Cardio-haemodynamic assessment and venous lactate in severe dengue: Relationship with recurrent shock and respiratory distress

Sophie Yacoub, Trieu Huynh Trung, Phung Khanh Lam, Vuong Huynh Ngoc Thien, Duong Ha Thi Hai, Tu Qui Phan, Oanh Pham Kieu Nguyet, Nguyen Than Ha Quyen, Cameron Paul Simmons, Christopher Broyd, Gavin Robert Screaton, Bridget Wills, Sophie Yacoub, Trieu Huynh Trung, Phung Khanh Lam, Vuong Huynh Ngoc Thien, Duong Ha Thi Hai, Tu Qui Phan, Oanh Pham Kieu Nguyet, Nguyen Than Ha Quyen, Cameron Paul Simmons, Christopher Broyd, Gavin Robert Screaton, Bridget Wills

Abstract

Background: Dengue can cause plasma leakage that may lead to dengue shock syndrome (DSS). In approximately 30% of DSS cases, recurrent episodes of shock occur. These patients have a higher risk of fluid overload, respiratory distress and poor outcomes. We investigated the association of echocardiographically-derived cardiac function and intravascular volume parameters plus lactate levels, with the outcomes of recurrent shock and respiratory distress in severe dengue.

Methods/principle findings: We performed a prospective observational study in Paediatric and adult ICU, at the Hospital for Tropical Diseases (HTD), Ho Chi Minh City, Vietnam. Patients with dengue were enrolled within 12 hours of admission to paediatric or adult ICU. A haemodynamic assessment and portable echocardiograms were carried out daily for 5 days from enrolment and all interventions recorded. 102 patients were enrolled; 22 patients did not develop DSS, 48 had a single episode of shock and 32 had recurrent shock. Patients with recurrent shock had a higher enrolment pulse than those with 1 episode or no shock (median: 114 vs. 100 vs. 100 b/min, P = 0.002), significantly lower Stroke Volume Index (SVI), (median: 21.6 vs. 22.8 vs. 26.8mls/m2, P<0.001) and higher lactate levels (4.2 vs. 2.9 vs. 2.2 mmol/l, P = 0.001). Higher SVI and worse left ventricular function (higher Left Myocardial Performance Index) on study days 3-5 was associated with the secondary endpoint of respiratory distress. There was an association between the total IV fluid administered during the ICU admission and respiratory distress (OR: 1.03, 95% CI 1.01-1.06, P = 0.001). Admission lactate levels predicted patients who subsequently developed recurrent shock (P = 0.004), and correlated positively with the total IV fluid volume received (rho: 0.323, P = 0.001) and also with admission ALT (rho: 0.764, P<0.001) and AST (rho: 0.773, P<0.001).

Conclusions/significance: Echo-derived intravascular volume assessment and venous lactate levels can help identify dengue patients at high risk of recurrent shock and respiratory distress in ICU. These findings may serve to, not only assist in the management of DSS patients, but also these haemodynamic endpoints could be used in future dengue fluid intervention trials.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1. “Stroke Volume Index over ICU…
Fig 1. “Stroke Volume Index over ICU admission in patients with no shock, shock and recurrent shock.”
Graph showing the dynamics of SVI by study day for 87 patients. Grey lines are changes of SVI for each patient. Colored lines connect medians of SVI on each study day for each patient group.

