[show abstract][hide abstract] ABSTRACT: Dermatomyositis is a chronic inflammatory disorder characterized by muscular and dermatologic symptoms with variable internal organ involvement. This is the first report on a patient with acute dermatomyositis and fulminant systemic capillary leak syndrome.
A 69-year-old Caucasian woman with chronic dermatomyositis presented with clinical signs of severe hypovolemic shock and pronounced hemoconcentration (hematocrit, 69%). Her colloid osmotic pressure was 4.6mmHg. Following a bolus dose of prednisolone (500mg), fluid resuscitation was initiated. During volume loading, anasarca and acute respiratory distress rapidly developed. Echocardiography revealed an underfilled, hypokinetic, diastolic dysfunctional left ventricle with pericardial effusion but no signs of tamponade. Despite continued fluid resuscitation and high-dosed catecholamine therapy, the patient died from refractory shock 12 hours after intensive care unit admission. A laboratory analysis of her complement system suggested the presence of C1 inhibitor deficiency as the cause for systemic capillary leakage. The post-mortem examination revealed bilateral pleural, pericardial and peritoneal effusions as well as left ventricular hypertrophy with patchy myocardial fibrosis. Different patterns of endomysial/perimysial lymphocytic infiltrations adjacent to degenerated cardiomyocytes in her myocardium and necrotic muscle fibers in her right psoas major muscle were found in the histological examination.
This case report indicates that acute exacerbation of chronic dermatomyositis can result in a fulminant systemic capillary leak syndrome with intense hemoconcentration, hypovolemic shock and acute heart failure. In the presented patient, the cause for diffuse capillary leakage was most probably acquired angioedema, a condition that has been associated with both lymphoproliferative and autoimmunologic disorders.
[show abstract][hide abstract] ABSTRACT: Ventricular torsion is an important component of cardiac function. The effect of septic shock on left ventricular torsion is not known. Because torsion is influenced by changes in preload, we compared the effect of fluid loading on left ventricular torsion in septic shock with the response in matched healthy control subjects.
We assessed left ventricular torsion parameters using transthoracic echocardiography in 11 patients during early septic shock and in 11 age- and sex-matched healthy volunteers before and after rapid volume loading with 250 mL of a Ringer's lactate solution.
Peak torsion and peak apical rotation were reduced in septic shock (10.2 ± 5.2° and 5.6 ± 5.4°) compared with healthy volunteers (16.3 ± 4.5° and 9.6 ± 1.5°; P = 0.009 and P = 0.006 respectively). Basal rotation was delayed and diastolic untwisting velocity reached its maximum later during diastole in septic shock patients than in healthy volunteers (104 ± 16% vs 111 ± 14% and 13 ± 5% vs 21 ± 10%; P = 0.03 and P = 0.034, respectively). Fluid challenge increased peak torsion in both groups (septic shock, 10.2 ± 5.3° vs 12.6 ± 3.9°; healthy volunteers, 16.3 ± 4.5° vs 18.1 ± 6°; P = 0.01). Fluid challenge increased left ventricular stroke volume in septic shock patients (P = 0.003).
Compared with healthy volunteers, left ventricular torsion is impaired in septic shock patients. Fluid loading attenuates torsion abnormalities in parallel with increasing stroke volume. Reduced torsional motion might constitute a relevant component of septic cardiomyopathy, a notion that merits further testing in larger populations.
The Canadian journal of cardiology 12/2013; 29(12):1665-1671. · 3.12 Impact Factor
[show abstract][hide abstract] ABSTRACT: Definitions of shock and resuscitation endpoints traditionally focus on blood pressures and cardiac output. This carries a high risk of overemphasizing systemic hemodynamics at the cost of tissue perfusion. In line with novel shock definitions and evidence of the lack of a correlation between macro- and microcirculation in shock, we recommend that macrocirculatory resuscitation endpoints, particularly arterial and central venous pressure as well as cardiac output, be reconsidered. In this viewpoint article, we propose a three-step approach of resuscitation endpoints in shock of all origins. This approach targets only a minimum individual and context-sensitive mean arterial blood pressure (for example, 45 to 50 mm Hg) to preserve heart and brain perfusion. Further resuscitation is exclusively guided by endpoints of tissue perfusion irrespectively of the presence of arterial hypotension ('permissive hypotension'). Finally, optimization of individual tissue (for example, renal) perfusion is targeted. Prospective clinical studies are necessary to confirm the postulated benefits of targeting these resuscitation endpoints.
