What is the management of sepsis-induced cardiomyopathy?

Management of Sepsis-Induced Cardiomyopathy

Manage sepsis-induced cardiomyopathy by performing bedside cardiac ultrasound to detect ventricular dysfunction, optimizing preload with crystalloid resuscitation (30 mL/kg initial bolus), maintaining MAP ≥65 mmHg with norepinephrine as first-line vasopressor, and adding dobutamine (up to 20 μg/kg/min) when myocardial dysfunction persists despite adequate fluid resuscitation and blood pressure restoration. 1, 2

Diagnostic Approach

Bedside Cardiac Ultrasonography

• Perform bedside cardiac ultrasound (BCU) on all septic patients to evaluate for left and right ventricular dysfunction to guide inotropic therapy, as both systolic and diastolic dysfunction commonly develop in sepsis 1
• BCU enables early recognition of LV dysfunction, helping augment decreased cardiac output and stroke volume with inotropic support 1
• Assess for RV dysfunction, which occurs in up to 30% of septic patients and requires different fluid and vasopressor management strategies 1
• Recognize that septic cardiomyopathy typically presents as reversible myocardial dysfunction that resolves within 7-10 days 3, 4

Hemodynamic Monitoring

• Place an arterial catheter as soon as practical in all patients requiring vasopressors for continuous blood pressure monitoring 1, 2
• Monitor dynamic variables (stroke volume variation, pulse pressure variation) or static variables (blood pressure, heart rate) to guide fluid therapy 2
• Consider pulmonary artery catheter monitoring in high-risk patients with suspected sepsis-induced cardiogenic shock, particularly those with pre-existing cardiac dysfunction 5

Fluid Resuscitation Strategy

Initial Resuscitation

• Administer at least 30 mL/kg of crystalloids as initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspected hypovolemia 2
• Use crystalloids (either balanced crystalloids or saline) as the fluid of choice for initial resuscitation 1, 2
• Continue fluid administration while hemodynamic parameters improve based on dynamic or static variables 2

Adjunctive Fluid Therapy

• Add albumin to crystalloids when patients require substantial amounts of crystalloids, though this is a weak recommendation 1, 2
• Avoid excessive fluid resuscitation in the presence of documented LV dysfunction, as this aggravates adverse consequences 1

Vasopressor Management

First-Line Therapy

• Initiate norepinephrine as the first-choice vasopressor to target MAP ≥65 mmHg 1, 2
• This represents a strong recommendation with moderate quality evidence from the Surviving Sepsis Campaign 1

Second-Line Vasopressor Options

• Add vasopressin (up to 0.03 U/min) to norepinephrine when additional agent is needed to raise MAP or decrease norepinephrine dosage 1, 2
• Alternatively, add epinephrine to norepinephrine when additional vasopressor support is required 1, 2
• Reserve dopamine only for highly selected patients with low risk of tachyarrhythmias and absolute or relative bradycardia 1, 2

Inotropic Support for Myocardial Dysfunction

Dobutamine Therapy

• Administer dobutamine infusion up to 20 μg/kg/min when evidence of myocardial dysfunction exists with elevated cardiac filling pressures and low cardiac output 1, 2
• Add dobutamine when ongoing signs of hypoperfusion persist despite achieving adequate intravascular volume and adequate MAP 1
• The combination of dobutamine and norepinephrine stimulates both α1 and β2 adrenergic receptors and serves as first-line treatment when inotropic support is needed 2
• Titrate dosing to endpoints reflecting tissue perfusion and reduce or discontinue if worsening hypotension or arrhythmias develop 1

Recognition of Low Cardiac Output State

• Identify low cardiac output septic shock associated with elevated systemic vascular resistance, which benefits from inotropes and vasodilators 1
• Use BCU findings of reduced ejection fraction, wall motion abnormalities, or elevated filling pressures to guide inotrope initiation 1

Corticosteroid Therapy

• Avoid IV hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy restore hemodynamic stability 1, 2
• If hemodynamic stability cannot be achieved with fluids and vasopressors, administer IV hydrocortisone at 200 mg per day 2

Monitoring Targets

Minimum Recommended Parameters

• Maintain oxygen saturation (SpO₂) ≥95% 2
• Target MAP ≥65 mmHg 1, 2
• Achieve urine output ≥0.5 mL/kg/h 2
• Continuously assess response to fluid and vasopressor therapy 2

Advanced Interventions for Refractory Cases

Mechanical Circulatory Support

• Consider extracorporeal membrane oxygenation (ECMO) for severe sepsis-induced cardiomyopathy complicated by cardiogenic shock when high-dose vasopressors and inotropes fail 5, 6
• Correct patient selection is critical for improving outcomes with mechanical circulatory support 5
• Engage a multidisciplinary cardiogenic shock team when considering mechanical support 5

Critical Pitfalls to Avoid

• Do not aggressively fluid resuscitate patients with documented ventricular dysfunction on BCU, as this worsens outcomes 1
• Avoid using low-dose dopamine for renal protection, as this has no benefit 1
• Do not use hydroxyethyl starches for volume replacement in septic patients 1
• Recognize that septic cardiomyopathy is reversible and typically resolves spontaneously as the patient's condition improves, so avoid long-term cardiac medications during the acute phase 1, 3