Critical Care: Sepsis I |

Diastolic Dysfunction in Septic Shock: Insights From Echocardiography FREE TO VIEW

Sagger Mawri, MD; Muhammad Yasser Alsafadi, MD; Tarun Jain, MEd; Waleed Al-Darzi; Jainil Shah, MD; Alexander Michaels, MD; Joseph Gibbs, MD; George Dirani, MD; Derar Albashaireh, MD; Karthik Ananthasubramaniam, MD
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Henry Ford Hospital, Detroit, MI

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):355A. doi:10.1016/j.chest.2016.08.368
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SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM

PURPOSE: Septic shock (SS) is a leading cause of intensive care unit (ICU) morbidity and mortality. It remains unclear what the correlation is between diastolic dysfunction severity and clinical outcomes in SS. Furthermore, whether sepsis causes transient diastolic dysfunction or whether diastolic dysfunction is a preceding condition has never been studied.

METHODS: We retrospectively studied 248 consecutive patients who were admitted to the ICU with SS from January 2011 to April 2013. Comprehensive baseline demographic, clinical and echocardiographic data was obtained at time of ICU admission. Multivariable logistic regression model was used to identify independent clinical and systolic/diastolic TTE predictors of mortality during ICU stay. Diastolic dysfunction (DD) was graded using echocardiographic Doppler variables, designated as normal, mild (grade I), moderate (grade II) or severe (grade III) dysfunction. The association between diastolic grade and clinical outcomes was done using Fisher’s exact test. A cohort of patients from our initial SS database with prior TTE within one year of ICU admission were then identified. Paired t-test was used to assess for differences in pre versus post-SS echocardiographic parameters.

RESULTS: Among the 248 patients (mean age, 64.9 ± 18 years; 51% men), there was 23% mortality in the ICU. Baseline demographics were similar between survivors and deceased patients. Multivariate analysis revealed the following three independent predictors of ICU mortality: ratio of mitral E wave to early diastolic velocity of medial mitral annulus (E/e’) (OR: 1.04, 95% CI: 1.0-1.08, p<0.05), APACHE II score (OR: 1.07, 95% CI: 1.0-1.1, p<0.05) and lactate levels (OR: 1.37, 95% CI: 1.2-1.6, p<0.05). 32% had normal diastolic function, 47% had grade I dysfunction and 19% had grade II dysfunction. There was an incremental increase in ICU mortality with higher grades of diastolic dysfunction; however, this trend did not reach significance (p=0.36). Compared to pre-SS, TTEs during SS demonstrated significantly higher E/e’ medial annulus (16.15 ± 12.44 and 21.04 ± 16.35; p = 0.048). There were no other statistically significant differences in diastolic dysfunction parameters.

CONCLUSIONS: Elevated E/e’, reflection of left ventricular filling pressures, is associated with poor outcomes in SS patients. Severity of diastolic dysfunction by grade appears to correlate with increased early mortality in SS; however, larger sized studies are needed verify the statistical significance of this observed trend. Furthermore, while evidence of pre-existing diastolic dysfunction is found pre SS, we note significant progression of DD as a consequence of SS.

CLINICAL IMPLICATIONS: Our study highlights the potential useful role of echocardiography in determining diastolic dysfunction which may be used in the risk stratification of critically ill patients admitted to the ICU with septic shock (SS). Furthermore, it suggests that rather than simply a transient consequence of SS, diastolic dysfunction precedes SS and appears to trend towards worse outcomes.

DISCLOSURE: The following authors have nothing to disclose: Sagger Mawri, Muhammad Yasser Alsafadi, Tarun Jain, Waleed Al-Darzi, Jainil Shah, Alexander Michaels, Joseph Gibbs, George Dirani, Derar Albashaireh, Karthik Ananthasubramaniam

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