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Cavefors O, Ljung Faxén U, Bech-Hanssen O, Lundin S, Ricksten SE, Redfors B, Oras J. Isolated diastolic dysfunction is associated with increased mortality in critically ill patients. J Crit Care 2023; 76:154290. [PMID: 36947970 DOI: 10.1016/j.jcrc.2023.154290] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 02/18/2023] [Accepted: 03/08/2023] [Indexed: 03/22/2023]
Abstract
PURPOSE Left ventricular (LV) diastolic dysfunction is important in critically ill patients, but prevalence and impact on mortality is not well studied. We classified intensive care patients with normal left ventricular function according to current diastolic guidelines and explored associations with mortality. MATERIAL AND METHODS Echocardiography was performed within 24 h of intensive care admission. Patients with reduced LV ejection fraction, regional wall motion abnormality, or a history of cardiac disease were excluded. Patients were classified according to the 2016 EACVI guidelines, Recommendations for the Evaluation of LV Diastolic Function by Echocardiography. RESULTS Out of 218 patients, 162 (74%) had normal diastolic function, 21 (10%) had diastolic dysfunction, and 35 (17%) had indeterminate diastolic function. Diastolic dysfunction were more common in female patients, older patients and associated with sepsis, respiratory and cardiovascular comorbidity as well as higher SAPS Score. In a risk-adjusted logistic regression model, patients with indeterminate diastolic dysfunction (OR 4.3 [1.6-11.4], p = 0.004) or diastolic dysfunction (OR 5.1 [1.6-16.5], p = 0.006) had an increased risk of death at 90 days compared to patients with normal diastolic function. CONCLUSION Isolated diastolic dysfunction, assessed by a multi-parameter approach, is common in critically ill patients and is associated with mortality. TRIAL REGISTRATION Secondary analysis of data from a single-center prospective observational study focused on systolic dysfunction in intensive care unit patients (Clinical Trials ID: NCT03787810.
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Affiliation(s)
- Oscar Cavefors
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Ulrika Ljung Faxén
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden; Department of Medicine, Cardiology Unit, Karolinska Institutet, Stockholm, Sweden
| | - Odd Bech-Hanssen
- Department of Clinical Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Stefan Lundin
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sven-Erik Ricksten
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jonatan Oras
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Sturgess DJ, Morrison S, Haluska B, Gobe GC, Jones MA, Volante S, Venkatesh B. Left Ventricular Impaired Relaxation and Interstitial Myocarditis Identified in Sepsis-Associated Cardiac Dysfunction: Use of a Rodent Model. Med Sci Monit 2021; 27:e929512. [PMID: 33866323 PMCID: PMC8061308 DOI: 10.12659/msm.929512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Sepsis is a serious clinical problem that results from the systemic response of the body to infection. Left ventricular (LV) diastolic dysfunction is increasingly appreciated as a contributor to morbidity and mortality in sepsis. Animal models may offer a method of studying diastolic dysfunction while controlling for many potential clinical confounders, such as sepsis duration, premorbid condition, and therapeutic interventions. This study sought to evaluate an endotoxemia (LPS) rodent model of sepsis, with regard to echocardiographic evidence, including tissue Doppler, of LV diastolic dysfunction and histopathology findings. MATERIAL AND METHODS Fourteen male Sprague-Dawley rats were randomly allocated (1: 1) to LPS or saline (control). Mean arterial blood pressure (MAP) was measured through cannulation of the carotid artery. After a 30-min stabilization, baseline assessment with echocardiography and blood collection was performed. Rats were administered 0.9% saline or LPS (10 mg/mL). Follow-up echocardiography and blood collection were performed after 2 h. Hearts were removed post-mortem and pathology studied using histology and immunohistochemistry. RESULTS LPS was associated with hypotension (MAP 81.86±31.67 mmHg; 124.29±20.16; p=0.02) and LV impaired relaxation (myocardial early diastolic velocity [e'] 0.06±0.02 m/s; 0.09±0.02; P=0.008). Histopathology and immunohistochemistry demonstrated evidence of interstitial myocarditis (hydropic changes and inflammation). CONCLUSIONS LPS was associated with both diastolic dysfunction (impaired relaxation) and interstitial myocarditis. These features may offer a link between the structural and functional changes that have previously been described separately in clinical sepsis. This may facilitate further studies focused upon the mechanism and potential benefit treatment of sepsis-associated cardiac dysfunction.
