What is the management of hypotension due to sepsis with a high right ventricular resistance (RVR)?

From the Guidelines

Management of hypotension from sepsis with a fib rvr requires immediate attention to both the septic shock and the cardiac dysrhythmia, with the primary goal of maintaining a mean arterial pressure (MAP) of at least 65 mmHg and controlling the ventricular rate. The initial step involves administering intravenous fluids with crystalloids at 30 ml/kg within the first 3 hours for initial resuscitation, as recommended by the Surviving Sepsis Campaign guidelines 1. If hypotension persists after adequate fluid resuscitation, start vasopressors, with norepinephrine as the first-line agent at 0.05-0.5 mcg/kg/min to maintain a MAP of at least 65 mmHg, as suggested by the guidelines 1. Some key points to consider in the management include:

• Administering broad-spectrum antibiotics within one hour of recognition of sepsis, with choices guided by the suspected source of infection.
• Obtaining blood cultures before starting antibiotics but not delaying treatment.
• Implementing source control measures if an infectious focus is identified.
• Continuous cardiac monitoring is essential, and if the patient remains unstable despite these measures, consider synchronized cardioversion. The combination of sepsis and a fib rvr creates a challenging clinical scenario, and the management should be tailored to the individual patient's needs, taking into account the underlying cause of sepsis, the severity of the cardiac dysrhythmia, and the patient's overall clinical condition. In terms of specific management strategies, the guidelines suggest:
• Using dynamic over static variables to predict fluid responsiveness, where available 1.
• Guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion 1.
• Considering the use of dobutamine in patients who show evidence of persistent hypoperfusion despite adequate fluid loading and the use of vasopressor agents 1.

From the Research

Management of Hypotension from Sepsis with a Fixed Right Ventricular (RV) Resistance

• The management of hypotension from sepsis with a fixed RV resistance involves treating the underlying cause of sepsis and reversing circulatory shock to maintain tissue perfusion and oxygen delivery 2.
• Decreasing pulmonary vascular resistance with selective pulmonary vasodilators is a reasonable approach to improving cardiac output in septic patients with right ventricular dysfunction 2.
• Treatment for right ventricular dysfunction in the setting of sepsis should concentrate on fluid repletion, monitoring for signs of RV overload, and correction of reversible causes of elevated pulmonary vascular resistance, such as hypoxia, acidosis, and lung hyperinflation 2.

Fluid Resuscitation and Vasopressor Therapy

• Fluid resuscitation is the priority in early management, including administering an intravenous crystalloid at 30 mL per kg within the first three hours 3.
• Vasopressor therapy is indicated if hypotension persists despite fluid administration 3.
• The use of vasopressors and fluid resuscitation varies by patient and hospital factors, and compliance with the surviving sepsis campaign bundle is not always associated with improved outcomes 4.

Monitoring and Diagnosis

• Monitoring left ventricular preload is critical to achieve adequate fluid resuscitation in patients with hypotension and sepsis 5.
• The measurement of serum lactate has been incorporated into the latest septic shock definition, and the Sequential Organ Failure Assessment (SOFA) score is an important tool for early diagnosis 3.
• Echocardiographic parameters, such as fractional area change (FAC) and tricuspid annulus systolic plane excursion (TAPSE), can be used to diagnose right ventricular dysfunction in septic patients 6.

Outcomes and Prognosis

• Right ventricular dysfunction is present in nearly half of septic patients and is associated with over threefold higher 28-day mortality 6.
• Patients with RV dysfunction had higher 28-day mortality, and RV dysfunction was associated with increased mortality in a multivariable regression model 6.
• Higher mortality is seen among those who remain in shock after initial resuscitation, regardless of compliance with the surviving sepsis campaign bundle 4.