Critical care (London, England) 10/2013; 17(5):326. · 4.72 Impact Factor
[show abstract][hide abstract] ABSTRACT: One of the rationales for the use of vasopressin in septic shock has been its potential cardioprotective mechanisms. Lower heart rates, higher arterial pressures, and fewer norepinephrine doses during vasopressin therapy were hypothesized to protect the heart from myocardial ischemia. In a prospective sub-study of the VASST (Vasopressin in Septic Shock Trial) project, Mehta and colleagues specifically evaluated this hypothesis but failed to find lower cardiac biomarkers or fewer ischemic electrocardiogram changes in patients receiving vasopressin compared with subjects receiving norepinephrine alone. After recent evidence of a lacking survival benefit, the present study results further challenge the future role of vasopressin as a vasopressor in septic shock.
Critical care (London, England) 10/2013; 17(5):1002. · 4.72 Impact Factor
[show abstract][hide abstract] ABSTRACT: PURPOSE: A heart rate >90 bpm serves as one of four characteristics defining the systemic inflammatory response syndrome and is used in scoring systems to predict in-hospital mortality of intensive care unit (ICU) patients. Despite its central role in critical illness, specific data regarding the relationship between heart rate and outcome are rare. METHODS: In this post hoc analysis of a prospectively collected database, we analyzed the value of heart rate averaged from four predefined time points during the last 24 h before ICU discharge as a predictor of post-ICU in-hospital and post-hospital mortality in medical ICU patients. Furthermore, the relationship between heart rate and inflammation, as well as the influence of rate control medications on the association between heart rate and outcome were identified. RESULTS: Among the 702 ICU patients discharged from the ICU, 7.1 % died before hospital discharge. At 4 years of follow-up, post-hospital mortality was 14.4 %. Multivariate Cox proportional hazards models revealed heart rate before ICU discharge (HR 5.95; 95 % CI 1.24-28.63; p = 0.03) as an independent predictor of post-ICU in-hospital mortality. Both heart rate (HR 2.56; 95 % CI, 1.05-6.34; p = 0.04) and the C-reactive protein serum concentration before ICU discharge (HR, 1.26; 95 % CI, 1.09-1.46; p = 0.002) were independently associated with post-hospital mortality. Heart rate control therapy reduced the risk of post-ICU in-hospital (HR 0.38; 95 % CI, 0.18-0.81; p = 0.01) and post-hospital (HR, 0.47; 95 % CI, 0.22-1.00; p = 0.05) mortality. CONCLUSION: Heart rate evaluated 24 h before ICU discharge was independently associated with post-ICU in-hospital and post-hospital mortality. Pharmacological interventions to control heart rate may beneficially influence post-ICU mortality.
Clinical Research in Cardiology 04/2013; · 3.67 Impact Factor
[show abstract][hide abstract] ABSTRACT: Myocardial depression in septic shock is well-known but its pathophysiological genesis is incompletely understood. To assess the incidence and extent of stress-induced histologic myocardial alterations in septic shock a prospective, observational, clinical and post-mortem study was conducted and twenty patients dying from septic shock were included. Exclusion criteria were <18 years, pregnancy, open heart surgery or cardiopulmonary resuscitation, acute neurologic diseases, pheochromocytoma, and forensic autopsy. A systematic macropathologic evaluation was performed. Nine predefined heart sections were histologically screened for myocytolysis, interstitial fibrosis, contraction band necrosis, mononuclear infiltrates, interstitial edema, and tissue hemorrhage. Stress-induced pathologies were found in 90-100% of patients in all heart sections (myocytolysis, 100%; interstitial fibrosis, 100%; contraction band necrosis, 95%; mononuclear infiltrates, 90%; interstitial edema, 90%; tissue hemorrhage, 30%). The incidence and extent of contraction band necrosis, mononuclear infiltrates, and myocytolysis did not differ between genders, patients with or without chronic ß-blocker, calcium-antagonist and/or statin premedication, or between the binary use of different catecholamine agents (all comparisons p>0.05). The maximum epinephrine dose correlated with the overall extent of mononuclear infiltrates (Spearman-Rho, r=0.704; p=0.05) and myocytolysis (Spearman-Rho, r=0.933; p=0.001). Maximum norepinephrine doses correlated with the extent of mononuclear infiltrates in the left ventricular anterior wall (Spearman-Rho, r=0.519; p=0.02). The total duration of catecholamine therapy was correlated with the extent of mononuclear infiltrates in the apex (Spearman-Rho, r=0.571; p=0.009) and right atrium (Spearman-Rho, r=0.535; p=0.02). In conclusion, our results suggest that histologic lesions potentially indicative of stress-induced cardiotoxicity can be observed in the majority of patients succumbing to septic shock.