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Affiliation(s)
- David J Sturgess
- Mater Research Institute (MRI-UQ), University of Queensland, Brisbane, Queensland, Australia
| | - Shannon Morrison
- Mater Research Institute (MRI-UQ), University of Queensland, Brisbane, Queensland, Australia
| | - Brian Haluska
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Glenda C Gobe
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Kidney Disease Research Collaborative, University of Queensland, Brisbane, Queensland, Australia
| | - Mark A Jones
- School of Public Health, University of Queensland, Brisbane, Queensland, Australia
| | - Sonia Volante
- Mater Research Institute (MRI-UQ), University of Queensland, Brisbane, Queensland, Australia
| | - Bala Venkatesh
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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3
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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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4
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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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5
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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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Lanspa MJ, Gutsche AR, Wilson EL, Olsen TD, Hirshberg EL, Knox DB, Brown SM, Grissom CK. Application of a simplified definition of diastolic function in severe sepsis and septic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:243. [PMID: 27487776 PMCID: PMC4973099 DOI: 10.1186/s13054-016-1421-3] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 07/20/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Left ventricular diastolic dysfunction is common in patients with severe sepsis or septic shock, but the best approach to categorization is unknown. We assessed the association of common measures of diastolic function with clinical outcomes and tested the utility of a simplified definition of diastolic dysfunction against the American Society of Echocardiography (ASE) 2009 definition. METHODS In this prospective observational study, patients with severe sepsis or septic shock underwent transthoracic echocardiography within 24 h of onset of sepsis (median 4.3 h). We measured echocardiographic parameters of diastolic function and used random forest analysis to assess their association with clinical outcomes (28-day mortality and ICU-free days to day 28) and thereby suggest a simplified definition. We then compared patients categorized by the ASE 2009 definition and our simplified definition. RESULTS We studied 167 patients. The ASE 2009 definition categorized only 35 % of patients. Random forest analysis demonstrated that the left atrial volume index and deceleration time, central to the ASE 2009 definition, were not associated with clinical outcomes. Our simplified definition used only e' and E/e', omitting the other measurements. The simplified definition categorized 87 % of patients. Patients categorized by either ASE 2009 or our novel definition had similar clinical outcomes. In both definitions, worsened diastolic function was associated with increased prevalence of ischemic heart disease, diabetes, and hypertension. CONCLUSIONS A novel, simplified definition of diastolic dysfunction categorized more patients with sepsis than ASE 2009 definition. Patients categorized according to the simplified definition did not differ from patients categorized according to the ASE 2009 definition in respect to clinical outcome or comorbidities.
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Affiliation(s)
- Michael J Lanspa
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT, 84157, USA. .,Division of Pulmonary and Critical Care Medicine, University of Utah, 30 North 1900 East, 701 Wintrobe Building, Salt Lake City, UT, 84132, USA.
