiency ameliorated cardiac function and reduced the inflammatory response and oxidative stress after LPS insult in mice, whereas AUB could not further prevent LPS-induced cardiac dysfunction in NLRP3-deficient mice. In summary, AUB exerts a protective effect against LPS-induced inflammation, oxidative stress, and apoptosis in vivo and in vitro by regulating the TXNIP pathway and inactivating the NLRP3/ASC/caspase-1 inflammasome. Hence, AUB may be a promising agent against LPS-induced cardiac dysfunction. SIGNIFICANCE STATEMENT: Aucubin exerts a protective effect against lipopolysaccharide-induced cardiac dysfunction by regulating nucleotide-binding oligomerization domain-like receptor family pyrin domain-containing 3 inflammasome.
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Affiliation(s)
- MingXia Duan
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, PR China (M.-X.D., Y.Y., C.L., Z.C., Q.X., T.H., Q.T., Q.-Q.W.); and Hubei Key Laboratory of Metabolic and Chronic Diseases, Wuhan, PR China (M.-X.D., Y.Y., C.L., Z.C., Q.X., T.H., Q.T., Q.-Q.W.)
| | - Yuan Yuan
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, PR China (M.-X.D., Y.Y., C.L., Z.C., Q.X., T.H., Q.T., Q.-Q.W.); and Hubei Key Laboratory of Metabolic and Chronic Diseases, Wuhan, PR China (M.-X.D., Y.Y., C.L., Z.C., Q.X., T.H., Q.T., Q.-Q.W.)
| | - Chen Liu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, PR China (M.-X.D., Y.Y., C.L., Z.C., Q.X., T.H., Q.T., Q.-Q.W.); and Hubei Key Laboratory of Metabolic and Chronic Diseases, Wuhan, PR China (M.-X.D., Y.Y., C.L., Z.C., Q.X., T.H., Q.T., Q.-Q.W.)
| | - Zhulan Cai
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, PR China (M.-X.D., Y.Y., C.L., Z.C., Q.X., T.H., Q.T., Q.-Q.W.); and Hubei Key Laboratory of Metabolic and Chronic Diseases, Wuhan, PR China (M.-X.D., Y.Y., C.L., Z.C., Q.X., T.H., Q.T., Q.-Q.W.)
| | - Qingwen Xie
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, PR China (M.-X.D., Y.Y., C.L., Z.C., Q.X., T.H., Q.T., Q.-Q.W.); and Hubei Key Laboratory of Metabolic and Chronic Diseases, Wuhan, PR China (M.-X.D., Y.Y., C.L., Z.C., Q.X., T.H., Q.T., Q.-Q.W.)
| | - Tongtong Hu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, PR China (M.-X.D., Y.Y., C.L., Z.C., Q.X., T.H., Q.T., Q.-Q.W.); and Hubei Key Laboratory of Metabolic and Chronic Diseases, Wuhan, PR China (M.-X.D., Y.Y., C.L., Z.C., Q.X., T.H., Q.T., Q.-Q.W.)
| | - Qizhu Tang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, PR China (M.-X.D., Y.Y., C.L., Z.C., Q.X., T.H., Q.T., Q.-Q.W.); and Hubei Key Laboratory of Metabolic and Chronic Diseases, Wuhan, PR China (M.-X.D., Y.Y., C.L., Z.C., Q.X., T.H., Q.T., Q.-Q.W.)
| | - QingQing Wu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, PR China (M.-X.D., Y.Y., C.L., Z.C., Q.X., T.H., Q.T., Q.-Q.W.); and Hubei Key Laboratory of Metabolic and Chronic Diseases, Wuhan, PR China (M.-X.D., Y.Y., C.L., Z.C., Q.X., T.H., Q.T., Q.-Q.W.)
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28
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Abstract
PURPOSE OF REVIEW Critical care echocardiography offers a comprehensive assessment of cardiac anatomy and function performed by the intensivist at point of care. This has resulted in widespread use of critical care echocardiography in ICUs leading to the question if this increased usage has resulted in improved patient outcomes. RECENT FINDINGS Recent studies have evaluated the role of critical care echocardiography in the ICU with an emphasis on establishing accurate diagnosis and measurement of haemodynamic variables. There are no prospective randomized controlled trials that have examined the effect of critical care echocardiography on patient outcomes SUMMARY: Although the effect of critical care echocardiography on patient outcomes has not yet been established, its value as a diagnostic tool has been well demonstrated. We can only assume that its diagnostic capability leads to an improvement in patient outcomes.
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29
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Worapratya P, Wuthisuthimethawee P. Septic shock in the ER: diagnostic and management challenges. OPEN ACCESS EMERGENCY MEDICINE 2019; 11:77-86. [PMID: 31114401 PMCID: PMC6489668 DOI: 10.2147/oaem.s166086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/21/2019] [Indexed: 12/20/2022] Open
Abstract
Sepsis is a common presentation in the emergency department and a common cause of intensive care unit admissions and death. Accurate triage, rapid recognition, early resuscitation, early antibiotics, and eradication of the source of infection are the key components in delivering quality sepsis care. Evaluation of the patient's volume status, optimal hemodynamic resuscitation, and evaluation of patient response is crucial for sepsis management in the emergency department.
