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Advisor(s)
Abstract(s)
Sépsis é uma síndrome de resposta inflamatória sistémica de origem infecciosa, suspeita ou documentada, cujo resultado final é falência multiorgânica. Choque séptico corresponde ao estadio final da sépsis e é caracterizado por anomalias circulatórias, celulares e metabólicas, consistentes com hipóxia tecidular. A disfunção miocárdica na sépsis, que está presente em mais de 50% dos doentes com sépsis, é caracterizada por (i) dilatação ventricular esquerda com pressões de enchimento normais ou diminuídas, (ii) contratilidade ventricular diminuída, e (iii) disfunção ventricular direita ou disfunção ventricular esquerda (sistólica e/ou diastólica) com uma resposta reduzida à administração de fluidos, apesar da falta de critérios de diagnóstico consistentes para disfunção miocárdica associada à sépsis até à data. Ao longo dos anos tem havido uma tentativa de definir disfunção miocárdica induzida pela sépsis, desde a primeira definição proposta por Parker et al. em 1984 até à era tecnológica actual. Há muitos parâmetros utilizados para avaliar a função cardíaca nos doentes sépticos, por vezes difícil de medir devido às alterações hemodinâmicas intrínsecas da sépsis, o que pode ser uma limitação para algumas técnicas utilizadas. No entanto, com as técnicas ecocardiográficas avançadas, como ecocardiografia speckle tracking, é possível diagnosticar e avaliar a disfunção sistólica e diastólica, mesmo em fases precoces da sépsis. Apesar do aumento do conhecimento acerca desta condição, não há tratamento específico para a disfunção miocárdica induzida pela sépsis e o tratamento é dirigido à sépsis em si. No entanto, a dobutamina é o inotrópico de primeira linha para doentes com baixo débito cardíaco, medido ou suspeito, na presença de pressão de enchimento ventricular esquerda e pressão arterial média adequadas. Deste modo, existem muitas incertezas acerca dos mecanismos, características, tratamento e prognóstico desta condição, com conclusões inconsistentes entre os estudos, e, como tal, esta revisão tenta sumarizar o conhecimento actual acerca da disfunção miocárdica induzida pela sépsis.
Sepsis is a systemic inflammatory response syndrome of infectious origin, suspected or documented, whose final outcome is multiorgan failure. Septic shock is the ultimate continuous evolution of sepsis and is characterized by circulatory, cellular and metabolic abnormalities, all of which are consistent with tissue hypoxia. Myocardial dysfunction in sepsis, which is present in more than 50% of septic patients, is characterized by (i) left ventricular dilatation with normal- or low-filling pressure, (ii) reduced ventricular contractility, and (iii) right ventricular or left ventricular (systolic and/or diastolic) dysfunction with a reduced response to volume infusion, although the lack of consistent diagnostic criteria for sepsis-induced myocardial dysfunction (SIMD). Throughout the years there has been an attempt to define SIMD, ever since the first proposed definition by Parker et al. in 1984 until the current technological era. There are a lot of parameters used to assess cardiac function in septic patients, sometimes difficult to measure due to the intrinsic hemodynamical changes in sepsis, which may present a limitation of some techniques used. Nevertheless, with the advanced echocardiographic techniques, such as speckle tracking echocardiogram, its possible to diagnose and evaluate systolic and diastolic dysfunction, even in the earliest stages of sepsis. Despite increasing knowledge about this condition, there isn´t a specific treatment for SIMD and the treatment is directed to sepsis itself. However, dobutamine is the first-choice inotrope for patients with measured or suspected low cardiac output in the presence of adequate left ventricular filling pressure and adequate median arterial pressure. Thus, many uncertainties exist regarding the mechanisms, characteristics, treatment and even the prognosis of this condition, with inconsistent conclusions among studies, and, therefore, this review attempts to summarize our current knowledge of SIMD.
Sepsis is a systemic inflammatory response syndrome of infectious origin, suspected or documented, whose final outcome is multiorgan failure. Septic shock is the ultimate continuous evolution of sepsis and is characterized by circulatory, cellular and metabolic abnormalities, all of which are consistent with tissue hypoxia. Myocardial dysfunction in sepsis, which is present in more than 50% of septic patients, is characterized by (i) left ventricular dilatation with normal- or low-filling pressure, (ii) reduced ventricular contractility, and (iii) right ventricular or left ventricular (systolic and/or diastolic) dysfunction with a reduced response to volume infusion, although the lack of consistent diagnostic criteria for sepsis-induced myocardial dysfunction (SIMD). Throughout the years there has been an attempt to define SIMD, ever since the first proposed definition by Parker et al. in 1984 until the current technological era. There are a lot of parameters used to assess cardiac function in septic patients, sometimes difficult to measure due to the intrinsic hemodynamical changes in sepsis, which may present a limitation of some techniques used. Nevertheless, with the advanced echocardiographic techniques, such as speckle tracking echocardiogram, its possible to diagnose and evaluate systolic and diastolic dysfunction, even in the earliest stages of sepsis. Despite increasing knowledge about this condition, there isn´t a specific treatment for SIMD and the treatment is directed to sepsis itself. However, dobutamine is the first-choice inotrope for patients with measured or suspected low cardiac output in the presence of adequate left ventricular filling pressure and adequate median arterial pressure. Thus, many uncertainties exist regarding the mechanisms, characteristics, treatment and even the prognosis of this condition, with inconsistent conclusions among studies, and, therefore, this review attempts to summarize our current knowledge of SIMD.
Description
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2019
Keywords
Disfunção miocárdica induzida por sépsis Disfunção sistólica Disfunção diastólica Diagnóstico Tratamento Sépsis Cardiomiopatia Cardiologia