Sepsis – ABC CARDIOL

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Editorial

Sepsis, Atrial Fibrillation, and Aging: A Dangerous Association

Evandro José Cesarino et al. Marildes Luiza de Castro Carolina Baraldi Araujo Restini

Atrial fibrillation (AF) is a common heart rhythm disorder often identified during sepsis’s progression.

Its prevalence increases in the general population with age, reaching 18% in the elderly over 85 years old.

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Original Article

Atrial Fibrillation and Sepsis in Elderly Patients and Their Associaton with In-Hospital Mortality

Michele Ouriques Honorato et al. Juscelio Trajano de Sousa Filho Luiz Frederico Bezerra Honorato Junior Nathalia Watanabe … Gabriela Machado Goulart Rogério Ruscitto do Prado

Abstract

Background

Atrial fibrillation (AF) affects about 2% to 4% of the world population, and in patients hospitalized in intensive care units, this incidence can reach up to 23% in those with septic shock. The impact of AF in patients with sepsis is reflected in worse clinical outcomes, and the identification of the triggering factors can be a target for future prevention and treatment strategies.

Objectives

To verify the relationship between the development of AF and mortality in patients over 80 years of age included in the sepsis protocol and to identify the risk factors that contribute to the development of AF in this population.

Methods

Retrospective observational study, with a review of electronic medical records and inclusion of 895 patients aged 80 years or older, included in the sepsis protocol of a high-complexity private hospital in São Paulo, SP, from January 2018 to December 2020. All tests were performed with a significance level of 5%.

Results

The incidence of AF in the sample was 13%. After multivariate analysis, using multiple logistic regression, it was possible to demonstrate an association of mortality, in the studied population, with the SOFA score (odds ratio [OR] 1.21 [1.09 – 1.35]), higher values of C-reactive protein (OR 1.04 [1.01 – 1.06]), need for vasoactive drugs (OR 2.4 [1.38 – 4.18]), use of mechanical ventilation (OR 3.49 [1.82 – 6.71]), and mainly AF (OR 3.7 [2.16 – 6.31])

Conclusion

In very elderly patients (80 years of age and older) with sepsis, the development of AF was shown to be an independent risk factor for in-hospital mortality.

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IJCS

Case Report

Kounis Syndrome: Case Report in Goiânia/BR

Marília Pereira et al. Gabriela Lima Vieitas Anna Ilona Hunkar Freitas Karoly Gyula Olivas Hunkar

Abstract

22-year-old male patient with no heart disease, who was given an ambulatory medication with analgesics due to an acute renal crisis. After the drug administration, the patient presented dyspnea, cyanosis, and hemoptysis. There was suspicion of anaphylactic shock, which was treated, but there was no improvement in the clinical condition. The patient was referred to the Intensive Care Unit, where tests were performed showing elevated cardiac enzymes and Immunoglobulin E and Computed Tomography of Thoracic revealed alveolar hemorrhage. He developed clinical worsening and died after sepsis. The final diagnosis was of kounis syndrome due to the hypersensitivity reaction to the analgesics introduced in the patient, generating an acute coronary syndrome (ACS). The purpose of this case report was to highlight a syndrome that is little reported because it is not part of the differential diagnosis routines of ACS, but it generates important complications.

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Editorial

Infections of Cardiac Implantable Electronic Devices – A Growing, Worrying Reality

Eduardo Arrais Rocha et al. João Lins de Araújo Neto Ricardo Pereira Silva

Infection rates of Cardiac Implantable Electronic Devices (CIEDs) have been increasing, determining the need for a wide debate on the subject. Several reasons can justify the issue, such as: a greater number of devices implanted over the latest years, overaging of the population, new techniques and equipment, with more complex and prolonged procedures.

Maciel and Silva address this topic in a clear, objective manner, bringing an important contribution from the national literature, in a significant case selection, confirming those worrying findings and discussing their impacts, considering the high rates of morbidity and mortality and high costs involved, particularly in the cases of endocarditis and sepsis.

