Invasive monitoring combined with two-dimensional echocardiographic study in septic shock
An investigation into the incidence and the clinical implication of discrepancies which may sometimes occur between invasive and non-invasive hemodynamic evaluation in septic patients.
A prospective, consecutive comparison.
Department of Intensive Care Medicine at a University Hospital.
32 patients undergoing therapy for an episode of septic shock.
Conventional hemodynamic support (including volume expansion in all cases and inotropic support if necessary) required to obtain a stable hemodynamic status.
Measurement and results
Cardiac output (thermodilution method), cardiac pressures (right heart catheterization) and left ventricular (LV) volumes (two-dimensional echocardiography) were simultaneously recorded. A comparison was thus made between both procedures, particularly concerning preload evaluation and assessment of left ventricular systolic function. Pulmonary artery occlusion pressure measurement was evidenced as an unreliable index of LV end-diastolic volume, determining preload. Assessment of LV systolic function by both methods was conflicting in 11 cases out of the 32.
Frequent discrepancies between to invasive and non-invasive procedure were observed. The reasons for these discrepancies, including low vascular resistance, reduced LV compliance, and a possible overestimation of cardiac output by the thermodilution method, are examined in the light of data recorded. It was concluded that invasive hemodynamic evaluation by right heart catheterization in septic patients should be seriously questioned.
Key wordsSeptic shock Thermodilution cardiac out-put Two-dimensional echocardiography Pulmonary artery occlusion pressure Tricuspid regurgitation
Unable to display preview. Download preview PDF.
- 1.Ozier Y, Gueret P, Jardin F, Farcot Jc, Bourdarias JP; Margairaz A (1984) Two-dimensional echocardiographic demonstration of acute myocardial depression in septic shock. Crit Care Med 12:596–599Google Scholar
- 2.Teboul JL, Besbes M, Andrivet P, Axler O, Douguet D, Zelter M, Lemaire F, Brun-Buisson Ch (1992) A bedside index assessing the reliability of pulmonary artery occlusion pressure measurements during mechanical ventilation with positive end-expiratory pressure. J Crit Care 7:22–29Google Scholar
- 3.Triulzi M, Wilkins G, Gillam L, Gentile F, Weyman A (1985) Normal adult cross-sectional echocardiographic values: left ventricular volumes. Echocardiography 2:153–169Google Scholar
- 4.Lieppe W, Behar V, Scallion R, Kisslo J (1978) Detection of tricuspid regurgitation with two-dimensional echocardiography and peripheral vein injections. Circulation 57:128–132Google Scholar
- 5.Ross J, Braunwald E (1964) The study of left ventricular function in man by increasing resistance to ventricular ejection with angiotensin. Circulation 29:739–749Google Scholar
- 6.Jardin F, Brun-Ney D, Auvert B, Beauchet A, Bourdarias JP (1990) Sepsis-related cardiogenic shock. Crit Care Med 18:1055–1060Google Scholar
- 7.Bland M, Altman D (1986) Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 307–310Google Scholar
- 8.Winslow E, Loeb H, Rahimtoola S, Kamath S, Gunnar R (1973) Hemodynamic studies and results of therapy in 50 patients with bacteriemic shock. Am J Med 54:421–432Google Scholar
- 9.Weisel R, Vito L, Dennis R, Valeri R, Hechtman H (1977) Myocardial depression during sepsis. Am J Surg 133:512–560Google Scholar
- 10.Parker M, Shelhamer J, Barach S, Green M, Natanson C, Frederick T, Damske B, Parillo J (1984) Profound but reversible myocardial depression in patients with septic shock. Ann Intern Med 100: 483–490Google Scholar
- 11.Ellrodt G, Riedinger M, Kimchi A, Berman D, Maddahi J, Swan H, Murata G (1985) Left ventricular performance in septic shock: reversible segmental and global abnormalities. Am Heart J 110: 402–409Google Scholar
- 12.Schneider A, Teule J, Groeneveld A, Nauta J, Heidendal G, Thijs L (1988) Biventricular performance during volume loading in patients with early septic shock, with emphasis on the right ventricle: a combined hemodynamic and radionuclide study. Am Heart J 116:103–112Google Scholar
- 13.Jardin F, Sportiche M, Bazin M, Bourokba A, Margairaz A (1981) Dobutamine: a hemodynamic evaluation in human septic shock. Crit Care Med 9:329–332Google Scholar
- 14.Parker M, Shelhamer J, Natanson C, Alling D, Parillo J (1987) Serial cardiovascular variables in survivors and nonsurvivors of human septic shock: heart rate as an early predictor of prognosis. Crit Care Med 15:923–929Google Scholar
- 15.Bemis C, Serur J, Borkenhagen D, Sonnenblick E, Urschel C (1974) Influence of right ventricular filling pressure on left ventricular pressure and dimension. Circ Res 34:498–504Google Scholar
- 16.Parker M, McCarthy K, Ognibene F, Parillo J (1990) Right ventricular dysfunction and dilatation, similar to left ventricular changes, characterize the cardiac depression of septic shock in humans. Chest 97:126–131Google Scholar
- 17.Thys D, Hillel Z, Goldman M, Mindich B, Kaplan J (1987) A comparison of hemodynamic indices derived by invasive monitoring and two-dimensional echocardiography. Anesthesiology 67: 630–634Google Scholar
- 18.Wyatt H, Heng M, Meerbaum S, Gueret P, Hestenes J, Dula E, Corday E (1980) Cross-sectional echocardiography. II. Analysis of mathematic models for quantifying volume of the formaline-fixed ventricle. Circulation 61:1119–1125Google Scholar
- 19.Chaudry K, Ogawa S, Pauletto F (1978) Biplane measurement of left and right ventricular volume using wide angle cross-sectional echocardiography. Am J Cardiol 41:391–399Google Scholar
- 20.Erbel R, Schweitzer P, Lambertz H, Henn G, Meyer J, Krebs W, Effert S (1983) Echoventriculography: a simultaneous analysis of two-dimensional echography and cineventriculography. Circulation 67:205–215Google Scholar
- 21.Dodge H, Sandler H, Ballew D (1960) The use of biplane angiography for the measurement of left ventricular volume in man. Am Heart J 60:762–776Google Scholar
- 22.Ganz W, Swan H (1972) Measurement of blood flow by thermodilution. Am J Cardiol 29:241–246Google Scholar
- 23.Norris S, King G, Grace M, Weir B (1986) Thermodilution cardiac output — an in vitro model of low flow states. Crit Care Med 14:57–59Google Scholar
- 24.VanGrondelle A, Ditchey R, Groves B, Wagner W, Reeves J (1983) Thermodilution method overestimates low cardiac output in humans. Am J Physiol 245:H690-H692Google Scholar