Sepsis-Induced Cardiomyopathy - CHEST

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…

Mild to moderate pericardial effusion with no obvious collapse of RV during diastole.

Practical Applications in Clinical Practice

Ketamine or Etomidate for Tracheal Intubation of Critically Ill Adults | New England Journal of Medicine

1. No Mortality Benefit

• The trial found no statistically significant difference in 28-day in-hospital mortality between ketamine (28.1%) and etomidate (29.1%) groups (adjusted risk difference −0.8%, 95% CI −4.5 to 2.9; P = 0.65).

• Implication: Either agent may be appropriate from a mortality standpoint, allowing clinicians to prioritize other patient-specific factors.

2. Risk Stratification

I completed Advanced Mechanical Ventilation Concepts!