Management of Sepsis-induced Cardiomyopathy
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Septic Shock
83 yo woman with morbid obesity, sleep apnea, DM, HTN, asthma, CAD who had presented at outlying facility for an elective cystoscopy with plans for laser lithotripsy and ureteral stent placement. During the procedure she became hypotensive and bradycardic. She was given atropine and epinephrine. Postprocedure she was initially extubated. Chest x-ray postprocedure showed right upper lobe and possible left lower lobe infiltrates concerning for aspiration. Troponins are positive consistent with non-STEMI demand ischemia. She has a severe metabolic acidosis with a lactate of almost 7. Her EKG showed sinus tach with a RBBB and no ischemic changes. She required to be intubated for severe respiratory distress. She was still hypotensive requiring norepinephrine and vasopressin despite 3 liters of LR. Her IVC was 1.4 cm. LiDCO was placed and the following hemodynamic parameters were obtained:
SVV was indicating fluid responsiveness and Pleth Variability Index was 18%:
SBP variation was also around 20%.
Patient was…
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SONIA TRIAL: Steroids for CAP in Africa
In a randomized trial across 18 public hospitals in Kenya involving 2,180 adults with community-acquired pneumonia (CAP), patients received either standard care or standard care plus oral low-dose glucocorticoids for 10 days. By day 30, mortality was 22.6% in the glucocorticoid group and 26.0% in the standard-care group (hazard ratio 0.84; 95% CI, 0.73–0.97; P=0.02). Adverse events were similar between groups. Conclusion: Adjunctive low-dose glucocorticoids reduced mortality without increasing adverse events, even in low-resource settings.
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Great case, indicating that fluid resuscitation should be individualized according functional hemodynamic (SVV, PPV,PVI) and not all patients will require the same amount of recommended IV fluid of 30 ml/kg; some will require less and others will require more. In this patient we don’t know the weight, ideally the IBW once the patient is morbid obese.
The patient despite having get 3 L of RL continued having evidence of hypovolemia (small IVC size) and high SVV, PPV, PVI indicating that the patient is fluid responsive; will be good to know the IVC distensibility index which is another sonography parameter of fluid responsiveness in a ventilated patient.
Also, should be highlighted the role of vasopressors in this patient once the SVR is low and high CO, and widen PP (86 mmHg) which is a pattern of vasoplegia, probably due to septic shock.