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Affiliation(s)
- Panita Worapratya
- Department of Emergency Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Prasit Wuthisuthimethawee
- Department of Emergency Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
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30
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Lanspa MJ, Olsen TD, Wilson EL, Leguyader ML, Hirshberg EL, Anderson JL, Brown SM, Grissom CK. A simplified definition of diastolic function in sepsis, compared against standard definitions. J Intensive Care 2019; 7:14. [PMID: 30820322 PMCID: PMC6381727 DOI: 10.1186/s40560-019-0367-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 01/24/2019] [Indexed: 01/20/2023] Open
Abstract
Background Guidelines for grading diastolic dysfunction poorly categorize septic patients. We compared how well the American Society of Echocardiography (ASE) 2009 and 2016 definitions and a simplified definition categorized septic patients. Methods We studied septic patients who received a transthoracic echocardiogram within 24 h of admission to an ICU. We categorized patients according to ASE 2009 and 2016 definitions and a definition using E/e’, a surrogate for left ventricular filling pressure. We assessed 28-day all-cause mortality and the presence of pre-existing diabetes, hypertension, or myocardial infarction. We tested for associations among diastolic grade, comorbidities, and outcomes using logistic regression. Results We studied 398 patients. Mortality was 23%. The simplified definition categorized more patients than ASE 2016 (78% vs. 71%, p = 0.035); both definitions categorized more patients than ASE 2009 (34%, p < 0.001 for both comparisons). Higher grades of diastolic dysfunction were associated with hypertension (ASE 2016, simplified), myocardial infarction (ASE 2009, simplified), and diabetes (simplified). Grade of diastolic dysfunction was not associated with mortality by any definition. Of 199 patients categorized as normal by ASE 2016, 40% had an abnormal E/e′ > 9 and 7% had a severely abnormal E/e′ > 13. Conclusions The ASE 2016 definition categorizes more septic patients than the ASE 2009 definition, but it does not categorize the diastolic function of a third of septic patients. ASE 2016 designates many patients with elevated E/e′ as normal. A simplified definition categorized patients with less ambiguity and is associated with relevant comorbidities. Electronic supplementary material The online version of this article (10.1186/s40560-019-0367-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael J Lanspa
- 1Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT 84157 USA.,2Division of Pulmonary and Critical Care Medicine, University of Utah, 30 N 1900 E, 701 Wintrobe, Salt Lake City, UT 84132 USA
| | - Troy D Olsen
- 1Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT 84157 USA
| | - Emily L Wilson
- 1Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT 84157 USA
| | - Mary Louise Leguyader
- 3Department of Internal Medicine, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132 USA
| | - Eliotte L Hirshberg
- 1Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT 84157 USA.,2Division of Pulmonary and Critical Care Medicine, University of Utah, 30 N 1900 E, 701 Wintrobe, Salt Lake City, UT 84132 USA.,4Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108 USA
| | - Jeffrey L Anderson
- 5Intermountain Medical Center Heart Institute, 5121 S Cottonwood St, Murray, UT 84157 USA.,6Division of Cardiology, University of Utah, 30 N 1900 E, 701 Wintrobe, Salt Lake City, UT 84132 USA
| | - Samuel M Brown
- 1Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT 84157 USA.,2Division of Pulmonary and Critical Care Medicine, University of Utah, 30 N 1900 E, 701 Wintrobe, Salt Lake City, UT 84132 USA
| | - Colin K Grissom
- 1Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT 84157 USA.,2Division of Pulmonary and Critical Care Medicine, University of Utah, 30 N 1900 E, 701 Wintrobe, Salt Lake City, UT 84132 USA
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31
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Ehrman RR, Sullivan AN, Favot MJ, Sherwin RL, Reynolds CA, Abidov A, Levy PD. Pathophysiology, echocardiographic evaluation, biomarker findings, and prognostic implications of septic cardiomyopathy: a review of the literature. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:112. [PMID: 29724231 PMCID: PMC5934857 DOI: 10.1186/s13054-018-2043-8] [Citation(s) in RCA: 140] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 04/16/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Sepsis is a common condition encountered by emergency and critical care physicians, with significant costs, both economic and human. Myocardial dysfunction in sepsis is a well-recognized but poorly understood phenomenon. There is an extensive body of literature on this subject, yet results are conflicting and no objective definition of septic cardiomyopathy exists, representing a critical knowledge gap. OBJECTIVES In this article, we review the pathophysiology of septic cardiomyopathy, covering the effects of key inflammatory mediators on both the heart and the peripheral vasculature, highlighting the interconnectedness of these two systems. We focus on the extant literature on echocardiographic and laboratory assessment of the heart in sepsis, highlighting gaps therein and suggesting avenues for future research. Implications for treatment are briefly discussed. CONCLUSIONS As a result of conflicting data, echocardiographic measures of left ventricular (systolic or diastolic) or right ventricular function cannot currently provide reliable prognostic information in patients with sepsis. Natriuretic peptides and cardiac troponins are of similarly unclear utility. Heterogeneous classification of illness, treatment variability, and lack of formal diagnostic criteria for septic cardiomyopathy contribute to the conflicting results. Development of formal diagnostic criteria, and use thereof in future studies, may help elucidate the link between cardiac performance and outcomes in patients with sepsis.
