Perioperative Management of Patients with Sepsis and Septic Shock, Part II: Ultrasound Support for Resuscitation

Point-of-care ultrasound is capable of identifying the precise causes of hemodynamic failure in patients with septic shock. Patients in shock demonstrate complex alterations in their circulation, including changes in loading conditions (preload and afterload), right and left ventricular function, and development of obstructive physiology, and some of them have a burden of underlying cardiac disease. Knowledge of underlying hemodynamic derangements in such situations allows targeted interventions, that is, fluids, vasoactive, and inotropic medications, to optimize patient's perfusion. One example of competing goals involves a patient with hypertrophic "thick" left ventricle (LV), which is easily identified using point-of-care ultrasound (POCUS). Such patients usually have diastolic dysfunction and commonly require higher filling pressures (mainly grade II and III diastolic dysfunction) to maintain adequate cardiac output. They are vulnerable to the effects of hypovolemia with the potential for dynamic LV outflow tract (LVOT) obstruction. The use of inotrope is harmful under these circumstances and could lead to worsening of the obstructive physiology because of systolic anterior motion of the mitral valve leaflet and mitral regurgitation with rapid progression toward a cardiac arrest. Recognizing the increasingly important role of POCUS in the perioperative arena, in this review, we highlight how POCUS allows anesthesiologists to recognize and manage hemodynamic derangements in patients with sepsis and septic shock. We provide a systematic approach to the evaluation of this patient population using qualitative assessment of myocardial performance, fluid responsiveness, and fluid tolerance. Our approach is based on a limited number of ultrasound views: subcostal, inferior vena cava (IVC), and lung views are obtained in rapid succession. A combination of findings in these views is grouped into distinct hemodynamic phenotypes, each of them requiring their own approach to management.