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Background: Septic shock is commonly diagnosed in critically ill patients and is an important cause of mortality. Techniques used to assess fluid responsiveness and hemodynamic profile with physical examination and central venous pressure have been shown to be insufficient. Thus, the importance of other methods, such as bedside ultrasound (POCUS), is evident. The aim of this study was to analyze patients with septic shock who developed left ventricular dysfunction by POCUS.
Methods: Prospective study involving 14 patients diagnosed with septic shock, over 18 years old, without previous cardiac pathologies. Clinical, laboratory and imaging data were collected. POCUS was applied by a cardiology resident; the results were compared with those found by an echocardiographer.
Results: Variables were compared between patients with normal and depressed ventricular function (VF). Mean arterial pressure was significantly lower in patients with depressed VF (p = 0.01). Vasopressor drug dose and Pro-BNP value were significantly higher in patients with depressed VF (p = 0.01). Regarding the POCUS inter-rater comparison, the variables of left ventricular global systolic function, vena cava index and presence of B line were significantly concordant (p= 0.02; 0.003; 0.002).
Conclusions: Patients with depressed VF had a greater severity of shock, suggesting refractoriness, with cardiac dysfunction as a possible aggravating factor, which was visualized only by POCUS and corroborated by higher Pro-BNP values. A short POCUS training is enough for the non-specialist physician to be able to use this resource in the management of these patients.
Referências
Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287
Vincent JL, DeBacker D. Circulatory shock. N Engl J Med. 2013;369(18):1726-1734. doi:10.1056/NEJMra1208943
De Backer D, Biston P, Devriendt J, et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010;362(9):779-789. doi:10.1056/NEJMoa0907118
Jones AE, Aborn LS, Kline JA. Severity of emergency department hypotension predicts adverse hospital outcome. Shock. 2004;22(5):410-414. doi:10.1097/01.shk.0000142186.95718.82
Jones AE, Aborn LS, Kline JA. Severity of emergency department hypotension predicts adverse hospital outcome. Shock. 2004;22(5):410-414. doi:10.1097/01.shk.0000142186.95718.82
Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med. 2013;41(7):1774-1781. doi:10.1097/CCM.0b013e31828a25fd
Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008;134(1):172-178. doi:10.1378/chest.07-2331
Lee CW, Kory PD, Arntfield RT. Development of a fluid resuscitation protocol using inferior vena cava and lung ultrasound. J Crit Care. 2016;31(1):96-100. doi:10.1016/j.jcrc.2015.09.016
Corl KA, George NR, Romanoff J, et al. Inferior vena cava collapsibility detects fluid responsiveness among critically ill, spontaneously breathing patients. J Crit Care. 2017;41:130-137. doi:10.1016/j.jcrc.2017.05.008
Lanspa MJ, Cirulis MM, Wiley BM, et al. Right Ventricular Dysfunction in Early Sepsis and Septic Shock. Chest. 2021;159(3):1055-1063. doi:10.1016/j.chest.2020.09.274
Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll. Emerg Med Clin North Am. 2010;28(1):29-vii. doi:10.1016/j.emc.2009.09.010
Cowie BS. Focused transthoracic echocardiography in the perioperative period. Anaesth Intensive Care. 2010;38(5):823-836. doi:10.1177/0310057X1003800505
Chew MS. Haemodynamic monitoring using echocardiography in the critically ill: a review. Cardiol Res Pract. 2012;2012:139537. doi:10.1155/2012/139537
Nagre AS. Focus-assessed transthoracic echocardiography: Implications in perioperative and intensive care. Ann Card Anaesth. 2019;22(3):302-308. doi:10.4103/aca.ACA_88_18
Cowie B. Focused cardiovascular ultrasound performed by anesthesiologists in the perioperative period: feasible and alters patient management. J Cardiothorac Vasc Anesth. 2009;23(4):450-456. doi:10.1053/j.jvca.2009.01.018
Holm JH, Frederiksen CA, Juhl-Olsen P, Sloth E. Perioperative use of focus assessed transthoracic echocardiography (FATE). Anesth Analg. 2012;115(5):1029-1032. doi:10.1213/ANE.0b013e31826dd867
Howard ZD, Noble VE, Marill KA, et al. Bedside ultrasound maximizes patient satisfaction. J Emerg Med. 2014;46(1):46-53. doi:10.1016/j.jemermed.2013.05.044
