DISCUSSION
The
clinical manifestations of sepsis are highly variable, depending on the
initial site of infection, the causative organism, the pattern of acute
organ dysfunction, the underlying health status of the patient, and the
interval before initiation of treatment[5]. The patient had met the
diagnostic criteria of sepsis when admission. He received the
examinations of pathogeny of local Centers for Disease Control and our
hospital at the time of hospitalization but no tests results were
positive. In this case, we mainly provided supportive treatment and
antibacterial treatment.
In 1984, Parker et al. first proposed the concept of sepsis induced
cardiomyopathy[6]. Recent literature suggests that
>10% of patients with sepsis and septic shock develop
septic cardiomyopathy. They observed that 65% of patients with septic
shock developed left ventricular systolic dysfunction (defined as
ejection fraction < 45%). SIC is a reversible myocardial
dysfunction caused by sepsis, and can be reversed in 7–10 days. The SIC
has been summarized as a global (systolic and diastolic) but reversible
dysfunction of both the left and right sides of the heart. More than
half of sepsis patients have secondary sepsis cardiomyopathy. The
combination of dysregulation of inflammatory mediators, mitochondrial
dysfunction, oxidative stress, disorder of calcium regulation, autonomic
nervous system dysregulation, and endothelial dysfunction contribute to
the complex pathogenesis of SIC[7-10]. In addition to the use of
vasoactive drugs, mechanical support with Intra-aortic balloon pumping
(IABP) or ECMO seems to be the last option for unresponsive severe
cardiogenic shock due to SIC.
IABP
is used to increase the cardiac output and reduce the dosage of a
vasopressor. Consequently, IABP prolongs survival time and lowers
vasopressor requirements[11]. ECMO is a life-saving method which is
used extensively due to its significant role in providing support in
patients with respiratory failure, cardiac failure, or both. It helps
via a modified form of cardiopulmonary bypass providing time to rest the
patients’ lung[12,13]. There are some studies reported the
successful use of V-A ECMO in patients with SIC[1,4]. In our study,
the patient used the V-V ECMO treatment due to ARDS. He progressed to
SIC during the application of ECMO. Compared with V-A ECMO, patients
undergoing V-V ECMO get more stable hemodynamic, and less complications
as well. Therefore, the case showed that patient with sepsis and sepsis
induced cardiomyopathy could benefit from V-V ECMO.
The patient had fever before admission, but the fever persists even
after antibiotics are used. However, the PCT tended to return to normal,
indicating that the anti-infection treatment was effective. The
eosinophils count substantially increased at the time of
hospitalization. And the patient recovered from the fever as soon as
moxifloxacin was stopped (Figure 3) . Therefore, the fever was
more likely to be caused by drugs. There are many reasons may contribute
to the drug-induced fever, and the allergic reaction is the most common
one[14]. Therefore, elevated serum total IgE and eosinophil counts
are common manifestations of drug fever[14,15]. For patients with
persistent high body temperature, we should accurately assess the
patient’s condition, timely determine the cause of fever, and provide
the most reasonable drug regimen for patients.
In conclusion, we report a patient with severe septic shock and sepsis
induced cardiomyopathy who recovered from V-V ECMO and prone position
ventilation treatments.
The
outcome of our patient shows that V-V ECMO may also benefit the patient
with less complications when managing septic shock and septic
cardiomyopathy.