Accuracy of different indicators in predicting volume responsiveness in septic shock patients with myocardial depression: a comparison between lung ultrasound and PiCCO / 中华麻醉学杂志

Objective To compare the accuracy of the lung ultrasound and pulse indicator continuous cardiac output (PiCCO) in predicting volume responsiveness in septic shock patients with myocardial suppression.Methods Fifty patients of both sexes with septic shock complicated with myocardial depression,aged ≥ 18 yr,were enrolled in the study.The method for fluid replacement test was as follows:0.9％ sodium chloride injection or lactated Ringer's solution 500 ml was rapidly infused intravenously.PiCCO was used to monitor cardiac output,stroke volume,extravascular lung water index (EVLWI),pulmonary vascular penetration index (PVPI),intra-thoracic blood volume index and global end-diastolic volume index.The chest wall was scanned by ultrasound and the lung ultrasound score (LUS) was assessed.Positive fluid responsiveness was defined as an increase in PiCCO-monitored cardiac output＞ 10％ after fluid replacement.Patients were divided into positive fluid responsiveness group and negative fluid responsiveness group according to the results of fluid resuscitation test.The receiver operating characteristic (ROC) curve was drawn to evaluate the accuracy of each index in predicting fluid responsiveness.Results Compared with negative fluid responsiveness group,EVLWI,PVPI and LUS were significantly decreased,the number of patients in whom the bilateral anterior chest wall presented as B-line was increased in positive fluid responsiveness group (P＜0.01).The area under the ROC curve and 95％ confidence interval of LUS in predicting volume responsiveness was 0.836 (0.720-0.952),the cutoff value was 14.5 points,sensitivity 88％,and specificity 72％.The area under the ROC curve and 95％ confidence interval of EVLWI in predicting volume responsiveness was 0.818 (0.701-0.936),the cutoff value was 9.6 ml/kg,sensitivity 84％,and specificity 72％.The area under the ROC curve and 95％ confidence interval of PVPI in predicting volume responsiveness was 0.720 (0.575-0.865),the cutoff value was 1.55,sensitivity 92％,and specificity 52％.Conclusion The lung ultrasound and PiCCO produce higher accuracy in predicting volume responsiveness in septic shock patients with myocardial suppression;LUS has more advantages due to non-invasive examination.

Accuracy of different parameters in predicting fluid responsiveness in septic shock patients with myocardial depression: a comparison between inferior vena cava ultrasound, PiCCO and CVP / 中华麻醉学杂志

Objective To compare the accuracy of inferior vena cava (IVC) ultrasound,central venous pressure (CVP) and pulse indicator continuous cardiac output (PiCCO) in predicting fluid responsiveness in septic shock patients with myocardial depression.Methods Fifty patients with septic shock complicated with myocardial depression,aged ＞ 18 yr,were enrolled in the study.The method for fluid replacement test was as follows:0.9％ sodium chloride injectionor lactated Ringer's solution 500 ml was intravenously infused over 20 min,and positive fluid responsiveness was defined as an increase in PiCCO-monitored CO＞ 10％ after fluid replacement.Patients were divided into positive fluid responsiveness group and negative fluid responsiveness group according to the fluid replacement test.PiCCO was used to monitor stroke volume (SV),stroke volume variation (SVV) and pulse pressure variability (PPV) before fluid replacement,CVP was measured,and the diameter of IVC (d-IVC) and variability of IVC (v-IVC) were measured by bedside ultrasound.The receiver operating characteristic curve was drawn to evaluate the accuracy of each index in predicting fluid responsiveness.Results Compared with negative fluid responsiveness group,d-IVC was significantly decreased and v-IVC,SVV and PPV were increased before fluid replacement in positive fluid responsiveness group (P＜0.01).Three point five mmHg,14.5 mm,16.5％,17.0％ and 11.5％ were selected as the cutoff value for CVP,d-IVC,v-IVC,SVV and PPV,respectively.The sensitivity of CVP,d-IVC,v-IVC,SVV and PPV in predicting fluid responsiveness was 100％,92％,80％,44％ and 68％,respectively,and the specificity was 28％,80％,72％,100％ and 72％,respectively,and the area under the receiver operating characteristic curve (95％ confidence interval) was 0.609 (0.450-0.768),0.862 (0.750-0.974),0.777 (0.642-0.911),0.734 (0.596-0.873) and 0.733 (0.594-0.872),respectively.Conclusion PiCCO and IVC ultrasound provide higher accuracy in predicting fluid responsiveness in septic shock patients with myocardial depression,and IVC ultrasound is more superior because of non-invasive examination.

