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Fig. 8 | Critical Ultrasound Journal

Fig. 8

From: Echocardiography in the sepsis syndromes

Fig. 8

Septic Shock ECHO-based goal-directed algorithm. To monitor hemodynamics in septic shock the targets of the echocardiographic investigation are organized in a systematic five-step approach. Starting point is to detect potential signs of pre-existing chronic cardiac dysfunction (Step 1): LV or LA significant dilatation, and LV marked hypertrophy are signs or chronic volume/pressure overload; RA significant dilatation, RV dilatation and hypertrophy have the same meaning for right-side chronic disease (isolated RV dilatation can vice versa be a sign of acute RV dysfunction). If unrecognized, these findings can mislead in interpretation of subsequent findings (i.e. primary cardiogenic cause of shock, instead of sepsis; wrong assessment of volume status based on LV or RV dimensions). LV and RV systolic function must then be assessed (Step 2), together with cardiac output Doppler measurement (Step 3). A low output state can then be ascribed to sepsis-related LV systolic dysfunction (associated or not to RV dysfunction) or isolated RV dysfunction, and treated accordingly. Low output with evidence of normal biventricular systolic function should prompt investigation of volume status (Step 4): overt hypovolemia or presence of volume responsiveness will lead to fluid infusion. When inadequacy of global perfusion and/or hypotension is associated with a non-low output state, persistent preload defect should be investigated (again step four) and if detected corrected. If this is not the case, an exclusion diagnosis of vasodilatation is made (Step 5), and systemic arterial tone corrected with upward titration of vasopressors. Whenever this is done, LV systolic function should subsequently be re-assessed, as normalization of LV afterload can unmask sepsis-related myocardial dysfunction. If chronic LV failure is found, or LV dysfunction develops acutely, LV filling pressure estimation is mandatory, to guide fluid management and differential diagnosis of potential hypoxemia and pulmonary edema (cardiogenic vs. non cardiogenic). ScvO2 central venous saturation, LV left ventricle, RV right ventricle, SV stroke volume, CI cardiac index, SAPm mean systemic arterial pressure

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