| | - Andrea R Gutsche
- Department of Anesthesiology, University of Utah, 30 North 1900 East, 701 Wintrobe, Salt Lake City, UT, 84132, USA
| | - Emily L Wilson
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT, 84157, USA
| | - Troy D Olsen
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT, 84157, USA
| | - Eliotte L Hirshberg
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT, 84157, USA.,Division of Pulmonary and Critical Care Medicine, University of Utah, 30 North 1900 East, 701 Wintrobe Building, 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
| | - Daniel B Knox
- Division of Pulmonary and Critical Care Medicine, University of Utah, 30 North 1900 East, 701 Wintrobe Building, Salt Lake City, UT, 84132, USA.,Division of Pulmonary, Allergy, and Critical Care Medicine, University of Massachusetts, 55 Lake Avenue North, Worchester, MA, 01655, USA
| | - Samuel M Brown
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT, 84157, USA.,Division of Pulmonary and Critical Care Medicine, University of Utah, 30 North 1900 East, 701 Wintrobe Building, Salt Lake City, UT, 84132, USA
| | - Colin K Grissom
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT, 84157, USA.,Division of Pulmonary and Critical Care Medicine, University of Utah, 30 North 1900 East, 701 Wintrobe Building, Salt Lake City, UT, 84132, USA
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7
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Garry D, Newton J, Colebourn C. Tissue Doppler indices of diastolic function in critically ill patients and association with mortality - a systematic review. J Intensive Care Soc 2015; 17:51-62. [PMID: 28979458 DOI: 10.1177/1751143715595641] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Systolic impairment is well reported in critically ill patients but diastolic function has been relatively understudied. The objective of this review was to assess tissue Doppler indices of diastolic function in critically ill patients along with any association with mortality. METHODS A systematic review of articles in English using Medline, EMBASE, CINAHL and the Cochrane database of systematic reviews. Search terms included diastolic function, diastolic dysfunction, diastolic abnormal*, diastolic heart failure, diastolic filling, ventricular relaxation, pulmonary artery occlusion pressure, left ventricular filling pressure, cardiac dysfunction, intensive care, critical care, critically ill, critical illness, sepsis and septic shock. Only studies of critically ill adult patients (excluding post-cardiac surgical patients) whose diastolic function was assessed using tissue Doppler imaging were included. Study quality was assessed using a modified version of the Newcastle-Ottawa Scale (NOS). RESULTS Nineteen studies were included, with a total of 1365 patients. All trials were observational. There was a large heterogeneity in patient populations and the methodology of tissue Doppler assessment of diastology resulting in a descriptive analysis. Patient groups included severe sepsis or septic shock (5 studies), septic shock (5 studies), systemic inflammatory response syndrome and shock (1 study), septic shock and acute lung injury (1 study), cancer and septic shock (2 studies), general ICU patients (1 study), combined medical and surgical ICU (2 studies) and sub-arachnoid haemorrhage patients (2 studies). Seventeen studies scored 5/6 on the NOS with the remaining two scoring 4/6. Fourteen studies reported on numbers of patients diagnosed with diastolic dysfunction (500/999, mean 50%, range 20-92%). Three studies found that diastolic dysfunction was an independent predictor of mortality. CONCLUSIONS Current data shows a large range in the incidence of diastolic dysfunction in this patient population and a variable link with mortality. Future research should focus on the definition of normal values for diastolic function in critically ill patients along with the effects of ICU therapies and consensus criteria for its assessment in this patient population.
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Affiliation(s)
- David Garry
- Department of Anaesthetics, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Jim Newton
- Department of Cardiology, OUH NHS Trust, Oxford, UK
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Dalla K, Hallman C, Bech-Hanssen O, Haney M, Ricksten SE. Strain echocardiography identifies impaired longitudinal systolic function in patients with septic shock and preserved ejection fraction. Cardiovasc Ultrasound 2015; 13:30. [PMID: 26134971 PMCID: PMC4487964 DOI: 10.1186/s12947-015-0025-4] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 06/25/2015] [Indexed: 01/22/2023] Open
Abstract
