1
|
Balik M, Waldauf P, Maly M, Brozek T, Rulisek J, Porizka M, Sachl R, Otahal M, Brestovansky P, Svobodova E, Flaksa M, Stach Z, Horejsek J, Volny L, Jurisinova I, Novotny A, Trachta P, Kunstyr J, Kopecky P, Tencer T, Pazout J, Krajcova A, Duska F. Echocardiography predictors of sustained sinus rhythm after cardioversion of supraventricular arrhythmia in patients with septic shock. J Crit Care 2024; 83:154832. [PMID: 38759581 DOI: 10.1016/j.jcrc.2024.154832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 05/02/2024] [Accepted: 05/09/2024] [Indexed: 05/19/2024]
Abstract
PURPOSE The echocardiography parameters may predict the maintenance of sinus rhythm after cardioversion of a supraventricular arrhythmia (SVA). MATERIALS AND METHODS Patients in septic shock with onset of an SVA, normal to moderately reduced LV systolic function (EF_LV˃̳35%) and on a continuous noradrenaline of <1.0 μg/kg.min were included. Echocardiography was performed at the arrhythmia onset, 1 h and 4 h post cardioversion on an infusion of propafenone or amiodarone. RESULTS Cardioversion was achieved in 96% of the 209 patients within a median time of 6(1.8-15.6)h, 134(64.1%) patients experienced at least one SVA recurrence after cardioversion. At 4 h the left atrial emptying fraction (LA_EF, cut-off 38.4%, AUC 0.69,p˂0.001), and transmitral A wave velocity-time-integral (Avti, cut-off 6.8 cm, AUC 0.65,p = 0.001) showed as limited predictors of a single arrhythmia recurrence. The LA_EF 44(36,49)%, (p = 0.005) and the Avti 8.65(7.13,9.50)cm, (p < 0.001) were associated with sustained sinus rhythm and decreased proportionally to increasing numbers of arrhythmia recurrences (p < 0.001 and p = 0.007, respectively). The enlarged left atrial end-systolic diameter at the arrhythmia onset (p = 0.04) and elevated systolic pulmonary artery pressure at 4 h (p = 0.007) were weak predictors of multiple(˃3) recurrences. CONCLUSION The LA_EF and Avti are related to arrhythmia recurrences post-cardioversion suggesting potential guidance to the choice between rhythm and rate control strategies. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03029169, registered on 24th of January 2017.
Collapse
Affiliation(s)
- M Balik
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia.
| | - P Waldauf
- Department of Anaesthesiology and Intensive Care, 3(rd) Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital in Prague, Czechia
| | - M Maly
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - T Brozek
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - J Rulisek
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - M Porizka
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - R Sachl
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - M Otahal
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - P Brestovansky
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - E Svobodova
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - M Flaksa
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - Z Stach
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - J Horejsek
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - L Volny
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - I Jurisinova
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - A Novotny
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - P Trachta
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - J Kunstyr
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - P Kopecky
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - T Tencer
- Department of Anaesthesiology and Intensive Care, 3(rd) Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital in Prague, Czechia
| | - J Pazout
- Department of Anaesthesiology and Intensive Care, 3(rd) Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital in Prague, Czechia
| | - A Krajcova
- Department of Anaesthesiology and Intensive Care, 3(rd) Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital in Prague, Czechia
| | - F Duska
- Department of Anaesthesiology and Intensive Care, 3(rd) Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital in Prague, Czechia
| |
Collapse
|
2
|
Cater DT, Meyers BA, Mitra S, Bhattacharya S, Machado RF, Serrano R, Rowan CM, Gaston B, Vlachos P. NOVEL ECHOCARDIOGRAM ANALYSIS OF CARDIAC DYSFUNCTION IS ASSOCIATED WITH MORTALITY IN PEDIATRIC SEPSIS. Shock 2024; 62:26-31. [PMID: 38661156 DOI: 10.1097/shk.0000000000002359] [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: 04/26/2024]
Abstract
ABSTRACT Objectives: The objective of our study was to semiautomatically generate echocardiogram indices in pediatric sepsis using novel algorithms and determine which indices were associated with mortality. We hypothesized that strain and diastolic indices would be most associated with mortality. Design: Retrospective cohort study of children with sepsis from 2017 to 2022. Survivors and nonsurvivors were compared for echocardiogram indices. Multivariate Cox proportional hazard models were constructed for our primary outcome of in-hospital mortality. Linear regression was performed for secondary outcomes, which included multiple composite 28-day outcomes. Results: Of the 54 patients in the study, 9 (17%) died. Multiple echocardiogram indices of both right (RV) and left ventricles (LV) were associated with in-hospital mortality [RV GLS adjusted hazard ratio (aHR): 1.16 (1.03-1.29), P = 0.011; RV global longitudinal early diastolic strain rate (GLSre) aHR: 0.24 (0.07 to 0.75), P = 0.014; LV GLSre aHR: 0.33 (0.11-0.97), P = 0.044]. Impairment in GLS was associated with fewer ventilator-free days [RV GLS β-coefficient: -0.47 (-0.84 to -0.10), P = 0.013; LV GLS β-coefficient -0.62 (-1.07 to -0.17), P = 0.008], organ-support free days [RV GLS β-coefficient: -0.49 (-0.87 to -0.11), P = 0.013; LV GLS β-coefficient: -0.64 (-1.10 to -0.17), P = 0.008], and days free from ICU [RV GLS β-coefficient: -0.42 (-0.79 to -0.05), P = 0.026; LV GLS β-coefficient: -0.58 (-1.03 to -0.13), P = 0.012]. Systolic indices were not associated with mortality in this cohort. Conclusion: Our study demonstrates the feasibility of obtaining echocardiogram indices in a semiautomatic method using our algorithms. We showed that abnormal strain is associated with worse outcomes in a cohort of children with sepsis.
Collapse
Affiliation(s)
- Daniel T Cater
- Division of Critical Care, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis Indiana
| | - Brett A Meyers
- School of Mechanical Engineering, Purdue University, West Lafayette, Indiana
| | - Shailee Mitra
- School of Mechanical Engineering, Purdue University, West Lafayette, Indiana
| | | | - Roberto F Machado
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ryan Serrano
- Division of Pediatric Cardiology, Loma Linda University Children's Hospital and Medical Center, Loma Linda, California
| | - Courtney M Rowan
- Division of Critical Care, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis Indiana
| | - Benjamin Gaston
- Riley Hospital for Children and the Herman B. Wells Center for Pediatric Research, Indianapolis, Indiana
| | - Pavlos Vlachos
- School of Mechanical Engineering, Purdue University, West Lafayette, Indiana
| |
Collapse
|
3
|
Duignan SM, Lakshminrusimha S, Armstrong K, de Boode WP, El-Khuffash A, Franklin O, Molloy EJ. Neonatal sepsis and cardiovascular dysfunction I: mechanisms and pathophysiology. Pediatr Res 2024; 95:1207-1216. [PMID: 38044334 DOI: 10.1038/s41390-023-02926-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 09/22/2023] [Accepted: 10/02/2023] [Indexed: 12/05/2023]
Abstract
The highest incidence of sepsis across all age groups occurs in neonates leading to substantial mortality and morbidity. Cardiovascular dysfunction frequently complicates neonatal sepsis including biventricular systolic and/or diastolic dysfunction, vasoregulatory failure, and pulmonary arterial hypertension. The haemodynamic response in neonatal sepsis can be hyperdynamic or hypodynamic and the underlying pathophysiological mechanisms are heterogeneous. The diagnosis and definition of both neonatal sepsis and cardiovascular dysfunction complicating neonatal sepsis are challenging and not consensus-based. Future developments in neonatal sepsis management will be facilitated by common definitions and datasets especially in neonatal cardiovascular optimisation. IMPACT: Cardiovascular dysfunction is common in neonatal sepsis but there is no consensus-based definition, making calculating the incidence and designing clinical trials challenging. Neonatal cardiovascular dysfunction is related to the inflammatory response, which can directly target myocyte function and systemic haemodynamics.
Collapse
Affiliation(s)
- Sophie M Duignan
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | | | - Kathryn Armstrong
- Children's Heart Centre, BC Children's Hospital, Vancouver, BC, Canada
| | - Willem P de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Afif El-Khuffash
- School of Medicine, Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Orla Franklin
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
- Discipline of Paediatrics, Trinity College, The University of Dublin, Trinity Research in Childhood (TRiCC) & Trinity Translational Medicine Institute (TTMI), Dublin, Ireland
| | - Eleanor J Molloy
- Discipline of Paediatrics, Trinity College, The University of Dublin, Trinity Research in Childhood (TRiCC) & Trinity Translational Medicine Institute (TTMI), Dublin, Ireland.
- Department of Neonatology, Children's Health Ireland at Crumlin, Dublin, Ireland.
- Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland.
- Paediatric Neurodisability, Children's Health Ireland at Tallaght, Dublin, Ireland.
| |
Collapse
|
4
|
Poelaert J, Lapage K. Letter to the Editor: Isolated diastolic dysfunction is associated with increased mortality in critically ill patients. J Crit Care 2023:154354. [PMID: 37353439 DOI: 10.1016/j.jcrc.2023.154354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/03/2023] [Indexed: 06/25/2023]
Affiliation(s)
- Jan Poelaert
- Dept of Anesthesiology, ICU and Chronic Pain Therapy, General Hospital Maria Middelares, B9000 Ghent, Belgium; Vrije Universiteit Brussel VUB, B1090 Jette, Belgium.
| | - Koen Lapage
- Dept of Anesthesiology, ICU and Chronic Pain Therapy, General Hospital Maria Middelares, B9000 Ghent, Belgium
| |
Collapse
|
5
|
Tsolaki V, Zakynthinos GE, Papanikolaou J, Vazgiourakis V, Parisi K, Fotakopoulos G, Makris D, Zakynthinos E. Levosimendan in the Treatment of Patients with Severe Septic Cardiomyopathy. Life (Basel) 2023; 13:1346. [PMID: 37374128 DOI: 10.3390/life13061346] [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: 04/20/2023] [Revised: 05/27/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
(1) Background: The optimal treatment of septic cardiomyopathy (SCM) remains questionable. The aim of the study was to compare the treatment of SCM based on levosimendan versus the best available therapy. (2) Methods: We conducted an observational study including patients with severe septic cardiomyopathy and circulatory failure. (3) Results: Fourteen patients (61%) received levosimendan, and nine received other treatments. The patients in the levosimendan group were more severely ill [APACHE II: 23.5 (14, 37) vs. 14 (13, 28), respectively, p = 0.012], and there was a trend for more decompensated LV function depicted by the LVEF [15% (10, 20) vs. 25% (5, 30), respectively, p = 0.061]. However, they presented a significantly higher increase in LVEF after seven days [15% (10, 20) to 50% (30, 68) (p < 0.0001) vs. 25% (5, 30) to 25% (15, 50) (p = 0.309), and a significantly higher decrease in lactate levels during the first 24 h [4.5 (2.5, 14.4) to 2.85 (1.2, 15), p = 0.036 vs. 2.9 (2, 18.9) to 2.8 (1, 15), p = 0.536]. Seven-day survival (64.3% vs. 33.3%, p = 0.424) and ICU survival (50% vs. 22.2%, p = 0.172) were higher in the first group, although differences did not reach statistical significance. The degree of left ventricular impairment and the magnitude of EF improvement by the seventh-day post-SCM onset were associated with mortality in regression analysis. (4) Conclusions: Our study presents main hemodynamic data supporting the possible efficacy of levosimendan treatment in patients with severe SCM.