References

    1. Bhatt S, Gething PW, Brady OJ, Messina JP, Farlow AW, Moyes CL, et al. The global distribution and burden of dengue. Nature. 2013;496(7446):504–7. doi: ; PubMed Central PMCID: PMCPMC3651993.
    1. Amancio FF, Heringer TP, de Oliveira Cda C, Fassy LB, de Carvalho FB, Oliveira DP, et al. Clinical Profiles and Factors Associated with Death in Adults with Dengue Admitted to Intensive Care Units, Minas Gerais, Brazil. PLoS One. 2015;10(6):e0129046 doi: ; PubMed Central PMCID: PMC4474920.
    1. Laoprasopwattana K, Chaimongkol W, Pruekprasert P, Geater A. Acute respiratory failure and active bleeding are the important fatality predictive factors for severe dengue viral infection. PLoS One. 2014;9(12):e114499 doi: ; PubMed Central PMCID: PMC4252142.
    1. Wills BA, Nguyen MD, Ha TL, Dong TH, Tran TN, Le TT, et al. Comparison of three fluid solutions for resuscitation in dengue shock syndrome. N Engl J Med. 2005;353(9):877–89. doi: .
    1. Ngo NT, Cao XT, Kneen R, Wills B, Nguyen VM, Nguyen TQ, et al. Acute management of dengue shock syndrome: a randomized double-blind comparison of 4 intravenous fluid regimens in the first hour. Clin Infect Dis. 2001;32(2):204–13. doi: .
    1. Yacoub S, Griffiths A, Chau TT, Simmons CP, Wills B, Hien TT, et al. Cardiac function in Vietnamese patients with different dengue severity grades. Crit Care Med. 2012;40(2):477–83. doi: ; PubMed Central PMCID: PMCPMC4140416.
    1. Kirawittaya T, Yoon IK, Wichit S, Green S, Ennis FA, Gibbons RV, et al. Evaluation of Cardiac Involvement in Children with Dengue by Serial Echocardiographic Studies. PLoS Negl Trop Dis. 2015;9(7):e0003943 doi: ; PubMed Central PMCID: PMCPMC4520477.
    1. Yacoub S, Wertheim H, Simmons CP, Screaton G, Wills B. Cardiovascular manifestations of the emerging dengue pandemic. Nat Rev Cardiol. 2014;11(6):335–45. doi: .
    1. Yacoub S, Lam PK, Vu le HM, Le TL, Ha NT, Toan TT, et al. Association of Microvascular Function and Endothelial Biomarkers With Clinical Outcome in Dengue: An Observational Study. J Infect Dis. 2016;214(5):697–706. doi: ; PubMed Central PMCID: PMCPMC4978369.
    1. Shapiro NI, Howell MD, Talmor D, Nathanson LA, Lisbon A, Wolfe RE, et al. Serum lactate as a predictor of mortality in emergency department patients with infection. Annals of emergency medicine. 2005;45(5):524–8. doi: .
    1. Thomas-Rueddel DO, Poidinger B, Weiss M, Bach F, Dey K, Haberle H, et al. Hyperlactatemia is an independent predictor of mortality and denotes distinct subtypes of severe sepsis and septic shock. Journal of critical care. 2015;30(2):439 e1-6. doi: .
    1. Thanachartwet V, Oer-Areemitr N, Chamnanchanunt S, Sahassananda D, Jittmittraphap A, Suwannakudt P, et al. Identification of clinical factors associated with severe dengue among Thai adults: a prospective study. BMC infectious diseases. 2015;15:420 doi: ; PubMed Central PMCID: PMC4606996.
    1. Sirikutt P, Kalayanarooj S. Serum lactate and lactate dehydrogenase as parameters for the prediction of dengue severity. Journal of the Medical Association of Thailand = Chotmaihet thangphaet. 2014;97 Suppl 6:S220–31. .
    1. Thanachartwet V, Desakorn V, Sahassananda D, Jittmittraphap A, Oer-Areemitr N, Osothsomboon S, et al. Serum Procalcitonin and Peripheral Venous Lactate for Predicting Dengue Shock and/or Organ Failure: A Prospective Observational Study. PLoS Negl Trop Dis. 2016;10(8):e0004961 doi: ; PubMed Central PMCID: PMC5001649.
    1. WHO. Dengue: Guidelines for treatment, prevention and control Geneva: World Health Organization; 2009.
