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The hypodynamic septic shock appears to be a promising indication to veno-arterial membrane oxygenation (VA-ECMO) support of a patient with insufficient cardiac output. With cardiac recovery most of those patients progress into a hyperdynamic septic shock with cardiac output, which may not match critically low systemic vascular resistance to maintain perfusion pressures. Such refractory distributive shock represents a challenging indication to VA-ECMO. We report a rare case of a 27-year old patient who developed severe refractory hypodynamic septic shock due to the bilateral staphylococcal pneumonia and had to be initially rescued by femoro-femoral VA-ECMO. Despite extensive measures, he remained in intractable hypotension and profound tissue hypoperfusion with imminent multiorgan failure. The commencement of a second jugulo-axillary VA ECMO secured a total blood flow of 14.3 L/min, which restored perfusion pressure and successfully bridged patient over the period of critical haemodynamic instability and ultimately may have facilitated recovery.

Glucocorticosteroids (steroids) are widely used for sepsis patients. However, the potential benefits and harms of both high and low dose steroids remain unclear. A systematic review of randomised clinical trials with meta-analysis and trial sequential analysis (TSA) might shed light on this clinically important question.A systematic review was conducted according to a published protocol and The Cochrane Handbook methodology including meta-analyses, TSA of randomised clinical trials, and external validity estimation (GRADE). Randomised clinical trials evaluating steroids were included for sepsis patients (systemic inflammatory response syndrome, sepsis, severe sepsis or septic shock) aged > 18 years. Cochrane Central Register of Controlled Trials (CENTRAL), PubMed/Medline, Embase, Web of Science and Cinahl were searched until 18 February 2015. No language restrictions were applied. Primary outcomes were mortality at longest follow-up and serious adverse events.A total of 35 trials randomising 4682 patients were assessed and reviewed in full text. All trials but two had high risk of bias. No statistically significant effect was found for any dose of steroids versus placebo or no intervention on mortality at maximal follow-up [relative risk (RR) 0.89; TSA adjusted confidence interval (CI) 0.74-1.08]. Two trials with low risk of bias also showed no statistically significant difference (random-effects model RR 0.38, 95 % CI 0.06-2.42). Similar results were obtained in subgroups of trials stratified according to high (> 500 mg) or low (a parts per thousand currency sign500 mg) dose hydrocortisone (or equivalent) (RR 0.87; TSA-adjusted CI 0.38-1.99; and RR 0.90; TSA-adjusted CI 0.49-1.67, respectively). There were also no statistically significant effects on serious adverse events other than mortality (RR 1.02; TSA-adjusted CI 0.7-1.48). The effects did not vary according to the degree of sepsis. TSA showed that many more randomised patients are needed before definitive conclusions may be drawn.Evidence to support or negate the use of steroids in any dose in sepsis patients is lacking. The results of ongoing and future well-designed, large randomised clinical trials are needed.

Objective To review the findings and discuss the implications of studies on the use of low-dose corticosteroids in septic shock. Design A critical appraisal of "Low-dose hydrocortisone improves shock reversal and reduces cytokine levels in early hyperdynamic septic shock" by Oppert et al. (Crit Care Med 2005; 33:2457-2464) with literature review. Findings Previous studies have shown that low-dose corticosteroids shorten duration of shock in adults with sepsis, which is confirmed by the results of Oppert et al. The benefit on mortality is much less clear. Review of the literature casts doubt on whether these data can be extrapolated to children. Conclusions There is some, albeit limited, evidence for the benefit of low-dose steroids in adults with sepsis. No supporting data are available for the pediatric population; therefore, a randomized controlled trial in septic children is needed.

Peripheral perfusion assessment is increasingly being recognized as a potential surrogate of global perfusion parameters during septic shock resuscitation. Nevertheless, its correlation with other perfusion parameters is not well established. This study explores the relationship between peripheral perfusion parameters and macrohemodynamic, metabolic, hepatosplanchnic, and micro-circulatory-related parameters during hyperdynamic septic shock.