Collapse
Affiliation(s)
- Vasiliki Tsolaki
- Intensive Care Unit, University Hospital of Larissa, University of Thessaly Faculty of Medicine, 44110 Larissa, Greece
| | - George E Zakynthinos
- Third Cardiology Clinic, University of Athens, Sotiria Hospital, 11527 Athens, Greece
| | | | - Vasileios Vazgiourakis
- Intensive Care Unit, University Hospital of Larissa, University of Thessaly Faculty of Medicine, 44110 Larissa, Greece
| | - Kyriaki Parisi
- Intensive Care Unit, University Hospital of Larissa, University of Thessaly Faculty of Medicine, 44110 Larissa, Greece
| | - George Fotakopoulos
- Neurosurgical Department, University Hospital of Larissa, 44110 Larissa, Greece
| | - Demosthenes Makris
- Intensive Care Unit, University Hospital of Larissa, University of Thessaly Faculty of Medicine, 44110 Larissa, Greece
| | - Epaminondas Zakynthinos
- Intensive Care Unit, University Hospital of Larissa, University of Thessaly Faculty of Medicine, 44110 Larissa, Greece
| |
Collapse
|
6
|
Petros S. [Fluid and vasopressor therapy in sepsis]. Med Klin Intensivmed Notfmed 2023; 118:163-171. [PMID: 36598519 DOI: 10.1007/s00063-022-00976-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/26/2022] [Accepted: 10/04/2022] [Indexed: 01/05/2023]
Abstract
Sepsis is one of the most common and lethal conditions in intensive care medicine. Besides adequate treatment of the infection, timely hemodynamic management is essential to treat tissue hypoperfusion due to sepsis. Adequate fluid resuscitation plays a central role, and this should be carried out with dynamic monitoring of the hemodynamic response. However, a positive fluid balance is associated with poor outcome. Vasopressor therapy is required in case of inadequate response to fluid resuscitation, with norepinephrine considered the first choice. With increasing norepinephrine dose, addition of hydrocortisone or vasopressin may contribute to maintaining the hemodynamic state, although the prognostic advantage of these drugs has not been demonstrated. While dobutamine may be considered in patients with septic cardiomyopathy, the evidence for inotropic therapy in sepsis is limited.
Collapse
Affiliation(s)
- Sirak Petros
- Interdisziplinäre Internistische Intensivmedizin, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland.
| |
Collapse
|
7
|
Zhang K, Wang Y, Chen S, Mao J, Jin Y, Ye H, Zhang Y, Liu X, Gong C, Cheng X, Huang X, Hoeft A, Chen Q, Li X, Fang X. TREM2 hi resident macrophages protect the septic heart by maintaining cardiomyocyte homeostasis. Nat Metab 2023; 5:129-146. [PMID: 36635449 PMCID: PMC9886554 DOI: 10.1038/s42255-022-00715-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 11/22/2022] [Indexed: 01/14/2023]
Abstract
Sepsis-induced cardiomyopathy (SICM) is common in septic patients with a high mortality and is characterized by an abnormal immune response. Owing to cellular heterogeneity, understanding the roles of immune cell subsets in SICM has been challenging. Here we identify a unique subpopulation of cardiac-resident macrophages termed CD163+RETNLA+ (Mac1), which undergoes self-renewal during sepsis and can be targeted to prevent SICM. By combining single-cell RNA sequencing with fate mapping in a mouse model of sepsis, we demonstrate that the Mac1 subpopulation has distinct transcriptomic signatures enriched in endocytosis and displays high expression of TREM2 (TREM2hi). TREM2hi Mac1 cells actively scavenge cardiomyocyte-ejected dysfunctional mitochondria. Trem2 deficiency in macrophages impairs the self-renewal capability of the Mac1 subpopulation and consequently results in defective elimination of damaged mitochondria, excessive inflammatory response in cardiac tissue, exacerbated cardiac dysfunction and decreased survival. Notably, intrapericardial administration of TREM2hi Mac1 cells prevents SICM. Our findings suggest that the modulation of TREM2hi Mac1 cells could serve as a therapeutic strategy for SICM.
Collapse
Affiliation(s)
- Kai Zhang
- Department of Anesthesiology and Intensive Care, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yang Wang
- Department of Anesthesiology and Intensive Care, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shiyu Chen
- Department of Anesthesiology and Intensive Care, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jiali Mao
- Department of Anesthesiology and Intensive Care, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yue Jin
- Department of Anesthesiology and Intensive Care, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hui Ye
- Department of Anesthesiology and Intensive Care, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yan Zhang
- The Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiwang Liu
- The Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Chenchen Gong
- The Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Xuejun Cheng
- The Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoli Huang
- The Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Andreas Hoeft
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Bonn, Bonn, Germany
| | - Qixing Chen
- The Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, China.
| | - Xuekun Li
- The Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, China.
- The Institute of Translational Medicine, School of Medicine, Zhejiang University, Hangzhou, China.
| | - Xiangming Fang
- Department of Anesthesiology and Intensive Care, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| |
Collapse
|
8
|
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.
Collapse
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:
| |
Collapse
|
9
|
Masi A, Apps A, Fontana M. Editorial on "Cardiac involvement in cystic fibrosis evaluated using cardiopulmonary magnetic resonance". Cardiac involvement in cystic fibrosis: more than a lung-related disease? THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2022; 38:1587-1589. [PMID: 38819544 DOI: 10.1007/s10554-022-02594-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Ambra Masi
- National Amyloidosis Centre, University College London, London, United Kingdom.
- Royal Free Hospital, London, United Kingdom.
| | - Andrew Apps
- Department of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, United Kingdom
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, London, United Kingdom
| |
Collapse
|
10
|
González-Hedström D, Moreno-Rupérez Á, de la Fuente-Fernández M, de la Fuente-Muñoz M, Román-Carmena M, Amor S, García-Villalón ÁL, López-Calderón A, Isabel Martín A, Priego T, Granado M. A Nutraceutical Product Based on a Mixture of Algae and Extra Virgin Olive Oils and Olive Leaf Extract Attenuates Sepsis-Induced Cardiovascular and Muscle Alterations in Rats. Front Nutr 2022; 9:918841. [PMID: 35795581 PMCID: PMC9252429 DOI: 10.3389/fnut.2022.918841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 05/30/2022] [Indexed: 12/12/2022] Open
Abstract
Nutraceuticals are products of natural origin widely used for the treatment and/or prevention of some chronic diseases that are highly prevalent in Western countries, such as obesity or type II diabetes, among others. However, its possible use in the prevention of acute diseases that can put life at risk has been poorly studied. Sepsis is an acute condition that causes cardiovascular and skeletal muscle damage due to a systemic inflammatory state. The aim of this work was to evaluate the possible beneficial effect of a new nutraceutical based on a mixture of algae oil (AO) and extra virgin olive oil (EVOO) supplemented with an olive leaf extract (OLE) in the prevention of cardiovascular alterations and skeletal muscle disorders induced by sepsis in rats. For this purpose, male Wistar rats were treated with the nutraceutical or with water p.o. for 3 weeks and after the treatment they were injected with 1mg/kg LPS twice (12 and 4 h before sacrifice). Pretreatment with the nutraceutical prevented the LPS-induced decrease in cardiac contractility before and after the hearts were subjected to ischemia-reperfusion. At the vascular level, supplementation with the nutraceutical did not prevent hypotension in septic animals, but it attenuated endothelial dysfunction and the increased response of aortic rings to the vasoconstrictors norepinephrine and angiotensin-II induced by LPS. The beneficial effects on cardiovascular function were associated with an increased expression of the antioxidant enzymes SOD-1 and GSR in cardiac tissue and SOD-1 and Alox-5 in arterial tissue. In skeletal muscle, nutraceutical pretreatment prevented LPS-induced muscle proteolysis and autophagy and significantly increased protein synthesis as demonstrated by decreased expression of MURF-1, atrogin-1, LC3b and increased MCH-I and MCH -IIa in gastrocnemius muscle. These effects were associated with a decrease in the expression of TNFα, HDAC4 and myogenin. In conclusion, treatment with a new nutraceutical based on a mixture of AO and EVOO supplemented with OLE is useful to prevent cardiovascular and muscular changes induced by sepsis in rats. Thus, supplementation with this nutraceutical may constitute an interesting strategy to reduce the severity and mortality risk in septic patients.