    1. Hue KD, Tuan TV, Thi HT, Bich CT, Anh HH, Wills BA, et al. Validation of an internally controlled one-step real-time multiplex RT-PCR assay for the detection and quantitation of dengue virus RNA in plasma. J Virol Methods. 2011;177(2):168–73. doi: ; PubMed Central PMCID: PMCPMC4347661.
    1. Moller JE, Poulsen SH, Egstrup K. Effect of preload alternations on a new Doppler echocardiographic index of combined systolic and diastolic performance. Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography. 1999;12(12):1065–72. .
    1. Khongphatthanayothin A, Lertsapcharoen P, Supachokchaiwattana P, La-Orkhun V, Khumtonvong A, Boonlarptaveechoke C, et al. Myocardial depression in dengue hemorrhagic fever: prevalence and clinical description. Pediatric critical care medicine: a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. 2007;8(6):524–9. doi: .
    1. Yacoub S, Lam PK, Vu LH, Le TL, Ha NT, Toan TT, et al. Association of microvascular function and endothelial biomarkers with clinical outcome in dengue: an observational study. J Infect Dis. 2016. doi: .
    1. Pathan N, Franklin JL, Eleftherohorinou H, Wright VJ, Hemingway CA, Waddell SJ, et al. Myocardial depressant effects of interleukin 6 in meningococcal sepsis are regulated by p38 mitogen-activated protein kinase. Crit Care Med. 2011;39(7):1692–711. doi: .
    1. Lam PK, Tam DT, Dung NM, Tien NT, Kieu NT, Simmons C, et al. A Prognostic Model for Development of Profound Shock among Children Presenting with Dengue Shock Syndrome. PLoS One. 2015;10(5):e0126134 doi: ; PubMed Central PMCID: PMC4422752.
    1. Iwamoto Y, Tamai A, Kohno K, Masutani S, Okada N, Senzaki H. Usefulness of respiratory variation of inferior vena cava diameter for estimation of elevated central venous pressure in children with cardiovascular disease. Circulation journal: official journal of the Japanese Circulation Society. 2011;75(5):1209–14. .
    1. Cecconi M, La Canna G, Manfrin M, Colonna P, Nardi M, Zanoli R, et al. Evaluation of mean right atrial pressure by two-dimensional and Doppler echocardiography in patients with cardiac disease. Giornale italiano di cardiologia. 1998;28(4):357–64. .
    1. Barbier C, Loubieres Y, Schmit C, Hayon J, Ricome JL, Jardin F, et al. Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients. Intensive Care Med. 2004;30(9):1740–6. doi: .
    1. Airapetian N, Maizel J, Alyamani O, Mahjoub Y, Lorne E, Levrard M, et al. Does inferior vena cava respiratory variability predict fluid responsiveness in spontaneously breathing patients? Crit Care. 2015;19:400 doi: ; PubMed Central PMCID: PMCPMC4643539.
    1. Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008;134(1):172–8. doi: .
    1. Trung DT, Thao le TT, Hien TT, Hung NT, Vinh NN, Hien PT, et al. Liver involvement associated with dengue infection in adults in Vietnam. Am J Trop Med Hyg. 2010;83(4):774–80. doi: ; PubMed Central PMCID: PMCPMC2946741.
    1. De Jonghe B, Cheval C, Misset B, Timsit JF, Garrouste M, Montuclard L, et al. Relationship between blood lactate and early hepatic dysfunction in acute circulatory failure. Journal of critical care. 1999;14(1):7–11. .
    1. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368–77. doi: .
    1. Investigators A, Group ACT, Peake SL, Delaney A, Bailey M, Bellomo R, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014;371(16):1496–506. doi: .
    1. Pro CI, Yealy DM, Kellum JA, Huang DT, Barnato AE, Weissfeld LA, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370(18):1683–93. doi: ; PubMed Central PMCID: PMC4101700.
    1. Maitland K, Kiguli S, Opoka RO, Engoru C, Olupot-Olupot P, Akech SO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011;364(26):2483–95. doi: .

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