Prognostic impact of left ventricular diastolic function in patients with septic shock

Abstract

BackgroundLeft ventricular (LV) diastolic dysfunction is highly prevalent in the general population and associated with a significant morbidity and mortality. Its prognostic role in patients sustaining septic shock in the intensive care unit (ICU) remains controversial. Accordingly, we investigated whether LV diastolic function was independently associated with ICU mortality in a cohort of septic shock patients assessed using critical care echocardiography.MethodsOver a 5-year period, patients hospitalized in a Medical–Surgical ICU who underwent an echocardiographic assessment with digitally stored images during the initial management of a septic shock were included in this retrospective single-center study. Off-line echocardiographic measurements were independently performed by an expert in critical care echocardiography who was unaware of patients’ outcome. LV diastolic dysfunction was defined by the presence of a lateral E′ maximal velocity <10 cm/s. A multivariate analysis was performed to determine independent risk factors associated with ICU mortality.ResultsAmong the 540 patients hospitalized in the ICU with septic shock during the study period, 223 were studied (140 men [63 %]; age 64 ± 13 years; SAPS II 55 ± 18; SOFA 10 ± 3; Charlson 3.5 ± 2.5) and 204 of them (91 %) were mechanically ventilated. ICU mortality was 35 %. LV diastolic dysfunction was observed in 31 % of patients. The proportion of LV diastolic dysfunction tended to be higher in non-survivors than in their counterparts (28/78 [36 %] vs. 41/145 [28 %]: p = 0.15). Inappropriate initial antibiotic therapy (OR 4.17 [CI 95 % 1.33–12.5]: p = 0.03), maximal dose of vasopressors (OR 1.38 [CI 95 % 1.16–1.63]: p = 0.01), SOFA score (OR 1.16 [CI 95 % 1.02–1.32]: p = 0.02) and lateral E′ maximal velocity (OR 1.12 [CI 95 % 1.01–1.24]: p = 0.02) were independently associated with ICU mortality. After adjusting for the SAPS II score, inappropriate initial antibiotic therapy and maximal dose of vasopressors remained independent factors for ICU mortality, whereas a trend was only observed for lateral E′ maximal velocity (OR 1.11 [CI 95 % 0.99–1.23]: p = 0.07).ConclusionThe present study suggests that LV diastolic function might be associated with ICU mortality in patients with septic shock. A multicenter prospective study assessing a large cohort of patients using serial echocardiographic examinations remains required to confirm the prognostic value of LV diastolic dysfunction in septic shock.

A Systematic Review of the Effect of Delayed Appropriate Antibiotic Treatment on the Outcomes of Patients With Severe Bacterial Infections

“…The full texts of 480 documents were assessed and 145 studies, reported in 147 records, were eligible for inclusion. Of these, 37 studies reported comparison of delay vs no delay in receiving appropriate therapy and/or time to appropriate therapy 18,22,27,30,32,35,[37][38][39][40][41][42][43][44][45][46][47][48][49][50][51] and are included in this analysis (Fig 1; e- Table 2).…”

“…Three prospective cohort studies, 20,24,31 32 retrospective cohort studies, [15][16][17][18][19][21][22][23][25][26][27][28][29][30]32,33,35,36,[38][39][40][41][42][43][44][45][46][47][48][49][50][51] and two casecontrol studies 34,37 were included. Two studies were carried out internationally 16,44 and 35 in single countries across Europe, 22,24,31,34,38,43 Asia, 16,20,21,23,25,26,…”

Utility of tissue Doppler imaging of systolic function to diagnose diastolic dysfunction in critically ill patients

“…But why is there so much interest in diastolic dysfunction in the ICU population? We think it might be influenced by studies identifying diastolic dysfunction as a predictor of mortality especially in the septic population [1,2,4,[6][7][8]. The 2016 ASE/EACVI guidelines simplify our approach to diastolic dysfunction but they do not solve all diagnostic problems in critically ill and mechanically ventilated patients.…”

Usefulness of echocardiography to detect cardiac involvement in COVID‐19 patients

“…However, several authors investigated the role of echocardiography for the study of septic shock, which could offer important information on cardiac loss of function due to sepsis. It has been shown that in these patients a certain grade of diastolic dysfunction could be detected by power and tissue Doppler imaging (TDI): The most used parameter is transmitral E/E′ ratio, with a lack of defined cutoff value; however, a higher proportion of diastolic dysfunction with values of E′ < 8‐10 cm/s was found to be independently associated with higher risk of death 48 (odds ratio, OR 7.7 of ICU mortality in a study by Mourad et al 49 ). Moreover, advanced echocardiography has shown good results for the evaluation of patients with septic shock: Orde et al demonstrated the superior value of STE over basic echocardiography in 60 patients with septic shock, detecting LV strain and RV strain impairment in 69% and 72% of patients, respectively, with only 33% patients having reduced LV ejection fraction (EF) and 32% having RV dysfunction based on conventional echocardiography (tricuspid annular plane systolic excursion, TDI s′ wave, RV fractional area change); moreover, they found RV‐free wall strain to be moderately associated with 6‐month mortality (OR 1.1, AUC 0.68) 50 .…”