Collapse
Affiliation(s)
- Daniel González-Hedström
- Departamento de Fisiología, Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
- R&D Department, Pharmactive Biotech Products S.L.U., Alcobendas, Madrid, Spain
| | - Álvaro Moreno-Rupérez
- Departamento de Fisiología, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | | | | | - Marta Román-Carmena
- Departamento de Fisiología, Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
| | - Sara Amor
- Departamento de Fisiología, Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
| | | | - Asunción López-Calderón
- Departamento de Fisiología, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Ana Isabel Martín
- Departamento de Fisiología, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Teresa Priego
- Departamento de Fisiología, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Miriam Granado
- Departamento de Fisiología, Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III, Madrid, Spain
- *Correspondence: Miriam Granado,
| |
Collapse
|
11
|
Muehlberg F, Blaszczyk E, Will K, Wilczek S, Brederlau J, Schulz-Menger J. Characterization of critically ill patients with septic shock and sepsis-associated cardiomyopathy using cardiovascular MRI. ESC Heart Fail 2022; 9:2147-2156. [PMID: 35587684 PMCID: PMC9288744 DOI: 10.1002/ehf2.13938] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 03/18/2022] [Accepted: 04/04/2022] [Indexed: 11/16/2022] Open
Abstract
Aims Sepsis‐induced cardiomyopathy is a major complication of septic shock and contributes to its high mortality. This pilot study investigated myocardial tissue differentiation in critically ill, sedated, and ventilated patients with septic shock using cardiovascular magnetic resonance (MR). Methods and results Fifteen patients with septic shock were prospectively recruited from the intensive care unit. Individuals received a cardiac MR scan (1.5 T) within 48 h after initial catecholamine peak and a transthoracic echocardiography at 48 and 96 h after cardiac MR. Left ventricular ejection fraction was assessed using both imaging modalities. During cardiac MR imaging, balanced steady‐state free precession imaging was performed for evaluation of cardiac anatomy and function in long‐axis and short‐axis views. Native T1 maps (modified Look–Locker inversion recovery 5 s(3 s)3 s), T2 maps, and extracellular volume maps were acquired in mid‐ventricular short axis and assessed for average plane values. Patients were given 0.2 mmol/kg of gadoteridol for extracellular volume quantification and late gadolinium enhancement imaging. Critical care physicians monitored sedated and ventilated patients during the scan with continuous invasive monitoring and realized breathholds through manual ventilation breaks. Laboratory analysis included high‐sensitive troponine T and N terminal pro brain natriuretic peptide levels. Twelve individuals with complete datasets were available for analysis (age 59.5 ± 16.9 years; 6 female). Nine patients had impaired systolic function with left ventricular ejection fraction (LVEF) < 50% (39.8 ± 5.7%), and three individuals had preserved LVEF (66.9 ± 6.7%). Global longitudinal strain was impaired in both subgroups (LVEF impaired: 11.0 ± 1.8%; LVEF preserved: 16.0 ± 5.8%; P = 0.1). All patients with initially preserved LVEF died during hospital stay; in‐hospital mortality with initially impaired LVEF was 11%. Upon echocardiographic follow‐up, LVEF improved in all previously impaired patients at 48 (52.3 ± 9.0%, P = 0.06) and 96 h (54.9 ± 7.0%, P = 0.02). Patients with impaired systolic function had increased T2 times as compared with patients with preserved LVEF (60.8 ± 5.6 ms vs. 52.2 ± 2.8 ms; P = 0.02). Left ventricular GLS was decreased in all study individuals with impaired LVEF (11.0 ± 1.8%) and less impaired with preserved LVEF (16.0 ± 5.8%; P = 0.01). T1 mapping showed increased T1 times in patients with LVEF impairment as compared with patients with preserved LVEF (1093.9 ± 86.6 ms vs. 987.7 ± 69.3 ms; P = 0.03). Extracellular volume values were elevated in patients with LVEF impairment (27.9 ± 2.1%) as compared with patients with preserved LVEF (22.7 ± 1.9%; P < 0.01). Conclusions Septic cardiomyopathy with impaired LVEF reflects inflammatory cardiomyopathy. Takotsubo‐like contractility patterns occur in some cases. Cardiac MR is safely feasible in critically ill, sedated, and ventilated patients using extensive monitoring and experienced staff. Trial Registration: retrospectively registered (ISRCTN85297773)
Collapse
Affiliation(s)
- Fabian Muehlberg
- Working Group on Cardiovascular Magnetic Resonance, Experimental and Clinical Research Center - a joint cooperation between the Charité Medical Faculty and the Max-Delbrück Center for Molecular Medicine; and HELIOS Hospital Berlin Buch, Department of Cardiology and Nephrology, DZHK (German Center for Cardiovascular Research) partner site, Berlin, Germany
| | - Edyta Blaszczyk
- Working Group on Cardiovascular Magnetic Resonance, Experimental and Clinical Research Center - a joint cooperation between the Charité Medical Faculty and the Max-Delbrück Center for Molecular Medicine; and HELIOS Hospital Berlin Buch, Department of Cardiology and Nephrology, DZHK (German Center for Cardiovascular Research) partner site, Berlin, Germany
| | - Kerstin Will
- Department for Critical Care Medicine, HELIOS Hospital Berlin-Buch, Berlin, Germany
| | - Stefan Wilczek
- Department for Critical Care Medicine, HELIOS Hospital Berlin-Buch, Berlin, Germany
| | - Joerg Brederlau
- Department for Critical Care Medicine, HELIOS Hospital Berlin-Buch, Berlin, Germany
| | - Jeanette Schulz-Menger
- Working Group on Cardiovascular Magnetic Resonance, Experimental and Clinical Research Center - a joint cooperation between the Charité Medical Faculty and the Max-Delbrück Center for Molecular Medicine; and HELIOS Hospital Berlin Buch, Department of Cardiology and Nephrology, DZHK (German Center for Cardiovascular Research) partner site, Berlin, Germany
| |
Collapse
|
12
|
Assessment of left and right ventricular Tei indices in critically ill children with septic shock. PROGRESS IN PEDIATRIC CARDIOLOGY 2022. [DOI: 10.1016/j.ppedcard.2022.101491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
13
|
Boissier F, Aissaoui N. Septic cardiomyopathy: Diagnosis and management. JOURNAL OF INTENSIVE MEDICINE 2021; 2:8-16. [PMID: 36789232 PMCID: PMC9923980 DOI: 10.1016/j.jointm.2021.11.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/14/2021] [Accepted: 11/25/2021] [Indexed: 12/12/2022]
Abstract
There is an extensive body of literature focused on sepsis-induced myocardial dysfunction, but results are conflicting and no objective definition of septic cardiomyopathy (SCM) has been established. SCM may be defined as a sepsis-associated acute syndrome of non-ischemic cardiac dysfunction with systolic and/or diastolic left ventricular (LV) dysfunction and/or right ventricular dysfunction. Physicians should consider this diagnosis in patients with sepsis-associated organ dysfunction, and particularly in cases of septic shock that require vasopressors. Echocardiography is currently the gold standard for diagnosis of SCM. Left ventricular ejection fraction is the most common parameter used to describe LV function in the literature, but its dependence on loading conditions, particularly afterload, limits its use as a measure of intrinsic myocardial contractility. Therefore, repeated echocardiography evaluation is mandatory. Evaluation of global longitudinal strain (GLS) may be more sensitive and specific for SCM than LV ejection fraction (LVEF). Standard management includes etiological treatment, adapted fluid resuscitation, use of vasopressors, and monitoring. Use of inotropes remains uncertain, and heart rate control could be an option in some patients.
Collapse
Affiliation(s)
- Florence Boissier
- Service de Médecine Intensive Réanimation, CHU de Poitiers, Poitiers 86021, France,Université de Poitiers, Poitiers INSERM CIC 1402 (ALIVE group), France
| | - Nadia Aissaoui
- Service de Médecine Intensive Réanimation, Hôpital Cochin, APHP, Paris 75014, France,Université de Paris, Paris Cardiovascular Research Center, INSERM U970, Paris 75015, France,Corresponding author: Nadia Aissaoui, Service de Médecine Intensive–Réanimation, Hôpital Cochin Assistance Publique–Hôpitaux de Paris, 27 Rue du Faubourg Saint-Jacques, 75014 Paris, France.
| |
Collapse
|
14
|
The Urosepsis-A Literature Review. ACTA ACUST UNITED AC 2021; 57:medicina57090872. [PMID: 34577795 PMCID: PMC8468212 DOI: 10.3390/medicina57090872] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/20/2021] [Accepted: 08/21/2021] [Indexed: 12/20/2022]
Abstract
Urosepsis is a very serious condition with a high mortality rate. The immune response is in the center of pathophysiology. The therapeutic management of these patients includes surgical treatment of the source of infection, antibiotic therapy and life support. The management of this pathology is multidisciplinary and requires good collaboration between the urology, intensive care, imaging and laboratory medicine departments. An imbalance of pro and anti-inflammatory cytokines produced during sepsis plays an important role in pathogenesis. The study of cytokines in sepsis has important implications for understanding pathophysiology and for development of other therapeutic solutions. If not treated adequately, urosepsis may lead to serious septic complications and organ sequelae, even to a lethal outcome.
Collapse
|
15
|
Rho-Proteins and Downstream Pathways as Potential Targets in Sepsis and Septic Shock: What Have We Learned from Basic Research. Cells 2021; 10:cells10081844. [PMID: 34440613 PMCID: PMC8391638 DOI: 10.3390/cells10081844] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/09/2021] [Accepted: 07/15/2021] [Indexed: 01/19/2023] Open
Abstract
Sepsis and septic shock are associated with acute and sustained impairment in the function of the cardiovascular system, kidneys, lungs, liver, and brain, among others. Despite the significant advances in prevention and treatment, sepsis and septic shock sepsis remain global health problems with elevated mortality rates. Rho proteins can interact with a considerable number of targets, directly affecting cellular contractility, actin filament assembly and growing, cell motility and migration, cytoskeleton rearrangement, and actin polymerization, physiological functions that are intensively impaired during inflammatory conditions, such as the one that occurs in sepsis. In the last few decades, Rho proteins and their downstream pathways have been investigated in sepsis-associated experimental models. The most frequently used experimental design included the exposure to bacterial lipopolysaccharide (LPS), in both in vitro and in vivo approaches, but experiments using the cecal ligation and puncture (CLP) model of sepsis have also been performed. The findings described in this review indicate that Rho proteins, mainly RhoA and Rac1, are associated with the development of crucial sepsis-associated dysfunction in different systems and cells, including the endothelium, vessels, and heart. Notably, the data found in the literature suggest that either the inhibition or activation of Rho proteins and associated pathways might be desirable in sepsis and septic shock, accordingly with the cellular system evaluated. This review included the main findings, relevance, and limitations of the current knowledge connecting Rho proteins and sepsis-associated experimental models.
Collapse
|
16
|
Ince ME, Turgut K, Naseri A. Echocardiographic Assessment of Left Ventricular Systolic and Diastolic Functions in Dogs with Severe Sepsis and Septic Shock; Longitudinal Study. Animals (Basel) 2021; 11:ani11072011. [PMID: 34359139 PMCID: PMC8300373 DOI: 10.3390/ani11072011] [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: 05/10/2021] [Revised: 06/23/2021] [Accepted: 07/01/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Sepsis is associated with cardiovascular changes. The aim of the study was to determine sepsis-induced myocardial dysfunction in dogs with severe sepsis and septic shock using transthoracic echocardiography. Clinical, laboratory and cardiologic examinations for the septic dogs were performed at admission, 6 and 24 h, and on the day of discharge from the hospital. Left ventricular (LV) systolic dysfunction, LV diastolic dysfunction, and both types of the dysfunction were present in 13%, 70%, and 9% of dogs with sepsis, respectively. Dogs with LV diastolic dysfunction had a worse outcome and short-term mortality. Transthoracic echocardiography can be used for monitoring cardiovascular dysfunction in dogs with sepsis. Abstract The purpose of this study was to monitor left ventricular systolic dysfunction (LVSD) and diastolic dysfunction (LVDD) using transthoracic echocardiography (TTE) in dogs with severe sepsis and septic shock (SS/SS). A prospective longitudinal study using 23 dogs with SS/SS (experimental group) and 20 healthy dogs (control group) were carried out. All the clinical, laboratory and cardiologic examinations for the experimental dogs were performed at admission, 6 and 24 h after the start of treatment and on the day of discharge. LVSD was described as LV ejection fraction (LVEF) < 50%. LVDD was determined when the septal mitral annulus early diastolic velocity (LVEm) was <8 cm/s. LVSD and LVDD were present in 3 and 16 dogs with SS/SS, respectively, with both types of dysfunction present in 2 of the dogs. Although all the dogs with LVSD survived, 8 dogs with LVDD did not. The survival period was significantly shorter in dogs with an LVEm < 8 cm/s (1.3 ± 1.4 days). In conclusion, LVDD, rather than LVSD, was a common cardiovascular abnormality in the septic dogs, and this may be a negative prognostic factor. TTE is a useful tool for the identifying and monitoring of myocardial dysfunction in the dogs with SS/SS.
Collapse
Affiliation(s)
- Mehmet Ege Ince
- Department of Internal Medicine, Faculty of Veterinary Medicine, Near East University, 99100 Nicosia, North Cyprus, Turkey;
- Correspondence: or ; Tel.: +90-533-822-92-50
| | - Kursad Turgut
- Department of Internal Medicine, Faculty of Veterinary Medicine, Near East University, 99100 Nicosia, North Cyprus, Turkey;
| | - Amir Naseri
- Department of Internal Medicine, Faculty of Veterinary Medicine, Selcuk University, 42130 Konya, Turkey;
| |
Collapse
|
17
|
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.
