Septic shock carries a high attendant risk of death to which impaired myocardial contractility may contribute. Recent interest in the use of glucose-insulin and potassium (GIK) infusions as therapy in ischemic myocardial depression has extended to septic myocardial depression. Few studies have demonstrated an improvement in the hemodynamics of hypodynamic septic shock on commencing GIK infusions. We describe two cases of hypo-dynamic septic shock in which such intervention was associated with an improvement in hemodynamic profile.
A 51-year-old woman with high-grade B-cell lymphoma (stage IIIb) had dyspnea 2 days following a second course of chemotherapy with cyclophosphamide, adriamycin, vincristine, and prednisolone. She was jaundiced, febrile (39°C), tachycardic (120 beats/min), and hypotensive (90/60 mm Hg) with evidence of right middle lobe consolidation. read more
Investigations revealed low arterial oxygen saturation (88% on room air); pancytopenia (hemoglobin, 7 g/dL; WBC, 1.6 X 109/L; neutrophils, 0.8 X 109/ L; platelets, 18 X 109/L); coagulopathy (prothrombin time [PT], 18 s; activated thromboplastin time [APTT], 38 s; thrombin time [TT], 12 s); deranged liver function test results (bilirubin, 266 |j,mol/L; alanine aminotransferase, 542 IU/L; alkaline phosphatase, 90 IU/L; albumin, 17 g/dL); and abnormal biochemistry results (urea, 12.2 mmol/L; creatinine, 112 mmol/L; sodium, 140 mmol/L; potassium, 5.1 mmol/L; C-reactive protein, 280 mg/L). Neutropenic septic shock with right middle lobe pneumonia was diagnosed. Therapy was commenced with fluid resuscitation, antibiotics (piperacillin/tazobactam, gentamicin, fluconazole, co-trimoxazole), and bone marrow stimulation (filgastrim). Spiral CT of the chest excluded pulmonary embolus.
Echocardiography showed a dilated left ventricle with trivial mitral regurgitation and ejection fraction of 70%. Progressive hypoxemia (pH 7.37; Po2, 56 mm Hg; Pco2, 47 mm Hg; base excess, — 4; bicarbonate, 20 mmol/L) despite noninvasive ventilatory support required endotracheal intubation and mechanical ventilation. Transesophageal Doppler analysis revealed a baseline cardiac output of 4.5 L/min (cardiac index, 2.8 L/min/m2) with stroke volume (SV) of 40 mL. Within 1 h of admission to the ICU, atrial fibrillation developed with a ventricular rate of 150 beats/min. Chemical (IV magnesium sulfate and amiodarone) and electrical cardioversion failed to re-establish sinus rhythm, although rate declined to 105 beats/min. Over the following 4 h, cardiac output declined (to 2.8 L/min; cardiac index, 1.6 L/min/m2; SV, 26 mL) despite a central venous pressure (CVP) of 15 mm Hg.