Section
Internal Medicine
DOI: 10.7860/JCDR/2015/10812.5640
Original Article
Prognosis of Left Ventricular Systolic Dysfunction in Septic Shock Patients
M.Mukhyaprana Prabhu1, Suresh Kumar Yalakala2, Ranjan Shetty3, Ashok Thakkar4, Tulsee Sitapara5
ABSTRACT Introduction: The prognosis of myocardial dysfunction in critically ill patients with sepsis and its association with mortality is controversial. We aim to determine the significance of left ventricular systolic dysfunction in septic shock patients and their associated outcome. Materials and Methods: A prospective, single center, observational study was carried out at an intensive care unit of a tertiary care hospital. A total of 66 patients diagnosed with septic shock were enrolled in the study from September 2010 to June 2012. The 2D echocardiography was performed for all the patients. Ejection fraction < 50% was the diagnosing parameter for the patients with systolic dysfunction in septic shock. Acute Physiology and Chronic Health Evaluation III (APACHE III) score was calculated.
Results: The mean age of patients were found to be 53.71 ± 16.76 years. The mortality rate was found to be 48.48% and among them 43.75% patients had ejection fraction < 50%. Non-survivors exhibited significantly lower mean blood pressure (74.19 ± 10.28 versus 80.59 ± 11.31; p = 0.008), lower ejection fraction (52.59 ± 16.37 versus 62.56 ± 8.31; p = 0.029) and higher APACHE III score (89.34 ± 15.41 versus 70.65 ± 13.27; p < 0.001). The receiver operating characteristic curves APACHE III score (area under curve = 0.830) and ejection fraction (area under curve = 0.656) were used to predict the mortality in septic patients. Conclusion: Low ejection fraction, a marker to measure left ventricular systolic dysfunction is a predictor of mortality in septic shock patients. However, more research is needed to confirm the findings.
Keywords: Echocardiography, Ejection fraction, Mortality
INTRODUCTION Sepsis is a serious medical condition affecting millions of patients each year. The average documented incidence of sepsis worldwide is 56-91 cases per 1,00,000 people, with a reported mortality rate of 30% [1]. Myocardial dysfunction is a common feature of sepsis. Cardiac dysfunction in septic shock is a crucial component of multiple organ dysfunction [2] and is an important cause of fatality [3,4]. Dysfunction of left ventricle (LV) associated with sepsis has been reported decades ago [2], but was not absolutely recognised until the widespread use of echocardiography in intensive care unit (ICU) [5,6]. The mechanism is still unclear and is probably multifactorial [7]. The pathophysiology and various types of myocardial dysfunction are well documented in literature. Numerous echocardiographic parameters have been developed to assess the LV function in sepsis [8]. Among these parameters, ejection fraction (EF) is most commonly used to evaluate LV systolic function [4,9]. In spite of larger data, the presence of LV systolic dysfunction and its relation with the outcome is still conflicting especially in septic shock patients [5,10]. The correlation between low ejection fraction and mortality is not clear [2,10,11]. The aim was to evaluate the significance of LV systolic dysfunction in the patients with septic shock and its association with the mortality in these patients.
The patients have been diagnosed with septic shock as per the guidelines of ACCP/SCCM Consensus Conference Committee [12]. The inclusion criteria included organ dysfunction and acute circulatory failure characterized by (a) persistent arterial hypotension (defined as a systolic arterial blood pressure 40 mm Hg), despite adequate volume resuscitation (septic shock) (b) presence of infection, documented or strongly suspected, with a systemic inflammatory response, together with two or more of the following: -
Temperature > 38°C or < 36°C
-
Heart Rate > 90 bpm
-
Respiratory Rate 30/min with PaCO2 < 32
-
Total leukocyte count > 12 x 109 /L or < 4x 109 /L or > 10% staff cells
Exclusion criteria included patients with age lesser than 18 years, pregnancy, patients who documented with valvular heart disease, known ischemic heart disease, dilated cardiomyopathy, hypertension, myocarditis, connective tissue diseases, abuse of drugs such as alcohol and cocaine, arrhythmias, diabetes mellitus, hypothyroidism or hyperthyroidism.
materials and METHODS
Baseline clinical variables were collected including age, gender, co-morbidities, hemodynamic parameters, requirement and dose of inotropes and Acute Physiology and Chronic Health Evaluation (APACHE) III score.
Study Design and Patient Population
Echocardiography
A prospective, single centre, observational study was carried out at Kasturba Medical College & Hospital, Manipal, India, from September 2010 to June 2012. A total of 66 patients with septic shock were enrolled in the study after complying with inclusion and exclusion criteria. The enrollment procedure of patients is shown in [Table/Fig-1]. Informed consent was obtained and the study was approved by the Institutional Ethics Committee. (177/2010 meeting held on 14th December 2010).