To hypothesize that reduced L-type calcium current with consequent shortening of cardiac repolarization is present in a clinically relevant porcine model of hyperdynamic septic shock. Myocardial depression is a well-recognized manifestation of sepsis and septic shock. Reduction of L-type calcium current was demonstrated to contribute to the myocardial depression in endotoxemic rodents.Laboratory animal experiments.Animal research laboratory at a university.Twenty-two domestic pigs of either gender.In anesthetized, mechanically ventilated, and instrumented pigs, sepsis was induced by bacteremia (central venous infusion of live Pseudomonas aeruginosa) and continued for 22 hrs.Electrocardiogram was recorded before and 22 hrs after induction of bacteremia. RR, QT, and QTc intervals were significantly shortened by sepsis. In vitro, action potentials were recorded in right ventricular trabeculae. Action potential durations were shortened in septic preparations. Tumor necrosis factor-alpha did not influence action potential durations. L-type calcium current was measured in isolated ventricular myocytes. Peak L-type calcium current density was reduced in myocytes from septic animals (8.3 +/- 0.4 pA/pF vs. 11.2 +/- 0.6 pA/pF in control). The voltage dependence of both L-type calcium current activation and inactivation was shifted to more negative potentials in myocytes from septic animals. Action potential-clamp experiments revealed that the contribution of L-type calcium current to the septic action potential was significantly diminished. In cardiac myocytes incubated with tumor necrosis factor-alpha, L-type calcium current was not further affected.In a clinically relevant porcine model, hyperdynamic septic shock induced shortening of ventricular repolarization and reduction of L-type calcium current. The contribution of L-type calcium current to the action potential in septic ventricular myocytes was significantly diminished. Tumor necrosis factor-alpha probably did not contribute to this effect.

The aim was to investigate effects of continuous hemofiltration (CHF) and of coupled plasma filtration adsorption (CPFA) on electrophysiological properties of the septic heart. Sepsis was induced in anesthetized pigs by fecal peritonitis and continued for 22 h either without intervention (control sepsis) or with intervention (CHF or CPFA) applied for the last 10 h of this period. Electrocardiograms were recorded at baseline, before induction of peritonitis, and 22 h later, at the end of in vivo experiment. In vitro, action potentials were recorded in right ventricular trabeculae. RR, QT, and QTc (QT corrected for heart rate) intervals were shortened by sepsis. Action potential durations (APDs) were shortened by CHF, but not by CPFA, compared with control sepsis. Continuous hemofiltration prolonged APD. Coupled plasma filtration adsorption filtrate did not exert any effect on APD. Plasma separated during CPFA prolonged APD. Continuous hemofiltration shortened cardiac repolarization, and this effect was reversed by the hemofiltrate. In contrast, neither CPFA nor the CPFA filtrate influenced APD. The data indicate that some inflammatory mediators able to delay cardiac repolarization were removed from plasma to hemofiltrate by CHF but not by CPFA.

We studied the effect of increasing systemic oxygen delivery (DO2) by packed RBC (PRBC) transfusion on oxygen consumption (VO2) in children with hyperdynamic septic shock. After routine resuscitation with volume loading and pharmacologic support, patients were studied if they had significant derangements of oxygen transport variables defined as: baseline VO2 less than 180 ml/min.m2 and oxygen extraction (O2 extr) less than 24%. Eight studies were performed. PRBC transfusion increased DO2 from 636 +/- 167 to 828 +/- 266 ml/min.m2 (p less than .01) without increasing cardiac index (5.2 +/- 1.3 vs. 5.0 +/- 1.4 L/min.m2). VO2 increased from 112 +/- 36 to 157 +/- 60 ml/min.m2 (p less than .01) while O2 extr was unchanged (18 +/- 3% vs. 19 +/- 6%). Despite initial low O2 extr, VO2 can be increased in pediatric septic shock by a further increase in DO2. Since VO2 correlates with survival, one should consider enhancing DO2 further despite initial low O2 extr and high DO2. Effects on morbidity and mortality require further study.

Extracorporeal blood purification techniques for the treatment of sepsis remain conceptually sound but are still an unresolved issue. Coupled plasma filtration adsorption (CPFA) enabling higher nonselective elimination of septic mediators represents a promising concept [1]. Its efficacy, however, has not been tested in a clinically relevant large animal model of septic shock. We therefore evaluated the biological effects of CPFA in a porcine long-term, hyperdynamic, peritonitis-induced septic shock model.