Construction of death early-warning model for patients with septic myocardial depression: a retrospective analysis of 129 patients / 中华危重病急救医学

Objective To explore the death risk factors of septic myocardial depression (SMD) and their predictive effect, and to set up a death early-warning model. Methods A retrospective analysis was conducted. The patients with SMD admitted to emergency department and rescue room of Beilun Branch of the First Affiliated Hospital of Zhejiang University Medical College from January 2015 to November 2017 were enrolled. The patients were divided into survival group and non-survival group according to 28-day outcome, and the gender, age, and the initial examination parameters [white blood cell (WBC) count, neutrophil (Neut) count, activated partial thromboplastin time (APTT), procalcitonin (PCT), D-dimer, C-reactive protein (CRP), cardiac troponin I (cTnI), N-terminal pro-brain natriuretic peptide (NT-proBNP), left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD), and left atrium diameter (LAD)] of both groups were compared. Binary logistic regression analysis was conducted on the factors with statistically significant difference analyzed in univariate analysis, and death early-warning model was set up subsequently. For parameters in early-warning model after variable screening, receiver operating characteristic curve (ROC) was applied to evaluate the predictive effect of death. Results A total of 129 patients were enrolled, 34 patients died within 28 days with the mortality of 26.4%. Univariate analysis showed that the PCT, cTnI and NT-proBNP in non-survival group were significantly higher than those of the survival group. However, there was no statistical difference in gender, age, WBC, Neut, APTT, D-dimer, CRP, LVEF, LVEDD or LAD between the two groups. Logistic stepwise regression analysis showed that PCT and cTnI were the independent factors influencing the death of patients with SMD [PCT: odds ratio (OR) =1.495, 95% confidence interval (95%CI) = 1.192-1.876, P = 0.001; cTnI: OR = 11.154, 95%CI = 5.709-17.264, P = 0.004], and the death early-warning model was logP =-3.737+0.402×PCT+2.412×cTnI. According to the statistics of Homser-Lemeshow, the effect of this model was good (χ2= 6.258, P = 0.617). The analysis of ROC displayed that the area under ROC curve (AUC) of the combination of PCT and cTnI for predicting the prognosis of SMD patients was 0.851, and it was significantly higher than that of PCT and cTnI alone (0.738 and 0.719, respectively, both P < 0.05). When the combination of PCT and cTnI was 0.26, the sensitivity was 79.97%, the specificity was 87.01%, the positive predictive value was 71.3%, and the negative predictive value was 91.7%. Conclusions PCT and cTnI are independent factors influencing the death of SMD patients. The combination of PCT and cTnI has predictive value for the prognosis of SMD patients. The death early-warning model of SMD patients can be used to predict the prognosis of SMD patients.

Combination therapy with milrinone and esmolol in patients with septic myocardial depression / 实用医学杂志

Objective To evaluate the effect of combination therapy with milrinone and esmolol on hemodynamics and cardiac function in patients with septic myocardial depression. Methods From October 2010 to October 2013,after the hemodynamics and cardiac function were evaluated by pulse indicator continuous cardiac output (PICCO),74 sepsispatients withCI < 2.2 L/min · m2 after fluid resuscitation were enrolled in the study and were divided into group A with intravenous injection of dobutamine hydrochloride ,and group B with intravenous injection of milrinone and esmolol,with 37 cases in each group. The patients'PICCO indicators, echocardiography and cardiac biomarker(CK,CK-MB,MYO,cTnI and ProBNP)in two groups were compared before and after 3-day treatment. Results (1)CI and GEF were significantly increased in group B after 3-day treatment when compared with those in group A.(2)Compared with those in group A,early diastolic mitral flow velocity/end diastolic mitral velocity (E/A) and right ventricular diastolic diameter(RVD) in group B had statistical significance.(3) CK-MB,cTnI and ProBNP decreased significantly in group B when compared with those in group A. Conclusion Combination therapy with milrinone and esmolol can increase cardiac ejection function,slow down the heart rate,reduce the heart blood and vascular preload,lessen the injury of myocardial and improve heart function.

Clinical diga nosis of sepsis-induced myocardial depression / 中国小儿急救医学

Sepsis is defined as the systemic inflammatory response to infection,with high morbidity, high mortality and high cost, which is the most common cause of death in ICU.The morbidity of sepsis-induced myocardial depression is about 37%~50%, and the mortality is 20% higher than simple sepsis. Although the research in sepsis-induced myocardial depression is deeper than ever before, the diagnostic standard of sepsis-induced myocardial depression is still unclear,the early diagnosis of sepsis-induced myocra-diald eprse sion seems patr icularly important.Nowd ays,ht e diga nostci ways include ce hocardiography,ivn asive andn oninvasive hemodynamic monitoring, electrocra diogram andb iological markers are the most common diang ostic methosd .This review discussed the diagnostic methdo s used in sepsis-induced myocardial deper ssion.

The role of mitochondrial permeability transition pore in the occurrence of septic myocardial depression / 中华危重病急救医学

Sepsis is defined as life-threatening organ dysfunction caused by a dys-regulated host response to infection and septic myocardial depression (SMD) is a common complication. Pathogenesis of SMD is complicated and there is lack of specific treatment. Mitochondrial damage is an important pathological basis of SMD, and mitochondrial permeability transition pore (MPTP) plays an important role in maintaining the normal structure and function of the mitochondria. The change of MPTP during sepsis is summarized in this review so as to reveal the significant mechanism of MPTP in the occurrence of SMD.

