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
Dr.S.Venkatesan MD 