Levosimendan in septic shock: a case series
1 Sheffield, UK
2 Fremantle, Australia
* E-mail: brucep{at}blueyonder.co.uk
Editor—Levosimendan, a novel calcium sensitizer and K-ATP channel opener, has been used in a variety of clinical settings, including acute decompensated and low output heart failure, adult respiratory distress syndrome, ischaemic myocardial stunning, and cardiac surgery. We would like to report our use of levosimendan (0.1–0.2 µg kg–1min–1) over 24 h as rescue therapy in six patients with refractory septic shock,1 despite conventional resuscitation.2 Cardio-respiratory, metabolic, and outcome data were collected and reviewed.
In this group of patients, post-levosimendan infusion, there was a trend towards increased mean arterial pressure, improved arterial oxygen partial pressure: fractional inspired oxygen ratio, increased cardiac index, reduced base excess, improved pH, and reduced lactate. There was also a reduction in heart rate, pulmonary vascular resistance index, and systemic vascular resistance index. Catecholamine requirements were reduced in all patients. There were no adverse effects associated with the use of levosimendan in this group and despite predicted 28 day mortality by APACHE II score being approximately 60%, all but one of the patients survived to leave hospital.
There are data emerging to support the use of levosimendan in septic myocardial depression3 and its role in reducing the incidence of ARDS4 in sepsis. There are also data from experimental models that levosimendan may have a protective role in endotoxaemic acute renal failure5 and an immuno-modulatory effect via pro-inflammatory cytokine level reduction.6
Our series of septic shock patients treated with levosimendan differs from previous series, in that its use as rescue therapy was not limited to those with previously normal left ventricular function or to those in whom dobutamine had been ineffective. We did not limit our use of levosimendan to those with low output cardiac states, but rather we used it as rescue therapy in those whose catecholamine requirements remained high, despite adequate fluid resuscitation.
Our observations appear to support the growing interest in the use of levosimendan in septic shock as a safe and potentially useful adjunct to conventional therapy. We are currently undertaking a prospective, randomized, placebo-controlled trial to further investigate the use of levosimendan as rescue therapy in refractory septic shock as an adjunct to conventional therapy.
References
1 American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med (1992) 20:864–74.[Web of Science][Medline]
2 Dellinger RP, Carlet JM, Masur H, et al, for the Surviving Sepsis Campaign Management Guidelines Committee: Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med (2004) 32:858–73.[CrossRef][Web of Science][Medline]
3 Morelli A, De Castro S, Teboul J-L, et al. Effects of levosimendan on systemic and regional hemodynamics in septic myocardial depression. Intensive Care Med (2005) 31:638–44.[CrossRef][Web of Science][Medline]
4 Morelli A, Teboul J-L, Maggiore SM, et al. Effects of levosimendan on right ventricular afterload in patients with acute respiratory distress syndrome: a pilot study. Crit Care Med (2006) 34:2287–93.[CrossRef][Web of Science][Medline]
5 Zager RA, Johnson AC, Lund S, Hanson SY, Abrass CK. Levosimendan protects against experimental endotoxemic acute renal failure. Am J Physiol Renal Physiol (2006) 290:1453–62.[CrossRef]
6 Avgeropoulou C, Andreadou I, Markantonis-Kyroudis S, et al. The Ca2+-sensitiser levosimendan improves oxidative damage, BNP and pro-inflammatory cytokine levels in patients with advanced decompensated heart failure in comparison to dobutamine. Eur J Heart Failure (2005) 7:882–7.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  J. D. Hunter and M. Doddi Sepsis and the heart Br. J. Anaesth., November 25, 2009; (2009) aep339v1. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||