Question 5: septic shock

Describe the echocardiographic features not uncommonly seen in the patient with septic shock

1. ECHO exam may be normal

2. Sepsis induced  cardiomyopathy:

  • Left Ventricular contraction impairment which may be global or segmental. MASPE < 8mm
  • EF  < 52%  in men and < 54% in women (2)
  • Left ventricular diastolic dysfunction:  Peak e’ velocity (cm/s) in early diastole measured using PW Doppler at lateral and septal basal regions and then averaged. Abnormal LV diastolic function suggested by e’ (septum) < 7 cm/s or e’ (lateral) < 10 cm/s
  • Right ventricular systolic and diastolic dysfunction TAPSE <17 mm
  • SV decreased LVOT VTI < 18 cm

3. LVOT obstruction

  • Ventricular outflow obstruction if sigmoid septum or ventricular hypertrophy  and small LV cavity

4. Valves

  • Functional problems such as  SAM (systolic anterior motion)
  • Endocarditis

Most common abnormality is small hyperdynamic LV best seen in PLAX and PSAX view “kissing ventricle”

5. LVOT VTI PW Doppler exam :

  • Early LVOT VTI >22 cm
  • Late LVOT VTI may be < 18 cm (hypovolaemic, cardiomyopathy)
  • Increase in LVOT VTI of > 15% if fluid responsive

6. IVC

  • IVC may be <1 cm collapsing > 50% – suggestive of underfilling
  • IVC > 2cm and collapsing <50% suggests high right ventricular pressures cardiomyopathy

Reference

  1. Echocardiography in shock management Anthony S. McLean
  2. Review Open Access Published: 04 May 2018 Pathophysiology, echocardiographic evaluation, biomarker findings, and prognostic implications of septic cardiomyopathy: a review of the literature Robert R. Ehrman, Ashley N. Sullivan, Mark J. Favot, Robert L. Sherwin, Christian A. Reynolds, Aiden Abidov & Phillip D. Levy Critical Care volume 22, Article number: 112 (2018)

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