[show abstract][hide abstract] ABSTRACT: Introduction
La torsion ventriculaire est une composante importante du fonctionnement cardiaque. On ne connaît pas l'effet du choc septique sur la torsion du ventricule gauche. Puisque les modifications en précharge influencent la torsion, nous avons comparé l'effet du remplissage sur la torsion du ventricule gauche lors de choc septique chez les témoins appariés en santé.
Nous avons évalué les paramètres de la torsion du ventricule gauche à l'aide de l'échocardiographie transthoracique chez 11 patients durant la phase précoce du choc septique et chez 11 volontaires en santé appariés selon l'âge et le sexe avant et après la charge volumique rapide de 250 ml d'une solution de Ringer lactate.
La torsion maximale et la rotation apicale maximale ont été réduites lors d'un choc septique (10,2 ± 5,2 et 5,6 ± 5,4) comparativement aux volontaires en santé (16,3 ± 4,5 et 9,6 ± 1,5; P = 0,009 et P = 0,006, respectivement). La rotation basale a été retardée et la vélocité de détorsion diastolique a atteint son maximum plus tard durant la diastole chez les patients ayant un choc septique que chez les volontaires en santé (104 ± 16 % vs 111 ± 14 % et 13 ± 5 % vs 21 ± 10 %; P = 0,03 et P = 0,034, respectivement). L'épreuve de remplissage a augmenté la torsion maximale dans les deux groupes (choc septique, 10,2 ± 5,3 vs 12,6 ± 3,9; volontaires en santé, 16,3 ± 4,5 vs 18,1 ± 6; P = 0,01). L'épreuve de remplissage a augmenté le volume d′éjection systolique du ventricule gauche chez les patients ayant un choc septique (P = 0,003).
Comparativement aux volontaires en santé, la torsion ventriculaire gauche est réduite chez les patients ayant un choc septique. Le remplissage atténue les anomalies de la torsion parallèlement à l'augmentation du volume d′éjection systolique. La réduction du mouvement de torsion pourrait être une composante pertinente de la cardiomyopathie septique. C'est une notion qui mérite d'autres études chez de plus vastes populations.
The Canadian journal of cardiology 01/2013; 29(12):1665–1671. · 3.12 Impact Factor
[show abstract][hide abstract] ABSTRACT: AIM OF THE STUDY: To evaluate the association between haemodynamic variables during the first 24hours after intensive care unit (ICU) admission and neurological outcome in out-of-hospital cardiac arrest (OHCA) victims undergoing therapeutic hypothermia. METHODS: In a multi-disciplinary ICU, records were reviewed for comatose OHCA patients undergoing therapeutic hypothermia. The hourly variable time integral of haemodynamic variables during the first 24hours after admission was calculated. Neurologic outcome was assessed at day 28 and graded as favourable or adverse based on the Cerebral Performance Category of 1-2 and 3-5. Bi- and multivariate regression models adjusted for confounding variables were used to evaluate the association between haemodynamic variables and functional outcome. RESULTS: 67/134 patients (50%) were classified as having favourable outcome. Patients with adverse outcome had a higher mean heart rate (73 [62-86] vs. 66 [60-78] bpm; p=0.04) and received noradrenaline more frequently (n=17 [25.4%] vs. n=9 [6%]; p=0.02) and at a higher dosage (128 [56-1004] vs. 13 [2-162] μg/h; p=0.03) than patients with favourable outcome. The mean perfusion pressure (mean arterial blood pressure minus central venous blood pressure) (OR=1.001, CI 95=1-1.003; p=0.04) and cardiac index time integral (OR=1.055, CI 95=1.003-1.109; p=0.04) were independently associated with adverse outcome at day 28. CONCLUSION: Mean perfusion pressure and cardiac index during the first 24hours after ICU admission were weakly associated with neurological outcome in an OHCA population undergoing therapeutic hypothermia. Further studies need to elucidate whether norepinephrine-induced increases in perfusion pressure and cardiac index may contribute to adverse neurologic outcome following OHCA.
