ABSTRACT
PURPOSE: Mechanisms of circulatory failure are complex and frequently intricate in septic shock. Better characterization could help to optimize hemodynamic support. METHODS: Two published prospective databases from 12 different ICUs including echocardiographic monitoring performed by a transesophageal route at the initial phase of septic shock were merged for post hoc analysis. Hierarchical clustering in a principal components approach was used to define cardiovascular phenotypes using clinical and echocardiographic parameters. Missing data were imputed. FINDINGS: A total of 360 patients (median age 64 [55; 74]) were included in the analysis. Five different clusters were defined: patients well resuscitated (cluster 1, n = 61, 16.9%) without left ventricular (LV) systolic dysfunction, right ventricular (RV) failure or fluid responsiveness, patients with LV systolic dysfunction (cluster 2, n = 64, 17.7%), patients with hyperkinetic profile (cluster 3, n = 84, 23.3%), patients with RV failure (cluster 4, n = 81, 22.5%) and patients with persistent hypovolemia (cluster 5, n = 70, 19.4%). Day 7 mortality was 9.8%, 32.8%, 8.3%, 27.2%, and 23.2%, while ICU mortality was 21.3%, 50.0%, 23.8%, 42.0%, and 38.6% in clusters 1, 2, 3, 4, and 5, respectively (p < 0.001 for both). CONCLUSION: Our clustering approach on a large population of septic shock patients, based on clinical and echocardiographic parameters, was able to characterize five different cardiovascular phenotypes. How this could help physicians to optimize hemodynamic support should be evaluated in the future.
Subject(s)
Echocardiography/statistics & numerical data , Aged , Echocardiography/methods , Female , Hemodynamics/physiology , Humans , Intensive Care Units/organization & administration , Intensive Care Units/statistics & numerical data , Male , Middle Aged , Organ Dysfunction Scores , Prospective Studies , Shock, Septic , Simplified Acute Physiology Score , Statistics, Nonparametric , Stroke VolumeABSTRACT
Mean systemic filling pressure (Pms) defines the pressure measured in the venous-arterial system when the cardiac output is nil. Its estimation has been proposed in patients with beating hearts by building the venous return curve, using different pairs of right atrial pressure/cardiac output during mechanical ventilation. We raised the hypothesis according to which the Pms is altered by tidal ventilation and positive end-expiratory pressure (PEEP), which would challenge this extrapolation method based on cardiopulmonary interactions. We conducted a two-center, noninterventional, observational, and prospective study, using an arterial and a venous catheter to measure the pressure in the circulatory system at the time of death in critically ill, mechanically ventilated patients with a PEEP. Arterial (Part) and venous pressures (Pra) were recorded in five conditions: at end expiration and end inspiration with and without PEEP and finally once the ventilator was disconnected. Part and Pra did not differ in any experimental conditions. Tidal ventilation increased Pra and Part by 2.4 and 1.9 mmHg, respectively, whereas PEEP increased both values by 1.2 and 1 mmHg, respectively. After disconnection of the ventilator, Pra and Part were 10.0 ± 4.2 and 9.9 ± 4.2 mmHg, respectively. Pms increases during mechanical ventilation, with an effect of tidal ventilation and PEEP. This calls into question the validity of its evaluation in heart-beating patients using cardiopulmonary interactions during mechanical ventilation.NEW & NOTEWORTHY The physiology of the mean systemic filling pressure (Pms) is not well understood in human beings. This study is the first report of a tidal ventilation- and positive end-expiratory pressure-related increase in Pms in critically ill patients. The results challenge the utility and the value estimating Pms in heart-beating patients by reconstruction of the venous return curve using varying inflation pressures.
Subject(s)
Venous Pressure/physiology , Aged , Arteries/physiology , Blood Volume/physiology , Cardiac Output/physiology , Critical Illness , Female , Humans , Intermittent Positive-Pressure Ventilation/methods , Male , Positive-Pressure Respiration/methods , Prospective Studies , Respiration, Artificial/methods , Veins/physiologySubject(s)
Endocarditis/complications , Pulmonary Artery/diagnostic imaging , Shock, Septic/etiology , Aged , Cardiac Surgical Procedures/adverse effects , Endocarditis/diagnosis , Foreign Bodies/diagnostic imaging , Humans , Male , Postoperative Complications , Staphylococcus aureus/isolation & purificationABSTRACT
Acute respiratory distress syndrome (ARDS) remains associated with a poor outcome despite recent major therapeutic advances. Forecasting the outcome of patients suffering from such a syndrome is of a crucial interest and many scores have been proposed, all suffering from limits responsible for important discrepancies. Authors try to elaborate simple, routine and reliable scores but most of them do not consider hemodynamics yet acknowledged as a major determinant of outcome. This article aims at reminding the approach of scoring in ARDS and at deeply describing the most recently published one in order to highlight their main pitfall, which is to forget the hemodynamics.
