Top

Published in:

01-05-2019 | Septic Shock | Original

Cardiovascular clusters in septic shock combining clinical and echocardiographic parameters: a post hoc analysis

Authors: Guillaume Geri, Philippe Vignon, Alix Aubry, Anne-Laure Fedou, Cyril Charron, Stein Silva, Xavier Repessé, Antoine Vieillard-Baron

Published in: Intensive Care Medicine | Issue 5/2019

Abstract

Purpose

Mechanisms of circulatory failure are complex and frequently intricate in septic shock. Better characterization could help to optimize hemodynamic support.

Methods

Two published prospective databases from 12 different ICUs including echocardiographic monitoring performed by a transesophageal route at the initial phase of septic shock were merged for post hoc analysis. Hierarchical clustering in a principal components approach was used to define cardiovascular phenotypes using clinical and echocardiographic parameters. Missing data were imputed.

Findings

A total of 360 patients (median age 64 [55; 74]) were included in the analysis. Five different clusters were defined: patients well resuscitated (cluster 1, n = 61, 16.9%) without left ventricular (LV) systolic dysfunction, right ventricular (RV) failure or fluid responsiveness, patients with LV systolic dysfunction (cluster 2, n = 64, 17.7%), patients with hyperkinetic profile (cluster 3, n = 84, 23.3%), patients with RV failure (cluster 4, n = 81, 22.5%) and patients with persistent hypovolemia (cluster 5, n = 70, 19.4%). Day 7 mortality was 9.8%, 32.8%, 8.3%, 27.2%, and 23.2%, while ICU mortality was 21.3%, 50.0%, 23.8%, 42.0%, and 38.6% in clusters 1, 2, 3, 4, and 5, respectively (p < 0.001 for both).

Conclusion

Our clustering approach on a large population of septic shock patients, based on clinical and echocardiographic parameters, was able to characterize five different cardiovascular phenotypes. How this could help physicians to optimize hemodynamic support should be evaluated in the future.

Available only for authorised users

Hess ML, Hastillo A, Greenfield LJ (1981) Spectrum of cardiovascular function during gram-negative sepsis. Prog Cardiovasc Dis 23:279–298CrossRefPubMed

Parker MM, Shelhamer JH, Bacharach SL et al (1984) Profound but reversible myocardial depression in patients with septic shock. Ann Intern Med 100:483–490CrossRefPubMed

De Backer D, Bakker J, Cecconi M et al (2018) Alternatives to the Swan–Ganz catheter. Intensive Care Med 44:730–741. https://doi.org/10.1007/s00134-018-5187-8 CrossRefPubMed

Vieillard-Baron A, Schmitt JM, Beauchet A et al (2001) Early preload adaptation in septic shock? A transesophageal echocardiographic study. Anesthesiology 94:400–406CrossRefPubMed

Bégot E, Dalmay F, Etchecopar C et al (2015) Hemodynamic assessment of ventilated ICU patients with cardiorespiratory failure using a miniaturized multiplane transesophageal echocardiography probe. Intensive Care Med 41:1886–1894. https://doi.org/10.1007/s00134-015-3998-4 CrossRefPubMed

Vieillard-Baron A, Caille V, Charron C et al (2008) Actual incidence of global left ventricular hypokinesia in adult septic shock. Crit Care Med 36:1701–1706. https://doi.org/10.1097/CCM.0b013e318174db05 CrossRefPubMed

Coopersmith CM, De Backer D, Deutschman CS et al (2018) Surviving Sepsis Campaign: research priorities for sepsis and septic shock. Intensive Care Med 44:1400–1426. https://doi.org/10.1007/s00134-018-5175-z CrossRefPubMed

Perner A, Cecconi M, Cronhjort M et al (2018) Expert statement for the management of hypovolemia in sepsis. Intensive Care Med 44:791–798. https://doi.org/10.1007/s00134-018-5177-x CrossRefPubMed

Macdonald SPJ, Keijzers G, Taylor DM et al (2018) Restricted fluid resuscitation in suspected sepsis associated hypotension (REFRESH): a pilot randomised controlled trial. Intensive Care Med 44:2070–2078. https://doi.org/10.1007/s00134-018-5433-0 CrossRefPubMed

10.

