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CASE SERIES: Resuscitation of septic shock: Case studies highlight the role of continuous noninvasive hemodynamic monitoring in influencing clinical decision-making
Introduction To Case One
16:00: An 81 year-old woman was admitted to the emergency department with nausea, vomiting and hypotension. She had a history of hypertension, Type II Diabetes, renal insufficiency and dementia.
Home medications: aspirin, furosemide, tolterodine tartrate, memantine, Valsartan, metformin, Lovastatin and niacin. On admission she presented with low grade fever 37.9, a blood pressure (BP) of 60/30 and heart rate (HR) of 130. Lab results on admission included: WBC 16.7k cells/ml, Hgb 9.2 gm/dl, creatinine 1.6 mg/dl, albumin 2.7 mg/dL, sodium 135 mEq/L and potassium 4.7 mEq/L. Abdominal CT was within normal limits (WNL).
The patient was treated with 2 liters of IV normal saline but her BP remained low. Dopamine was added and at a dose greater than 5mcg/kg/min her HR increased to 150 bpm and the dose was reduced to 3mcg/Kg/min. Dobutamine was added at 7mcg/kg/min. The patient was diagnosed with septic shock and admitted to the Intensive Care Unit (ICU).
Treatment plan was fluids, pressors as needed and antibiotic treatment.
21:30: Hemodynamic test with the NICOM was requested in the ICU in order to determine fluid responsiveness and help guide resuscitation. NICOM Passive Leg Raise (PLR) test results are summarized in Table 1 below (click to enlarge):
Table 1. PLR test results
The hemodynamic profile of high cardiac index and low TPRI are classical for septic shock. The hemodynamic responses to PLR were negative, with a 3.4% reduction in SV (Figure 1), suggesting that the patient was not fluid responsive. Subsequently, Dobutamine was weaned and CO and CI decreased to 5.4 L/min and 3.4 L/min/m2, respectively, with a slight increase in TPRI to 1154.
Impact On Clinical Management
Based on the negative PLR it was determined that the patient is not fluid responsive. Her CO was highly dependent on inotropic support and decreased dramatically when the inotropic therapy (dobutamine) was tapered. In the face of low blood pressure and lack of fluid responsiveness, vasopressors were added in order to increase peripheral resistance.
Specifically, dopamine was left at low dose (renal dosing), dobutamine was weaned off and norepinephrine was added at 2mcg/min. Antibiotic treatment was started. The patient’s BP immediately improved from around 80/40 mmHg to 110/60 mmHg with CO and CI stabilizing at 5.1 L/min and3.0 L/min/m2, respectively, with a TPRI of 1716 dynes*sec/cm5/m2.
Clinical Course
Norepinephrine and dopamine were completely weaned within 36hrs. Vital signs normalized, the patient was transferred out of ICU to a regular medical ward and eventually was discharged home.
Figure 1. Stroke volume index (SVI) following PLR
Introduction To Case Two
9:00: A A 69 year-old woman was admitted to the emergency department with fever, “burning abdominal pain” and hypotension. She had a history of coronary artery disease, Type II diabetes mellitus, and hypertension. At home she was treated with atenolol, simvastatin, ramipril, and hydrocortisone.
On admission she had BP ranging between 70/40 to 100/30, HR 90-100, temperature of 38.3°C. Lab results include WBC 11.3k cells/cc, Hgb 10.1 mg/dL, creatinine 0.62 mg/dl, BUN 14 mg/dL, sodium 143 mEq/L and potassium 3.4 mEq/L. Abdominal CT was within normal limits. The patient was treated with 1500cc IV fluids but remained hypotensive. Norepinephrine was started up to 8 mcg/min with little improvement in BP.
The patient was diagnosed with sepsis and admitted to the ICU.
10:00 the Next Morning: NICOM test was requested since the patient remained hypotensive despite norepinephrine treatment and addition of dopamine. Table 2 summarizes the baseline and post passive leg raise hemodynamic parameters.
Table 2. The baseline and post passive leg raise hemodynamic parameters
Similar to the patient in Case 1, this patient also exhibited a high resting CI and a low TPRI consistent with
the clinical diagnosis of sepsis. In contrast to Case 1, however, the PLR challenge induced a 50% increase
in cardiac index and 37% increase in SVI (Figure 2). The results of the PLR challenge implied that that
patient was extremely fluid responsive and would benefit from fluid resuscitation.
Impact On Clinical Management
The patient received IV normal saline, dopamine at 5mcg/kg/min and antibiotics.
Clinical Course
The patient improved rapidly following fluids and antibiotic treatment. After 36 hours (she was transferred to the floor and discharged from hospital three days later.
Figure 2. Stroke volume index (SVI) following PLR
Discussion
Both patients presented with similar clinical picture of sepsis and hypotension that was ineffectively
treated initial treatment plans (Table 3). As is common in patients with sepsis, the fluid status was unclear
in both cases.
in both cases.
Table 3.
Traditional therapy would call for titrating fluids and pressors based on blood pressures, central venous pressure and urine output. However, dynamic measurements of cardiac output and associated hemodynamic variables have been shown to provide better insight into fluid responsiveness and to more effectively guide titration of fluids and vasoactive medications.
In the cases presented, the PLR challenge with the NICOM uncovered very different conditions for two outwardly similar patients which ultimately drove resuscitation strategies. The first patient was not fluid responsive so resuscitation was based on pressors and inotropes. The second patient was highly fluid responsive which enabled appropriate resuscitation with fluids.
PLR is a bedside maneuver that mobilizes the equivalent of approximately 250 ml of blood sequestered in the calf veins mainly back to the heart. It is quick, safe and reversible. It provides information that very quickly helps to guide therapy. A positive PLR test (increase of ≥10% in SVI or CI) implies that there is sufficient cardiac reserve to pump the increased preload forward; in other words, a positive test indicates that the patient is on the ascending limb of the Starling curve.
For the first patient, the PLR challenge indicated that the two liters of fluids that the patient received were sufficient, and that this patient required pressors support until antibiotics could take effect.
For the second patient, the PLR challenge indicated that despite having received two liters of fluid, the patient was still significantly hypovolemic. Pressors were ineffective; additional fluid therapy could be administered safely and help steer this patient’s clinical course towards rapid recovery.
Cheetah Medical wishes to thank Mike Minehart, CRNA, Riverside Medical Center for contributing the cases
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