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Anatomopathological Correlation

Case 1/2020 – A 56 Year-Old Woman Developed Heart Failure after a Presumed Diagnosis of Acute Myocardial Infarction and Mitral Valve Regurgitation with Rupture of Chordae Tendineae

Desiderio Favarato et al. Luiz Alberto Benvenuti

Clinical aspects

A 55-year-old patient with arterial hypertension and heart failure for one year and with chest pain, had a cardiorespiratory arrest five months before, developed heart failure and mitral regurgitation due to mitral valve prolapse and rupture of chordae tendineae.

The diagnostic impression is that heart failure due to mitral valve disease preceded the episode of precordial pain and severe dyspnea.

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Review Article

From Echocardiographic Evaluation to Biomarkers Measurement: The Role of Myocardial Dysfunction in Mortality Associated with Sepsis

Márcio da Silva Campista et al. Wolney de Andrade Martins Mariana de Andrade Guedes Antonio José Lagoeiro Jorge

Abstract

Sepsis remains the leading cause of mortality and critical illness worldwide. Myocardial dysfunction is one of the most clinically relevant manifestations of sepsis and results from a complex interaction among genetic, molecular, metabolic, and structural changes. Despite the prominence given to the occurrence of systolic dysfunction during sepsis, the association between diastolic dysfunction and mortality is controversial, while diastolic dysfunction and right ventricular dysfunction are identified as independent predictors of mortality in the most recent studies. Elevation of biomarkers during sepsis may result from several mechanisms, and although the role of the B-type natriuretic peptide (BNP) and the N-terminal portion of its prohormone (NT-proBNP) as independent predictors of mortality is well defined, the same cannot be said about cardiac troponins due to conflicting results among currently available studies.

The objective of the present review is to discuss the pathophysiological mechanisms of myocardial dysfunction induced by sepsis in adults and the role of echocardiography and cardiac biomarkers as tools for prognostic evaluation in this clinical setting.

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Editorial

Infections in Heart Failure – Impact on Mortality

Evandro Tinoco Mesquita

Infections represent an important emerging clinical problem that cause decompensation of heart failure (HF), and in many cases, life-threatening acute systemic disorder (sepsis) and septic shock. Cardiovascular system plays an important role in the development of multiorgan dysfunction in sepsis and refractory septic shock. Although intra-hospital death for sepsis decreased from 35% in 2000 to 18% in 2002, one third of patients die within one year after a septic event. Cardiovascular dysfunction significantly increases mortality rates in sepsis as compared with sepsis without cardiac dysfunction. Infection, per se, precipitates the occurrence of cardiac decompensation and is a direct marker of mortality in HF patients.

The study by Cardoso et al. report a high hospital infection rate (45.8%) and relevant mortality (21,5%) among patients with decompensated HF. Interestingly, during the first year after hospital discharge, mortality rate was lower in patients with infection as compared with those without infection (11.5%vs. 22.2%; p = 0.04).

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Artigo Original

Sepsis in the postoperative period of cardiac surgery: problem description

Dinaldo Cavalcanti de Oliveira et al. João Bosco de Oliveira Filho Rogério Ferreira Silva Simone Soares Moura … Diego Janstk Silva Enilton Sergio Tabosa do Egito Stevan Krieger Martins Luis Carlos Bento Souza Adib Domingos Jatene Leopoldo Soares Piegas

BACKGROUND: In spite of the advances in sepsis diagnosis and treatment in the last years, the morbidity and mortality are still high. OBJECTIVE: To assess the prevalence, in-hospital evolution and prognosis of patients that presented sepsis in the postoperative period of cardiac surgery. METHODS: This is a prospective study that included patients (n = 7,332) submitted to cardiac surgery (valvular or coronary) between January 1995 and December 2007. The classic criteria of sepsis diagnosis were used to identify the patients that developed such condition and the preoperative comorbidities, in-hospital evolution and prognosis were evaluated. RESULTS: Sepsis occurred in 29 patients (prevalence = 0.39%). There was a predominance of the male when compared to the female sex (79% vs. 21%). Mean age was 69 ± 6.5 years. The main preoperative comorbidities were: systemic arterial hypertension (79%), dyslipidemia (48%) and family history of coronary artery disease (38%). The mean Apache score was 18 ± 7, whereas the Sofa score was 14.2 ± 3.8. The primary infectious focus was pulmonary in 19 patients (55%). There were 19 positive cultures and the mean IV hydration during the first 24 hours was 1,016 ± 803 ml. The main complications were acute renal failure (65%), low cardiac output syndrome (55%) and malignant ventricular arrhythmia (55%). Mortality was 79% (23 patients). CONCLUSION: The occurrence of sepsis after cardiac surgery was a rare event; however, its occurrence showed catastrophic clinical outcomes. The high morbidity and mortality showed the need to improve treatment, aiming at patients’ better clinical evolution.

