STRESS AND SHOCK: CASE OF MECHANICAL CIRCULATORY SUPPORT IN TOXIC SHOCK

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Sepsis may induce stress-induced cardiomyopathy by increased catecholamines. Although reversible, In severe cases this may lead to ventricular arrhythmias, thromboembolism, and cardiogenic shock. There is increased hospital mortality with age >80, black race, and presence of multi organ failure. CASE PRESENTATION: 52 yo black male with unknown medical history presents with belligerent behavior and shortness of breath. He was noted to be febrile to 108F, hypotensive with MAPs in the 40s, tachycardic to 140s, and hypoxic to 79% on room air. Labs significant for WBC 1, Cr 4.2, lactic acid 11.7, CK 2407, Troponin 0.104. ABG showed pH 7.19, pCO2 54, pO2 48, FiO2 100%. Chest xray showed bilateral interstitial and airspace opacities. Patient was intubated for hypoxic and hypercapnic respiratory failure and started on norepinephrine, vasopressin, and epinephrine with 5L fluid bolus and stress dose steroids. TTE demonstrated left ventricle apical and mid wall segment akinesis with left ventricular ballooning. VA-ECMO emergently initiated for ARDS management and Impella was placed for cardiogenic shock secondary to sepsis-induced Takotsubo cardiomyopathy. Sputum cultures returned positive for MRSA and Streptococcus pyogenes. Antibiotics changed to vancomycin, zosyn, azithromycin, cefepime, and clindamycin to account for toxic shock. Hospital course was complicated by development of pancytopenia requiring use of granix, atrial fibrillation with rapid ventricular rate requiring emergent cardioversion, and renal failure requiring CRRT. Impella was removed on the sixth hospital day and the patient started on dobutamine. Patient eventually developed critical limb ischemia in all four extremities with need for bilateral hand and hip disarticulations. On the ninth hospital day, the patient was transitioned to comfort care and passed away. DISCUSSION: In the case above, toxic and septic shock caused stress-induced cardiomyopathy that required VA-ECMO and Impella. In the adult population, VA-ECMO has not been widely used in the treatment of refractory shock and outcomes with VV-ECMO have been better than VA-ECMO. This is likely due to VA-ECMO's use in profound hypoperfusion and higher incidence of neurological complications, renal failure, and limb ischemia. The addition of Impella helps unload the left ventricle and helps with EMCO weaning. CONCLUSIONS: Studies have found that better outcomes were associated with door-to-ECMO times of ≤96 hours, Gram-positive sepsis, and pneumonia rather than primary bloodstream infections. Though our patient met all of these criteria, his case still resulted in poor outcomes. REFERENCE #1: Cheng A, Sun HY, Tsai MS, Ko WJ, Tsai PR, Hu FC, Chen YC, Chang SC. Predictors of survival in adults undergoing extracorporeal membrane oxygenation with severe infections. The Journal of thoracic and cardiovascular surgery. 2016 Dec 1;152(6):1526-36. REFERENCE #2: Nabzdyk CS, Couture EJ, Shelton K, Cudemus G, Bittner EA. Sepsis induced cardiomyopathy: Pathophysiology and use of mechanical circulatory support for refractory shock. Journal of critical care. 2019 Dec 1;54:228-34. REFERENCE #3: Schmitz, M., Roux, X., Huttner, B. et al. Streptococcal toxic shock syndrome in the intensive care unit. Ann. Intensive Care 8, 88 (2018). https://doi.org/10.1186/s13613-018-0438-y DISCLOSURES: No relevant relationships by Debapria Das, source=Web Response No relevant relationships by Abigail Go, source=Web Response No relevant relationships by Daniele Valentini, source=Web Response