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Impact of norepinephrine on right ventricular afterload and function in septic shock-a strain echocardiography study

Journal article
Authors Keti Dalla
Odd Bech-Hanssen
Sven-Erik Ricksten
Published in Acta Anaesthesiologica Scandinavica
Volume 63
Issue 10
Pages 1337-1345
ISSN 0001-5172
Publication year 2019
Published at Institute of Clinical Sciences, Department of Anesthesiology and Intensive care
Institute of Medicine, Department of Molecular and Clinical Medicine
Pages 1337-1345
Language en
Links dx.doi.org/10.1111/aas.13454
Keywords cardiac output, norepinephrine, pulmonary vascular resistance, right, ventricular strain, septic shock, strain echocardiography, speckle tracking echocardiography, effective arterial elastance, guidelines, sepsis, Anesthesiology
Subject categories Anaesthetics

Abstract

Background In this observational study, the effects of norepinephrine‐induced changes in mean arterial pressure (MAP) on right ventricular (RV) systolic function, afterload and pulmonary haemodynamics were studied in septic shock patients. We hypothesised that RV systolic function improves at higher doses of norepinephrine/MAP levels. Methods Eleven patients with septic shock requiring norepinephrine after fluid resuscitation were included <24 hours after ICU arrival. Study enrolment and insertion of a pulmonary artery catheter was performed after written informed consent from the next of kin. Norepinephrine infusion was titrated to target mean arterial pressures (MAP) of 60, 75 and 90 mmHg in a random sequential order. At each target MAP, strain—and conventional echocardiographic—and pulmonary haemodynamic variables were measured. RV afterload was assessed as effective pulmonary arterial elastance, (Epa) and pulmonary vascular resistance index, (PVRI). RV free wall peak strain was the primary end‐point. Results At highest compared to lowest norepinephrine dose/MAP level, RV free wall peak strain increased from −19% to −25% (32%, P = .003), accompanied by increased tricuspid annular plane systolic excursion (22%, P = .01). At the highest norepinephrine dose/MAP, RV end‐diastolic area index (16%, P < .001), central venous pressure (38%, P < .001), stroke volume index (7%, P = .001), mean pulmonary artery pressure (19%, P < .001) and RV stroke work index (15%, P = .045) increased, with no effects on PVRI or Epa. Cardiac index did not change, assessed by thermodilution (P = .079) and echocardiography (P = .054). Conclusions Higher doses of norepinephrine to a target MAP of 90 mm Hg improved RV systolic function while RV afterload was not affected.

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