Shane M. Gillespie

Clinical Spectrum, Frequency, and Significance of Myocardial Dysfunction in Severe Sepsis and Septic Shock

OBJECTIVE To determine the frequency and spectrum of myocardial dysfunction in patients with severe sepsis and septic shock using transthoracic echocardiography and to evaluate the impact of the myocardial dysfunction types on mortality. PATIENTS AND METHODS A prospective study of 106 patients with severe sepsis or septic shock was conducted from August 1, 2007, to January 31, 2009. All patients underwent transthoracic echocardiography within 24 hours of admission to the intensive care unit. Myocardial dysfunction was classified as left ventricular (LV) diastolic, LV systolic, and right ventricular (RV) dysfunction. Frequency of myocardial dysfunction was calculated, and demographic, hemodynamic, and physiologic variables and mortality were compared between the myocardial dysfunction types and patients without cardiac dysfunction. RESULTS The frequency of myocardial dysfunction in patients with severe sepsis or septic shock was 64% (n=68). Left ventricular diastolic dysfunction was present in 39 patients (37%), LV systolic dysfunction in 29 (27%), and RV dysfunction in 33 (31%). There was significant overlap. The 30-day and 1-year mortality rates were 36% and 57%, respectively. There was no difference in mortality between patients with normal myocardial function and those with left, right, or any ventricular dysfunction. CONCLUSION Myocardial dysfunction is frequent in patients with severe sepsis or septic shock and has a wide spectrum including LV diastolic, LV systolic, and RV dysfunction types. Although evaluation for the presence and type of myocardial dysfunction is important for tailoring specific therapy, its presence in patients with severe sepsis and septic shock was not associated with increased 30-day or 1-year mortality.

Outcome prediction in sepsis: Speckle tracking echocardiography based assessment of myocardial function

IntroductionSpeckle tracking echocardiography (STE) is a relatively novel and sensitive method for assessing ventricular function and may unmask myocardial dysfunction not appreciated with conventional echocardiography. The association of ventricular dysfunction and prognosis in sepsis is unclear. We sought to evaluate frequency and prognostic value of biventricular function, assessed by STE in patients with severe sepsis or septic shock.MethodsOver an eighteen-month period, sixty patients were prospectively imaged by transthoracic echocardiography within 24 hours of meeting severe sepsis criteria. Myocardial function assessment included conventional measures and STE. Association with mortality was assessed over 12 months.ResultsMortality was 33% at 30 days (n = 20) and 48% at 6 months (n = 29). 32% of patients had right ventricle (RV) dysfunction based on conventional assessment compared to 72% assessed with STE. 33% of patients had left ventricle (LV) dysfunction based on ejection fraction compared to 69% assessed with STE. RV free wall longitudinal strain was moderately associated with six-month mortality (OR 1.1, 95% confidence interval, CI, 1.02-1.26, p = 0.02, area under the curve, AUC, 0.68). No other conventional echocardiography or STE method was associated with survival. After adjustment (for example, for mechanical ventilation) severe RV free wall longitudinal strain impairment remained associated with six-month mortality.ConclusionSTE may unmask systolic dysfunction not seen with conventional echocardiography. RV dysfunction unmasked by STE, especially when severe, was associated with high mortality in patients with severe sepsis or septic shock. LV dysfunction was not associated with survival outcomes.

Urgent Ultrasound-Guided Bilateral Stellate Ganglion Blocks in a Patient With Medically Refractory Ventricular Arrhythmias.

Objectives:To describe the successful treatment of medically refractory ventricular arrhythmias in the ICU with ultrasound-guided bilateral stellate ganglion blocks. Data Sources:The data were gathered from the medical record. Study Selection:This case was selected as it describes the use of ultrasound in the successful termination of a recurrent, malignant arrhythmia, rather than fluoroscopy, to perform bilateral stellate ganglion blocks at the patient’s bedside in the ICU. Data Extraction:The data were extracted from the medical record. Data Synthesis:The data were synthesized from the patient’s medical record. Conclusions:Performance of stellate ganglion blocks at the bedside in the ICU is feasible for patients who are suffering from refractory ventricular arrhythmias. This potentially life-saving block can be performed using ultrasound guidance, sparing the patient transport to a fluoroscopy suite.