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Affiliation(s)
- Robert R Ehrman
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 3R, Detroit, MI, 48201, USA.
| | - Ashley N Sullivan
- Department of Emergency Medicine, Wayne State University School of Medicine, St. John Hospital and Medical Center, 22101 Moross Rd, Detroit, MI, 48236, USA
| | - Mark J Favot
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 3R, Detroit, MI, 48201, USA
| | - Robert L Sherwin
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 3R, Detroit, MI, 48201, USA
| | - Christian A Reynolds
- Department of Emergency Medicine, Cardiovascular Research Institute, Wayne State University School of Medicine, 540 E. Canfield, Detroit, MI, 48201, USA
| | - Aiden Abidov
- Division of Cardiology, Wayne State University School of Medicine, John D. Dingell VA Medical Center, 3990 John R. 4 Hudson, Detroit, MI, 48377, USA
| | - Phillip D Levy
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit Medical Center/Detroit Receiving Hospital, 4201 St. Antoine, Suite 3R, Detroit, MI, 48201, USA
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Vallabhajosyula S, Pruthi S, Shah S, Wiley BM, Mankad SV, Jentzer JC. Basic and advanced echocardiographic evaluation of myocardial dysfunction in sepsis and septic shock. Anaesth Intensive Care 2018; 46:13-24. [PMID: 29361252 DOI: 10.1177/0310057x1804600104] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Sepsis continues to be a leading cause of mortality and morbidity in the intensive care unit. Cardiovascular dysfunction in sepsis is associated with worse short- and long-term outcomes. Sepsis-related myocardial dysfunction is noted in 20%-65% of these patients and manifests as isolated or combined left or right ventricular systolic or diastolic dysfunction. Echocardiography is the most commonly used modality for the diagnosis of sepsis-related myocardial dysfunction. With the increasing use of ultrasonography in the intensive care unit, there is a renewed interest in sepsis-related myocardial dysfunction. This review summarises the current scope of literature focused on sepsis-related myocardial dysfunction and highlights the use of basic and advanced echocardiographic techniques for the diagnosis of sepsis-related myocardial dysfunction and the management of sepsis and septic shock.
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Greenstein YY, Mayo PH. Evaluation of Left Ventricular Diastolic Function by the Intensivist. Chest 2018; 153:723-732. [DOI: 10.1016/j.chest.2017.10.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 10/17/2017] [Accepted: 10/19/2017] [Indexed: 12/15/2022] Open
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Preliminary Exploration of Epidemiologic and Hemodynamic Characteristics of Restrictive Filling Diastolic Dysfunction Based on Echocardiography in Critically Ill Patients: A Retrospective Study. BIOMED RESEARCH INTERNATIONAL 2018; 2018:5429868. [PMID: 29682549 PMCID: PMC5841041 DOI: 10.1155/2018/5429868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 01/07/2018] [Accepted: 01/15/2018] [Indexed: 02/05/2023]
Abstract
Objective To preliminarily describe the epidemiologic and hemodynamic characteristics of critically ill patients with restrictive filling diastolic dysfunction based on echocardiography. Setting A retrospective study. Methods Epidemiologic characteristics of patients with restrictive filling diastolic dysfunction in ICU were described; clinical and hemodynamic data were preliminarily summarized and compared between patients with and without restrictive filling diastolic dysfunction; most of the data were based on echocardiography. Results More than half of the patients in ICU had diastolic dysfunction and about 16% of them had restrictive filling pattern. The patients who had restrictive filling diastolic dysfunction were more likely to have wider diameter of IVC (2.18 ± 0.50 versus 1.92 ± 0.43, P = 0.037), higher extravascular lung water score (15.9 ± 9.2 versus 13.2 ± 9.1, P = 0.014), lower left ventricular ejection fraction (EF-S: 53.0 ± 16.3 versus 59.3 ± 12.5, P = 0.014), and lower percentage of normal LAP that was estimated by E/e′ (8.9% versus 90.0%, P = 0.001) when compared with those of patients without restrictive filling diastolic dysfunction. Conclusion Our results suggest that critically ill patients with restrictive filling diastolic dysfunction may experience rising volume status, increasing extravascular lung water ultrasonic score, reducing long-axis systolic dysfunction, and less possibility of normal left atrial pressure. Intensivists are advised to pay more attention to patients with diastolic dysfunction, especially the exquisite fluid management of patients with restrictive filling pattern due to the close relationship of restrictive filling diastolic dysfunction with volume status and extravascular lung water in our study.
