Abstract
BackgroundBedside 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.MethodsThis 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.ResultsAfter 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).ConclusionPatients 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.
Highlights
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
Diagnostic process of septic shock included the following: for patients with infection or suspected infection, if their sequential organ failure assessment (SOFA) score was ≥ 2 or doctors suspected sepsis, we further evaluated whether there is an evidence of organ dysfunction; if the patient’s SOFA score was ≥ 2 or the new score was ≥ 2, it was diagnosed as sepsis
Haemodynamic response to esmolol in septic shock patients A total of 85 patients satisfied inclusion criteria, of them 56 enrolled patients were treated with appropriate hemodynamic therapy, had a heart rate > 95 bpm 24 h after admission to the intensive care unit (ICU), required norepinephrine (≥ 0.10 μg/kg/min) to maintain MAP > 65 mmHg, and had a Global End-Diastolic Volume Index (GEDVI) > 700 mL/m2 and Intrathoracic Blood (ITBVI) > 850 mL/m2
Summary
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. In contrast with traditional flow, dependant on cardiac output and systemic vascular resistance, flow of the waterfall depends on the pressure difference between the upstream source (arterial blood pressure, ABP) and the top of the waterfall (critical closure pressure, Pcc), while the pressure at the bottom of the waterfall (mean systemic filling pressure, Pmsf ) and the downstream resistance do not affect the flow [8]. Under these circumstances, the whole vasculature would be divided into arterial units, microcirculation units and venous units, as opposed to the classic hemodynamics that compares the entire vascular system to a set of stiff ducts, which no longer seems suitable [9]. Under the premise of ensuring average arterial pressure and cardiac displacement, many patients will still develop acute kidney injury or acute renal failure, and oliguria or anuria may occur [2, 10]
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