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Signa Vitae

Journal of Intensive Care and Emergency Medicine

Septic cardiomyopathy : pathophysiology and prognosis

Abstract

Septic cardiomyopathy is a separate clinical entity clearly distinct from myocarditis on histological grounds. Physiologically it characteristically presents, unlike other types of heart failure, with normal or increased cardiac output with normal or low preload pressures & a reduced systemic vascular resistance. Speckle tracking echocardiography is now the diagnostic tool of choice for detecting subtle changes in myocardial dysfunction

Ventricular contractility is invariably reduced to some degree in septic shock but, if severe ventricular dysfunction with low blood pressure and a falling cardiac output develops, mortality is twice that of septic shock without cardiac organ failure. However if the patient survives the episode of sepsis, septic cardiomyopathy is largely reversible since the changes are predominantly functional rather than structural although it is as yet uncertain if this applies when contraction band necrosis has developed as a result of the use of high doses of vasopressors.

Key words: sepsis, septic shock, septic cardiomyopathy, sepsis induced cardiomyopathy, ventricular contractility, speckle tracking echocardiography, ventricular re-synchronisation

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Predictors of 30-day mortality in medical patients with severe sepsis or septic shock

Abstract

Objectives. To evaluate independent predictors of 30-day mortality in patients with severe sepsis or septic shock.

Background. Severe sepsis and septic shock are associated with increased mortality. Admission APACHE II score is the gold standard for assessing prognosis in critically ill, but several other predictors of mortality have been evaluated.

Methods. We retrospectively evaluated clinical and laboratory data in adult patients with severe sepsis or septic shock as predictors of 30-day mortality.

Results. Thirty-day mortality was 62.7%. Nonsurvivors in comparison to survivors were significantly more likely to be treated with noradrenalin, renal replacement therapy, mechanically ventilated, to have suffered a fungal infection, had lower admission arterial pH, increased admission Acute Physiology, Age, Chronic Health Evaluation (APACHE) II score and a higher peak lactate level (5.6 ± 6.2 vs 3.1 ± 1.75, p=0.021). Binary logistic regression demonstrated that only peak in-hospital serum lactate level was a significant independent predictor of 30-day mortality (OR 1.367, 95% CI 1.041 to 1.795, p=0.025).

Conclusion. Only peak in-hospital lactate significantly and independently predicts 30-day mortality in severe sepsis or septic shock medical patients.

Key words: severe sepsis, septic shock, 30-day mortality, serum lactate

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Incessant ventricular tachycardia as a manifestation of septic cardiomyopathy – case report

Abstract

Incessant ventricular tachycardia is defined as frequent, repetitive and persistent ventricular arrhythmia or appropriate activation of an implantable cardioverter-defibrillator when present, which occurs more than three times within 24 hours and is ultimately followed by hemodynamic collapse. It is usually associated with structural heart disease ischaemia and often has a poor prognosis. The treatment strategy involves defining the aetiology through a targeted medical history and a physical examination (toxins, drugs, etc.), a 12-lead ECG, laboratory tests (electrolytes, etc.) and the detection of ischaemia. This report presents a case of young puerpera with peripartal sepsis, with no evidence of peripartal cardiomyopathy or ischaemia, which manifested itself initially with an arrhythmic cardiac arrest and a sequentially lethal outcome after a prolonged resuscitation procedure.

Keywords: peripartal sepsis, septic shock, septic cardiomyopathy, electrical storm, ventricular tachycardia

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Successful use of venovenous extracorporeal membranous oxygenation in a 22-month old boy with necrotizing pneumonia, osteomyelitis and septic shock caused by Panton Valentine leukocidin – producing Staphylococcus aureus

Abstract

Extracorporeal membrane oxygenation (ECMO) is a life saving treatment for patients with severe respiratory failure. We present a case of a young child with invasive Panton Valentine leukocidin-producing Staphylococcus aureus infection, which is responsible for severe and invasive infection with a high mortality rate, commonly associated with necrotizing pneumonia. Our patient presented with septic shock and necrotizing pneumonia leading to severe respiratory failure, refractory to conventional ventilation means. After 1-day of treatment, venovenous ECMO (VV ECMO) was successfully instituted and inotropic support was gradually decreased. Acute renal failure was managed with peritoneal dialysis and intermittent venovenous hemofiltration. The patient was weaned from ECMO 9-days later and was mechanically ventilated for another 3 weeks. Necrotizing pneumonia with pleuropulmonary complications was finally managed by videothoracoscopy with evacuation of debris and partial pleural decortication. Osteomyelitis was confirmed by positron emission tomography – computed tomography (PET-CT) and was surgically treated. The child was treated with antistaphylococcal antibiotic therapy for 54 days. Finally, he was discharged to a rehabilitation center without supplemental oxygen and with his neurologic status at his baseline. Our case shows that VV ECMO can be applied to children with severe bacterial pneumonia resistant to conventional ventilation strategies and with moderate circulatory failure.

Key words: extracorporeal membranous oxygenation, septic shock, Staphylococcus aureus pneumonia, Staphylococcus aureus, Panton Valentine leukocidin, child

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