Background Myocardial dysfunction is recognized in sepsis. We hypothesized that mechanical left (LV) and right (RV) ventricular function analysed using 2-dimensional speckle-tracking echocardiography in a cohort of early severe sepsis or septic shock patients, would be different to that of a group of critically ill, non-septic patients. Methods Critically ill adult patients with early, severe sepsis/septic shock (n = 48) and major trauma patients with no sepsis (n = 24) were included retrospectively, as well as healthy controls (n = 16). Standard echocardiographic examinations, including right (RV) left (LV) volumes and mitral, aortic and pulmonary vein Doppler flow profiles, were retrospectively identified and the studies were then reanalysed for assessment of myocardial strain using speckle-tracking echocardiography. Endocardial tracing of the LV was performed in apical four-chamber (4-Ch), two-chamber (2-Ch), apical long-axis (3-Ch) and apical views of RV determining the longitudinal LV and RV free wall strain in each subject. Results In septic patients, heart rate was significantly higher (p = 0.009) and systolic (p < 0.001) and mean arterial pressures (p < 0.001), as well as systemic vascular resistance (p < 0.001) were significantly lower when compared to the non-septic trauma group. Ninety-three per cent of the septic patients and 50 % of the trauma patients were treated with norepinephrine (p < 0.001). LV ejection fraction (LVEF) was lower in the septic patients (p = 0.019). In septic patients with preserved LVEF (>50 %, n = 34), seventeen patients (50 %) had a depressed LV global longitudinal function, defined as a LV global strain > −15 %, compared to two patients (8.7 %) in the non-septic group (p = 0.0014). In septic patients with preserved LVEF, LV global and RV free wall strain were 14 % (p = 0.014) and 17 % lower (p = 0.008), respectively, compared to the non-septic group with preserved LVEF. There were no significant differences between groups with respect to LV end-diastolic or end-systolic volumes, stroke volume, or cardiac output. There were no signs of diastolic dysfunction from the mitral or pulmonary vein Doppler profiles in the septic patients. Conclusions LV and RV systolic function is impaired in critically ill patients with early septic shock and preserved LVEF, as detected by Speckle-tracking 2D echocardiography. Strain imaging may be useful in the early detection of myocardial dysfunction in sepsis. Electronic supplementary material The online version of this article (doi:10.1186/s12947-015-0025-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Keti Dalla
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Caroline Hallman
- Department of Clinical Physiology, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Odd Bech-Hanssen
- Department of Clinical Physiology, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Michael Haney
- Department of Anaesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden.
| | - Sven-Erik Ricksten
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Coronary flow reserve is associated with tissue ischemia and is an additive predictor of intensive care unit mortality to traditional risk scores in septic shock. Int J Cardiol 2014; 172:103-8. [PMID: 24447732 DOI: 10.1016/j.ijcard.2013.12.155] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Revised: 10/31/2013] [Accepted: 12/26/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Reduced coronary velocity flow reserve (CFR) is associated with poor outcome in patients with cardiovascular disease. We investigated whether CFR is associated with tissue ischemia and acidosis, impaired myocardial deformation and adverse outcome in patients with septic shock. METHODS In 70 mechanically-ventilated patients with septic shock, we examined: a) S' and E' mitral annular velocities using tissue Doppler imaging (TDI), b) CFR of the left anterior descending artery after adenosine infusion using transesophageal Doppler echocardiography and c) lactate, pyruvate and glycerol in tissue by means of a microdialysis (MD) catheter inserted into the subcutaneous adipose tissue as markers of tissue ischemia and acidosis. SOFA and APACHE II prognostic scores and mortality in the intensive care unit (ICU) were recorded. RESULTS Reduced CFR, S' and E' as well as increased E/E' correlated with increased SOFA, APACHE II and MD lactate to pyruvate ratio (p<0.05 for all correlations). Impaired TDI markers also correlated with increased MD glycerol (p<0.05). Reduced CFR correlated with decreased E' (p<0.05). CFR was 1.8 ± 0.42 in non-survivors (n=34) versus 2.08 ± 0.44 in survivors (p=0.007). A CFR<1.90 predicted mortality with sensitivity of 70% and specificity of 69% (area under the curve 77%; p=0.003). CFR had an additive value to APACHE (chi-square change: 4.358, p=0.03) and SOFA (chi-square change: 3.692, p=0.04) for the prediction of mortality. CONCLUSION Tissue ischemia and acidosis is a common pathophysiological link between decreased CFR and impaired LV myocardial deformation in septic shock. CFR is an additive predictor of ICU mortality to traditional risk scores in septic shock.
