Sepsis & septic shock
Septic cardiomyopathy, fluid responsiveness and tolerance, the endocarditis source — echo guides every hour.
Echo approach, step by step
The Surviving Sepsis Campaign recommends dynamic measures rather than static ones to guide fluid, and suggests adding dobutamine or switching to adrenaline for cardiac dysfunction with persistent hypoperfusion [155]. Echo provides both [152]. Diastolic dysfunction in septic patients was associated with increased mortality [207].
- LVLVEF, global or regional dysfunction (septic cardiomyopathy); LVOT VTI [152].
- Diastolice′ and E/e′ (associated with mortality) [207].
- RVDilatation and dysfunction (ARDS, ventilation) [152].
- Dynamic LVOT obstructionHyperdynamic, underfilled LV with catecholamines [13].
- Fluid responsivenessPLR with VTI; IVC distensibility if ventilated [121,122].
- Fluid toleranceB-lines, E/e′, IVC plethora [202].
- SourceVegetations; pericardial effusion (purulent pericarditis) [31,136].
- LVEF, LVOT VTI
- E/e′
- RV
- LVOTO
- PLR response
- B-lines
- Vegetations
Causes & echo clues
| Pattern | Echo | Action |
|---|---|---|
| Vasoplegia with hyperdynamic LV | High EF, normal or high VTI | Noradrenaline, fluid if responsive [155] |
| Septic cardiomyopathy (LV) | Low EF, low VTI | Consider dobutamine or adrenaline [155] |
| RV dysfunction | Dilated RV (ARDS, high PEEP) | Protective ventilation; review PEEP [152] |
| Hypovolaemia | Small cavity, VTI rises with PLR | Fluid [121] |
| Dynamic LVOTO | SAM, gradient | Reduce inotropes; fluid; beta-blocker [13] |
| Endocarditis source | Vegetation | TOE, surgery review [136] |
Clinical pathway to the diagnosis
- Hour-1 bundleLactate, blood cultures before antibiotics, broad-spectrum antibiotics, fluid (30 mL/kg crystalloid is suggested within 3 hours for hypoperfusion), and vasopressors for MAP ≥65 mmHg [155].
- Echo earlyTo phenotype and guide fluid [152,155].
- Re-assessCapillary refill, lactate and echo after each intervention [155].
Clinical pearls & pitfalls
PitfallA normal or high EF in septic shock can hide myocardial depression. Low afterload flatters EF. Look at the VTI and GLS [152].
- Septic cardiomyopathy is usually reversible within 7–10 days in survivors [152].
- Fluid tolerance matters as much as responsiveness. Stop when B-lines appear or E/e′ rises [202].
Red flags
- Persistent hypoperfusion despite fluid and vasopressors → assess cardiac function [155]
- New murmur or S. aureus bacteraemia → endocarditis [136]
- Rising lactate with a low VTI → cardiogenic component [152]