[show abstract][hide abstract] ABSTRACT: Primary health care delivery in the developing world faces many challenges. Priority setting favours HIV, TB and malaria interventions. Little is known about the challenges faced in this setting with regard to critical care medicine. The aim of this study was to analyse and categorise the diagnosis and outcomes of 1,774 patients admitted to a hospital intensive care unit (ICU) in a low-income country over a 7-year period. We also assessed the country's ICU bed capacity and described the challenges faced in dealing with critically ill patients in this setting.
A retrospective audit was conducted in a general ICU in a university hospital in Uganda. Demographic data, admission diagnosis, and ICU length of stay were recorded for the 1,774 patients who presented to the ICU in the period January 2003 to December 2009. Their mean age was 35.5 years. Males accounted for 56.5% of the study population; 92.8% were indigenous, and 42.9% were referrals from upcountry units. The average mortality rate over the study period was 40.1% (n = 715). The highest mortality rate (44%) was recorded in 2004 and the lowest (33.2%) in 2005. Children accounted for 11.6% of admissions (40.1% mortality). Sepsis, ARDS, traumatic brain injuries and HIV related conditions were the most frequent admission diagnoses. A telephonic survey determined that there are 33 adult ICU beds in the whole country.
Mortality was 40.1%, with sepsis, head injury, acute lung injury and HIV/AIDS the most common admission diagnoses. The country has a very low ICU bed capacity. Prioritising infectious diseases poses a challenge to ensuring that critical care is an essential part of the health care package in Uganda.
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Exercise capacity in patients with dilated cardiomyopathy has low correlation to resting left ventricular function. Dysfunctional autonomic activity, cardiomechanics and inflammation are associated with exercise capacity but were investigated under inhomogeneous situations. It remains essentially unclear which factor mainly determines exercise capacity in dilated cardiomyopathy. METHODS: In a prospective, observational study in a narrow time frame we assessed clinically, inflammatory, hemodynamic and, autonomic parameters as well as echocardiographic measures to explore independent determinants of exercise capacity in 28 treated patients with dilated cardiomyopathy. RESULTS: Right ventricular end-diastolic diameter, tricuspid regurgitation velocity, and sympathovagal balance were independent determinants of exercise capacity (B coefficient, 69; CI 95 %, 15-122; p = 0.004); (B coefficient, - 226; CI 95 %, - 374 to - 79; p = 0.007) and (B coefficient, - 104; CI 95 %, - 172 to - 37), respectively. C-reactive protein, serum creatinin and body mass index were independently associated with right ventricular end-diastolic diameter (B coefficient, 0.34; CI 95 %, 0.12-0.56; p = 0.004); (B coefficient, 0.9; CI 95 %, 0.34-1.455; p = 0.003); and (B coefficient, 0.09; CI 95 %, 0.02-0.15; p = 0.01), respectively. CONCLUSIONS: In stable patients with dilated cardiomyopathy, autonomic modulation, and right ventricular dysfunction may be the most important determinants of exercise capacity, whereas inflammation, kidney dysfunction, and body mass index are independently associated with right ventricle remodeling.