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Lichtenstein D, Karakitsos D. Integrating lung ultrasound in the hemodynamic evaluation of acute circulatory failure (the fluid administration limited by lung sonography protocol). J Crit Care 2012; 27:533.e11-9. [DOI: 10.1016/j.jcrc.2012.03.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Revised: 03/05/2012] [Accepted: 03/12/2012] [Indexed: 01/10/2023]
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11
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Bergenzaun L, Ohlin H, Gudmundsson P, Düring J, Willenheimer R, Chew MS. High-sensitive cardiac Troponin T is superior to echocardiography in predicting 1-year mortality in patients with SIRS and shock in intensive care. BMC Anesthesiol 2012; 12:25. [PMID: 23006477 PMCID: PMC3524030 DOI: 10.1186/1471-2253-12-25] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Accepted: 09/17/2012] [Indexed: 01/31/2023] Open
Abstract
Background Left ventricular (LV) dysfunction is well documented in the critically ill. We assessed 1-year mortality in relation to cardiac biomarkers and LV function parameters by echocardiography in patients with shock. Methods A prospective, observational, cohort study of 49 patients. B-natriuretic peptide (BNP), high-sensitive troponin T (hsTNT) and transthoracic echocardiography (TTE) were assessed within 12 h of study inclusion. LV systolic function was measured by ejection fraction (LVEF), mean atrioventricular plane displacement (AVPDm), peak systolic tissue Doppler velocity imaging (TDIs) and velocity time integral in the LV outflow tract (LVOT VTI). LV diastolic function was evaluated by transmitral pulsed Doppler (E, A, E/A, E-deceleration time), tissue Doppler indices (é, á, E/é) and left atrial volume (La volume). APACHE II (Acute Physiology and Chronic Health Evaluation) and SOFA (Sequential Organ Failure Assessment) scores were calculated. Results hsTNT was significantly higher in non-survivors than in survivors (60 [17.0-99.5] vs 168 [89.8-358] ng/l, p = 0.003). Other univariate predictors of mortality were APACHE II (p = 0.009), E/é (p = 0.023), SOFA (p = 0.024) and age (p = 0.031). Survivors and non-survivors did not differ regarding BNP (p = 0.26) or any LV systolic function parameter (LVEF p = 0.87, AVPDm p = 0.087, TDIs p = 0.93, LVOT VTI p = 0.18). Multivariable logistic regression analysis identified hsTNT (p = 0.010) as the only independent predictor of 1-year mortality; adjusted odds ratio 2.0 (95% CI 1.2- 3.5). Conclusions hsTNT was the only independent predictor of 1-year mortality in patients with shock. Neither BNP nor echocardiographic parameters had an independent prognostic value. Further studies are needed to establish the clinical significance of elevated hsTNT in patients in shock.
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Affiliation(s)
- Lill Bergenzaun
- Department of Anaesthesiology and Intensive Care, Institution of Clinical Sciences, Skåne University Hospital, Lund University, Inga Marie Nilssons gata 47, S-20502 , Malmö, Sweden.
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Brown SM, Pittman JE, Hirshberg EL, Jones JP, Lanspa MJ, Kuttler KG, Litwin SE, Grissom CK. Diastolic dysfunction and mortality in early severe sepsis and septic shock: a prospective, observational echocardiography study. Crit Ultrasound J 2012; 4:8. [PMID: 22870900 PMCID: PMC3512479 DOI: 10.1186/2036-7902-4-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 04/04/2012] [Indexed: 01/07/2023] Open
Abstract
Background Patients with severe sepsis or septic shock often exhibit significant cardiovascular dysfunction. We sought to determine whether severity of diastolic dysfunction assessed by transthoracic echocardiography (TTE) predicts 28-day mortality. Methods In this prospective, observational study conducted in two intensive care units at a tertiary care hospital, 78 patients (age 53.2 ± 17.1 years; 51% females; mean APACHE II score 23.3 ± 7.4) with severe sepsis or septic shock underwent TTE within 6 h of ICU admission, after 18 to 32 h, and after resolution of shock. Left ventricular (LV) diastolic dysfunction was defined according to modified American Society of Echocardiography 2009 guidelines using E, A, and e’ velocities; E/A and E/e’; and E deceleration time. Systolic dysfunction was defined as an ejection fraction < 45%. Results Twenty-seven patients (36.5%) had diastolic dysfunction on initial echocardiogram, while 47 patients (61.8%) had diastolic dysfunction on at least one echocardiogram. Total mortality was 16.5%. The highest mortality (37.5%) was observed among patients with grade I diastolic dysfunction, an effect that persisted after controlling for age and APACHE II score. At time of initial TTE, central venous pressure (CVP) (11+/- 5 mmHg) did not differ among grades I-III, although patients with grade I received less intravenous fluid. Conclusions LV diastolic dysfunction is common in septic patients. Grade I diastolic dysfunction, but not grades II and III, was associated with increased mortality. This finding may reflect inadequate fluid resuscitation in early sepsis despite an elevated CVP, suggesting a possible role for TTE in sepsis resuscitation.