Vieillard-Baron A, Prin S, Chergui K et al (2003) Hemodynamic instability in sepsis: bedside assessment by Doppler echocardiography. Am J Respir Crit Care Med 168:1270–1276. https://doi.org/10.1164/rccm.200306-816CC CrossRefPubMed

11.

Åneman A, Vieillard-Baron A (2016) Cardiac dysfunction in sepsis. Intensive Care Med 42:2073–2076. https://doi.org/10.1007/s00134-016-4503-4 CrossRefPubMed

12.

Vignon P, Bégot E, Mari A et al (2018) Hemodynamic assessment of patients with septic shock using transpulmonary thermodilution and critical care echocardiography: a comparative study. Chest 153:55–64. https://doi.org/10.1016/j.chest.2017.08.022 CrossRefPubMed

13.

Vignon P, Repesse X, Bégot E et al (2017) Comparison of echocardiographic indices used to predict fluid responsiveness in ventilated patients. Am J Respir Crit Care Med 195:1022–1032. https://doi.org/10.1164/rccm.201604-0844OC CrossRefPubMed

14.

Huang SJ, Nalos M, McLean AS (2013) Is early ventricular dysfunction or dilatation associated with lower mortality rate in adult severe sepsis and septic shock? A meta-analysis. Crit Care 17:R96. https://doi.org/10.1186/cc12741 CrossRefPubMedPubMedCentral

15.

Landesberg G, Gilon D, Meroz Y et al (2012) Diastolic dysfunction and mortality in severe sepsis and septic shock. Eur Heart J 33:895–903. https://doi.org/10.1093/eurheartj/ehr351 CrossRefPubMed

16.

Vieillard-Baron A, Naeije R, Haddad F et al (2018) Diagnostic workup, etiologies and management of acute right ventricle failure. Intensive Care Med 44:774–790. https://doi.org/10.1007/s00134-018-5172-2 CrossRefPubMed

17.

Vieillard-Baron A, Chergui K, Rabiller A et al (2004) Superior vena caval collapsibility as a gauge of volume status in ventilated septic patients. Intensive Care Med 30:1–6. https://doi.org/10.1007/s00134-004-2361-y CrossRef

18.

Wetterslev M, Møller-Sørensen H, Johansen RR, Perner A (2016) Systematic review of cardiac output measurements by echocardiography vs. thermodilution: the techniques are not interchangeable. Intensive Care Med 42:1223–1233. https://doi.org/10.1007/s00134-016-4258-y CrossRefPubMed

19.

Lê S, Josse J, Husson F (2008) FactoMineR: an R package for multivariate analysis. J Stat Soft 25:1–18CrossRef

20.

Husson F, Josse J, Pagès J (2010) Principal component methods—hierarchical clustering—partitional clustering: why would be need to choose for visualizing data? Technical report, pp 1–17

21.

Josse J, Pagès J, Husson F (2011) Multiple imputation in principal component analysis. Adv Data Anal Classif 5:231–246. https://doi.org/10.1007/s11634-011-0086-7 CrossRef

22.

Barraud D, Faivre V, Damy T et al (2007) Levosimendan restores both systolic and diastolic cardiac performance in lipopolysaccharide-treated rabbits: comparison with dobutamine and milrinone. Crit Care Med 35:1376–1382. https://doi.org/10.1097/01.CCM.0000261889.18102.84 CrossRefPubMed

23.

Robotham JL, Takata M, Berman M, Harasawa Y (1991) Ejection fraction revisited. Anesthesiology 74:172–183. https://doi.org/10.1097/00000542-199101000-00026 CrossRefPubMed

24.

Jardin F, Brun-Ney D, Auvert B et al (1990) Sepsis-related cardiogenic shock. Crit Care Med 18:1055–1060. https://doi.org/10.1097/00003246-199010000-00001 CrossRefPubMed

25.