Collapse
|
18
|
Daulasim A, Vieillard-Baron A, Geri G. Hemodynamic clinical phenotyping in septic shock. Curr Opin Crit Care 2021; 27:290-297. [PMID: 33899819 DOI: 10.1097/mcc.0000000000000834] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Recent studies have failed to show significant benefit from a uniform strategy, suggesting that hemodynamic management must be individually adapted in septic shock depending on different phenotypes. Different approaches that may be used to this end will be discussed. RECENT FINDINGS Fluid management is a cornerstone of resuscitation, as the positive fluid balance has been associated with higher mortality and right ventricular failure. Myocardial evaluation is mandatory, as sepsis patients may present with a hyperkinetic state, left ventricular (systolic and diastolic) and/or right ventricular dysfunction, the latter being associated with higher mortality. Statistical approaches with the identification of hemodynamic clusters based on echocardiographic and clinical parameters might be integrated into daily practice to develop precision medicine. Such approaches may also predict the progression of septic shock. SUMMARY Different hemodynamic phenotypes can occur at any stage of sepsis and be associated with one another. The clinician must regularly assess dynamic changes in phenotypes in septic shock patients. Statistical approaches based on machine learning need to be validated by prospective studies.
Collapse
Affiliation(s)
- Anousone Daulasim
- Medical Intensive Care Unit, Ambroise Paré Hospital, AP-HP, Boulogne-Billancourt, INSERM UMR 1018, Clinical Epidemiology Team, CESP, Paris-Saclay University, Villejuif, France
| | | | | |
Collapse
|
19
|
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.
Collapse
|
20
|
Pecchiari M, Pontikis K, Alevrakis E, Vasileiadis I, Kompoti M, Koutsoukou A. Cardiovascular Responses During Sepsis. Compr Physiol 2021; 11:1605-1652. [PMID: 33792902 DOI: 10.1002/cphy.c190044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Sepsis is the life-threatening organ dysfunction arising from a dysregulated host response to infection. Although the specific mechanisms leading to organ dysfunction are still debated, impaired tissue oxygenation appears to play a major role, and concomitant hemodynamic alterations are invariably present. The hemodynamic phenotype of affected individuals is highly variable for reasons that have been partially elucidated. Indeed, each patient's circulatory condition is shaped by the complex interplay between the medical history, the volemic status, the interval from disease onset, the pathogen, the site of infection, and the attempted resuscitation. Moreover, the same hemodynamic pattern can be generated by different combinations of various pathophysiological processes, so the presence of a given hemodynamic pattern cannot be directly related to a unique cluster of alterations. Research based on endotoxin administration to healthy volunteers and animal models compensate, to an extent, for the scarcity of clinical studies on the evolution of sepsis hemodynamics. Their results, however, cannot be directly extrapolated to the clinical setting, due to fundamental differences between the septic patient, the healthy volunteer, and the experimental model. Numerous microcirculatory derangements might exist in the septic host, even in the presence of a preserved macrocirculation. This dissociation between the macro- and the microcirculation might account for the limited success of therapeutic interventions targeting typical hemodynamic parameters, such as arterial and cardiac filling pressures, and cardiac output. Finally, physiological studies point to an early contribution of cardiac dysfunction to the septic phenotype, however, our defective diagnostic tools preclude its clinical recognition. © 2021 American Physiological Society. Compr Physiol 11:1605-1652, 2021.
Collapse
Affiliation(s)
- Matteo Pecchiari
- Dipartimento di Fisiopatologia Medico Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Konstantinos Pontikis
- Intensive Care Unit, 1st Department of Pulmonary Medicine, National & Kapodistrian University of Athens, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
| | - Emmanouil Alevrakis
- 4th Department of Pulmonary Medicine, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
| | - Ioannis Vasileiadis
- Intensive Care Unit, 1st Department of Pulmonary Medicine, National & Kapodistrian University of Athens, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
| | - Maria Kompoti
- Intensive Care Unit, Thriassio General Hospital of Eleusis, Magoula, Greece
| | - Antonia Koutsoukou
- Intensive Care Unit, 1st Department of Pulmonary Medicine, National & Kapodistrian University of Athens, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
| |
Collapse
|
21
|
Bréchot N, Hajage D, Kimmoun A, Demiselle J, Agerstrand C, Montero S, Schmidt M, Luyt CE, Lebreton G, Hékimian G, Flecher E, Zogheib E, Levy B, Slutsky AS, Brodie D, Asfar P, Combes A. Venoarterial extracorporeal membrane oxygenation to rescue sepsis-induced cardiogenic shock: a retrospective, multicentre, international cohort study. Lancet 2020; 396:545-552. [PMID: 32828186 DOI: 10.1016/s0140-6736(20)30733-9] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/26/2020] [Accepted: 03/18/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Patients with sepsis-induced cardiomyopathy with cardiogenic shock have a high mortality. This study assessed venoarterial extracorporeal membrane oxygenation (VA-ECMO) support for sepsis-induced cardiogenic shock refractory to conventional treatments. METHODS In this retrospective, multicentre, international cohort study, we compared outcomes of 82 patients (aged ≥18 years) with septic shock who received VA-ECMO at five academic ECMO centres, with 130 controls (not receiving ECMO) obtained from three large databases of septic shock. All patients had severe myocardial dysfunction (cardiac index 3 L/min per m2 or less or left ventricular ejection fraction [LVEF] 35% or less) and severe haemodynamic compromise (inotrope score at least 75 μg/kg per min or lactic acidaemia at least 4 mmol/L) at time of inclusion. The primary endpoint was survival at 90 days. A propensity score-weighted analysis was done to control for confounders. FINDINGS At baseline, patients treated with VA-ECMO had more severe myocardial dysfunction (mean cardiac index 1·5 L/min per m2vs 2·2 L/min per m2, LVEF 17% vs 27%), more severe haemodynamic impairment (inotrope score 279 μg/kg per min vs 145 μg/kg per min, lactataemia 8·9 mmol/L vs 6·5 mmol/L), and more severe organ failure (Sequential Organ Failure Assessment score 17 vs 13) than did controls, with p<0·0001 for each comparison. Survival at 90 days for patients treated with VA-ECMO was significantly higher than for controls (60% vs 25%, risk ratio [RR] for mortality 0·54, 95% CI [0·40-0·70]; p<0·0001). After propensity score weighting, ECMO remained associated with improved survival (51% vs 14%, adjusted RR for mortality 0·57, 95% CI [0·35-0·93]; p=0·0029). Lactate and catecholamine clearance were also significantly enhanced in patients treated with ECMO. Among the 49 survivors treated with ECMO, 32 who had been treated at the largest centre reported satisfactory Short Form-36 evaluated health-related quality of life at 1-year follow-up. INTERPRETATION Patients with severe sepsis-induced cardiogenic shock treated with VA-ECMO had a large and significant improvement in survival compared with controls not receiving ECMO. However, despite the careful propensity-weighted analysis, we cannot rule out unmeasured confounders. FUNDING None.
Collapse
Affiliation(s)
- Nicolas Bréchot
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France; Collège de France, Centre of Interdisciplinary Research in Biology, CNRS UMR7241, INSERM U1050, Paris, France.
| | - David Hajage
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Département Biostatistique Santé Publique et Information Médicale, Centre de Pharmacoépidémiologie (Cephepi), Paris, France
| | - Antoine Kimmoun
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Universitaire de Nancy and INSERM U1116, Université de Lorraine, Nancy, France
| | - Julien Demiselle
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Universitaire Angers, Angers, France
| | - Cara Agerstrand
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Centre, and New York-Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Santiago Montero
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France; Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol, Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Matthieu Schmidt
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France; Sorbonne Université INSERM-UMRS 1166, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France; Sorbonne Université INSERM-UMRS 1166, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Guillaume Lebreton
- Service de Chirurgie Cardiaque et Cardiovasculaire, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France; Sorbonne Université INSERM-UMRS 1166, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Guillaume Hékimian
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
| | - Erwan Flecher
- Service de Chirurgie Cardiaque, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Elie Zogheib
- Critical Care Department, Amiens University Hospital, Picardy Jules Verne University, Amiens, France
| | - Bruno Levy
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Universitaire de Nancy and INSERM U1116, Université de Lorraine, Nancy, France
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, Departments of Medicine, Surgery and Biomedical Engineering, University of Toronto, Toronto, ON, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Centre, and New York-Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Pierre Asfar
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Universitaire Angers, Angers, France
| | - Alain Combes
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France; Sorbonne Université INSERM-UMRS 1166, Institute of Cardiometabolism and Nutrition, Paris, France
| |
Collapse
|
22
|
Vascular K ATP channels protect from cardiac dysfunction and preserve cardiac metabolism during endotoxemia. J Mol Med (Berl) 2020; 98:1149-1160. [PMID: 32632751 PMCID: PMC7399691 DOI: 10.1007/s00109-020-01946-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 06/17/2020] [Accepted: 06/25/2020] [Indexed: 11/25/2022]
Abstract
Abstract KATP channels in the vasculature composed of Kir6.1 regulate vascular tone and may contribute to the pathogenesis of endotoxemia. We used mice with cell-specific deletion of Kir6.1 in smooth muscle (smKO) and endothelium (eKO) to investigate this question. We found that smKO mice had a significant survival disadvantage compared with their littermate controls when treated with a sub-lethal dose of lipopolysaccharide (LPS). All cohorts of mice became hypotensive following bacterial LPS administration; however, mean arterial pressure in WT mice recovered to normal levels, whereas smKO struggled to overcome LPS-induced hypotension. In vivo and ex vivo investigations revealed pronounced cardiac dysfunction in LPS-treated smKO, but not in eKO mice. Similar results were observed in a cecal slurry injection model. Metabolomic profiling of hearts revealed significantly reduced levels of metabolites involved in redox/energetics, TCA cycle, lipid/fatty acid and amino acid metabolism. Vascular smooth muscle-localised KATP channels have a critical role in the response to systemic infection by normalising cardiac function and haemodynamics through metabolic homeostasis. Key messages • Mice lacking vascular KATP channels are more susceptible to death from infection. • Absence of smooth muscle KATP channels depresses cardiac function during infection. • Cardiac dysfunction is accompanied by profound changes in cellular metabolites. • Findings from this study suggest a protective role for vascular KATP channels in response to systemic infection. Electronic supplementary material The online version of this article (10.1007/s00109-020-01946-3) contains supplementary material, which is available to authorized users.
Collapse
|
23
|
Habimana R, Choi I, Cho HJ, Kim D, Lee K, Jeong I. Sepsis-induced cardiac dysfunction: a review of pathophysiology. Acute Crit Care 2020; 35:57-66. [PMID: 32506871 PMCID: PMC7280799 DOI: 10.4266/acc.2020.00248] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 05/27/2020] [Indexed: 12/28/2022] Open
Abstract
It is well known that cardiac dysfunction in sepsis is associated with significantly increased mortality. The pathophysiology of sepsis-induced cardiac dysfunction can be summarized as involving impaired myocardial circulation, direct myocardial depression, and mitochondrial dysfunction. Impaired blood flow to the myocardium is associated with microvascular dysfunction, impaired endothelium, and ventriculo-arterial uncoupling. The mechanisms behind direct myocardial depression consist of downregulation of β-adrenoceptors and several myocardial suppressants (such as cytokine and nitric oxide). Recent research has highlighted that mitochondrial dysfunction, which results in energy depletion, is a major factor in sepsis-induced cardiac dysfunction. Therefore, the authors summarize the pathophysiological process of cardiac dysfunction in sepsis based on the results of recent studies.
