Persistent preload defect in severe sepsis despite fluid loading - A longitudinal echocardiographic study in patients with septic shock

Study objective: To investigate the rate of recovery from septic shock in p atients with suspected left ventricular (LV) preload deficiency and LV syst olic dysfunction. Design: A monitoring period was defined by the need for inotropic/vasopress or support, and LV function nas assessed daily during this period by bedsid e two-dimensional echocardiography (BD-ECHO). Setting: University hospital ICU. Patients: During a 5-year period, 90 patients with an episode of septic sho ck (60% with gram-positive bacteria as the causative agent) were consecutiv ely enrolled in the study (mean age, 55 +/- 18 years). Standard volume resu scitation combined with inotropic/vasopressor support was used to maintain systolic arterial pressure >90 mm Hg. All patients received mechanical vent ilation because of associated respiratory failure. The average duration of hemodynamic support was 4.4 +/- 11.6 days. Thirty-four patients were weaned from hemodynamic support during the monitoring period and ultimately recov ered (group I). Twenty-eight patients died from refractory circulatory fail ure during the monitoring period, and 28 died later from ARDS or multiple o rgan dysfunction syndrome, lending to a 62% overall mortality rate (group I I), Methods: Daily bedside LV volumes and ejection fraction (LVEF) were recorde d using ED-ECHO. Data obtained at the start (day 1 and day 2) and end of th e monitoring period (day n) were compared, Results: LV end-diastolic volume was within the normal range of our laborat ory values in all patients, but nas initially smaller in group II than in g roup I, and remained so despite fluid loading, LVEF was significantly depre ssed in all patients, resulting in severe reduction in LV stroke volume (LV SV), which was initially more marked in group I. In group I patients, LVEF significantly improved during die monitoring period, resulting in an increa se in LVSV. Conclusion: ED-ECHO changes during hemodynamic support in 90 septic patient s confirmed defective LV preload with a propensity to worsen despite fluid loading in nonsurvivors (62% in the present study). Our results are also in agreement with previous studies reporting depressed LV systolic function a t the initial phase of septic shock Since LV dysfunction was more marked in patients who recovered, we suggest that the exact significance of this fin ding should be reevaluated.