Septic shock is associated with severe vasoplegia, increased permeability, maldistribution of regional blood flows, and microvascular alterations. Hemodynamic management includes fluid and vasopressor agents and, in s...Septic shock is associated with severe vasoplegia, increased permeability, maldistribution of regional blood flows, and microvascular alterations. Hemodynamic management includes fluid and vasopressor agents and, in selected cases, inotropic agents. However, several patients remain tachycardic after initial resuscitation. Tachycardia is frequently observed in sepsis and is associated with a poor outcome.[1] Given the negative impact of tachycardia, the use of short-acting beta-blockers was proposed.[2] Of note, tachycardia was suggested to be protective in patients with increased lactate levels whereas opposite effects were observed in patients with normal lactate levels.[3] The impact of tachycardia should hence not be evaluated without looking at tissue perfusion. In addition, patients in septic shock with elevated left ventricular (LV) ejection fraction (EF) at echocardiography present an increased risk of death. In a retrospective single-center study including 1014 patients, an elevation in LVEF was found to be independently correlated with mortality (odds ratio=3.90 [2.09-7.40]).[4] In another cohort of patients with sepsis and septic shock, the relationship between LVEF and mortality showed a U-shaped pattern, with severely impaired (<25%) and elevated (≥70%) EF, both being independently associated with an increased risk of death.[5] In tachycardic hyperkinetic hearts, beta-blockers are expected to be particularly useful. Several randomized controlled trials (RCTs) evaluated the impact of short-term beta-blockers to control tachycardia in septic patients, sometimes with diverging results. In this review, we analyze the results of three main RCTs to discuss whether there is a place for the use of beta-blockers in septic patients with tachycardia.[2,6,7].展开更多
Microvascular alterations were first described in critically ill patients about 20 years ago. These alterations are characterized by a decrease in vascular density and presence of non-perfused capillaries close to wel...Microvascular alterations were first described in critically ill patients about 20 years ago. These alterations are characterized by a decrease in vascular density and presence of non-perfused capillaries close to well-perfused vessels. In addition, heterogeneity in microvascular perfusion is a key finding in sepsis. In this narrative review, we report our actual understanding of microvascular alterations, their role in the development of organ dysfunction, and the implications for outcome. Herein, we discuss the state of the potential therapeutic interventions and the potential impact of novel therapies. We also discuss how recent technologic development may affect the evaluation of microvascular perfusion.展开更多
文摘Septic shock is associated with severe vasoplegia, increased permeability, maldistribution of regional blood flows, and microvascular alterations. Hemodynamic management includes fluid and vasopressor agents and, in selected cases, inotropic agents. However, several patients remain tachycardic after initial resuscitation. Tachycardia is frequently observed in sepsis and is associated with a poor outcome.[1] Given the negative impact of tachycardia, the use of short-acting beta-blockers was proposed.[2] Of note, tachycardia was suggested to be protective in patients with increased lactate levels whereas opposite effects were observed in patients with normal lactate levels.[3] The impact of tachycardia should hence not be evaluated without looking at tissue perfusion. In addition, patients in septic shock with elevated left ventricular (LV) ejection fraction (EF) at echocardiography present an increased risk of death. In a retrospective single-center study including 1014 patients, an elevation in LVEF was found to be independently correlated with mortality (odds ratio=3.90 [2.09-7.40]).[4] In another cohort of patients with sepsis and septic shock, the relationship between LVEF and mortality showed a U-shaped pattern, with severely impaired (<25%) and elevated (≥70%) EF, both being independently associated with an increased risk of death.[5] In tachycardic hyperkinetic hearts, beta-blockers are expected to be particularly useful. Several randomized controlled trials (RCTs) evaluated the impact of short-term beta-blockers to control tachycardia in septic patients, sometimes with diverging results. In this review, we analyze the results of three main RCTs to discuss whether there is a place for the use of beta-blockers in septic patients with tachycardia.[2,6,7].
文摘Microvascular alterations were first described in critically ill patients about 20 years ago. These alterations are characterized by a decrease in vascular density and presence of non-perfused capillaries close to well-perfused vessels. In addition, heterogeneity in microvascular perfusion is a key finding in sepsis. In this narrative review, we report our actual understanding of microvascular alterations, their role in the development of organ dysfunction, and the implications for outcome. Herein, we discuss the state of the potential therapeutic interventions and the potential impact of novel therapies. We also discuss how recent technologic development may affect the evaluation of microvascular perfusion.