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Clancy DJ, Scully T, Slama M, Huang S, McLean AS, Orde SR. Application of updated guidelines on diastolic dysfunction in patients with severe sepsis and septic shock. Ann Intensive Care 2017; 7:121. [PMID: 29260409 PMCID: PMC5736511 DOI: 10.1186/s13613-017-0342-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 12/07/2017] [Indexed: 12/29/2022] Open
Abstract
Background Left ventricular diastolic dysfunction is suggested to be associated with higher mortality in severe sepsis and septic shock, yet the methods of diagnosis described in the literature are often inconsistent. The recently published 2016 American Society of Echocardiography and European Association of Cardiovascular Imaging (ASE/EACVI) guidelines offer the opportunity to apply a simple pragmatic diagnostic algorithm for the detection of diastolic dysfunction; however, it has not been tested in this cohort. Aims We sought to assess the applicability in septic patients of recently published 2016 ASE/EACVI guidelines on diastolic dysfunction compared with the 2009 ASE guidelines. Our hypothesis was that there would be poor agreement in classifying patients. Methods Prospective observational study includes patients identified as having severe sepsis and septic shock. Patients underwent transthoracic echocardiography on day 1 and day 3 of their ICU admission. Patients with normal and abnormal (ejection fraction < 52%) systolic function had their diastolic function stratified according to both the 2009 ASE and 2016 ASE/EACVI guidelines. Results On day 1 echocardiography, of the 62 patients analysed, 37 (60%) had diastolic dysfunction according to the 2016 ASE/EACVI guideline with a further 23% having indeterminate diastolic function, compared to the 2009 ASE guidelines where only 13 (21%) had confirmed diastolic dysfunction with 46 (74%) having indeterminate diastolic dysfunction. On day 3, of the 55 patients studied, 22 patients (40%) were defined as having diastolic dysfunction, with 6 (11%) having indeterminate diastolic dysfunction according to the 2016 ASE/EACVI guidelines, compared to the 2009 guidelines where 11 (20%) were confirmed to have diastolic dysfunction and 41 (75%) had indeterminate diastolic function. Systolic dysfunction was identified in 18 of 62 patients (29%) on day 1 and 18 of 55 (33%) on day 3. These patients were classified as having abnormal diastolic function in 94 and 89% with the 2016 guidelines on day 1 and day 3, respectively, compared with 50 and 28% using the 2009 guidelines. The 2016 guidelines had less patients with indeterminate diastolic function on days 1 and 3 (11 and 6%) compared to the 2009 guidelines (50 and 72%). Normal systolic function was identified in 44 patients on day 1 and 37 on day 3. In this group, abnormal diastolic function was present in 45 and 54% on days 1 and 3 according to the 2016 ASE/EACVI guidelines, compared with 9 and 16% using the 2009 guidelines, respectively. In those with normal systolic function, the 2016 guidelines had less indeterminate patients with 30 and 16% on days 1 and 3, respectively, compared to 84 and 76% in the 2009 guidelines. Conclusion The 2016 ASE/EACVI diastolic function guidelines identify a significantly higher incidence of dysfunction in patients with severe sepsis and septic shock compared to the previous 2009 guidelines. Although the new guidelines seem to be an improvement, issues remain with the application of guidelines using traditional measures of diastolic dysfunction in this cohort. Electronic supplementary material The online version of this article (10.1186/s13613-017-0342-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | - Michel Slama
- Medical ICU, Amiens University Hospital, Amiens, France
| | - Stephen Huang
- ICU, Nepean Hospital, Kingswood, NSW, 2747, Australia
| | | | - Sam R Orde
- ICU, Nepean Hospital, Kingswood, NSW, 2747, Australia.
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Echocardiography in the Intensive Care Unit. CURRENT CARDIOVASCULAR IMAGING REPORTS 2017. [DOI: 10.1007/s12410-017-9438-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sanfilippo F, Corredor C, Arcadipane A, Landesberg G, Vieillard-Baron A, Cecconi M, Fletcher N. Tissue Doppler assessment of diastolic function and relationship with mortality in critically ill septic patients: a systematic review and meta-analysis. Br J Anaesth 2017; 119:583-594. [DOI: 10.1093/bja/aex254] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
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Ibrahim M, Behairy M, El-Ashry M, Mostafa AE. Cardiovascular risk of circulating endotoxin level in prevalent hemodialysis patients. Egypt Heart J 2017; 70:27-33. [PMID: 29622994 PMCID: PMC5883510 DOI: 10.1016/j.ehj.2017.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 06/13/2017] [Indexed: 02/08/2023] Open
Abstract
Background Cardiovascular diseases (CVDs) are a major cause of morbidity and mortality in patients with end stage renal disease (ESRD). Circulating endotoxins may have toxic effect on myocardial functions and are speculated as pathogens of accelerated atherosclerosis and hemodialysis (HD) patients. Objective We aimed to assess the possible relation between circulating endotoxin levels and left ventricular functions parameters, common carotid artery intimal media thickness (CIMT) in prevalent HD patients. Patients and Methods Forty stable prevalent HD patients with mean age (47.97 ± 14.42) year using regular conventional hemodialysis sessions in Ain shams university hemodialysis unit, Cairo, Egypt were randomly selected. Diabetics, congestive heart failure and those with history of myocardial infarction or coronary artery disease were excluded from the study. All patients were studied by CBC and routine chemistry, as well as hs CRP, Intact PTH, lipid profile and endotoxin level by ELISA before and after the HD session, Delta change of endotoxin (pre dialysis endotoxin-post dialysis endotoxin) was calculated, resting Doppler echocardiographic and carotid duplex. Results Mean of Pre-HD session serum endotoxin level was (0.356 ± 0.090) EU/mL and the mean of post -HD endotoxin levels was (0.367 ± 0.110) EU/mL. Significant positive correlation between post dialysis endotoxin, MV E/A ratio and grades of left ventricular diastolic dysfunction (P < 0.05) and significant correlation between delta change in endotoxin and EF% (r = -0.36,P = 0.02). By stepwise linear regression analysis for determinants of MVE/A post -HD endotoxin level independently associated with MV E/A ratio (ß = 0.350, P = 0.027). We did not detect any significant correlation between CCA atherosclerosis and neither pre nor post- HD endotoxin level nor with delta change of pre and post HD endotoxin levels. Conclusion Acute increase in post dialytic circulating endotoxin level in prevalent HD patients may be associated with both left ventricular systolic and diastolic dysfunction and that attempts to reduce endotoxin level may have a positive impact on cardiovascular complications in HD Patients.