Testa A, Francesconi A, Giannuzzi R, Berardi S, Sbraccia P. Economic analysis of bedside ultrasonography (US) implementation in an Internal Medicine department. Intern Emerg Med. 2015;10(8):1015-1024. doi:10.1007/s11739-015-1320-7
Cavanna L, Mordenti P, Bertè R, et al. Ultrasound guidance reduces pneumothorax rate and improves safety of thoracentesis in malignant pleural effusion: report on 445 consecutive patients with advanced cancer. World J Surg Oncol. 2014;12:139. Published 2014 May 2. doi:10.1186/1477-7819-12-139
Via G, Hussain A, Wells M, et al. International evidence-based recommendations for focused cardiac ultrasound. J Am Soc Echocardiogr. 2014;27(7):683.e1-683.e33. doi:10.1016/j.echo.2014.05.001
Price S, Via G, Sloth E, et al. Echocardiography practice, training and accreditation in the intensive care: document for the World Interactive Network Focused on Critical Ultrasound (WINFOCUS). Cardiovasc Ultrasound. 2008;6:49. Published 2008 Oct 6. doi:10.1186/1476-7120-6-49
Khasawneh FA, Smalligan RD. Focused transthoracic echocardiography. Postgraduate Med. 2010;122(3):230-237. doi:10.3810/pgm.2010.05.2162
Mustafa RC, Salvi Junior WF. Echocardiogram in the emergency room. In: Brazilian Society of Internal Medicine; Lopes AC, Tallo FS, Lopes RD, Vendrame LS, organizers. PROURGEM Urgency and Emergency Medicine Update Program: Cycle 14. Porto Alegre: Artmed Panamericana; 2020. p. 99-150. (Distance Continuing Education System, v.1)
Mann DL, Zipes DP, Libby P, Bonow RO, Braunwald E. Textbook of Cardiovascular Diseases 10th Edition. Braunwald. 2017
Ge WD, Li FZ, Hu BC, Wang LH, Ren DY. Factors associated with left ventricular diastolic dysfunction in patients with septic shock. Eur J Med Res. 2022;27(1):134. Published 2022 Jul 27. doi:10.1186/s40001-022-00761-5
Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287
Grewal J, McKelvie R, Lonn E, et al. BNP and NT-proBNP predict echocardiographic severity of diastolic dysfunction. Eur J Heart Fail. 2008;10(3):252-259. doi:10.1016/j.ejheart.2008.01.017
Grewal J, McKelvie RS, Persson H, et al. Usefulness of N-terminal pro-brain natriuretic Peptide and brain natriuretic peptide to predict cardiovascular outcomes in patients with heart failure and preserved left ventricular ejection fraction. Am J Cardiol. 2008;102(6):733-737. doi:10.1016/j.amjcard.2008.04.048
Mak GS, DeMaria A, Clopton P, Maisel AS. Utility of B-natriuretic peptide in the evaluation of left ventricular diastolic function: comparison with tissue Doppler imaging recordings. Am Heart J. 2004;148(5):895-902. doi:10.1016/j.ahj.2004.02.016
Rice JA, Brewer J, Speaks T, Choi C, Lahsaei P, Romito BT. The POCUS Consultation: How Point-of-Care Ultrasound Helps Guide Medical Decision-Making.Int J Gen Med. 2021;14:9789-9806. Published on December 15, 2021. doi:10.2147/IJGM.S339476
Smallwood N, Dachsel M. Point-of-care ultrasound (POCUS): unnecessary gadgets or evidence-based medicine?. Clin Med (Lond).2018;18(3):219-224. doi:10.7861/clinmedicine.18-3-219
Andersen CA, Holden S, Vela J, Rathleff MS, Jensen MB. Point-of-Care Ultrasound in General Practice: A Systematic Review. Ann Fam Med. 2019;17(1):61-69. doi:10.1370/afm.2330
Russell, F.M., Kennedy, S.K., Rood, L.K., Nti, B., Herbert, A., Rutz, M.A., Palmer, M., & Ferre, R.M. (2022). Design and implementation of a core, global point-of-care ultrasound (POCUS) certification curriculum for teachers of emergency medicine. The ultrasound journal, 14(1), 10. https://doi.org/10.1186/s13089-022-00260-y
Smalley CM, Fertel BS, Broderick E. Standardizing Point-of-Care Ultrasound Credentialing Across a Large Health Care System. Jt Comm J Qual Patient Saf. 2020;46(8):471-476. doi:10.1016/j.jcjq.2020.03.009
Souza MCLA, Martins CS, Silva Junior IM, et al (2014) NR3C1 polymorphisms in Brazilians of Caucasian, African, and Asian descent: glucocorticoid sensitivity and genotype association.Arq Bras Endocrinol Metab 58: 53–61. https://doi.org/10.1590/0004-2730000002868
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Copyright (c) 2023 Gabriel Sonchini Barbosa, Daniel Sonchini Barbosa, Natalia Keiko Aoki, Tauanne Fernanda dos Santos, Baldomero Antônio Kato da Silva, Reiby Caetano Mustafa