Collapse
Affiliation(s)
| | - Insu Choi
- Department of Pediatrics, Chonnam National University Children's Hospital, Gwangju, Korea
| | - Hwa Jin Cho
- Department of Pediatrics, Chonnam National University Children's Hospital and Medical School, Gwangju, Korea
| | - Dowan Kim
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital and Medical School, Gwangju, Korea
| | - Kyoseon Lee
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital and Medical School, Gwangju, Korea
| | - Inseok Jeong
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital and Medical School, Gwangju, Korea
| |
Collapse
|
24
|
Lado-Abeal J. Non-thyroidal illness syndrome, the hidden player in the septic shock induced myocardial contractile depression. Med Hypotheses 2020; 142:109775. [PMID: 32344285 DOI: 10.1016/j.mehy.2020.109775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/21/2020] [Indexed: 12/14/2022]
Abstract
Septic shock causes high mortality in hospitalized patients, especially in those that develop myocardial dysfunction as an early complication. The myocardial dysfunction of septic shock is characterized by a decrease in ventricular relaxation (diastolic dysfunction) and reduced ventricular ejection fraction (systolic dysfunction). Most patients with septic shock have low serum thyroid hormone levels, a condition known as non-thyroidal illness syndrome. Thyroid hormones sustain myocardial contractility and energy metabolism. Septic shock non-thyroidal illness syndrome causes myocardial hypothyroidism, and hypothyroidism causes myocardial dysfunction that resembles the myocardial depression of septic shock. We hypothesize that the myocardial hypothyroidism that occurs during septic shock has a causal role in the pathogenesis of septic shock-induced myocardial dysfunction. Thyroid hormones regulate the calcium cycle, the phenotype of contractile proteins, adrenergic response, and fatty acid transport and oxidation in the cardiomyocytes. Therefore, the administration of levothyroxine and liothyronine to normalize thyroid hormones level within the myocardium will improve the myocardial function. The hypothesis will be tested in humans with septic shock by performing a prospective, randomized, placebo-controlled study to compare the effect of thyroid hormone administration with placebo on myocardial function. The proposed hypothesis challenges the idea that non-thyroidal illness syndrome is a beneficial response of the thyroid hormone axis to illness and that thyroid hormone replacement is detrimental. The administration of thyroid hormone in order to prevent and reverse myocardial hypothyroidism during septic shock is a new theoretical concept on thyroid hormone metabolism and action at the tissue level during non-thyroidal illness syndrome. If the hypothesis is correct, clinicians should consider cardiac hypothyroidism as a central player in myocardial dysfunction caused by sepsis. Thyroid hormone replacement should be incorporated into the armamentarium of septic shock treatment.
Collapse
Affiliation(s)
- Joaquin Lado-Abeal
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Truman Medical Centers and University of Missouri Kansas City, MO, USA.
| |
Collapse
|
25
|
Moscote-Salazar L, Janjua T, Florez-Perdomo W, Garcia-Ballestas E, Amit A. Heart Rate Variability: A Potential Noninvasive Biomarker in Viral Sepsis by COVID19 Infection. JOURNAL OF TRANSLATIONAL CRITICAL CARE MEDICINE 2020. [PMCID: PMC9070593 DOI: 10.4103/jtccm.jtccm_3_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
26
|
Ince ME, Turgut K, Akar A, Naseri A, Sen I, Süleymanoglu H, Ertan M, Sagmanligil V. Prognostic importance of tissue Doppler imaging of systolic and diastolic functions in dogs with severe sepsis and septic shock. Acta Vet Hung 2019; 67:517-528. [PMID: 31842599 DOI: 10.1556/004.2019.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The goal of this study was to determine the distribution of left ventricular (LV) systolic and diastolic dysfunctions and their prognostic value in canine parvovirus-infected dogs suffering from severe sepsis and septic shock (SS/SS). Twenty dogs with SS/SS (experimental group) and 18 healthy dogs (control group) were used in the study. Systolic and diastolic dysfunction was present in three (15%) and 14 (70%) diseased dogs, respectively, with both types of dysfunction present in two (10%) of the patients. These dogs were split into two groups: survivors (Sv, n = 14) and non-survivors (non-Sv, n = 6). The pulsed wave tissue Doppler (PW-TDI) septal mitral annulus systolic velocity (LVS'), an index of systolic dysfunction, had a high sensitivity and specificity to differentiate Sv and non-Sv animals, with values of 83.3% (95% CI: 41.6-98.4) and 83.3% (95% CI: 59.8-94.8), respectively, at an optimum cut-off point of ≥ 9.90. The PW-TDI septal early mitral annulus early-diastolic peak velocity (E'), an index of diastolic dysfunction, had the best sensitivity and specificity to differentiate Sv and non-Sv dogs, with values of 100% (95% CI: 55.2-100) and 100% (95% CI: 78.9-100), respectively, at an optimum cut-off point of ≤ 6.50. Therefore, diastolic dysfunction determined by E' is a good independent outcome predictor.
Collapse
Affiliation(s)
- Mehmet Ege Ince
- 1Department of Internal Medicine, Faculty of Veterinary Medicine, Near East University, 99138 Nicosia, North Cyprus, Turkey
| | - Kursad Turgut
- 1Department of Internal Medicine, Faculty of Veterinary Medicine, Near East University, 99138 Nicosia, North Cyprus, Turkey
| | - Aybars Akar
- 2Department of Internal Medicine, Faculty of Veterinary Medicine, Mehmet Akif Ersoy University, Turkey
| | - Amir Naseri
- 3Department of Internal Medicine, Faculty of Veterinary Medicine, Selcuk University, Konya, Turkey
| | - Ismail Sen
- 4Department of Internal Medicine, Faculty of Veterinary Medicine, Kyrgyz Turkish Manas University, Bishkek, Kyrgyzstan
| | - Havva Süleymanoglu
- 1Department of Internal Medicine, Faculty of Veterinary Medicine, Near East University, 99138 Nicosia, North Cyprus, Turkey
| | - Merve Ertan
- 1Department of Internal Medicine, Faculty of Veterinary Medicine, Near East University, 99138 Nicosia, North Cyprus, Turkey
| | - Vedat Sagmanligil
- 5Department of Physiology, Faculty of Veterinary Medicine, Near East University, Nicosia, North Cyprus, Turkey
| |
Collapse
|
27
|
Balik M, Waldauf P, Maly M, Matousek V, Brozek T, Rulisek J, Porizka M, Sachl R, Otahal M, Brestovansky P, Svobodova E, Flaksa M, Stach Z, Pazout J, Duska F, Smid O, Stritesky M. Efficacy and safety of 1C class antiarrhythmic agent (propafenone) for supraventricular arrhythmias in septic shock compared to amiodarone: protocol of a prospective randomised double-blind study. BMJ Open 2019; 9:e031678. [PMID: 31481571 PMCID: PMC6731952 DOI: 10.1136/bmjopen-2019-031678] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Supraventricular arrhythmias contribute to haemodynamic compromise in septic shock. A retrospective study generated the hypothesis that propafenone could be more effective than amiodarone in achieving and maintaining sinus rhythm (SR). Certain echocardiographic parameters may predict a successful cardioversion and help in the decision on rhythm or rate control strategy. METHODS AND ANALYSIS The trial includes septic shock patients with new-onset arrhythmia, but without severe impairment of the left ventricular ejection fraction. After baseline echocardiography, the patient is randomised to receive a bolus and maintenance dose of either amiodarone or propafenone. The primary outcome is the proportion of patients that have achieved rhythm control at 24 hours after the start of the infusion. The secondary outcomes are the percentages of patients that needed rescue treatments (DC cardioversion or unblinding and crossover of the antiarrhythmics), the recurrence of arrhythmias, intensive care unit mortality, 28-day and 1-year mortality. In the posthoc analysis, we separately assess subgroups of patients with pulmonary hypertension and right ventricular dysfunction. In the exploratory part of the study, we assess whether the presence of a transmitral diastolic A wave and its higher velocity-time integral is predictive for the sustainability of mechanical SR and whether the indexed left atrial endsystolic volume is predictive of recurrent arrhythmia. Considering that the restoration of SR within 24 hours occurred in 74% of the amiodarone-treated patients and in 89% of the patients treated with propafenone, we plan to include 200 patients to have an 80% chance to demonstrate the superiority of propafenone at p=0.05. ETHICS AND DISSEMINATION The trial is recruiting patients according to its second protocol version approved by the University Hospital Ethical Board on the 6 October 2017 (No. 1691/16S-IV). The results will be disseminated through peer reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER NCT03029169.
Collapse
Affiliation(s)
- Martin Balik
- Anaesthesia and Intensive Care, 1st Medical Faculty, Charles University and General University Hospital in Prague, Prague, Czech Republic, EU
| | - Petr Waldauf
- Anaesthesia and Intensive Care, 3rd Medical Faculty, Charles University and Kralovske Vinohrady University Hospital in Prague, Prague, Czech Republic, EU
| | - Michal Maly
- Anaesthesia and Intensive Care, 1st Medical Faculty, Charles University and General University Hospital in Prague, Prague, Czech Republic, EU
| | - Vojtech Matousek
- Anaesthesia and Intensive Care, 1st Medical Faculty, Charles University and General University Hospital in Prague, Prague, Czech Republic, EU
| | - Tomas Brozek
- Anaesthesia and Intensive Care, 1st Medical Faculty, Charles University and General University Hospital in Prague, Prague, Czech Republic, EU
| | - Jan Rulisek
- Anaesthesia and Intensive Care, 1st Medical Faculty, Charles University and General University Hospital in Prague, Prague, Czech Republic, EU
| | - Michal Porizka
- Anaesthesia and Intensive Care, 1st Medical Faculty, Charles University and General University Hospital in Prague, Prague, Czech Republic, EU
| | - Robert Sachl
- Anaesthesia and Intensive Care, 1st Medical Faculty, Charles University and General University Hospital in Prague, Prague, Czech Republic, EU
| | - Michal Otahal
- Anaesthesia and Intensive Care, 1st Medical Faculty, Charles University and General University Hospital in Prague, Prague, Czech Republic, EU
| | - Petr Brestovansky
- Anaesthesia and Intensive Care, 1st Medical Faculty, Charles University and General University Hospital in Prague, Prague, Czech Republic, EU
| | - Eva Svobodova
- Anaesthesia and Intensive Care, 1st Medical Faculty, Charles University and General University Hospital in Prague, Prague, Czech Republic, EU
| | - Marek Flaksa
- Anaesthesia and Intensive Care, 1st Medical Faculty, Charles University and General University Hospital in Prague, Prague, Czech Republic, EU
| | - Zdenek Stach
- Anaesthesia and Intensive Care, 1st Medical Faculty, Charles University and General University Hospital in Prague, Prague, Czech Republic, EU
| | - Jaroslav Pazout
- Anaesthesia and Intensive Care, 3rd Medical Faculty, Charles University and Kralovske Vinohrady University Hospital in Prague, Prague, Czech Republic, EU
| | - Frantisek Duska
- Anaesthesia and Intensive Care, 3rd Medical Faculty, Charles University and Kralovske Vinohrady University Hospital in Prague, Prague, Czech Republic, EU
| | - Ondrej Smid
- 2nd Department of Medicine, 1st Medical Faculty, Charles University and General Univeristy Hospital in Prague, Prague, Czech Republic, EU
| | - Martin Stritesky
- Anaesthesia and Intensive Care, 1st Medical Faculty, Charles University and General University Hospital in Prague, Prague, Czech Republic, EU
| |
Collapse
|
28
|
Gyawali B, Ramakrishna K, Dhamoon AS. Sepsis: The evolution in definition, pathophysiology, and management. SAGE Open Med 2019; 7:2050312119835043. [PMID: 30915218 PMCID: PMC6429642 DOI: 10.1177/2050312119835043] [Citation(s) in RCA: 224] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 02/11/2019] [Indexed: 12/11/2022] Open
Abstract
There has been a significant evolution in the definition and management of sepsis over the last three decades. This is driven in part due to the advances made in our understanding of its pathophysiology. There is evidence to show that the manifestations of sepsis can no longer be attributed only to the infectious agent and the immune response it engenders, but also to significant alterations in coagulation, immunosuppression, and organ dysfunction. A revolutionary change in the way we manage sepsis has been the adoption of early goal-directed therapy. This involves the early identification of at-risk patients and prompt treatment with antibiotics, hemodynamic optimization, and appropriate supportive care. This has contributed significantly to the overall improved outcomes with sepsis. Investigation into clinically relevant biomarkers of sepsis are ongoing and have yet to yield effective results. Scoring systems such as the sequential organ failure assessment and Acute Physiology and Chronic Health Evaluation help risk-stratify patients with sepsis. Advances in precision medicine techniques and the development of targeted therapy directed at limiting the excesses of the inflammatory and coagulatory cascades offer potentially viable avenues for future research. This review summarizes the progress made in the diagnosis and management of sepsis over the past two decades and examines promising avenues for future research.
