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Impact of norepinephrine on right ventricular afterload and function in septic shock-a strain echocardiography study.

ABSTRACT: BACKGROUND:In this observational study, the effects of norepinephrine-induced changes in mean arterial pressure (MAP) on right ventricular (RV) systolic function, afterload and pulmonary haemodynamics were studied in septic shock patients. We hypothesised that RV systolic function improves at higher doses of norepinephrine/MAP levels. METHODS:Eleven patients with septic shock requiring norepinephrine after fluid resuscitation were included <24 hours after ICU arrival. Study enrolment and insertion of a pulmonary artery catheter was performed after written informed consent from the next of kin. Norepinephrine infusion was titrated to target mean arterial pressures (MAP) of 60, 75 and 90 mmHg in a random sequential order. At each target MAP, strain-and conventional echocardiographic-and pulmonary haemodynamic variables were measured. RV afterload was assessed as effective pulmonary arterial elastance, (Epa ) and pulmonary vascular resistance index, (PVRI). RV free wall peak strain was the primary end-point. RESULTS:At highest compared to lowest norepinephrine dose/MAP level, RV free wall peak strain increased from -19% to -25% (32%, P = .003), accompanied by increased tricuspid annular plane systolic excursion (22%, P = .01). At the highest norepinephrine dose/MAP, RV end-diastolic area index (16%, P < .001), central venous pressure (38%, P < .001), stroke volume index (7%, P = .001), mean pulmonary artery pressure (19%, P < .001) and RV stroke work index (15%, P = .045) increased, with no effects on PVRI or Epa . Cardiac index did not change, assessed by thermodilution (P = .079) and echocardiography (P = .054). CONCLUSIONS:Higher doses of norepinephrine to a target MAP of 90 mm Hg improved RV systolic function while RV afterload was not affected.

SUBMITTER: Dalla K

PROVIDER: S-EPMC7159388 | biostudies-literature | 2019 Nov

REPOSITORIES: biostudies-literature

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Impact of norepinephrine on right ventricular afterload and function in septic shock-a strain echocardiography study.

Dalla Keti K Bech-Hanssen Odd O Ricksten Sven-Erik SE

Acta anaesthesiologica Scandinavica 20190819 10

<h4>Background</h4>In this observational study, the effects of norepinephrine-induced changes in mean arterial pressure (MAP) on right ventricular (RV) systolic function, afterload and pulmonary haemodynamics were studied in septic shock patients. We hypothesised that RV systolic function improves at higher doses of norepinephrine/MAP levels.<h4>Methods</h4>Eleven patients with septic shock requiring norepinephrine after fluid resuscitation were included <24 hours after ICU arrival. Study enrolm ...[more]

PMID: 31361336

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Project description:BackgroundThe pathophysiology of advanced liver cirrhosis may induce alterations in the circulatory system that may be challenging for the anesthesiologist to manage intraoperatively, and perioperative cardiovascular events are associated with worse outcomes in cirrhotic patients undergoing liver transplantation. It remains controversial whether right ventricular function is impaired during this procedure. Studies using transesophageal echocardiography for quantitative analysis of the right ventricle remain scarce in this setting, yielding conflicting results. The aim of this study was to perform a quantitative assessment of right ventricular function with two parameters derived from transesophageal echocardiography during liver transplantation.MethodsNineteen adult patients of both genders undergoing liver transplantation were evaluated in this observational study. The exclusion criteria were age under 18 or above 65 years old, fulminant hepatic failure, hepatopulmonary syndrome, portopulmonary hypertension, cardiopulmonary disease, and contraindications to the transesophageal echocardiogram. Right ventricular function was assessed at five stages during liver transplantation: baseline, hepatectomy, anhepatic, postreperfusion, and closure by measuring tricuspid annular plane systolic excursion and right ventricular fractional area change obtained with transesophageal echocardiography.ResultsRight ventricular function was found to be normal throughout the procedure. The tricuspid annular plane systolic excursion showed a trend toward a decrease in the anhepatic phase compared to baseline (2.0 ± 0.9 cm vs. 2.4 ± 0.7 cm; P = 0.24) but with full recovery after reperfusion. Right ventricular fractional area change remained nearly constant during all stages studied (minimum: 50% ± 10 at baseline and anhepatic phase; maximum: 56% ± 12 at postreperfusion; P = 0.24).ConclusionsRight ventricular function was preserved during liver transplantation at the time points evaluated by two quantitative parameters derived from transesophageal echocardiogram.

Project description:BACKGROUND:Right ventricular (RV) function is a major determinant of outcome in patients with pulmonary hypertension. Cardiac magnetic resonance (CMR) is gold standard to assess RV ejection fraction (RVEFCMR), however this is a crude measure. New CMR measures of RV function beyond RVEFCMR have emerged, such as RV lateral atrio-ventricular plane displacement (AVPDlat), maximum emptying velocity (S'CMR), RV fractional area change (FACCMR) and feature tracking of the RV free wall (FWSCMR). However, it is not fully elucidated if these CMR measures are in parity with the equivalent echocardiography-derived measurements: tricuspid annular plane systolic excursion (TAPSE), S'-wave velocity (S'echo), RV fractional area change (FACecho) and RV free wall strain (FWSecho). The aim of this study was to compare regional RV function parameters derived from CMR to their echocardiographic equivalents in patients with pulmonary hypertension and to RVEFCMR. METHODS:Fifty-five patients (37 women, 62?±?15?years) evaluated for pulmonary hypertension underwent CMR and echocardiography. AVPDlat, S'CMR, FACCMR and FWSCMR from cine 4-chamber views were compared to corresponding echocardiographic measures and to RVEFCMR delineated in cine short-axis stack. RESULTS:A strong correlation was demonstrated for FAC whereas the remaining measurements showed moderate correlation. The absolute bias for S' was 2.4?±?3.0?cm/s (relative bias 24.1?±?28.3%), TAPSE/AVPDlat 5.5?±?4.6?mm (33.2?±?25.2%), FWS 4.4?±?5.8% (20.2?±?37.5%) and for FAC 5.1?±?8.4% (18.5?±?32.5%). In correlation to RVEFCMR, FACCMR and FWSecho correlated strongly, FACecho, AVPDlat, FWSCMR and TAPSE moderately, whereas S' had only a weak correlation. CONCLUSION:This study has demonstrated a moderate to strong correlation of regional CMR measurements to corresponding echocardiographic measures. However, biases and to some extent wide limits of agreement, exist between the modalities. Consequently, the equivalent measures are not interchangeable at least in patients with pulmonary hypertension. The echocardiographic parameter that showed best correlation with RVEFCMR was FWSecho. At present, FACecho and FWSecho as well as RVEFCMR are the preferred methods to assess and follow up RV function in patients with pulmonary hypertension. Future investigations of the CMR right ventricular measures, beyond RVEF, are warranted.

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Impact of norepinephrine on right ventricular afterload and function in septic shock-a strain echocardiography study.

Publications

Impact of norepinephrine on right ventricular afterload and function in septic shock-a strain echocardiography study.

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