Wiener klinische Wochenschrift 08/2012; · 0.81 Impact Factor
[show abstract][hide abstract] ABSTRACT: : Early treatment in sepsis may improve outcome. The aim of this study was to evaluate how the delay in starting resuscitation influences the severity of sepsis and the treatment needed to achieve hemodynamic stability.
: Prospective, randomized, controlled experimental study.
: Experimental laboratory in a university hospital.
: Thirty-two anesthetized and mechanically ventilated pigs.
: Pigs were randomly assigned (n = 8 per group) to a nonseptic control group or one of three groups in which fecal peritonitis (peritoneal instillation of 2 g/kg autologous feces) was induced, and a 48-hr period of protocolized resuscitation started 6 (ΔT-6 hrs), 12 (ΔT-12 hrs), or 24 (ΔT-24 hrs) hrs later. The aim of this study was to evaluate the impact of delays in resuscitation on disease severity, need for resuscitation, and the development of sepsis-associated organ and mitochondrial dysfunction.
: Any delay in starting resuscitation was associated with progressive signs of hypovolemia and increased plasma levels of interleukin-6 and tumor necrosis factor-α prior to resuscitation. Delaying resuscitation increased cumulative net fluid balances (2.1 ± 0.5 mL/kg/hr, 2.8 ± 0.7 mL/kg/hr, and 3.2 ± 1.5 mL/kg/hr, respectively, for groups ΔT-6 hrs, ΔT-12 hrs, and ΔT-24 hrs; p < .01) and norepinephrine requirements during the 48-hr resuscitation protocol (0.02 ± 0.04 μg/kg/min, 0.06 ± 0.09 μg/kg/min, and 0.13 ± 0.15 µg/kg/min; p = .059), decreased maximal brain mitochondrial complex II respiration (p = .048), and tended to increase mortality (p = .08). Muscle tissue adenosine triphosphate decreased in all groups (p < .01), with lowest values at the end in groups ΔT-12 hrs and ΔT-24 hrs.
: Increasing the delay between sepsis initiation and resuscitation increases disease severity, need for resuscitation, and sepsis-associated brain mitochondrial dysfunction. Our results support the concept of a critical window of opportunity in sepsis resuscitation.
Critical care medicine 08/2012; 40(10):2841-9. · 6.37 Impact Factor
[show abstract][hide abstract] ABSTRACT: To determine the incidence of and risk factors for adverse cardiac events during catecholamine vasopressor therapy in surgical intensive care unit patients with cardiovascular failure.
The occurrence of any of seven predefined adverse cardiac events (prolonged elevated heart rate, tachyarrhythmia, myocardial cell damage, acute cardiac arrest or death, pulmonary hypertension-induced right heart dysfunction, reduction of systemic blood flow) was prospectively recorded during catecholamine vasopressor therapy lasting at least 12 h.
Fifty-four of 112 study patients developed a total of 114 adverse cardiac events, an incidence of 48.2 % (95 % CI, 38.8-57.6 %). New-onset tachyarrhythmia (49.1 %), prolonged elevated heart rate (23.7 %), and myocardial cell damage (17.5 %) occurred most frequently. Aside from chronic liver diseases, factors independently associated with the occurrence of adverse cardiac events included need for renal replacement therapy, disease severity (assessed by the Simplified Acute Physiology Score II), number of catecholamine vasopressors (OR, 1.73; 95 % CI, 1.08-2.77; p = 0.02) and duration of catecholamine vasopressor therapy (OR, 1.01; 95 % CI, 1-1.01; p = 0.002). Patients developing adverse cardiac events were on catecholamine vasopressors (p < 0.001) and mechanical ventilation (p < 0.001) for longer and had longer intensive care unit stays (p < 0.001) and greater mortality (25.9 vs. 1.7 %; p < 0.001) than patients who did not.
Adverse cardiac events occurred in 48.2 % of surgical intensive care unit patients with cardiovascular failure and were related to morbidity and mortality. The extent and duration of catecholamine vasopressor therapy were independently associated with and may contribute to the pathogenesis of adverse cardiac events.
European Journal of Intensive Care Medicine 04/2012; 38(6):950-8. · 5.17 Impact Factor