Collapse
Affiliation(s)
- Bishal Gyawali
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Karan Ramakrishna
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Amit S Dhamoon
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| |
Collapse
|
29
|
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.
Collapse
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
| |
Collapse
|
30
|
Irion CI, Parrish K, John-Williams K, Gultekin SH, Shehadeh LA. Osteopontin Expression in Cardiomyocytes Is Increased in Pediatric Patients With Sepsis or Pneumonia. Front Physiol 2018; 9:1779. [PMID: 30618794 PMCID: PMC6295581 DOI: 10.3389/fphys.2018.01779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 11/23/2018] [Indexed: 11/15/2022] Open
Abstract
Sepsis and pneumonia are major causes of death in the United States, and their pathophysiology includes infection with inflammation and immune dysfunction. Both sepsis and pneumonia cause cardiovascular dysfunction. The expression of Osteopontin (OPN) in cardiomyocytes of patients with sepsis or pneumonia, and its role the induced cardiac dysfunction have not been thoroughly investigated. OPN is a matricellular protein synthesized by multiple diseased tissues and cells including cardiomyocytes. Here, we studied the expression of OPN protein using immunofluorescence in human myocardial autopsy tissues from pediatric and mid age or elderly patients with sepsis and/or pneumonia. Fourteen human myocardial tissues from six pediatric patients and eight mid-age or elderly patients were studied. Immunofluorescence was used to investigate the expression of OPN in paraffin-embedded heart sections co-stained with the myocyte markers Actin Alpha 1 (ACTA1) and Myosin Light Chain 2 (MLC2). A quantitative analysis was performed to determine the number of ACTA1 and MLC2 positive cardiomyocytes that express OPN. The results showed that OPN expression was significantly increased in cardiomyocytes in the hearts from pediatric patients with sepsis and/or pneumonia (N = 3) relative to pediatric patients without sepsis/pneumonia (N = 3), or adult to elderly patients with sepsis/pneumonia (N = 5). Among the older septic hearts, higher levels of cardiomyocyte OPN expression was seen only in conjunction with severe coronary arterial occlusion. This is the first study to document increased OPN expression in cardiomyocytes of pediatric subjects with sepsis or pneumonia. Our findings highlight a potentially important role for OPN in sepsis- or pneumonia-mediated cardiac dysfunction in pediatric patients.
Collapse
Affiliation(s)
- Camila Iansen Irion
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States.,Division of Cardiology, Department of Medicine, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
| | - Kiera Parrish
- Division of Cardiology, Department of Medicine, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
| | - Krista John-Williams
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States.,Division of Cardiology, Department of Medicine, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
| | - Sakir H Gultekin
- Department of Pathology, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
| | - Lina A Shehadeh
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States.,Division of Cardiology, Department of Medicine, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States.,Vascular Biology Institute, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States.,Peggy and Harold Katz Family Drug Discovery Center, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
| |
Collapse
|
31
|
Jain A, Sankar J, Anubhuti A, Yadav DK, Sankar MJ. Prevalence and Outcome of Sepsis-induced Myocardial Dysfunction in Children with 'Sepsis' 'With' and 'Without Shock'-A Prospective Observational Study. J Trop Pediatr 2018; 64:501-509. [PMID: 29304220 DOI: 10.1093/tropej/fmx105] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To estimate the prevalence and effects of sepsis-induced myocardial dysfunction (SIMD) in children with septic shock. METHODOLOGY Enrolled children with septic shock (n = 31) and sepsis (n = 30) underwent echocardiography and cardiac troponin-I (cTnI) estimation within first 3 h. SIMD was defined as presence of systolic/diastolic dysfunction by echocardiography. RESULTS The prevalence of SIMD was 71% in 'septic shock' and 23% in 'sepsis'. Diastolic dysfunction (45.2%) was more prevalent than systolic dysfunction (32.3%). Children with SIMD had higher requirement of inotropes [81 vs. 44%; adjusted odds ratio: 1.41 (1.04-1.92)] in first 48 h. cTnI had low sensitivity (62.5%) and specificity (55.1%) for detecting SIMD. On follow-up at 3 months, there was no residual dysfunction in the majority (71.3%). CONCLUSION SIMD, especially diastolic dysfunction, is common in septic shock and may increase inotrope requirement. It is reversible in majority. Sepsis patients may have asymptomatic underlying SIMD. cTnI does not correlate with the degree of SIMD.
Collapse
Affiliation(s)
- Aditi Jain
- Department of Pediatrics, PGIMER and Dr RML Hospital, New Delhi, Delhi 110001, India
| | - Jhuma Sankar
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, Delhi 110001, India
| | - Anubhuti Anubhuti
- Department of Biochemistry, PGIMER and Dr RML Hospital, New Delhi, Delhi 110001, India
| | - Dinesh Kumar Yadav
- Department of Pediatrics, PGIMER and Dr RML Hospital, New Delhi, Delhi 110001, India
| | - M Jeeva Sankar
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, Delhi 110001, India
| |
Collapse
|
32
|
The role of mitochondria in sepsis-induced cardiomyopathy. Biochim Biophys Acta Mol Basis Dis 2018; 1865:759-773. [PMID: 30342158 DOI: 10.1016/j.bbadis.2018.10.011] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/02/2018] [Accepted: 10/05/2018] [Indexed: 02/08/2023]
Abstract
Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. Myocardial dysfunction, often termed sepsis-induced cardiomyopathy, is a frequent complication and is associated with worse outcomes. Numerous mechanisms contribute to sepsis-induced cardiomyopathy and a growing body of evidence suggests that bioenergetic and metabolic derangements play a central role in its development; however, there are significant discrepancies in the literature, perhaps reflecting variability in the experimental models employed or in the host response to sepsis. The condition is characterised by lack of significant cell death, normal tissue oxygen levels and, in survivors, reversibility of organ dysfunction. The functional changes observed in cardiac tissue may represent an adaptive response to prolonged stress that limits cell death, improving the potential for recovery. In this review, we describe our current understanding of the pathophysiology underlying myocardial dysfunction in sepsis, with a focus on disrupted mitochondrial processes.
Collapse
|
33
|
Suzuki T, Sakai M, Yamashita S, Tomita K, Hattori Y. [Septic cardiomyopathy: pathophysiology and potential new therapeutic approaches]. Nihon Yakurigaku Zasshi 2018. [PMID: 29526919 DOI: 10.1254/fpj.151.111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Sepsis is the leading cause of death in critically ill patients, and its incidence continues to rise. Sepsis was defined as a systemic inflammatory response syndrome with an identifiable focus of infection, but therapeutic strategies aimed at eliminating the inflammatory response have only modest clinical benefit. The development of a failure of one or more organs poses a major threat to the survival of patients with sepsis, and mortality in sepsis is most often attributed to multiple organ dysfunction. Accordingly, sepsis has been recently redefined as life-threatening organ dysfunction due to a dysregulated host response to infection. Cardiac dysfunction is a well-recognized important component of septic multiple organ failure and can compromise the balance between oxygen supply and demand, ultimately leading to the development of multiple organ failure. The existence of cardiac dysfunction in sepsis is associated with much higher mortality when compared with septic patients without heart problems. Dobutamine, a β1-selective adrenoceptor agonist, has been used in septic shock for many years as an only inotrope, but limited clinical outcome measures have been provided as to advisability of the usefulness of dobutamine in septic shock management. Here we provide an overview on the possible mechanisms underlying intrinsic myocardial depression during sepsis and discuss the perspective of several inotropes for sepsis-associated cardiac dysfunction.
Collapse
Affiliation(s)
- Tokiko Suzuki
- Department of Molecular and Medical Pharmacology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama
| | - Mari Sakai
- Department of Molecular and Medical Pharmacology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama
| | - Shigeyuki Yamashita
- Department of Molecular and Medical Pharmacology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama
| | - Kengo Tomita
- Department of Molecular and Medical Pharmacology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama
| | - Yuichi Hattori
- Department of Molecular and Medical Pharmacology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama
| |
Collapse
|
34
|
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.
Collapse
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
| |
Collapse
|
35
|
|
36
|
Poelaert J. Diastolic dysfunction and sepsis: the devil is in the detail. Br J Anaesth 2017; 119:555-557. [DOI: 10.1093/bja/aex325] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
37
|
Balik M, Kolnikova I, Maly M, Waldauf P, Tavazzi G, Kristof J. Propafenone for supraventricular arrhythmias in septic shock-Comparison to amiodarone and metoprolol. J Crit Care 2017; 41:16-23. [PMID: 28463737 DOI: 10.1016/j.jcrc.2017.04.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 03/11/2017] [Accepted: 04/20/2017] [Indexed: 01/31/2023]
Abstract
PURPOSE The occurence of supraventricular arrhythmias associate with an unfavourable prognosis in septic shock. Propafenone could be a feasible antiarrhythmic. MATERIALS AND METHODS Patients collected over a period of 24months were divided into the three groups based on antiarrhythmic: Group1(amiodarone), Group2(propafenone), Group3(metoprolol). Type of arrhythmia, cardioversion rates, demographic, haemodynamic, laboratory parameters were recorded in the first 24h. The outcome data were compared between the groups. RESULTS 234 patients (99.1% ventilated) were included, the prevailing arrhythmia was acute onset atrial fibrillation (AF,69.7%). Except for the dosage of noradrenaline (0.35(0.14-0.78) in Group1(n=142)vs 0.25(0.10-0.50),p<0.01 in Group2(n=78)vs 0.14(0.07-0.25)μg/kg·min,p<0.05 in Group3(n=14)) the ejection fraction of left ventricle, rates of renal replacement therapy, arterial lactate and procalcitonin levels were not different between the groups. The cardioversion rate in Group1(74%) was lower than in Group2(89%) and Group3(92%). ICU and 28-day mortalities of Group1 were not significantly higher than in Group2 and Group3. Multivariate analysis demonstrated higher 12-month mortality in Group1 than in Group2 (HR1.58(1.04;2.38),p=0.03). CONCLUSIONS Propafenone demonstrated a higher cardioversion rate than amiodarone with a similar impact on the outcome. Patients remaining in acute onset arrhythmia did not demonstrate significantly higher ICU, 28-day and 12-month mortalities compared to those successfully cardioverted or to those having chronic AF.
