Posts Tagged ‘refractory hypotension in septic shock’

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

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