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Affiliation(s)
- Mohamed Ibrahim
- Internal Medicine and Nephrology Department - Ain Shams University, Egypt
| | - Maha Behairy
- Internal Medicine and Nephrology Department - Ain Shams University, Egypt
| | - Marwa El-Ashry
- Clinical and Chemical Pathology Department - Ain Shams University, Egypt
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Detecting impaired myocardial relaxation in sepsis with a novel tissue Doppler parameter (septal e'/s'). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:175. [PMID: 28705247 PMCID: PMC5512826 DOI: 10.1186/s13054-017-1727-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 05/22/2017] [Indexed: 12/19/2022]
Abstract
Background Left ventricular diastolic dysfunction is associated with mortality outcomes in severe sepsis and septic shock. There are ongoing issues with diagnosing diastolic dysfunction in this cohort, partly owing to the poor applicability of traditional parameters in the hyperdynamic circulation. In this feasibility study, we sought to assess the utility of a novel parameter (septal e′/s′) to identify diastolic dysfunction in patients with severe sepsis and septic shock who had normal systolic function against the 2016 American Society Echocardiography and European Association of Cardiovascular Imaging (ASE/EACI) guidelines on diastolic dysfunction. Methods In this prospective observational pilot study, patients identified as having severe sepsis and septic shock underwent transthoracic echocardiography on day 1 and day 3 of their intensive care unit admission. In patients with normal systolic function, septal e′/s′ was calculated using the peak modal velocity of the s′ compared with the e′ from the septal annulus tissue Doppler imaging and compared with their diastolic grade according to the 2016 ASE/EACI guidelines on diastolic dysfunction. Results On day 1 of admission, 44 of 62 patients with severe sepsis and septic shock had normal systolic function. There was a strong association of those with diastolic dysfunction having a reduced septal e′/s′ compared with patients with normal diastolic function (AUC 0.91). A similar relationship was seen with patients who had indeterminate diastolic dysfunction. On day 3, 37 patients had normal systolic function. Again, there was a strong association of those with diastolic dysfunction and a reduced septal e′/s′ (AUC 0.95). Conclusions A reduction in septal e′/s′ may indicate diastolic dysfunction in patients with severe sepsis and septic shock who have normal systolic function. As opposed to limited traditional measures of diastolic dysfunction, it is applicable in those with hyperdynamic systolic function. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1727-9) contains supplementary material, which is available to authorized users.
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Abstract
OBJECTIVES Tachycardia is common in septic shock, but many patients with septic shock are relatively bradycardic. The prevalence, determinants, and implications of relative bradycardia (heart rate, < 80 beats/min) in septic shock are unknown. To determine mortality associated with patients who are relatively bradycardic while in septic shock. DESIGN Retrospective study of patients admitted for septic shock to study ICUs during 2005-2013. SETTING One large academic referral hospital and two community hospitals. PATIENTS Adult patients with septic shock requiring vasopressors. INTERVENTION None. MEASUREMENTS Primary outcome was 28-day mortality. We used multivariate logistic regression to evaluate the association between relative bradycardia and mortality, controlling for confounding with inverse probability treatment weighting using a propensity score. RESULTS We identified 1,554 patients with septic shock, of whom 686 (44%) met criteria for relative bradycardia at some time. Twenty-eight-day mortality in this group was 21% compared to 34% in the never-bradycardic group (p < 0.001). Relatively bradycardic patients were older (65 vs 60 yr; p < 0.001) and had slightly lower illness severity (Sequential Organ Failure Assessment, 10 vs 11; p = 0.004; and Acute Physiology and Chronic Health Evaluation II, 27 vs 28; p = 0.008). After inverse probability treatment weighting, covariates were balanced, and the association between relative bradycardia and survival persisted (p < 0.001). CONCLUSIONS Relative bradycardia in patients with septic shock is associated with lower mortality, even after adjustment for confounding. Our data support expanded investigation into whether inducing relative bradycardia will benefit patients with septic shock.