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Affiliation(s)
- Samuel M Brown
- Division of Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, 84132, USA.
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Yacoub S, Griffiths A, Chau TTH, Simmons CP, Wills B, Hien TT, Henein M, Farrar J. Cardiac function in Vietnamese patients with different dengue severity grades. Crit Care Med 2012; 40:477-83. [PMID: 21946658 PMCID: PMC4140416 DOI: 10.1097/ccm.0b013e318232d966] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Dengue continues to cause significant global morbidity and mortality. Severe disease is characterized by cardiovascular compromise from capillary leakage. Cardiac involvement in dengue has also been reported but has not been adequately studied. SETTING Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam. SUBJECTS AND DESIGN Seventy-nine patients aged 8-6 yrs with different dengue severity grades were studied using echocardiography including tissue Doppler imaging. The patients were split into severity grades: dengue, dengue with warning signs, and severe dengue. Changes in cardiac functional parameters and hemodynamic indices were monitored over the hospital stay. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Patients with severe dengue had worse cardiac function compared with dengue in the form of left ventricular systolic dysfunction with increased left myocardial performance index (0.58 [0.26-0.80] vs. 0.38 [0.22-0.70], p = .006). Septal myocardial systolic velocities were reduced (6.4 [4.8-10] vs. 8.1 [6-13] cm/s, p = .01) as well as right ventricular systolic (11.4 [7.5-17] vs. 13.5 [10-17] cm/s, p = .016) and diastolic velocities (13 [8-23] vs. 17 [12-25] cm/s, p = .0026). In the severe group, these parameters improved from hospital admission to discharge; septal myocardial systolic velocities to 8.8 (7-11) cm/s (p = .002), right ventricular myocardial systolic velocities to 15.0 (11.8-23) cm/s, (p = .003), and diastolic velocity to 21 (11-25) cm/s (p = .002). Patients with cardiac impairment were more likely to have significant pleural effusions. CONCLUSIONS Patients with severe dengue have evidence of systolic and diastolic cardiac impairment with septal and right ventricular wall being predominantly affected.
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Affiliation(s)
- Sophie Yacoub
- Department of Infection and Immunity, Imperial College, London, UK.
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14
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Papanikolaou J, Makris D, Saranteas T, Karakitsos D, Zintzaras E, Karabinis A, Kostopanagiotou G, Zakynthinos E. New insights into weaning from mechanical ventilation: left ventricular diastolic dysfunction is a key player. Intensive Care Med 2011; 37:1976-85. [PMID: 21976188 DOI: 10.1007/s00134-011-2368-0] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Accepted: 08/06/2011] [Indexed: 12/16/2022]
Abstract
PURPOSE To investigate the diagnostic performance of Doppler echocardiography (DE) in predicting the outcome of weaning from mechanical ventilation in patients without overt cardiac disease. METHODS Fifty critical care noncardiac patients who fulfilled predetermined criteria for weaning underwent DE before and at the end of spontaneous breathing trial (pre-SBT/end-SBT, respectively). "Conventional" mitral inflow analysis and "advanced" DE parameters [tissue Doppler imaging (TDI)-derived mitral/tricuspid annular velocities and color M-mode Doppler velocity of propagation (V p)] were used to assess left ventricular (LV) diastolic function/filling pressures. Weaning was considered successful if patients had been extubated after successful SBT and sustained spontaneous breathing for more than 48 h. RESULTS Twenty-eight patients (56%) failed weaning: 23 patients failed SBT and 5 required reintubation within 48 h. Weaning failure was associated with the degree of LV diastolic dysfunction at pre-SBT (P = 0.01). Patients who failed weaning presented evidence of increased LV filling pressures at pre-SBT, by demonstrating increased E/E m and E/V p ratios compared with patients with successful outcome (P ≤ 0.004); pre-SBT values of lateral E/E m greater than 7.8 and E/V p greater than 1.51 predicted weaning failure with an area under the curve, sensitivity (%), and specificity (%) of 0.86, 79, and 100, and 0.74, 75, and 73, respectively. Lateral E/E m was the only factor independently associated with weaning failure before SBT; OR (95% CI) 5.62 (1.17-26.96), P = 0.03. CONCLUSIONS Our findings suggest that LV diastolic dysfunction is significantly associated with weaning outcome in critically ill patients with preserved LV systolic function. An E/E m ratio greater than 7.8 may identify patients at high risk of weaning failure.
