Cardiac dysfunction in septic shock Observational studies on characteristics and outcome
Abstract: Background: Cardiac dysfunction is a well-known complication of sepsis, but its characteristics and consequences, especially on a longer term, remain unclear. The aim of this thesis was to study the characteristics and the implications of cardiac dysfunction for outcome in intensive care unit (ICU) patients with septic shock.Purpose: First, to assess the ability of a cardiac biomarker to predict outcome in ICU patients. Second, to characterise cardiac dysfunction in septic shock using speckle tracking echocardiography. Third, to investigate the reliability of echocardiographic methods used to describe cardiac dysfunction in septic shock. Fourth, to study long-term cardiac outcome in severe sepsis and septic shock patients.Materials and methods: The cardiac biomarker amino-terminal pro-brain natriuretic peptide (NTproBNP) was collected in 481 patients on ICU admission and its ability to predict death was assessed. In 50 patients with septic shock, echocardiography was performed on ICU admission and was repeated during and after ICU stay. Measurements of cardiac strain using speckle tracking echocardiography were assessed in relation to other echocardiographic function parameters, NT-proBNP and severity of illness scores, and their change over time was analysed. Echocardiograms from patients with septic shock were independently evaluated by two physicians and the results analysed regarding measurement variability. A nationwide-registry-based open cohort of 9,520 severe sepsis and septic shock ICU patients discharged alive from the ICU was analysed together with a non-septic control group matched for age, sex and severity of illness. In patients who died after ICU discharge, information on causes of death was collected.Results: A discriminatory level of significance of NT-proBNP on ICU admission was identified at ≥1,380 ng/L, above which NT-proBNP was an independent predictor of death. With increasing levels of NT-proBNP, patients were more severely ill, had a longer ICU stay and were more often admitted with septic shock. Cardiac strain was frequently impaired in septic shock patients but was not superior to other echocardiographic measurements in detecting cardiac dysfunction. Cardiac strain correlated with other echocardiographic function parameters and with NT-proBNP, and was the least user-dependent echocardiographic parameter in septic shock patients. Cardiac strain remained unchanged over time, did not differ between survivors and non-survivors and could not predict an increased risk of death. During a follow-up of up to nearly 6 years after ICU discharge, 3,954 (42%) of sepsis patients died, 654 (17%) with cardiac failure as the cause of death. With increasing severity of illness on admission, the risk of death with cardiac failure as the cause of death after ICU discharge increased. In comparison to other ICU patients with similar severity of illness, however, the risk of death due to cardiac was not increased in patients with severe sepsis or septic shock.Conclusions: Laboratory or echocardiographic signs of cardiac dysfunction are commonly seen in ICU patients in general and in septic shock patients in particular. The assessment of cardiac dysfunction in patients with septic shock is, however, complicated by pre-existing comorbidities, by treatment given in the ICU and by critical illness in itself. Signs of cardiac dysfunction, and the increasing risk of death related to cardiac failure seen after remission of sepsis, may therefore be reflections of critical illness per se, rather than of sepsis.
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