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Lanspa MJ, Shahul S, Hersh A, Wilson EL, Olsen TD, Hirshberg EL, Grissom CK, Brown SM. Associations among left ventricular systolic function, tachycardia, and cardiac preload in septic patients. Ann Intensive Care 2017; 7:17. [PMID: 28213737 PMCID: PMC5315651 DOI: 10.1186/s13613-017-0240-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 02/01/2017] [Indexed: 01/25/2023] Open
Abstract
Background In sepsis, tachycardia may indicate low preload, adrenergic stimulation, or both. Adrenergic overstimulation is associated with septic cardiomyopathy. We sought to determine whether tachycardia was associated with left ventricular longitudinal strain, a measure of cardiac dysfunction. We hypothesized an association would primarily exist in patients with high preload. Methods We prospectively observed septic patients admitted to three study ICUs, who underwent early transthoracic echocardiography. We measured longitudinal strain using speckle tracking echocardiography and estimated preload status with an echocardiographic surrogate (E/e′). We assessed correlation between strain and heart rate in patients with low preload (E/e′ < 8), intermediate preload (E/e′ 8–14), and high preload (E/e′ > 14), adjusting for disease severity and vasopressor dependence. Results We studied 452 patients, of whom 298 had both measurable strain and preload. Abnormal strain (defined as >−17%) was present in 54%. Patients with abnormal strain had higher heart rates (100 vs. 93 beat/min, p = 0.001). After adjusting for vasopressor dependence, disease severity, and cardiac preload, we observed an association between heart rate and longitudinal strain (β = 0.05, p = 0.003). This association persisted among patients with high preload (β = 0.07, p = 0.016) and in patients with shock (β = 0.07, p = 0.01), but was absent in patients with low or intermediate preload and those not in shock. Conclusions Tachycardia is associated with abnormal left ventricular strain in septic patients with high preload. This association was not apparent in patients with low or intermediate preload. Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0240-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael J Lanspa
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT, 84157, USA. .,Division of Pulmonary and Critical Care Medicine, University of Utah, 30 N 1900 E, 701 Wintrobe, Salt Lake City, UT, 84132, USA.
| | - Sajid Shahul
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Anesthesia and Critical Care, University of Chicago, 5841 South Maryland Avenue, Chicago, IL, 60637, USA
| | - Andrew Hersh
- Division of Pulmonary and Critical Care Medicine, University of Utah, 30 N 1900 E, 701 Wintrobe, Salt Lake City, UT, 84132, USA
| | - Emily L Wilson
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT, 84157, USA
| | - Troy D Olsen
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT, 84157, USA
| | - Eliotte L Hirshberg
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT, 84157, USA.,Division of Pulmonary and Critical Care Medicine, University of Utah, 30 N 1900 E, 701 Wintrobe, Salt Lake City, UT, 84132, USA.,Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Colin K Grissom
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT, 84157, USA.,Division of Pulmonary and Critical Care Medicine, University of Utah, 30 N 1900 E, 701 Wintrobe, Salt Lake City, UT, 84132, USA
| | - Samuel M Brown
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT, 84157, USA.,Division of Pulmonary and Critical Care Medicine, University of Utah, 30 N 1900 E, 701 Wintrobe, Salt Lake City, UT, 84132, USA
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Focused cardiac ultrasound in the early resuscitation of severe sepsis and septic shock: a prospective pilot study. J Anesth 2017; 31:487-493. [PMID: 28144779 DOI: 10.1007/s00540-017-2312-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 01/20/2017] [Indexed: 12/29/2022]
Abstract
PURPOSE Point-of-care ultrasonography has been increasingly used in the care of critically ill patients; however, reports on its use during active resuscitation are limited. The aim of this study was to investigate the true impact of focused cardiac ultrasound (FCU) during the management of sepsis with early (6-h) resuscitation. METHODS A prospective pilot observational study was conducted at an academic medical center from March 2011 through July 2012. Patients undergoing resuscitation for severe sepsis or septic shock were prospectively enrolled at medical and combined medical-surgical intensive care units. Patients underwent a 10-min FCU examination when echocardiography was not part of their care plan. FCU was performed by sonographers and interpreted by cardiologists to minimize risks of inadequate image acquisition and misinterpretation. Intensivists completed surveys on their diagnostic and therapeutic plans before and after receiving FCU information. RESULTS Of the 30 patients enrolled, 18 (60%) were male and the median age was 61 years [interquartile range (IQR) 50-71 years]. Median central venous oxygen saturation and lactate levels were 59.6% (IQR 53.1-66.2%) and 2.7 mmol/L (IQR 1.2-4.1 mmol/L), respectively. Clinical assessment by intensivists before FCU commonly failed to correctly estimate ventricular function; specifically, left ventricular in 12 patients [40%, 95% confidence interval (CI) 25-58%] and right ventricular function in 15 patients (50%, 95% CI 33-67%). Intensivists' therapeutic plans changed in eight cases (27%, 95% CI 14-44%) after FCU information became available. The most common changes were fluid management and imaging tests. Intensivists' confidence in their therapeutic plans improved for 11 patients (37%, 95% CI 22-55%). CONCLUSION FCU is a valuable examination tool during early resuscitation of severe sepsis and septic shock.
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Abstract
Since its original description in 1832, fluid resuscitation has become the cornerstone of early and aggressive treatment of severe sepsis and septic shock. However, questions remain about optimal fluid composition, dose, and rate of administration for critically ill patients. This article reviews pertinent physiology of the circulatory system, pathogenesis of septic shock, and phases of sepsis resuscitation, and then focuses on the type, rate, and amount of fluid administration for severe sepsis and septic shock, so providers can choose the right fluid, for the right patient, at the right time.