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Affiliation(s)
- John Papanikolaou
- Department of Critical Care, School of Medicine, University of Thessaly, University Hospital of Larissa, Thessaly, Greece. .,Biopolis, 41110, Larissa, Greece.
| | - Demosthenes Makris
- Department of Critical Care, School of Medicine, University of Thessaly, University Hospital of Larissa, Thessaly, Greece
| | - Theodosios Saranteas
- 2nd Department of Anaesthesiology, School of Medicine, University of Athens, University Hospital of Athens 'Attikon', Athens, Greece
| | | | - Elias Zintzaras
- Department of Biomathematics, School of Medicine, University of Thessaly, Larissa, Greece.,Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Andreas Karabinis
- Department of Critical Care, General State Hospital of Athens, Athens, Greece
| | - Georgia Kostopanagiotou
- 2nd Department of Anaesthesiology, School of Medicine, University of Athens, University Hospital of Athens 'Attikon', Athens, Greece
| | - Epaminondas Zakynthinos
- Department of Critical Care, School of Medicine, University of Thessaly, University Hospital of Larissa, Thessaly, Greece. .,Biopolis, 41110, Larissa, Greece.
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Bergenzaun L, Gudmundsson P, Öhlin H, Düring J, Ersson A, Ihrman L, Willenheimer R, Chew MS. Assessing left ventricular systolic function in shock: evaluation of echocardiographic parameters in intensive care. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R200. [PMID: 21846331 PMCID: PMC3387642 DOI: 10.1186/cc10368] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Revised: 06/13/2011] [Accepted: 08/16/2011] [Indexed: 01/31/2023]
Abstract
Introduction Assessing left ventricular (LV) systolic function in a rapid and reliable way can be challenging in the critically ill patient. The purpose of this study was to evaluate the feasibility and reliability of, as well as the association between, commonly used LV systolic parameters, by using serial transthoracic echocardiography (TTE). Methods Fifty patients with shock and mechanical ventilation were included. TTE examinations were performed daily for a total of 7 days. Methods used to assess LV systolic function were visually estimated, "eyeball" ejection fraction (EBEF), the Simpson single-plane method, mean atrioventricular plane displacement (AVPDm), septal tissue velocity imaging (TDIs), and velocity time integral in the left ventricular outflow tract (VTI). Results EBEF, AVPDm, TDIs, VTI, and the Simpson were obtained in 100%, 100%, 99%, 95% and 93%, respectively, of all possible examinations. The correlations between the Simpson and EBEF showed r values for all 7 days ranging from 0.79 to 0.95 (P < 0.01). the Simpson correlations with the other LV parameters showed substantial variation over time, with the poorest results seen for TDIs and AVPDm. The repeatability was best for VTI (interobserver coefficient of variation (CV) 4.8%, and intraobserver CV, 3.1%), and AVPDm (5.3% and 4.4%, respectively), and worst for the Simpson method (8.2% and 10.6%, respectively). Conclusions EBEF and AVPDm provided the best, and Simpson, the worst feasibility when assessing LV systolic function in a population of mechanically ventilated, hemodynamically unstable patients. Additionally, the Simpson showed the poorest repeatability. We suggest that EBEF can be used instead of single-plane Simpson when assessing LV ejection fraction in this category of patients. TDIs and AVPDm, as markers of longitudinal function of the LV, are not interchangeable with LV ejection fraction.
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Affiliation(s)
- Lill Bergenzaun
- Department of Anaesthesiology, Institution of Clinical Sciences, Entrance 42, Skåne University Hospital, Lund University, Södra Förstadsgatan 101, S-20502 Malmö, Sweden.