All patients underwent 12 lead electrocardiogram and 2D echocardiography using Vivid e portable echo machine from GE healthcare using 2.5 MHz transducer and Doppler echocardiography including Tissue Doppler Imaging. Left lateral position was used to analyse the patients. Assessments were made using parasternal long axis, short axis, apical four chamber and two chamber images according to the American Echocardiography Association Criteria. The modified Simpson’s method was used to measure the LV
Journal of Clinical and Diagnostic Research. 2015 Mar, Vol-9(3): OC05-OC08
5
M.Mukhyaprana Prabhu et al., Prognosis of Left Ventricular Systolic Dysfunction in Septic Shock patients
www.jcdr.net
[Table/Fig-3]: Sources of infection in septic shock patients
Types of micro-organism
7 (10.6)
E.coli [Table/Fig-1]: Enrollment procedure of study patients Variables
Septic Shock
Demographic Parameters
Klebsiella
5 (7.5)
Leptospirosis
4 (6.06)
Pseudomonas
9 (13.6)
Pseudomonas + Klebsiella
1 (1.5)
Staphylococcus aureus
3 (1)
Age (years)
53.71 ± 16.76
Male, n (%)
34 (51.5%)
Streptococcus
1 (1.5)
Length of hospital stay
9.76 ± 4.21
Acinetobacter
6 (9.09)
Length of ICU stay
6.09 ± 3.45
Polymicrobial
0 (0.00)
APACHE III Score
79.71 ± 17.07
Candida
2 (3.03)
Enterococcus
2 (3.03) 1 (1.5)
Laboratory Parameters Serum creatinine (mg/dL)
1.66 ± 1.18
Klebsiella + E coli
pH
7.13 ± 0.75
Rikettsial Not Known
Hemodynamic parameters Mean blood pressure (mm Hg)
77.48 ± 11.21
Noradrenaline, n (%)
27 (30.3%)
Dopamine, n (%)
13 (19.7%)
Noradrenaline + Dopamine, n (%)
20 (30.3%)
No medication, n (%)
6 (9.1%)
Echocardiographic Parameters Ejection Fraction Cardiac Index
57.73 ± 13.72 4.17 ± 0.90
[Table/Fig-2]: Baseline characteristics of patients with septic shock
ejection fraction (EF). Left ventricular (LV) systolic dysfunction was defined as LVEF with
Internal Medicine
DOI: 10.7860/JCDR/2015/10812.5640
Original Article
Prognosis of Left Ventricular Systolic Dysfunction in Septic Shock Patients
M.Mukhyaprana Prabhu1, Suresh Kumar Yalakala2, Ranjan Shetty3, Ashok Thakkar4, Tulsee Sitapara5
ABSTRACT Introduction: The prognosis of myocardial dysfunction in critically ill patients with sepsis and its association with mortality is controversial. We aim to determine the significance of left ventricular systolic dysfunction in septic shock patients and their associated outcome. Materials and Methods: A prospective, single center, observational study was carried out at an intensive care unit of a tertiary care hospital. A total of 66 patients diagnosed with septic shock were enrolled in the study from September 2010 to June 2012. The 2D echocardiography was performed for all the patients. Ejection fraction < 50% was the diagnosing parameter for the patients with systolic dysfunction in septic shock. Acute Physiology and Chronic Health Evaluation III (APACHE III) score was calculated.
Results: The mean age of patients were found to be 53.71 ± 16.76 years. The mortality rate was found to be 48.48% and among them 43.75% patients had ejection fraction < 50%. Non-survivors exhibited significantly lower mean blood pressure (74.19 ± 10.28 versus 80.59 ± 11.31; p = 0.008), lower ejection fraction (52.59 ± 16.37 versus 62.56 ± 8.31; p = 0.029) and higher APACHE III score (89.34 ± 15.41 versus 70.65 ± 13.27; p < 0.001). The receiver operating characteristic curves APACHE III score (area under curve = 0.830) and ejection fraction (area under curve = 0.656) were used to predict the mortality in septic patients. Conclusion: Low ejection fraction, a marker to measure left ventricular systolic dysfunction is a predictor of mortality in septic shock patients. However, more research is needed to confirm the findings.