Research status on pathogenesis of myocardial depression in sepsis / 中华实用儿科临床杂志

The cardiovascular system plays a key role in sepsis,and septic myocardial depression is a common finding associated with increased morbidity and mortality.Myocardial depression during sepsis is not clearly defined,but it can perhaps be best described as a global (systolic and diastolic)dysfunction of both the left and right sides of the heart.The pathogenesis of septic myocardial depression involves a complex mix factor of genetic,molecular,metabolic, and structural.Now,the research status on pathogenesis of myocardial depress in sepsis was reviewed.

Alteraciones hemodinámicas en pacientes con sepsis grave visualizadas por ecocardiografía, reporte de casos clínicos / Hemodynamic alterations in patients with acute septicemia visualized by echocardiography: clinical cases report

Introducción: las alteraciones hemodinámicas presentadas en los pacientes con sepsis grave son varias, entre estas podemos nombrar a la depresión miocárdica, la dilatación biventricular y la disminución de la fracción de eyección, tanto del ventrículo derecho como izquierdo; aunque la fsiopatología de la disfunción cardiaca es complicada sabemos que entre estos están involucrados mecanismos infamatorios metabólicos y de señalización intracelular relacionados al movimiento del calcio, del receptor de rianodina y a una alteración en la producción de óxido nítrico además de la IL1 y el TNF. La depresión miocárdica secundaria a sepsis es independiente de reanimación con volumen, la cual se normaliza entre el séptimo a décimo día, El uso racional de los líquidos y el inicio de vasoactivos e inotrópicos son fundamentales para su manejo. La ecocardiografía puede proporcionar un rápido diagnóstico confirmatorio de la sospecha clínica. Actualmente, la ecocardiografía se considera una indicación actual en todo paciente hemodinámicamente inestable, y puede obtenerse información relacionada con anormalidades de la estructura y función, que puede facilitar la investigación de isquemia miocárdica, disfunción valvular y patología pericárdica, proporcionando un rápido diagnostico confirmatorio de la sospecha clínica. Teniendo en cuenta que los pacientes que ingresan a las unidades de cuidados intensivos en su mayoría no son previamente sanos y presentan alteraciones funcionales a nivel cardiaco, la valoración hemodinámica avanzada para guiar el plan de tratamiento es indispensable y personalizado. Caso: a continuación describimos una serie de casos en los que la valoración hemodinámica avanzada a través de la ecocardiografía proporcionó una guía para el manejo y resolución del problema.

Introduction: hemodynamic alterations are frequent in critically ill patients of which we can mention myocardial depression, biventricular dilatation and reduced ejection fraction, both from the right and left ventricle, although the pathophysiology of cardiac dysfunction is complicated, it is known that the inflammatory mechanisms and intracellular signaling of calcium, ryanodine receptor and an alteration in nitric oxide production, in addition IL1, TNF. The secondary myocardial depression conducive to septic shock is independent to volume resuscitation, which usually normalizes between the seventh to tenth day. The rational use of fluid, vasoactive and inotropic are essential for its management. Case: following we describe some cases in which we describe a hemodynamic evaluation using echocardiography, which served as a guide for its management.

The Direct Myocardial Depressant Effect of Methylmethacrylate Monomer in vitro: Mechanical and Electrophysiological Actions / 대한마취과학회지

BACKGROUND: Methylmethacrylate monomer (MMA) bone cement has been associated with sudden systemic hypotension. The present study was aimed to explore the mechanism of direct myocardial depressant actions of MMA. METHODS: The isometric contraction of isolated guinea pig's right ventricular papillary muscle was measured. Normal and slow action potentials were evaluated by a conventional micro-electrode technique. The effects of MMA on sarcoplasmic reticulum (SR) function were evaluated by its effect on: rapid cooling contractures, rested state contraction of rat papillary muscle in normal Tyrode's solution and of guinea pig's papillary muscle in low Na+ Tyrode's solution. To measure the inward calcium currents (ICa), whole cell patch clamp techniques were applied. RESULTS: MMA caused a dose-dependent depression of the peak force (PF) and maximal rate of peak force (dF/dt-max). About a 30% depression of PF was shown at rested state (RS) contraction in rat myocardium and under low Na+ Tyrode's solution in guinea pig myocardium, respectively. In the 26 mM K+ Tyrode's solution, MMA caused dose-dependent depression of late force development without alteration in early force development. MMA depressed rapid cooling contracture accompanied by prolongation of time to peak contracture. MMA did not alter the amplitude or maximum depolarization rate of normal and slow action potentials. Action potential durations were significantly reduced. In patch clamp studies, MMA reduced ICa in a dose-dependent manner. CONCLUSIONS: MMA depressed cardiac contractility in a dose-dependent manner and may be partly related to the depression of Ca2+ influx through the cardiac membrane. SR Ca2+ release seems to be mildly inhibited by MMA. Based on common clinical concentrations, the direct myocardial depressant effect of MMA may not be a main cause of hypotension during an operation.