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Artigo Original

Positive end-expiratory pressure and renal function influence B-type natriuretic peptide in patients with severe sepsis and septic shock

Victor Sarli Issa et al. Leandro Utino Taniguchi Marcelo Park Luiz Monteiro Cruz … Edimar Alcides Bocchi Irineu Tadeu Velasco Francisco Soriano

BACKGROUND: Myocardial dysfunction is a complication associated with a poor prognosis in septic patients. A biomarker of cardiac function providing prognostic information is of paramount interest. OBJECTIVE: We sought to determine the value of B-type natriuretic peptide in patients with severe sepsis/septic shock. METHODS: We performed a prospective study in patients with severe sepsis/septic shock in a medical intensive care unit. B-type natriuretic peptide level was determined within 24 hours after the diagnosis of severe sepsis/septic shock. We also analyzed mortality, and presence of association between B-type natriuretic peptide and clinical, hemodynamic and respiratory variables. RESULTS: 23 (9 women; 14 men) patients with ages ranging from 20-79 (mean 51.3±18.6) years old and APACHE score of 22.6±11.8 were included; 15 (65.2%) patients received pulmonary artery catheters, and 20 (87%) were mechanically ventilated. Multivariate analysis disclosed inverse association between B-type natriuretic peptide values with positive end-expiratory pressure values, and direct association with creatinine (beta 0.548 and 0.377, p 0.02 and 0.002, respectively), but not with mortality, clinical and hemodynamic parameters. CONCLUSION: This is the first report on an inverse association between positive end-expiratory pressure and BNP levels in patients with severe sepsis and septic shock. BNP and creatinine levels should be taken into consideration when analyzing B-type natriuretic peptide levels in this setting.

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Artigo Original

Correlation between oxygen consumption calculated using Fick's method and measured with indirect calorimetry in critically ill patients

Flávio Marson et al. Maria Auxiliadora Martins Francisco Antonio Coletto Antonio Dorival Campos Anibal Basile-Filho

OBJECTIVE: To compare the oxygen consumption index measured by using indirect calorimetry (VO2I Delta) with a portable metabolic cart and calculated according to Fick’s principle (VO2 I Fick) in critically ill patients. METHODS: Fourteen patients (10 men and 4 women, mean age 39.4 ± 5.4 years) were analyzed, 5 of them trauma victims and 9 sepsis victims. The following mean scores were obtained for these patients: APACHE II = 21.3±1.8, ISS = 24.8±6, and sepsis score = 19.6±2.3. The mortality risk (odds ratio), calculated from APACHE II, was 41.9±7.1%. All patients underwent mechanical ventilation and invasive hemodynamic monitoring with a Swan-Ganz catheter. VO2 was obtained using the 2 methods (VO2I Delta and VO2I Fick) at 4 different times (T1-T4). RESULTS: A good correlation was found between the 2 methods (r=0.77) for the mean of the 4 serial measurements. No statistically significant differences were observed between indirect calorimetry and Fick’s equation at T1 (VO2I Delta = 138±28 and VO2I Fick = 59±38 mL.min-2.m-2, P=0.10) and T3 (VO2I Delta = 144±26 and VO2I Fick = 158±35 mL.min-2.m-2, P=0.14), but a significant difference was observed at T2 (VO2I Delta = 141±27 and VO2I Fick = 155±26 mL.min-2.m-2, P=0.03) and T4 (VO2I Delta = 145±24 and VO2I Fick = 162±26 mL.min-2.m-2, P=0.01). CONCLUSION: We may state that indirect calorimetry can be used for oxygen consumption analysis in critically ill patients and is as efficient as Fick’s reverse equation, with the benefit of being a noninvasive and risk-free procedure.

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