Keywords: Echocardiography, Ejection fraction, Mortality
INTRODUCTION Sepsis is a serious medical condition affecting millions of patients each year. The average documented incidence of sepsis worldwide is 56-91 cases per 1,00,000 people, with a reported mortality rate of 30% [1]. Myocardial dysfunction is a common feature of sepsis. Cardiac dysfunction in septic shock is a crucial component of multiple organ dysfunction [2] and is an important cause of fatality [3,4]. Dysfunction of left ventricle (LV) associated with sepsis has been reported decades ago [2], but was not absolutely recognised until the widespread use of echocardiography in intensive care unit (ICU) [5,6]. The mechanism is still unclear and is probably multifactorial [7]. The pathophysiology and various types of myocardial dysfunction are well documented in literature. Numerous echocardiographic parameters have been developed to assess the LV function in sepsis [8]. Among these parameters, ejection fraction (EF) is most commonly used to evaluate LV systolic function [4,9]. In spite of larger data, the presence of LV systolic dysfunction and its relation with the outcome is still conflicting especially in septic shock patients [5,10]. The correlation between low ejection fraction and mortality is not clear [2,10,11]. The aim was to evaluate the significance of LV systolic dysfunction in the patients with septic shock and its association with the mortality in these patients.
The patients have been diagnosed with septic shock as per the guidelines of ACCP/SCCM Consensus Conference Committee [12]. The inclusion criteria included organ dysfunction and acute circulatory failure characterized by (a) persistent arterial hypotension (defined as a systolic arterial blood pressure 40 mm Hg), despite adequate volume resuscitation (septic shock) (b) presence of infection, documented or strongly suspected, with a systemic inflammatory response, together with two or more of the following: -
Temperature > 38°C or < 36°C
-
Heart Rate > 90 bpm
-
Respiratory Rate 30/min with PaCO2 < 32
-
Total leukocyte count > 12 x 109 /L or < 4x 109 /L or > 10% staff cells
Exclusion criteria included patients with age lesser than 18 years, pregnancy, patients who documented with valvular heart disease, known ischemic heart disease, dilated cardiomyopathy, hypertension, myocarditis, connective tissue diseases, abuse of drugs such as alcohol and cocaine, arrhythmias, diabetes mellitus, hypothyroidism or hyperthyroidism.
materials and METHODS
Baseline clinical variables were collected including age, gender, co-morbidities, hemodynamic parameters, requirement and dose of inotropes and Acute Physiology and Chronic Health Evaluation (APACHE) III score.
Study Design and Patient Population
Echocardiography
A prospective, single centre, observational study was carried out at Kasturba Medical College & Hospital, Manipal, India, from September 2010 to June 2012. A total of 66 patients with septic shock were enrolled in the study after complying with inclusion and exclusion criteria. The enrollment procedure of patients is shown in [Table/Fig-1]. Informed consent was obtained and the study was approved by the Institutional Ethics Committee. (177/2010 meeting held on 14th December 2010).
All patients underwent 12 lead electrocardiogram and 2D echocardiography using Vivid e portable echo machine from GE healthcare using 2.5 MHz transducer and Doppler echocardiography including Tissue Doppler Imaging. Left lateral position was used to analyse the patients. Assessments were made using parasternal long axis, short axis, apical four chamber and two chamber images according to the American Echocardiography Association Criteria. The modified Simpson’s method was used to measure the LV
Journal of Clinical and Diagnostic Research. 2015 Mar, Vol-9(3): OC05-OC08
5
M.Mukhyaprana Prabhu et al., Prognosis of Left Ventricular Systolic Dysfunction in Septic Shock patients
www.jcdr.net
[Table/Fig-3]: Sources of infection in septic shock patients
Types of micro-organism
7 (10.6)
E.coli [Table/Fig-1]: Enrollment procedure of study patients Variables
Septic Shock
Demographic Parameters
Klebsiella
5 (7.5)
Leptospirosis
4 (6.06)
Pseudomonas
9 (13.6)
Pseudomonas + Klebsiella
1 (1.5)
Staphylococcus aureus
3 (1)
Age (years)
53.71 ± 16.76
Male, n (%)
34 (51.5%)
Streptococcus
1 (1.5)
Length of hospital stay
9.76 ± 4.21
Acinetobacter
6 (9.09)
Length of ICU stay
6.09 ± 3.45
Polymicrobial
0 (0.00)
APACHE III Score
79.71 ± 17.07
Candida
2 (3.03)
Enterococcus
2 (3.03) 1 (1.5)
Laboratory Parameters Serum creatinine (mg/dL)
1.66 ± 1.18
Klebsiella + E coli
pH
7.13 ± 0.75
Rikettsial Not Known
Hemodynamic parameters Mean blood pressure (mm Hg)
77.48 ± 11.21
Noradrenaline, n (%)
27 (30.3%)
Dopamine, n (%)
13 (19.7%)
Noradrenaline + Dopamine, n (%)
20 (30.3%)
No medication, n (%)
6 (9.1%)
Echocardiographic Parameters Ejection Fraction Cardiac Index
57.73 ± 13.72 4.17 ± 0.90
[Table/Fig-2]: Baseline characteristics of patients with septic shock
ejection fraction (EF). Left ventricular (LV) systolic dysfunction was defined as LVEF with