Boissier F, Razazi K, Seemann A et al (2017) Left ventricular systolic dysfunction during septic shock: the role of loading conditions. Intensive Care Med 43:633–642. https://doi.org/10.1007/s00134-017-4698-z CrossRefPubMed

26.

Vignon P, Allot V, Lesage J et al (2007) Diagnosis of left ventricular diastolic dysfunction in the setting of acute changes in loading conditions. Crit Care 11:R43. https://doi.org/10.1186/cc5736 CrossRefPubMedPubMedCentral

27.

Suffredini AF, Fromm RE, Parker MM et al (1989) The cardiovascular response of normal humans to the administration of endotoxin. N Engl J Med 321:280–287. https://doi.org/10.1056/NEJM198908033210503 CrossRefPubMed

28.

Perner A, Vieillard-Baron A, Bakker J (2015) Fluid resuscitation in ICU patients: Quo vadis? Intensive Care Med 41:1667–1669. https://doi.org/10.1007/s00134-015-3900-4 CrossRefPubMed

29.

Murakawa K, Kobayashi A (1988) Effects of vasopressors on renal tissue gas tensions during hemorrhagic shock in dogs. Crit Care Med 16:789–792CrossRefPubMed

30.

31.

Harjola V-P, Mebazaa A, Čelutkienė J et al (2016) Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and Right Ventricular Function of the European Society of Cardiology. Eur J Heart Fail 18:226–241. https://doi.org/10.1002/ejhf.478 CrossRef

32.

Lahm T, Douglas IS, Archer SL et al (2018) Assessment of right ventricular function in the research setting: knowledge gaps and pathways forward. An official American Thoracic Society Research Statement. Am J Respir Crit Care Med 198:e15–e43. https://doi.org/10.1164/rccm.201806-1160ST CrossRefPubMed

33.

Vieillard-Baron A, Matthay M, Teboul JL et al (2016) Experts’ opinion on management of hemodynamics in ARDS patients: focus on the effects of mechanical ventilation. Intensive Care Med 42:739–749. https://doi.org/10.1007/s00134-016-4326-3 CrossRefPubMed

34.

Mahjoub Y, Pila C, Friggeri A et al (2009) Assessing fluid responsiveness in critically ill patients: false-positive pulse pressure variation is detected by Doppler echocardiographic evaluation of the right ventricle. Crit Care Med 37:2570–2575. https://doi.org/10.1097/CCM.0b013e3181a380a3 CrossRefPubMed

35.

Peters G, Crespo F, Lingras P, Weber R (2013) Soft clustering—fuzzy and rough approaches and their extensions and derivatives. Int J Approx Reason 54:307–322. https://doi.org/10.1016/j.ijar.2012.10.003 CrossRef

36.

Charron C, Vignon P, Prat G et al (2013) Number of supervised studies required to reach competence in advanced critical care transesophageal echocardiography. Intensive Care Med 39:1019–1024. https://doi.org/10.1007/s00134-013-2838-7 CrossRefPubMed

Title: Cardiovascular clusters in septic shock combining clinical and echocardiographic parameters: a post hoc analysis
Authors: Guillaume Geri
Philippe Vignon
Alix Aubry
Anne-Laure Fedou
Cyril Charron
Stein Silva
Xavier Repessé
Antoine Vieillard-Baron
Publication date: 01-05-2019
Publisher: Springer Berlin Heidelberg
Keyword: Septic Shock
Published in: Intensive Care Medicine / Issue 5/2019
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-019-05596-z

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Cardiovascular clusters in septic shock combining clinical and echocardiographic parameters: a post hoc analysis

Abstract

Purpose

Methods

Findings

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Findings

Conclusion

Please log in to get access to this content

Other articles of this Issue 5/2019

Autopsy-confirmed fulminant mucormycosis: a skin lesion revealing multiple organ dissemination

Modifiable elements of ICU supportive care and communication are associated with surrogates’ PTSD symptoms

Prolonged corrected QT interval is associated with short-term and long-term mortality in critically ill patients: results from the FROG-ICU study

Personalized antibiotic dosing for the critically ill

Displaced gag diagnosed on MRI

Diagnostic and therapeutic approach to infectious diseases in solid organ transplant recipients