Gonzalez Céline, Begot Emmanuelle, Dalmay François, Pichon Nicolas, François Bruno, Fedou Anne-Laure, Chapellas Catherine, Galy Antoine, Mancia Claire, Daix Thomas, Vignon Philippe
Medical-Surgical ICU, Dupuytren Teaching Hospital, Limoges, France.
Inserm CIC 1435, Dupuytren Teaching Hospital, Limoges, France.
Ann Intensive Care. 2016 Dec;6(1):36. doi: 10.1186/s13613-016-0136-6. Epub 2016 Apr 21.
Left ventricular (LV) diastolic dysfunction is highly prevalent in the general population and associated with a significant morbidity and mortality. Its prognostic role in patients sustaining septic shock in the intensive care unit (ICU) remains controversial. Accordingly, we investigated whether LV diastolic function was independently associated with ICU mortality in a cohort of septic shock patients assessed using critical care echocardiography.
Over a 5-year period, patients hospitalized in a Medical-Surgical ICU who underwent an echocardiographic assessment with digitally stored images during the initial management of a septic shock were included in this retrospective single-center study. Off-line echocardiographic measurements were independently performed by an expert in critical care echocardiography who was unaware of patients' outcome. LV diastolic dysfunction was defined by the presence of a lateral E' maximal velocity <10 cm/s. A multivariate analysis was performed to determine independent risk factors associated with ICU mortality.
Among the 540 patients hospitalized in the ICU with septic shock during the study period, 223 were studied (140 men [63 %]; age 64 ± 13 years; SAPS II 55 ± 18; SOFA 10 ± 3; Charlson 3.5 ± 2.5) and 204 of them (91 %) were mechanically ventilated. ICU mortality was 35 %. LV diastolic dysfunction was observed in 31 % of patients. The proportion of LV diastolic dysfunction tended to be higher in non-survivors than in their counterparts (28/78 [36 %] vs. 41/145 [28 %]: p = 0.15). Inappropriate initial antibiotic therapy (OR 4.17 [CI 95 % 1.33-12.5]: p = 0.03), maximal dose of vasopressors (OR 1.38 [CI 95 % 1.16-1.63]: p = 0.01), SOFA score (OR 1.16 [CI 95 % 1.02-1.32]: p = 0.02) and lateral E' maximal velocity (OR 1.12 [CI 95 % 1.01-1.24]: p = 0.02) were independently associated with ICU mortality. After adjusting for the SAPS II score, inappropriate initial antibiotic therapy and maximal dose of vasopressors remained independent factors for ICU mortality, whereas a trend was only observed for lateral E' maximal velocity (OR 1.11 [CI 95 % 0.99-1.23]: p = 0.07).
The present study suggests that LV diastolic function might be associated with ICU mortality in patients with septic shock. A multicenter prospective study assessing a large cohort of patients using serial echocardiographic examinations remains required to confirm the prognostic value of LV diastolic dysfunction in septic shock.
左心室舒张功能障碍在普通人群中非常普遍，且与显著的发病率和死亡率相关。其在重症监护病房（ICU）感染性休克患者中的预后作用仍存在争议。因此，我们在一组使用重症超声心动图评估的感染性休克患者队列中，研究左心室舒张功能是否与ICU死亡率独立相关。
在一项回顾性单中心研究中，纳入了在5年期间入住内科-外科ICU的患者，这些患者在感染性休克初始治疗期间接受了超声心动图评估并存储了数字图像。离线超声心动图测量由一位对患者结局不知情的重症超声心动图专家独立进行。左心室舒张功能障碍定义为侧壁E'最大速度<10 cm/s。进行多变量分析以确定与ICU死亡率相关的独立危险因素。
在研究期间入住ICU的540例感染性休克患者中，223例被纳入研究（140例男性[63%]；年龄64±13岁；简化急性生理学评分II（SAPS II）为55±18；序贯器官衰竭评估（SOFA）为10±3；Charlson评分为3.5±2.5），其中204例（91%）接受了机械通气。ICU死亡率为35%。31%的患者观察到左心室舒张功能障碍。左心室舒张功能障碍在非幸存者中的比例往往高于幸存者（28/78[36%]对41/145[28%]：p = 0.15）。初始抗生素治疗不当（比值比（OR）4.17[95%置信区间（CI）1.33 - 12.5]：p = 0.03）、血管升压药最大剂量（OR 1.38[CI 95% 1.16 - 1.63]：p = 0.01）、SOFA评分（OR 1.16[CI 95% 1.02 - 1.32]：p = 0.02）和侧壁E'最大速度（OR 1.12[CI 95% 1.01 - 1.24]：p = 0.02）与ICU死亡率独立相关。在调整SAPS II评分后，初始抗生素治疗不当和血管升压药最大剂量仍然是ICU死亡率的独立因素，而仅观察到侧壁E'最大速度有趋势性关联（OR 1.11[CI 95% 0.99 - 1.23]：p = 0.07）。
本研究表明，左心室舒张功能可能与感染性休克患者的ICU死亡率相关。仍需要一项多中心前瞻性研究，通过连续超声心动图检查评估大量患者队列，以确认左心室舒张功能障碍在感染性休克中的预后价值。