Collapse
Affiliation(s)
- M Balik
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University, General University Hospital in Prague, Czechia.
| | - I Kolnikova
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University, General University Hospital in Prague, Czechia
| | - M Maly
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University, General University Hospital in Prague, Czechia
| | - P Waldauf
- Department of Anesthesiology and Intensive Care, 3rd Faculty of Medicine, University Hospital Kralovske Vinohrady in Prague, Czechia
| | - G Tavazzi
- University of Pavia, Department of Anesthesia, Intensive Care & Pain Medicine, Foundation Policlinico St. Matteo, IRCCS, Pavia, Italy
| | - J Kristof
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University, General University Hospital in Prague, Czechia
| |
Collapse
|
38
|
Sims CR, Singh SP, Mu S, Gokden N, Zakaria D, Nguyen TC, Mayeux PR. Rolipram Improves Outcome in a Rat Model of Infant Sepsis-Induced Cardiorenal Syndrome. Front Pharmacol 2017; 8:237. [PMID: 28515693 PMCID: PMC5413568 DOI: 10.3389/fphar.2017.00237] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 04/18/2017] [Indexed: 02/06/2023] Open
Abstract
While the mortality rate associated with sepsis in children has fallen over the years, it still remains unacceptably high. The development of both acute cardiac dysfunction and acute kidney injury during severe sepsis is categorized as type 5 cardiorenal syndrome (CRS) and is poorly understood in infants. To address this lack of understanding and the need for an appropriate animal model in which to conduct relevant preclinical studies, we developed a model of infant sepsis-induced CRS in rat pups then evaluated the therapeutic potential of the phosphodiesterase (PDE) 4 inhibitor, rolipram. Rat pups at 17-18-days old were subjected to cecal ligation and puncture (CLP) to induce fecal polymicrobial sepsis. Uptake of Evans Blue dye was used to assess renal microvascular leakage. Intravital videomicroscopy was used to assess renal microvascular perfusion and oxidant generation. Glomerular filtration rate (GFR) was used to assess renal function. Left ventricular (LV) catheterization and echocardiography were used to assess cardiac function. Impairment of both cardiac and renal function developed rapidly following CLP, indicating type 5 CRS. Most notable were the rapid decline in LV diastolic function, the decline in cardiac output, renal microvascular failure, and the decline in GFR. A dose-response study with rolipram determined 0.1 mg/kg, ip as the lowest most efficacious dose to protect the renal microcirculation. Rolipram was then evaluated using a clinically relevant delayed dosing paradigm (a single dose at 6 h post-CLP). With delayed dosing, rolipram restored the renal microcirculation and reduced microvascular leakage but did not reduce oxidant generation in the kidney nor restore GFR. In contrast, delayed dosing with rolipram restored cardiac function. Rolipram also improved 4-days survival. In summary, CLP in the rat pup produces a clinically relevant pediatric model of sepsis-induced CRS. The PDE4 inhibitor rolipram was effective in improving renal microvascular function and cardiac function, which improved mortality. These findings suggest that rolipram should be evaluated further as adjunctive therapy for the septic infant with CRS.
Collapse
Affiliation(s)
- Clark R. Sims
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little RockAR, USA
| | - Sharda P. Singh
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little RockAR, USA
| | - Shengyu Mu
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little RockAR, USA
| | - Neriman Gokden
- Department of Pathology, University of Arkansas for Medical Sciences, Little RockAR, USA
| | - Dala Zakaria
- Department of Pediatrics, Division of Pediatric Cardiology, University of Arkansas for Medical Sciences and Arkansas Children’s Hospital, Little RockAR, USA
| | - Trung C. Nguyen
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine and Center for Translational Research on Inflammatory Diseases, Michael E. DeBakey Veterans Affairs Medical Center, HoustonTX, USA
| | - Philip R. Mayeux
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little RockAR, USA
| |
Collapse
|
39
|
Stress cardiomyopathy of the critically ill: Spectrum of secondary, global, probable and subclinical forms. Indian Heart J 2017; 70:177-184. [PMID: 29455775 PMCID: PMC5903071 DOI: 10.1016/j.ihj.2017.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 04/05/2017] [Indexed: 02/06/2023] Open
Abstract
Stress cardiomyopathy (SC) typically presents as potential acute coronary syndrome (ACS) in previously healthy people. While there may be physical or mental stressors, the initial symptom is usually chest pain. This form conforms to the published Mayo diagnostic criteria, is well reported and as the presentation is initially cardiac, is considered primary SC. Increasingly we see SC develop several days into the hospitalization secondary to medical or surgical critical illness. This condition is more complex, presents atypically, is not easy to recognize and carries a much worse prognosis. Label of Secondary SC is appropriate as it manifests in sicker hospitalized patients with numerous comorbidities. We review the limited but provocative literature pertinent to SC in the critically ill and describe important clues to identify global, subclinical and probable forms of SC. We illustrate the several unique clinical features, demographic differences and propose a diagnostic algorithm to optimize cardiac care in the critically ill.
Collapse
|
40
|
Haileselassie B, Su E, Pozios I, Niño DF, Liu H, Lu DY, Ventoulis I, Fulton WB, Sodhi CP, Hackam D, O'Rourke B, Abraham T. Myocardial oxidative stress correlates with left ventricular dysfunction on strain echocardiography in a rodent model of sepsis. Intensive Care Med Exp 2017; 5:21. [PMID: 28405943 PMCID: PMC5389950 DOI: 10.1186/s40635-017-0134-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 04/04/2017] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Recognition of cardiomyopathy in sepsis can be challenging due to the limitations of conventional measures such as ejection fraction (EF) and fractional shortening (FS) in the context of variable preload and afterload conditions. This study correlates myocardial function using strain echocardiography (SE) with cardiomyocyte oxidative stress in a murine model of sepsis. METHODS C57BL/6J mice were randomized into control (n = 10), sham (n = 25), and a cecal ligation and puncture (CLP) (n = 33) model of sepsis. Echocardiography was performed pre-, 12, 24, and 48 h post-injury. Cardiac pro-inflammatory cytokines and mitochondrial redox scavenger expression were evaluated in a subset of each arm. To evaluate the influence of redox scavenger upregulation on oxidative injury and cardiac function, CLP was performed on mitochondrial catalase-upregulated C57BL/6J MCAT+/+ mice (n = 12) and wild-type (WT) animals for comparison. RESULTS Septic C57BL/6J mice exhibited depressed longitudinal strain (LS) when compared to sham and control at 24 h (p < 0.01) and 48 h (p = 0.04) post-CLP despite having a preserved EF. Furthermore, there was a significant association between increased odds of mortality and depressed LS (OR = 1.23, p = 0.04). Septic C57BL/6J mice concomitantly demonstrated increased expression of cardiomyocyte pro-inflammatory cytokines and decreased expression of redox scavengers at 24 and 48 h. When comparing C57Bl/6 MCAT +/+ mice and C57BL/6J WT mice, a significant decrease in LS was identified in the WT mice at 24 h (MCAT = -23 ± 5% vs. WT = -15 ± 4% p < 0.01) and 48 h (MCAT = -23 ± 7% vs. WT = -15 ± 4.3% p = 0.04) post-CLP which correlated with significant increase in the level of cardiac oxidative stress following CLP. CONCLUSIONS In this sepsis model, SE identified cardiomyopathy despite normal EF. SE depression temporally coincides with upregulation of inflammatory cytokines and decreases expression of key mitochondrial ROS scavengers. Upregulation of redox scavenger (CAT) abrogates oxidative stress and cardiac dysfunction in this sepsis model.
Collapse
Affiliation(s)
- Bereketeab Haileselassie
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Department of Pediatrics, Division of Critical Care, Stanford University School of Medicine, 770 Welch Road, Suite 435, Palo Alto, CA, 94304-5731, USA.
| | - Erik Su
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Iraklis Pozios
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Diego F Niño
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hongyun Liu
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dai-Yin Lu
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ioannis Ventoulis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William B Fulton
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chhinder P Sodhi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David Hackam
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brian O'Rourke
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Theodore Abraham
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
41
|
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.
Collapse
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.
| |
Collapse
|
42
|
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.
Collapse
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
| |
Collapse
|
43
|
Alvarez S, Vico T, Vanasco V. Cardiac dysfunction, mitochondrial architecture, energy production, and inflammatory pathways: Interrelated aspects in endotoxemia and sepsis. Int J Biochem Cell Biol 2016; 81:307-314. [PMID: 27477311 DOI: 10.1016/j.biocel.2016.07.032] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 07/22/2016] [Accepted: 07/27/2016] [Indexed: 10/21/2022]
Abstract
Septic patients with myocardial dysfunction have a 3-fold increase in mortality compared with patients without cardiovascular impairment, and usually show myocarditis, disruption of the contractile apparatus, increased amounts of interstitial collagen, and damaged mitochondria. The presence of nitric oxide and cytokines in cardiac tissue constitute the molecular markers and the intracellular messengers of inflammatory conditions in the heart due to the onset of sepsis and endotoxemia, derived from the nuclear factor-κB pathway activation and proinflammatory gene transcription. Sepsis occurs with an exacerbated inflammatory response that damages tissue mitochondria and impaired bioenergetic processes. The heart consumes 20-30 times its own weight in adenosine triphosphate every day, and 90% of this molecule is derived from mitochondrial oxidative phosphorylation. Cardiac energy management is comprised in sepsis and endotoxemia; both a deficit in energy production and alterations in the source of energy substrates are believed to be involved in impaired cardiac function. Although several hypotheses try to explain the molecular mechanisms underlying the complex condition of sepsis and endotoxemia, the current view is that these syndromes are the result of an intricate balance between prevailing levels of mitochondrial stress, biogenesis/autophagy signaling and mitochondria quality control processes, rather on a single factor. The aim of this review is to discuss current hypothesis of cardiac dysfunction related to energy metabolism and mitochondrial function in experimental models of sepsis and endotoxemia, and to introduce the importance of lipids (mainly cardiolipin) in the mechanism of cardiac energy mismanagement in these inflammatory conditions.