Left Main Coronary Artery Compression following Melody Pulmonary Valve Implantation: Use of Impella Support as Rescue Therapy and Perioperative Challenges with ECMO

The purpose of this case is to describe the complex perioperative management of a 30-year-old woman with congenital heart disease and multiple resternotomies presenting with pulmonary homograft dysfunction and evaluation for percutaneous pulmonary valve replacement. Transvenous, transcatheter Melody valve placement caused left main coronary artery occlusion and cardiogenic shock. An Impella ventricular assist device (VAD) provided rescue therapy during operating room transport for valve removal and pulmonary homograft replacement. ECMO support was required following surgery. Several days later during an attempted ECMO wean, her hemodynamics deteriorated abruptly. Transesophageal and epicardial echocardiography identified pulmonary graft obstruction, requiring homograft revision due to large thrombosis. This case illustrates a role for Impella VAD as bridge to definitive procedure after left coronary occlusion and describes management of complex perioperative ECMO support challenges.

Images in Anesthesiology: Spontaneous Hyphema after Cardiac Surgery.

1186 November 2015 T he anterior chamber of the eye, bordered by the iris and lens posteriorly and cornea anteriorly, normally contains clear aqueous humor. hyphema (fig. A), or blood grossly visible in the anterior chamber, may cause permanent vision loss and most commonly occurs after ocular trauma. Spontaneous (nontraumatic) hyphema may arise from underlying bleeding disorders, anticoagulation/antiplatelet medications, vascular malformations, ocular abnormalities, closed-angle glaucoma, sickle cell anemia, acute leukemia, rheumatologic disorders, or lymphoma.1–3 Rarely, spontaneous hyphema may present after nonophthalmic surgery (fig. A), perhaps as a result of intraoperative heparinization, coagulopathy, severe hypertension, or during emergence from anesthesia.1 Patients with spontaneous hyphema commonly present with vision loss; however, careful physical examination (fig. B) may be the only indication of its presence in mechanically ventilated and sedated patients after interventions such as cardiac surgery. After spontaneous hyphema diagnosis postoperatively, prompt ophthalmologic consultation and examination should be sought to rule out open globe injury and other ocular conditions such as microbial keratitis, iris neovascularization, iritis, uveitis, and retinoblastoma.2,3 Management includes head elevation facilitating hyphema clearance (typically occurring in about 1 week), coagulopathy correction, medical treatment of intraocular hypertension if present, eye shield use, analgesia, and antiemetic therapy as required to mitigate intraocular pressure increases. Intraocular pressure should be serially monitored by tonometry only after open globe injury has been excluded. Need for surgical hyphema evacuation is based on the presence of intraocular hypertension, secondary hemorrhage, or large nonresolving hyphemas. Poor visual prognosis is associated with large hyphemas, rebleeding, intraocular hypertension, or underlying conditions such as sickle cell anemia.

Three-Dimensional Echocardiographic Assessment of Mitral Annular Physiology in Patients With Degenerative Mitral Valve Regurgitation Undergoing Surgical Repair: Comparison between Early- and Late-Stage Severe Mitral Regurgitation

Background: Ventricular‐annular decoupling is thought to exist in all degenerative myxomatous mitral valve (MV) diseases. However, the annular physiology of degenerative MV disease may differ when severe mitral regurgitation (MR) presents at different stages. The aim of this study was to assess differences in mitral annular physiology and surgical effects between early‐ and late‐stage severe MR. Methods: Three‐dimensional (3D) transesophageal echocardiography was performed before and after MV surgery in 74 patients with degenerative MV disease, including 57 with early‐stage severe MR (without left ventricular remodeling) and 17 with late‐stage MR (with left ventricular remodeling). A control group comprised 46 patients without MV disease. Novel 3D MV software was used to evaluate mitral annular dynamics. The degree of annular saddle shape was calculated as the ratio of annular height (AH) to lateromedial diameter (LM). Ventricular‐annular decoupling was defined as insufficient systolic AH/LM compared with the control group. Results: Prebypass 3D measurements demonstrated that systolic AH/LM in the early‐stage group (0.19 ± 0.04) was similar to that in the control group (0.21 ± 0.05; P = .101), while systolic AH/LM in the late‐stage group (0.17 ± 0.04) was lower than that in the control group (P = .011). Postbypass comparison showed saddle shape accentuation in the early‐stage group (0.20 ± 0.04), similar to that in the control group (P = .3127); the mitral annulus remained flat in the late‐stage group (0.17 ± 0.03; P = .004). Conclusions: Ventricular‐annular decoupling, present in the late‐stage group, was absent in the early‐stage group. MV repair surgery did not disrupt mitral annular saddle shape in the early‐stage group; however, it failed to correct annular dysfunction in the late‐stage group. Sequential 3D transesophageal echocardiographic analysis provides comprehensive mitral annular evaluation beyond conventional two‐dimensional parameters for determining stages of severe MR. HIGHLIGHTSVentricular‐annular decoupling is thought to exist in all degenerative severe MR.Mitral annular saddle shape was compared between early‐ and late‐stage severe MR.Ventricular‐annular decoupling seen in late‐severe MR is absent in early‐stage MR.Surgery in early‐stage severe MR preserves mitral annular function.3D TEE provides full mitral annular evaluation which is beyond 2D parameters.

