Dr.S.Venkatesan MD

Time and again cardiologists are called to opine  in critically ill ICU patients with  hypotension.  The circulatory shock of septic shock  is often refractory  . Many  times it  degenerates  into multi -organ failure . The mortality remains high in- spite modern treatment .Even in those patients who recover , they require prolonged  inotropic support  (for days or even weeks)

Here is a  recent call I attended to .

A 44 year old   febrile   , ventilated patient  (With a pneumonitic patch , PEEP of  6 , near ARDS )  ,  precarious renal function and altered sensorium , maintaining a blood pressure of 100/70mmhg with high dose dopamine and nor- adrenaline  , monitor showing a heart rate of 125 /mt sinus  .This status -quo  has continued for more than 72 hours. To my surprise,  the ICU physician told  me there is  in-fact a  minor improvement in general condition than before  . After blinking  at the patient’s  file for few  minutes  , I did a customary bed side echocardiogram .The only positive finding  I  found was  his  heart was  structurally normal  and EF was  64 %  , still the right heart chambers were struggling  to do it’s job   fighting with the PEEP.

The physician had  a very  specific query  from the cardiologist . How to wean the inotropic support and shift him off  ICU ?

(The poor patient  has no  insurance  , and has to shell  Rs 10000 everyday  which is equal to his monthly income ! )

A very  valid question indeed   !   After all  , cardiologists  claim to  have special  knowledge  and wisdom about disorders of  vascular system .

Heart being normal , the crux of the problem is loss of vascular tone. (Autonomic dysfunction ) .How to improve it ? I  discussed the following suggestions.

• Early passive muscle exercise (Augmenting  muscle tone and transforming it to  into arteriolar and venous tone )
• Venous support ,stockings etc.
• Ensure adequate intra-vascular  fluids
• Sodium supplements
• Corticosteroids.
• Fludro-cortisone , the mineralo-corticoid may have a specific advantage as it could retain sodium in vessel wall that can be exchanged with smooth muscle calcium and improve vascular tone .
• ECMO is  often a pre terminal intervention .
• Will power . We know vascular  tone is in fact neurogenic in origin .The tone flows from brain stem .Administering  will power could be a useful intervention . (parental infusion of fighting spirit !)It can be done through pep talks from  close family  members   in   conscious patients .(One controversial advice is to allow  near and dear  into bedside , ICU phobia may delay recovery of vascular tone !)

• Finally  I suggested , a  vascular consult from the GOD  . Organised prayer .  There is some evidence ,  even  proxy prayers do exert benefits in unconscious patients .

After a 15 minutes stay in the ICU , for doing nothing  I  received a significant consultation fee  , and I left the  place  sheepishly  with a  definite dose of guilt !

Reference for role of Hydrocortisone in septic shock

The CORTICUS study

It has no overall impact but hastens recovery from septic shock . Even though the study appears to denote a negative connotation

it has the role in selected individuals .http://www.nejm.org/doi/full/10.1056/NEJMoa071366