Esmolol response in septic shock patients in relation to vascular waterfall phenomenon measured by critical closure pressure and mean systemic filling pressure: a prospective observational study

Background Bedside measurements of critical closure pressure (Pcc) and mean systemic circulation filling pressure (Pmsf) were utilized to evaluate the response to esmolol in septic shock patients, in relation to the vascular waterfall phenomenon and body oxygen supply and demand. Methods This prospective observational self-controlled study included patients with septic shock, newly admitted to the intensive care unit, between August 2019 and January 2021. Pcc and Pmsf, along with the heart rate and other hemodynamic indicators were observed and compared before and 1 h after esmolol IV infusion. Results After 24 h of initial hemodynamic optimization, 56 patients were finally enrolled. After start of esmolol infusion, patients had a significant decrease in cardiac index (CI) (4.0 vs. 3.3 L/min/m2, P < 0.001), a significant increase in stroke index (SI) (34.1 vs. 36.6 mL/m2, P < 0.01), and a significant decrease in heart rate (HR) (116.8 vs. 90.6 beats/min, P < 0.001). After 1 h of treatment with esmolol, patients had a significant increase in Pcc (31.4 vs. 36.7 mmHg, P < 0.01). The difference between Pcc and Pmsf before and after treatment was statistically different (4.0 vs. 10.0 mmHg, P < 0.01). After heart rate control with esmolol, the patients had a significant increase in the body circulation vascular resistance indices (RIs) (15.14 vs. 18.25 mmHg/min/m2/L, P < 0.001). There was an increase in ScvO2 in patients after treatment with esmolol, but the difference was not statistically significant (68.4% vs. 69.8%, P > 0.05), while Pcv-aCO2 was significantly lower (6.3 vs. 4.9 mmHg, P < 0.001) and patients had a significant decrease in blood lactate levels (4.0 vs. 3.6 mmol/L, P < 0.05). Conclusion Patients with septic shock whose heart rate is greater than 95 beats/min after hemodynamic optimization were treated with esmolol, which could effectively control heart rate and reduce CI, as well as improve Pcc and increase the difference between Pcc and Pmsf (known as “vascular waterfall” phenomenon), without affecting MAP, CVP, Pmsf and arteriovenous vascular resistance, and improve the balance of oxygen supply and demand in the body.

Early Diagnosis and Antibiotic Treatment Combined with Multicomponent Hemodynamic Support for Addressing a Severe Case of Lemierre’s Syndrome

A 20-year-old man was admitted to the intensive care unit for septic shock due to Lemierre’s syndrome. It is a rare syndrome that manifests as an upper respiratory infection, although systemic involvement, severe coagulopathy, and multi-organ failure can dangerously complicate the clinical picture. In this syndrome, sepsis-related neuroendocrine dysregulation and microcirculation impairment can have a rapid deleterious progression. Consequently, proper diagnosis, early source control, and appropriate antibiotics administration are mandatory to improve the prognosis. The intensive treatment is aimed at limiting organ damage through hemodynamic optimization. Remarkably, in septic shock due to Lemierre’s syndrome, hemodynamic optimization can be achieved through the synergic effect of norepinephrine, argipressin, and hydrocortisone.

Pheochromocytoma, Fulminant Heart Failure, and a Phenylephrine Challenge. The Perioperative Management of Adrenalectomy in a Jehovah’s Witness Patient: A Case Report

Perioperative management of pheochromocytoma in the setting of catecholamine-induced heart failure requires careful consideration of hemodynamic optimization and possible mechanical circulatory support. A Jehovah’s Witness patient with catecholamine-induced acutely decompensated heart failure required dependable afterload reduction for a cardio-protective strategy. This was emphasized due to the relative contraindication to perioperative anticoagulation required for mechanical circulatory support. A phenylephrine challenge clearly demonstrated adequate alpha blockade after only 24 hours of phenoxybenzamine treatment. This resulted in advancement of the surgery date. This case also highlights management of beta blockade, volume and salt loading, autologous blood transfusion, and profound post-operative vasoplegia in the setting of cardiogenic shock. Careful attention to hemodynamic optimization and cardio-protective strategies ultimately resulted in positive outcome for this challenging clinical scenario.

Effects of Esmolol on Vascular Waterfall Phenomenon in Septic Shock Patients by Bedside Measurement of Critical Closure Pressure and Mean Systemic Filling Pressure: A Prospective Observational Study

Background To explore the effect of esmolol on the vascular waterfall phenomenon and body oxygen supply and demand in septic shock patients by bedside measurements of critical closure pressure (Pcc) and mean systemic circulation filling pressure (Pmsf). Methods Enrolled in the Intensive Care Medicine Unit (ICU) of the Third People's Hospital of Chengdu City/Southwest Jiaotong University Hospital from August 2019 to January 2021, admitted to our department for infectious shock. Adults with endotracheal intubation, invasive ventilator-assisted ventilation, pulse-indicated continuous cardiac output monitoring (PiCCO) catheters and deep venous catheters placed for medical reasons. Results After 24 hours of initial hemodynamic optimization, 56 patients were finally enrolled. After heart rate control with esmolol, patients had a significant decrease in cardiac index (CI) (4.0 vs. 3.3 L/min/m2, p < 0.001), a significant increase in stroke index (SI) (34.1 vs. 36.6 ml/m2, p < 0.01), and a significant decrease in heart rate (HR) (116.8 vs. 90.6 beats/min, p < 0.001). After 1 hour of treatment with esmolol, patients had a significant increase in Pcc (31.4 vs 36.7 mmHg, p < 0.01). The difference between Pcc and Pmsf before and after treatment was statistically different (4.0 vs 10.0 mmHg, p < 0.01). After heart rate control with esmolol, the patients had a significant increase in the body circulation vascular resistance indices (RIs) (15.14 vs 18.25 mmHg/min/m2-L-1, p < 0.001). There was an increase in ScvO2 in patients after treatment with esmolol, but the difference was not statistically significant (68.4% vs 69.8%, p > 0.05), while Pcv-aCO2 was significantly lower (6.3 vs 4.9 mmHg, p < 0.001) and patients had a significant decrease in blood lactate levels (4.0 vs 3.6 mmol/L, p < 0.05) . Conclusion Patients with septic shock whose heart rate was still greater than 95 beats/min after hemodynamic optimization were treated with esmolol, which could effectively control heart rate and reduce CI, as well as improve Pcc and increase the difference between Pcc and Pmsf, without affecting MAP, CVP, Pmsf and arteriovenous vascular resistance, and improve the balance of oxygen supply and demand in the body.