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Affiliation(s)
- Rob Loflin
- University of Rochester Medical Center, Rochester, NY, USA
| | - Michael E Winters
- Critical Care Program, Internal Medicine, Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
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Vallabhajosyula S, Gillespie SM, Barbara DW, Anavekar NS, Pulido JN. Impact of New-Onset Left Ventricular Dysfunction on Outcomes in Mechanically Ventilated Patients With Severe Sepsis and Septic Shock. J Intensive Care Med 2016; 33:680-686. [PMID: 28553776 DOI: 10.1177/0885066616684774] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND: Left ventricular systolic dysfunction (LVSD) and LV diastolic dysfunction (LVDD) are commonly seen in severe sepsis and septic shock; however, their role in patients with concurrent invasive mechanical ventilation (IMV) is less well defined. METHODS: This was a prospective observational study on all patients admitted to all the intensive care units (ICUs) at Mayo Clinic, Rochester from August 2007 to January 2009. All adult patients with severe sepsis and septic shock and concurrent IMV without prior heart failure underwent transthoracic echocardiography within 24 hours. Patients with active pregnancy, prior congenital or valvular heart disease, and prosthetic cardiac valves were excluded. Left ventricular systolic dysfunction was defined as LV ejection fraction (LVEF) <50% and LVDD as E/e' >15. Primary outcome was hospital mortality, and secondary outcomes included IMV duration, ICU length of stay (LOS), and total LOS. Two-tailed P value of <.05 was considered statistically significant. RESULTS: In a total of 106 patients, 58 (54.7%) met our inclusion criteria, with 17 (29.3%), 11 (19.0%), and 5 (8.6%) having LVSD, LVDD, and both, respectively. The cohorts with and without LVSD and LVDD did not differ significantly in their baseline characteristics and laboratory and ventilatory parameters. Compared to those without LVSD, patients with LVSD had higher LV end-systolic diameters but were not different in their left atrial diameters or E/e' ratio. Patients with LVDD had a higher E velocity and E/e' ratio compared to those without LVDD. Hospital mortality was not different in patients with and without LVSD (8 [47%] vs 21 [51%], P = 1.00) and LVDD (8 [73%] vs 21 [45%], P = .18). Secondary outcomes were not different between the 2 groups. CONCLUSION: Left ventricular systolic or diastolic dysfunction did not influence in-hospital outcomes in patients with severe sepsis and septic shock and concurrent IMV.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- 1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.,2 Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Shane M Gillespie
- 3 Divisions of Cardiothoracic and Critical Care Anesthesiology, Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - David W Barbara
- 3 Divisions of Cardiothoracic and Critical Care Anesthesiology, Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Nandan S Anavekar
- 4 Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.,5 Division of Cardiac Radiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Juan N Pulido
- 6 Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Swedish Heart and Vascular Institute, Seattle, WA, USA
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Dantas VCDS, Costa ELV. A look at the diastolic function in severe sepsis and septic shock. Rev Bras Ter Intensiva 2016; 27:307-8. [PMID: 26761465 PMCID: PMC4738813 DOI: 10.5935/0103-507x.20150052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Nizamuddin J, Mahmood F, Tung A, Mueller A, Brown SM, Shaefi S, O'Connor M, Talmor D, Shahul S. Interval Changes in Myocardial Performance Index Predict Outcome in Severe Sepsis. J Cardiothorac Vasc Anesth 2016; 31:957-964. [PMID: 28094172 DOI: 10.1053/j.jvca.2016.11.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Septic cardiomyopathy is a well-described consequence of septic shock and is associated with increased sepsis-related mortality. The myocardial performance index (MPI), a parameter derived from echocardiographic tissue Doppler measurements, allows for a more sensitive assessment of global cardiac function than do traditional metrics for cardiac function. The authors hypothesized that changes in left ventricular MPI in patients with severe sepsis would be associated with a higher 90-day mortality. DESIGN Prospective, observational study. SETTING Intensive care units of a tertiary medical center. PARTICIPANTS The study comprised 47 patients admitted with new diagnoses of severe sepsis or septic shock. INTERVENTIONS All patients underwent transthoracic echocardiograms with assessment of MPI at enrollment and 24 hours later. Hemodynamic data and information on sepsis-related mortality were collected. In the primary analysis, the association between change in MPI from enrollment to 24 hours and sepsis-related 90-day mortality was assessed. MEASUREMENTS AND MAIN RESULTS Of the 47 patients enrolled, 30 demonstrated an improvement in MPI from 0 to 24 hours ("improved" group), and MPI worsened in the remaining 17 patients ("worsened" group). Despite no significant differences in ejection fraction or severity of illness, the median MPI at enrollment in the "improved" group was higher than baseline values in the "worsened" group (p = 0.005). A worsening MPI over the 24-hour study interval was associated with increased mortality at 90 days (p = 0.04), which remained significant (hazard ratio 3.72; 95% confidence interval 1.12-12.41; p = 0.03) after adjusting for severity of illness (Acute Physiology and Chronic Health Evaluation II score), intravenous fluids, and vasopressor use. CONCLUSIONS In patients admitted to the intensive care unit with a diagnosis of severe sepsis or septic shock, a worsening MPI during the first 24 hours after intensive care unit admission was associated with higher 90-day mortality.
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Affiliation(s)
- Junaid Nizamuddin
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Feroze Mahmood
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Avery Tung
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Ariel Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Samuel M Brown
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, University of Utah School of Medicine, Salt Lake City, UT
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Michael O'Connor
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sajid Shahul
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL.