We recently showed in a hyperdynamic mouse model of septic shock that endogenous glucose production is depressed [1]. However, the mechanism for this depression remains unclear. In this context, the role of excess NO release due to activation of the inducible isoform of the NO synthase (iNOS) has been controversially discussed: while Stadler reported a direct relation between excess NO release and the inhibition of gluconeogenesis [2], other authors did not demonstrate any NO effect [3]. We therefore investigated the effects of genetic iNOS deletion on hepatic glucose production in a clinically relevant murine model of normotensive, hyperdynamic, volume-resuscitated septic shock. Wild-type mice served as controls.

A case report of a patient with hemophygocytic syndrome - a rare cause of life-threatening pancytopenia in the critical care.

Study objective: To compare the ability of dopamine and norepinephrine to reverse hemodynamic and metabolic abnormalities of human hyperdynamic septic shock. Design: Prospective, double-blind, randomized trial. Setting: An ICU in a university hospital. Patients: Adult patients with hyperdynamic septic shock after fluid resuscitation. Interventions: Patients were assigned to receive either dopamine (2.5 to 25 µg/kg/min) or norepinephrine (0.5 to 5.0 µg/kg/min). If hemodynamic and metabolic abnormalities were not corrected with the maximum dose of one drug, the other was added. Measurements and results: The aim of therapy was to achieve and maintain for at least 6 h all of the following: (1) systemic vascular resistance index >1, 100 dynes-s/cm 5. m 2 and/or mean systemic blood pressure ≥80 mm Hg; (2) cardiac index ≥4.0 L/min/m 2 ; (3) oxygen delivery >550 ml/min/m 2 ; and (4) oxygen uptake >150 ml/min/m 2 . With the use of dopamine 10 to 25 µg/kg/min, 5 of 16 patients (31 percent) were successfully treated, as compared with 15 of 16 patients (93 percent) by norepinephrine at a dose of 1.5 ± 1.2 µg/kg/min (p Conclusions: At the doses tested, norepinephrine was found, in the present study, to be more effective and reliable than dopamine to reverse the abnormalities of hyperdynamic septic shock. In the great majority of the study patients, norepinephrine was able to increase mean perfusing pressure without apparent adverse effect on peripheral blood flow or on renal blood flow (since urine flow was reestablished). At the same time, oxygen uptake was increased. (Chest 1993; 103:1826-31)

We analyzed the relationship of increases in oxygen delivery to changes in oxygen consumption in ten patients with hyperdynamic septic shock. Increases in oxygen delivery from 413 +/- 14 (SEM) to 535 +/- 19 ml/min X m2 (p less than .01) were associated with increases in oxygen consumption from 136 +/- 10 to 161 +/- 5 ml/min X m2 (p less than .05). Arterial lactate decreased from 4.6 +/- 1.6 to 2.1 +/- 0.3 mmol/L (p less than .05). These observations suggest that oxygen utilization is perfusion-limited in hyperdynamic septic shock.

Background Recent clinical studies have confirmed the strong prognostic value of persistent hyperlactatemia and delayed lactate clearance in septic shock. Several potential hypoxic and nonhypoxic mechanisms have been associated with persistent hyperlactatemia, but the relative contribution of these factors has not been specifically addressed in comprehensive clinical physiological studies. Our goal was to determine potential hemodynamic and perfusion-related parameters associated with 6-hour lactate clearance in a cohort of hyperdynamic, hyperlactatemic, septic shock patients. Methods We conducted an acute clinical physiological pilot study that included 15 hyperdynamic, septic shock patients undergoing aggressive early resuscitation. Several hemodynamic and perfusion-related parameters were measured immediately after preload optimization and 6 hours thereafter, with 6-hour lactate clearance as the main outcome criterion. Evaluated parameters included cardiac index, mixed venous oxygen saturation, capillary refill time and central-to-peripheral temperature difference, thenar tissue oxygen saturation (StO2) and its recovery slope after a vascular occlusion test, sublingual microcirculatory assessment, gastric tonometry (pCO2 gap), and plasma disappearance rate of indocyanine green (ICG-PDR). Statistical analysis included Wilcoxon and Mann–Whitney tests. Results Five patients presented a 6-hour lactate clearance