Collapse
Affiliation(s)
- Silvia Alvarez
- Institute of Biochemistry and Molecular Medicine (IBIMOL, UBA-CONICET), School of Pharmacy and Biochemistry, University of Buenos Aires, Junín 956, C1113AAD Buenos Aires, Argentina.
| | - Tamara Vico
- Institute of Biochemistry and Molecular Medicine (IBIMOL, UBA-CONICET), School of Pharmacy and Biochemistry, University of Buenos Aires, Junín 956, C1113AAD Buenos Aires, Argentina
| | - Virginia Vanasco
- Institute of Biochemistry and Molecular Medicine (IBIMOL, UBA-CONICET), School of Pharmacy and Biochemistry, University of Buenos Aires, Junín 956, C1113AAD Buenos Aires, Argentina
| |
Collapse
|
44
|
Nguyen HB, Lu S, Possagnoli I, Stokes P. Comparative Effectiveness of Second Vasoactive Agents in Septic Shock Refractory to Norepinephrine. J Intensive Care Med 2016; 32:451-459. [PMID: 27189952 DOI: 10.1177/0885066616647941] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE We aim to identify the appropriate vasoactive agent in patients with septic shock who are refractory to optimal doses of norepinephrine. METHODS In this retrospective observational cohort study over a 4-year period, patients who received norepinephrine within 24 hours of ICU admission and a second agent within 48 hours were enrolled. RESULTS Among 2640 patients screened, 234 patients were enrolled, aged 60.8 ± 17.8 years, Acute Physiology and Chronic Health Evaluation IV 98.3 ± 27.5, 81.6% mechanically ventilated, and 65.8% in-hospital mortality. Within 96 hours, 2.8 ± 1.0 vasoactive agents were administered. Fifty, 50, 66, and 68 patients received dobutamine, dopamine, phenylephrine, and vasopressin as the second agent, with crude in-hospital mortality 40.0%, 66.0%, 74.2%, and 76.5%, respectively, P < .001. Survival analysis showed a statistically significant difference in survival time by second vasoactive agent, P < .001. After adjusting for confounding variables, dobutamine showed significant decreased odds ratio (OR) for mortality compared to vasopressin: OR 0.34 (95% confidence interval 0.14-0.84, P = .04). The relative risk of dying was 55.8% lower in patients receiving dobutamine versus vasopressin, P < .01. CONCLUSION Dobutamine is associated with decreased mortality compared to other second vasoactive agents in septic shock when norepinephrine is not sufficient. A prospective randomized trial examining the outcome impact of the second vasoactive agent is needed.
Collapse
Affiliation(s)
- H Bryant Nguyen
- 1 Division of Pulmonary and Critical Care Medicine, Loma Linda University, Loma Linda, CA, USA.,2 Department of Medicine, Loma Linda University, Loma Linda, CA, USA.,3 Department of Emergency Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Samantha Lu
- 4 School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | | | - Phillip Stokes
- 4 School of Medicine, Loma Linda University, Loma Linda, CA, USA
| |
Collapse
|
45
|
Abstract
OBJECTIVES In the progression of severe sepsis, sepsis-induced myocardial dysfunction contributes to severity of illness and ultimate mortality. Identification of sepsis-induced myocardial dysfunction causing depressed cardiac function during critical illness has implications for ongoing patient management. However, assessing pediatric cardiac function traditionally relies on echocardiographic qualitative assessment and measurement of left ventricular ejection fraction or fractional shortening. These metrics are often insensitive for detecting early or regional myocardial dysfunction. Strain echocardiography is a contemporary echocardiographic modality that may be more sensitive to perturbations in cardiac function. This investigation hypothesizes that strain echocardiography metrics correlate with severity of illness in pediatric sepsis despite normal fractional shortening. DESIGN Single-center retrospective observational study. SETTING Tertiary 36-bed medical/surgical PICU. PATIENTS Pediatric patients admitted with sepsis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Twenty-three children with sepsis received an echocardiogram in the study period. Patients with sepsis demonstrated abnormal peak systolic longitudinal strain for age (mean = -0.13 ± 0.07; p < 0.01) and low normal peak systolic circumferential strain (mean = -0.17 ± 0.14; p = 0.02) compared with internal controls as well as previously published normal values. Depressed strain was demonstrated in the septic patients despite having normal fractional shortening (mean = 0.41; 95% CI, 0.38-0.43). On initial echocardiographic imaging, worsening peak systolic longitudinal strain was associated with increasing lactate (p = 0.04). CONCLUSIONS Pediatric patients with sepsis demonstrate evidence of depressed strain echocardiography parameters not shown by fractional shortening that correlate with clinical indices of sepsis severity. Whether strain echocardiography could eventually assist in grading pediatric sepsis severity and affect management is an area for potential future investigation.
Collapse
|
46
|
Kakihana Y, Ito T, Nakahara M, Yamaguchi K, Yasuda T. Sepsis-induced myocardial dysfunction: pathophysiology and management. J Intensive Care 2016; 4:22. [PMID: 27011791 PMCID: PMC4804632 DOI: 10.1186/s40560-016-0148-1] [Citation(s) in RCA: 295] [Impact Index Per Article: 36.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 03/04/2016] [Indexed: 12/29/2022] Open
Abstract
Sepsis is aggravated by an inappropriate immune response to invading microorganisms, which occasionally leads to multiple organ failure. Several lines of evidence suggest that the ventricular myocardium is depressed during sepsis with features of diastolic dysfunction. Potential candidates responsible for septic cardiomyopathy include pathogen-associated molecular patterns (PAMPs), cytokines, and nitric oxide. Extracellular histones and high-mobility group box 1 that function as endogenous damage-associated molecular patterns (DAMPs) also contribute to the myocardial dysfunction associated with sepsis. If untreated, persistent shock causes cellular injury and the liberation of further DAMPs. Like PAMPs, DAMPs have the potential to activate inflammation, creating a vicious circle. Early infection control with adequate antibiotic care is important during septic shock to decrease PAMPs arising from invasive microorganisms. Early aggressive fluid resuscitation as well as the administration of vasopressors and inotropes is also important to reduce DAMPs generated by damaged cells although excessive volume loading, and prolonged administration of catecholamines might be harmful. This review delineates some features of septic myocardial dysfunction, assesses its most common underlying mechanisms, and briefly outlines current therapeutic strategies and potential future approaches.
Collapse
Affiliation(s)
- Yasuyuki Kakihana
- Department of Emergency and Intensive Care Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8520 Japan
| | - Takashi Ito
- Department of Emergency and Intensive Care Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8520 Japan ; Department of Systems Biology in Thromboregulation, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Mayumi Nakahara
- Department of Anesthesiology and Critical Care Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Keiji Yamaguchi
- Department of Emergency and Intensive Care Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8520 Japan
| | - Tomotsugu Yasuda
- Department of Emergency and Intensive Care Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8520 Japan
| |
Collapse
|
47
|
|
48
|
|
49
|
Berk J, Wade R, Baser HD, Lado J. Case report: severe reversible cardiomyopathy associated with systemic inflammatory response syndrome in the setting of diabetic hyperosmolar hyperglycemic non-ketotic syndrome. BMC Cardiovasc Disord 2015; 15:123. [PMID: 26466591 PMCID: PMC4606557 DOI: 10.1186/s12872-015-0112-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 09/24/2015] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND This case study features a woman who presented with clinical and laboratory findings consistent with hyperosmolar hyperglycemic non-ketotic syndrome (HHNS), systemic inflammatory response syndrome (SIRS), and non-thyroidal illness syndrome (NTIS) who was noted to have a transient decrease in myocardial function. To our knowledge, this is the first case discussing the overlapping pathophysiological mechanisms could increase susceptibility to SIRS-induced cardiomyopathy. It is imperative that this clinical question be investigated further as such a relationship may have significant clinical implications for prevention and future treatments, particularly in patients similar to the one presented in this clinical case. CASE PRESENTATION A 53-year old Caucasian female presented to the Emergency Department for cough, nausea, vomiting and "feeling sick for 3 weeks." Labs were indicative of diabetic ketoacidosis. Initial electrocardiograms were suggestive of possible myocardial infarction and follow-up echocardiogram showed severely depressed left ventricular systolic function which resolved upon treatment of ketoacidosis. CONCLUSION We suggest that her cardiomyopathy could have three synergistic sources: SIRS, HHNS and NTIS. Overlapping mechanisms suggest uncontrolled diabetes mellitus and NTIS could increase susceptibility to SIRS-induced cardiomyopathy as seen in this case. HHNS and SIRS cause cardiac tissue injury through mechanisms including impairment of fatty acid oxidation and formation of reactive oxygen species, as well as modifying the function of membrane calcium channels. As a result, it is conceivable that diabetes may amplify the deleterious effects of inflammatory stressors on cardiac myocytes. This novel case report offers a path for future research into prevention and treatment of SIRS-induced cardiomyopathy in, but not exclusive to, the setting of diabetes.
Collapse
Affiliation(s)
- Justin Berk
- Department of Internal Medicine, Texas Tech University Health Sciences Center, School of Medicine, 3601 4th St Stop 9410, Lubbock, TX, 79416, USA.
| | - Raymond Wade
- Department of Internal Medicine, Texas Tech University Health Sciences Center, School of Medicine, 3601 4th St Stop 9410, Lubbock, TX, 79416, USA.
| | - Hatice Duygu Baser
- Department of Internal Medicine, Texas Tech University Health Sciences Center, School of Medicine, 3601 4th St Stop 9410, Lubbock, TX, 79416, USA.
| | - Joaquin Lado
- Department of Internal Medicine, Texas Tech University Health Sciences Center, School of Medicine, 3601 4th St Stop 9410, Lubbock, TX, 79416, USA.
| |
Collapse
|
50
|
Nader ND, Asgeri M, Davari-Farid S, Pourafkari L, Ahmadpour F, Porhomayon J, Javadzadeghan H, Negargar S, Knight PR. The Effect of Lipopolysaccharide on Ischemic-Reperfusion Injury of Heart: A Double Hit Model of Myocardial Ischemia and Endotoxemia. J Cardiovasc Thorac Res 2015; 7:81-6. [PMID: 26430494 PMCID: PMC4586603 DOI: 10.15171/jcvtr.2015.19] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Introduction: Myocardial ischemia may coincide and interact with sepsis and inflammation. Our objective was to examine the effects of bacterial endotoxin on myocardial functions and cell injury during acute ischemia.
Methods: Rabbits were pretreated with incremental doses of E. Coli lipopolysaccharide (LPS) or normal saline. Myocardial ischemia was induced by 50-minute occlusion of left anterior descending artery. S-TNFaR was additionally used to block the effects LPS.
Results: Ventricular contractility as it was measured by dp/dt during systole decreased from 2445± 1298 to 1422 ± 944 mm Hg/s, P = .019. Isovolumetric relaxation time as an index of diastolic function was prolonged from 50±18 ms to 102± 64 ms following ischemia. Pretreatment with low concentrations of LPS (<1 μg) had no effect on dp/dt, while at higher concentrations it suppressed both contractility and prolonged IVRT. Cell injury as measured by cardiac troponin I level increased to 15.1± 3.2 ng/dL following ischemia and continued to rise with higher doses of LPS. While blocking TNFa did not improve the myocardial contractility after ischemia, it eliminated additional deleterious effects of LPS.
Conclusion: Lower doses of LPS had no deleterious effect on myocardial function, whereas higher doses of this endotoxin cause cardiac dysfunction and increased extent of injury.
Collapse
Affiliation(s)
- Nader D Nader
- Department of Anesthesiology, University at Buffalo, Buffalo, NY, USA
| | - Mehrdad Asgeri
- Private Practicing Gastroenterologist, Cleveland Area, OH, USA
| | - Sina Davari-Farid
- Department of Anesthesiology, University at Buffalo, Buffalo, NY, USA
| | - Leili Pourafkari
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Jahan Porhomayon
- Department of Anesthesiology, University at Buffalo, Buffalo, NY, USA
| | - Hassan Javadzadeghan
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sohrab Negargar
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Paul R Knight
- Department of Anesthesiology, University at Buffalo, Buffalo, NY, USA
| |
Collapse
|