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Makara MA, Hoang KV, Ganesan LP, Crouser ED, Gunn JS, Turner J, Schlesinger LS, Mohler PJ, Rajaram MVS. Cardiac Electrical and Structural Changes During Bacterial Infection: An Instructive Model to Study Cardiac Dysfunction in Sepsis. J Am Heart Assoc 2016; 5:e003820. [PMID: 27620887 PMCID: PMC5079037 DOI: 10.1161/jaha.116.003820] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 08/18/2016] [Indexed: 01/14/2023]
Abstract
BACKGROUND Sepsis patients with cardiac dysfunction have significantly higher mortality. Although several pathways are associated with myocardial damage in sepsis, the precise cause(s) remains unclear and treatment options are limited. This study was designed to develop a new model to investigate the early events of cardiac damage during sepsis progression. METHODS AND RESULTS Francisella tularensis subspecies novicida (Ft.n) is a Gram-negative intracellular pathogen causing severe sepsis syndrome in mice. BALB/c mice (N=12) were sham treated or infected with Ft.n through the intranasal route. Serial electrocardiograms were recorded at multiple time points until 96 hours. Hearts were then harvested for histology and gene expression studies. Similar to septic patients, we illustrate both cardiac electrical and structural phenotypes in our murine Ft.n infection model, including prominent R' wave formation, prolonged QRS intervals, and significant left ventricular dysfunction. Notably, in infected animals, we detected numerous microlesions in the myocardium, previously observed following nosocomial Streptococcus infection and in sepsis patients. We show that Ft.n-mediated microlesions are attributed to cardiomyocyte apoptosis, increased immune cell infiltration, and expression of inflammatory mediators (tumor necrosis factor, interleukin [IL]-1β, IL-8, and superoxide dismutase 2). Finally, we identify increased expression of microRNA-155 and rapid degradation of heat shock factor 1 following cardiac Ft.n infection as a primary cause of myocardial inflammation and apoptosis. CONCLUSIONS We have developed and characterized an Ft.n infection model to understand the pathogenesis of cardiac dysregulation in sepsis. Our findings illustrate novel in vivo phenotypes underlying cardiac dysfunction during Ft.n infection with significant translational impact on our understanding of sepsis pathophysiology.
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Affiliation(s)
- Michael A Makara
- Department of Physiology and Cell Biology, Dorothy M. Davis Heart and Lung Institute, Wexner Medical Center, College of Medicine, The Ohio State University, Columbus, OH
| | - Ky V Hoang
- Department of Microbial Infection and Immunity, Center for Microbial Interface Biology, Wexner Medical Center, College of Medicine, The Ohio State University, Columbus, OH
| | - Latha P Ganesan
- Department of Physiology and Cell Biology, Dorothy M. Davis Heart and Lung Institute, Wexner Medical Center, College of Medicine, The Ohio State University, Columbus, OH
| | - Elliot D Crouser
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Internal Medicine, Wexner Medical Center, College of Medicine, The Ohio State University, Columbus, OH
| | - John S Gunn
- Department of Microbial Infection and Immunity, Center for Microbial Interface Biology, Wexner Medical Center, College of Medicine, The Ohio State University, Columbus, OH
| | - Joanne Turner
- Department of Microbial Infection and Immunity, Center for Microbial Interface Biology, Wexner Medical Center, College of Medicine, The Ohio State University, Columbus, OH
| | - Larry S Schlesinger
- Department of Microbial Infection and Immunity, Center for Microbial Interface Biology, Wexner Medical Center, College of Medicine, The Ohio State University, Columbus, OH
| | - Peter J Mohler
- Department of Physiology and Cell Biology, Dorothy M. Davis Heart and Lung Institute, Wexner Medical Center, College of Medicine, The Ohio State University, Columbus, OH
| | - Murugesan V S Rajaram
- Department of Microbial Infection and Immunity, Center for Microbial Interface Biology, Wexner Medical Center, College of Medicine, The Ohio State University, Columbus, OH
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Suárez JC, López P, Mancebo J, Zapata L. Diastolic dysfunction in the critically ill patient. Med Intensiva 2016; 40:499-510. [PMID: 27569679 DOI: 10.1016/j.medin.2016.06.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 06/14/2016] [Accepted: 06/20/2016] [Indexed: 12/16/2022]
Abstract
Left ventricular diastolic dysfunction is a common finding in critically ill patients. It is characterized by a progressive deterioration of the relaxation and the compliance of the left ventricle. Two-dimensional and Doppler echocardiography is a cornerstone in its diagnosis. Acute pulmonary edema associated with hypertensive crisis is the most frequent presentation of diastolic dysfunction critically ill patients. Myocardial ischemia, sepsis and weaning failure from mechanical ventilation also may be associated with diastolic dysfunction. The treatment is based on the reduction of pulmonary congestion and left ventricular filling pressures. Some studies have found a prognostic role of diastolic dysfunction in some diseases such as sepsis. The present review aims to analyze thoroughly the echocardiographic diagnosis and the most frequent scenarios in critically ill patients in whom diastolic dysfunction plays a key role.
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Affiliation(s)
- J C Suárez
- Servicio de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Calle de Sant Quintí, 89, 08026 Barcelona, Spain
| | - P López
- Servicio de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Calle de Sant Quintí, 89, 08026 Barcelona, Spain
| | - J Mancebo
- Servicio de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Calle de Sant Quintí, 89, 08026 Barcelona, Spain
| | - L Zapata
- Servicio de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Calle de Sant Quintí, 89, 08026 Barcelona, Spain.
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