Traitement de la d

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Traitement de la défaillance cardiovasculaire du
sepsis Alexandre MebazaaDépartement
dAnesthésie-Réanimation-SMURHôpital
Lariboisière, Paris, France
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In patients with septic shock

• There is, by definition, a vascular dysfunction
  that needs treatment in 100 of the patients
• Myocardial dysfunction
• is likely present all those patients
• but only 15 need treatment with cardiac
  enhancing agents

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Vascular dysfunction
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Mechanisms of sepsis-induced vascular dysfunction

• Overexpression of vasodilating agent including
  nitric oxide (NO)
• Intracellular dysfunction, such as alteration in
  mitochondrial properties

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Endocardial and coronary endothelial cells in
LPS12h rats
NOS-2
COX-2
Mebazaa et al. Circulation,2001, 1043137
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Mechanisms of sepsis-induced vascular dysfunction

• Overexpression of vasodilating agent including
  nitric oxide (NO)
• Intracellular dysfunction such alteration in
  mitochondrial properties low VO2 and high mixed
  SvO2

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How to treat vascular dysfunction
?Norepinephrine (NE) is advised as the
first-line therapySCCM/ESICM guidelines
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Martin C. Crit Care Med 2000 28(8) 2758
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NE improves survival in patients with severe
sepsis
Survival
Days
Martin C. Crit Care Med 2000 28(8) 2758
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Aim of the study

• - To assess beneficial effect of NE on vascular
  bed
• - To evaluate what hemodynamic parameter may
  predict mortality in septic patients

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Hemodynamic effects of vascular dysfunction in
sepsis shock
n D-1 D0 p HR Max 41 11228 12426 lt0.001 (b/min)
SBP Min 68 9621 7717 lt0.001 (mmHg) DBP
Min 68 5112 4010 lt0.001 (mmHg) Diuresis 41 1180
1072 1041927 0.18 (ml/j) T Max 37 371 381 0.02
4 (C)
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EFFECT OF NOREPINEPHRINE ON HYPOVASCULAR
REACTIVITY
120
SBP
S
100
P lt 0.001
80
NS
60
S
mmHg
P lt 0.001
40
NS
20
DBP
0
D-1
D0
D1
D2
D3
D4
days
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Total dose of norepinephrine/day
NS
S
3
2.5
2
P lt0.001
1.5
1
0.5
0
D0
D1
D2
D3
D4
D5
days
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EFFECT OF NOREPINEPHRINE ON HYPOVASCULAR
REACTIVITY
120
SBP
S
100
P lt 0.001
80
NS
60
S
mmHg
P lt 0.001
40
NS
20
DBP
0
D-1
D0
D1
D2
D3
D4
days
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Total dose of norepinephrine/day
NS
S
3
2.5
2
P lt0.001
1.5
1
0.5
0
D0
D1
D2
D3
D4
D5
days
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Predictive factors of mortalitymultivariate
analysis

• At day 0 SAPS II score OR 6.8
• At day 3 (60 hrs)
• Maximum concentration of NE OR 17.7
• Diastolic BP OR 24.9

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Myocardial dysfunction
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Time-course of myocardial dysfunction in septic
shock patients
Index of contractility
85 of the patients
high CO high SvO2
1-2
4-5
7-8
Time (d)
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Thus, the  most frequent  scenario in septic
shock is Vascular dysfunction Compensated
septic cardiomyopathy
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Thoracic CT scan of an anterior-mediastinitis foll
owing cervical cellulitis (40 yo, man)
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Hemodynamic parameters
Before surgery
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Temperature (C)
2700
Leucocytes (x109/l)
70
Mean arterial pressure (mmHg)
116
Heart rate (bpm)
4.2
CO (L/min)
Lactates (mmol/L)
3.4
-
Norpinephrine (mg/h)
57
LVEF ()
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What monitoring for a septic patient?

• Is there a need for arterial catheter?
• YES! SCCM/ESICM consensus conference 2001
• Is there a need for a Pulmonary Artery Catheter ?
  
• NO! Richard et al JAMA 2003,2902713
• Exception patient with sepsis-induced RVF
• Mebazaa et al. Intensive Care Med,
  200430185-96

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New monitoring for a septic patient ScvO2

• Measure venous O2 saturation
• Continuous measurement of RAP
• Continuous Superior vena cava O2 saturation
  (ScvO2)

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Comparison of venous O2 saturation in pulmonary
artery and in Superior vena cava
? ScvO2
? SvO2
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Tension pneumothorax and insertion of chest tube
SvO2
ScvO2
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28/02 29/02 800 29/02 2000 1/03 800 1/03 2000
HR bpm 57 65 86 125 144
SBP mmHg 158 133 113 110 85
DBP mmHg 84 65 54 40 32
UO ml/h 150 300 100 200 50
mixed ven. O2Sat 73 79 83 68 84
NE mg/h 2.0 1.6 2.5 6.4 5
Lactate mmol/L 1.7 2.6 3.1 10.3 16.7
GB /mm3 7000 7600 7600 1100 500
Arterial O2 Sat 100 98 98 100 65
Temperature C 36.6 36 36 35 38.8
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28/02 29/02 800 29/02 2000 1/03 800 1/03 2000
HR bpm 57 65 86 125 144
SBP mmHg 158 133 113 110 85
DBP mmHg 84 65 54 40 32
UO ml/h 150 300 100 200 50
mixed ven. O2Sat 73 79 83 68 84
NE mg/h 2.0 1.6 2.5 6.4 5
Lactate mmol/L 1.7 2.6 3.1 10.3 16.7
GB /mm3 7000 7600 7600 1100 500
Arterial O2 Sat 100 98 98 100 65
Temperature C 36.6 36 36 35 38.8
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28/02 29/02 800 29/02 2000 1/03 800 1/03 2000
HR bpm 57 65 86 125 144
SBP mmHg 158 133 113 110 85
DBP mmHg 84 65 54 40 32
UO ml/h 150 300 100 200 50
mixed ven. O2Sat 73 79 83 68 84
NE mg/h 2.0 1.6 2.5 6.4 5
Lactate mmol/L 1.7 2.6 3.1 10.3 16.7
GB /mm3 7000 7600 7600 1100 500
Arterial O2 Sat 100 98 98 100 65
Temperature C 36.6 36 36 35 38.8
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28/02 29/02 800 29/02 2000 1/03 800 1/03 2000
HR bpm 57 65 86 125 144
SBP mmHg 158 133 113 110 85
DBP mmHg 84 65 54 40 32
UO ml/h 150 300 100 200 50
mixed ven. O2Sat 73 79 83 68 84
NE mg/h 2.0 1.6 2.5 6.4 5
Lactate mmol/L 1.7 2.6 3.1 10.3 16.7
GB /mm3 7000 7600 7600 1100 500
Arterial O2 Sat 100 98 98 100 65
Temperature C 36.6 36 36 35 38.8