Whole-lung lavage in a patient with pulmonary alveolar proteinosis

Pulmonary alveolar proteinosis (PAP) is a rare syndrome in which phospholipoproteinaceous matter accumulates in the alveoli leading to compromised gas exchange. Whole-lung lavage is considered the gold standard for severe autoimmune PAP and offers favorable long-term outcomes. In this case report, we describe the perioperative management and procedural specifics of a patient undergoing WLL for PAP in which an anesthesiologist serves as the proceduralist and a separate anesthesiologist provides anesthesia care for the patient.

Impact of New-Onset Left Ventricular Dysfunction on Outcomes in Mechanically Ventilated Patients With Severe Sepsis and Septic Shock

Background: Left ventricular systolic dysfunction (LVSD) and LV diastolic dysfunction (LVDD) are commonly seen in severe sepsis and septic shock; however, their role in patients with concurrent invasive mechanical ventilation (IMV) is less well defined. Methods: This was a prospective observational study on all patients admitted to all the intensive care units (ICUs) at Mayo Clinic, Rochester from August 2007 to January 2009. All adult patients with severe sepsis and septic shock and concurrent IMV without prior heart failure underwent transthoracic echocardiography within 24 hours. Patients with active pregnancy, prior congenital or valvular heart disease, and prosthetic cardiac valves were excluded. Left ventricular systolic dysfunction was defined as LV ejection fraction (LVEF) <50% and LVDD as E/e′ >15. Primary outcome was hospital mortality, and secondary outcomes included IMV duration, ICU length of stay (LOS), and total LOS. Two-tailed P value of <.05 was considered statistically significant. Results: In a total of 106 patients, 58 (54.7%) met our inclusion criteria, with 17 (29.3%), 11 (19.0%), and 5 (8.6%) having LVSD, LVDD, and both, respectively. The cohorts with and without LVSD and LVDD did not differ significantly in their baseline characteristics and laboratory and ventilatory parameters. Compared to those without LVSD, patients with LVSD had higher LV end-systolic diameters but were not different in their left atrial diameters or E/e′ ratio. Patients with LVDD had a higher E velocity and E/e′ ratio compared to those without LVDD. Hospital mortality was not different in patients with and without LVSD (8 [47%] vs 21 [51%], P = 1.00) and LVDD (8 [73%] vs 21 [45%], P = .18). Secondary outcomes were not different between the 2 groups. Conclusion: Left ventricular systolic or diastolic dysfunction did not influence in-hospital outcomes in patients with severe sepsis and septic shock and concurrent IMV.

Quality Initiative to Reduce Benzodiazepine Use in a Cardiothoracic Intensive Care Unit

Delirium has been shown to increase the length of mechanical ventilation, intensive care unit (ICU) and hospital length of stay, and rates of post-discharge institutionalization and in-hospital mortality. The incidence of delirium in nonventilated patients in the ICU has been shown to be approximately 50%, and the incidence in ventilated patients is even higher at approximately 80%. Several risk factors have been associated with the development of delirium, including patient age, baseline cognitive impairment, severity of illness, history of alcoholism, elevated creatinine, hypertension, and benzodiazepine use. The majority of these characteristics are patient associated and difficult to intervene on with the exception of benzodiazepine administration. Benzodiazepines can be used as a sedative during mechanical ventilation and as a treatment for agitation in both ventilated and nonventilated patients. The ideal agent for sedation is not known, but there is evidence that propofol and dexmedetomidine may be associated with reduced delirium and potentially improved outcomes. Although these drugs have excellent sedative effects, both have hemodynamic effects that may be unfavorable. Once delirium has occurred, both pharmacologic and nonpharmacologic techniques are important. Benzodiazepines have been used in patients with delirium, but there is no evidence that this class of drugs is useful for delirium treatment and has been shown to be a risk factor for delirium development. Antipsychotics, although they do not prevent delirium, may decrease the duration of delirium after occurrence. Decreasing the use of benzodiazepines through education of acceptable alternatives may decrease the