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Ingul CB, Malm S, Refsdal E, Hegbom K, Amundsen BH, Støylen A. Recovery of Function After Acute Myocardial Infarction Evaluated by Tissue Doppler Strain and Strain Rate. J Am Soc Echocardiogr 2010; 23:432-8. [DOI: 10.1016/j.echo.2010.01.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2009] [Indexed: 10/19/2022]
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Sturgess DJ, Marwick TH, Joyce C, Jenkins C, Jones M, Masci P, Stewart D, Venkatesh B. Prediction of hospital outcome in septic shock: a prospective comparison of tissue Doppler and cardiac biomarkers. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R44. [PMID: 20331902 PMCID: PMC2887156 DOI: 10.1186/cc8931] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Revised: 01/20/2010] [Accepted: 03/24/2010] [Indexed: 01/20/2023]
Abstract
Introduction Diastolic dysfunction as demonstrated by tissue Doppler imaging (TDI), particularly E/e' (peak early diastolic transmitral/peak early diastolic mitral annular velocity) is common in critical illness. In septic shock, the prognostic value of TDI is undefined. This study sought to evaluate and compare the prognostic significance of TDI and cardiac biomarkers (B-type natriuretic peptide (BNP); N-terminal proBNP (NTproBNP); troponin T (TnT)) in septic shock. The contribution of fluid management and diastolic dysfunction to elevation of BNP was also evaluated. Methods Twenty-one consecutive adult patients from a multidisciplinary intensive care unit underwent transthoracic echocardiography and blood collection within 72 hours of developing septic shock. Results Mean ± SD APACHE III score was 80.1 ± 23.8. Hospital mortality was 29%. E/e' was significantly higher in hospital non-survivors (15.32 ± 2.74, survivors 9.05 ± 2.75; P = 0.0002). Area under ROC curves were E/e' 0.94, TnT 0.86, BNP 0.78 and NTproBNP 0.67. An E/e' threshold of 14.5 offered 100% sensitivity and 83% specificity. Adjustment for APACHE III, cardiac disease, fluid balance and grade of diastolic function, demonstrated E/e' as an independent predictor of hospital mortality (P = 0.019). Multiple linear regression incorporating APACHE III, gender, cardiac disease, fluid balance, noradrenaline dose, C reactive protein, ejection fraction and diastolic dysfunction yielded APACHE III (P = 0.033), fluid balance (P = 0.001) and diastolic dysfunction (P = 0.009) as independent predictors of BNP concentration. Conclusions E/e' is an independent predictor of hospital survival in septic shock. It offers better discrimination between survivors and non-survivors than cardiac biomarkers. Fluid balance and diastolic dysfunction were independent predictors of BNP concentration in septic shock.
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Affiliation(s)
- David J Sturgess
- School of Medicine, The University of Queensland, Princess Alexandra Hospital, Brisbane, Australia.
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Camporota L, Terblanche M, Bennett D. Year in review 2007: Critical Care--cardiology. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:232. [PMID: 18983703 PMCID: PMC2592741 DOI: 10.1186/cc7007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
This review summarises key research papers in the fields of cardiology and intensive care published during 2007 in Critical Care. To create a context and for comparison with the papers described in the review, we cite studies on the same subject published in other journals. The papers have been grouped into four categories: venous oximetry, cardiac surgery, perioperative fluid optimisation, and haemodynamic monitoring.
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Affiliation(s)
- Luigi Camporota
- Adult Intensive Care Unit, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, 1st Floor East Wing, Lambeth Palace Road, London SE1 7EH, UK
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Chew M, Bergenzaun L, Ersson A, Ohlin H. Tissue Doppler in critical illness. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:424. [PMID: 18086330 PMCID: PMC2246211 DOI: 10.1186/cc6178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Poelaert J, Roosens C. Myocardial Doppler velocities as a marker of prognosis in the ICU. Crit Care 2007; 11:167. [PMID: 18001500 PMCID: PMC2556752 DOI: 10.1186/cc6129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Relatively simple measures of echocardiography and Doppler, as left ventricular end-systolic area and volume, should be taken in consideration when performing a Doppler echocardiographic examination, as they could have both clinical and prognostic value.
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