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Septic Shock and Hemodynamic Management

  • Fabio Guarracino
  • Giulia Brizzi
  • Rubia Baldassarri
Chapter

Abstract

Sepsis has recently been defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. Initial management, as defined by the Surviving Sepsis Guidelines (SSG), consists of source control, early broad-spectrum antibiotics, and hemodynamic stabilization.

Hemodynamic instability can persist following fluid resuscitation. Although circulatory dysfunction is considered the main determinant of hemodynamic instability in septic shock, the presence of a coexisting cardiac dysfunction may play a very important role in the pathogenesis of hemodynamic failure and response to treatment. Septic shock is characterized by hypotension with important peripheral vasodilatation; therefore a possible cardiopathy might not be immediately recognized (Guarracino et al., Crit Care 18(2):R80, 2014). In septic shock sepsis-induced myocardium depression is the main cause of cardiac dysfunction even though, in the critically ill patient, it is not uncommon that a cardiogenic shock preexisted the septic shock. The circulatory dysfunction results in the maldistribution of blood flow and oxygen supply to the various organs with consequent cellular damage.

The complexity of septic shock from a hemodynamic point of view requires careful evaluation before starting the treatments. In this scenario, the combination of pathophysiological information provided by echocardiography with those from traditional hemodynamic monitoring allows the clinician to manage the resuscitation in the critical patient with septic shock in a more “tailored” way.

Keywords

Sepsis Septic shock Cardiovascular function Pathophysiology Resuscitation Volume Vasopressors Ventriculo-arterial coupling Arterial elastance Ventricular elastance Hemodynamics 

References

  1. 1.
    Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, Bellomo R, Bernard GR, Chiche JD, Coopersmith CM, Hotchkiss RS, Levy MM, Marshall JC, Martin GS, Opal SM, Rubenfeld GD, van der Poll T, Vincent JL, Angus DC. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801–10.  https://doi.org/10.1001/jama.2016.0287.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, Kumar A, Sevransky JE, Sprung CL, Nunnally ME, Rochwerg B, Rubenfeld GD, Angus DC, Annane D, Beale RJ, Bellinghan GJ, Bernard GR, Chiche JD, Coopersmith C, De Backer DP, French CJ, Fujishima S, Gerlach H, Hidalgo JL, Hollenberg SM, Jones AE, Karnad DR, Kleinpell RM, Koh Y, Lisboa TC, Machado FR, Marini JJ, Marshall JC, Mazuski JE, McIntyre LA, McLean AS, Mehta S, Moreno RP, Myburgh J, Navalesi P, Nishida O, Osborn TM, Perner A, Plunkett CM, Ranieri M, Schorr CA, Seckel MA, Seymour CW, Shieh L, Shukri KA, Simpson SQ, Singer M, Thompson BT, Townsend SR, Van der Poll T, Vincent JL, Wiersinga WJ, Zimmerman JL, Dellinger RP. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017;43(3):304–77.  https://doi.org/10.1007/s00134-017-4683-6.CrossRefPubMedGoogle Scholar
  3. 3.
    Kakihana Y, Ito T, Nakahara M, Yamaguchi K, Yasuda T. Sepsis-induced myocardial dysfunction: pathophysiology and management. J Intensive Care. 2016;4:22.  https://doi.org/10.1186/s40560-016-0148-1.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Zhang Z, Hong Y, Smischney NJ, Kuo HP, Tsirigotis P, Rello J, Kuan WS, Jung C, Robba C, Taccone FS, Leone M, Spapen H, Grimaldi D, Van Poucke S, Simpson SQ, Honore PM, Hofer S. Caironi PEarly management of sepsis with emphasis on early goal directed therapy: AME evidence series 002. J Thorac Dis. 2017;9(2):392–405.  https://doi.org/10.21037/jtd.2017.02.10.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Guarracino F, Baldassarri R, Pinsky MR. Ventriculo-arterial decoupling in acutely altered hemodynamic states. Crit Care. 2013;17(2):213.  https://doi.org/10.1186/cc12522.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Guarracino F, Ferro B, Morelli A, Bertini P, Baldassarri R, Pinsky MR. Ventriculoarterial decoupling in human septic shock. Crit Care. 2014;18(2):R80.  https://doi.org/10.1186/cc13842.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Margaret M. Parker, (1984) Profound but Reversible Myocardial Depression in Patients with Septic Shock. Annals of Internal Medicine 100 (4):483CrossRefGoogle Scholar
  8. 8.
    Bianchi ME. DAMPs, PAMPs and alarmins: all we need to know about danger. J Leukoc Biol. 2007;81:1–5.CrossRefGoogle Scholar
  9. 9.
    Pulido JN, Afessa B, Masaki M, Yuasa T, Gillespie S, Herasevich V, Brown DR, Oh JK. Clinical spectrum, frequency, and significance of myocardial dysfunction in severe sepsis and septic shock. Mayo Clin Proc. 2012;87(7):620–8.  https://doi.org/10.1016/j.mayocp.2012.01.018.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Pinsky MR. Both perfusion pressure and flow are essential for adequate resuscitation. Sepsis. 2000;4:143–6.CrossRefGoogle Scholar
  11. 11.
    Vieillard-Baron A. Septic cardiomyopathy. Ann Intensive Care. 2011;1:6.CrossRefGoogle Scholar
  12. 12.
    Guarracino F, Ferro B, Forfori F, Bertini P, Magliacano L, Pinsky MR. Jugular vein distensibility predicts fluid responsiveness in septic patients. Crit Care. 2014;18(6):647.  https://doi.org/10.1186/s13054-014-0647-1.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Fabio Guarracino
    • 1
  • Giulia Brizzi
    • 1
  • Rubia Baldassarri
    • 1
  1. 1.Department of Anaesthesia and Critical Care Medicine, Cardiothoracic and Vascular Anaesthesia and Critical CareAzienda Ospedaliero Universitaria PisanaPisaItaly

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