Sepsis-induced myocardial dysfunction is a well-recognized condition and confers worse outcomes in septic patients. Echocardiographic assessment by conventional parameters such as left ventricular ejection fraction (LVEF) is often affected by ongoing changes in preload and afterload conditions. Novel echocardiographic technologies such as speckle tracking echocardiography (STE) have evolved for direct assessment of the myocardial function. We investigate the measurement of myocardial strain by speckle tracking echocardiography for the diagnosis of sepsis-induced myocardial dysfunction. This is a case-control study at a university-affiliated medical intensive care unit. Consecutive adult medical patients admitted with a diagnosis of septic shock were included. Patients with other causes of myocardial dysfunction were excluded. They were compared to age-matched, gender-matched, and cardiovascular risk-factor-matched controls, who were admitted to hospital for sepsis but did not develop septic shock. Transthoracic echocardiography was performed on all patients within 24 hours of diagnosis, and a reassessment echocardiogram was performed in the study group of patients upon recovery. Patients with septic shock (n = 33) (study group) and 29 matched patients with sepsis but no septic shock (control group) were recruited. The mean sequential organ failure assessment (SOFA) score for the study and control groups were 10.2 and 1.6, respectively (P < 0.001). In patients with septic shock, the mean arterial pressure was lower (76 mmHg vs 82 mmHg, P = 0.032), and the heart rate was higher (99 bpm vs 86 bpm, P = 0.008). The cardiac output (5.9 L/min vs 5.5 L/min, P = 0.401) and systemic vascular resistance (1090 dynes•sec/cm5 vs 1194 dynes•sec/cm5, P = 0.303) were similar. The study group had a greater degree of myocardial dysfunction measured by global longitudinal strain (GLS) (–14.5 % vs –18.3 %, P <0.001), and the myocardial strain differed upon diagnosis and recovery (–14.5 % vs –16.0 %, P = 0.010). Conventional echocardiographic measurements such as LVEF (59 % in the study group vs 61 % in the control group, P = 0.169) did not differ between the two groups. Speckle tracking echocardiography can detect significant left ventricular impairment in patients with septic shock, which was not otherwise detectable by conventional echocardiography. The reversible nature of myocardial dysfunction in sepsis was also demonstrable. This echocardiographic technique is useful in the diagnosis and monitoring of sepsis-induced myocardial dysfunction.

The annual global surgical volume has been increasing, with an estimated 312 million surgical procedures taking place worldwide in 2012.¹ Perioperative stroke is a major postoperative complication, with significant implications on postoperative morbidity, discharge disposition, and 30-day mortality.² With a reported incidence ranging from 0.2% to 9.7% for patients undergoing different surgeries,³ and possibly an even higher incidence of covert strokes,⁴ the estimated annual global burden of perioperative stroke could exceed 1 million.

While the long-term negative effects of obesity on health is a well-studied phenomenon, its effects on acute illnesses seem to be the contrary. Several studies have indicated the possibility of an ‘obesity paradox’ in sepsis – where overweight and obese patients have better outcomes than normal weight patients. These meta-analyses including large numbers of patients across different countries raised an interesting but debatable topic. Results from meta-analyses of observational studies should be interpreted with caution, and a prove of association not be mistaken as prove of causality. Limitations common to such studies include inadequate adjustment for confounding and selection bias. More rigorous investigations to clarify any causal relationship between obesity and mortality in sepsis are needed.

Summary: We thought that the rate of postoperative pulmonary complications might be higher after pressure‐controlled ventilation than after volume‐controlled ventilation. We analysed peri‐operative data recorded for 109,360 adults, whose lungs were mechanically ventilated during surgery at three hospitals in Massachusetts, USA. We used multivariable regression and propensity score matching. Postoperative pulmonary complications were more common after pressure‐controlled ventilation, odds ratio (95%CI) 1.29 (1.21–1.37), p < 0.001. Tidal volumes and driving pressures were more varied with pressure‐controlled ventilation compared with volume‐controlled ventilation: mean (SD) variance from the median 1.61 (1.36) ml.kg ⁻¹ vs. 1.23 (1.11) ml.kg ⁻¹ , p < 0.001; and 3.91 (3.47) cmH ₂ O vs. 3.40 (2.69) cmH ₂ O, p < 0.001. The odds ratio (95%CI) of pulmonary complications after pressure‐controlled ventilation compared with volume‐controlled ventilation at positive end‐expiratory pressures < 5 cmH ₂ O was 1.40 (1.26–1.55) and 1.20 (1.11–1.31) when ≥ 5 cmH ₂ O, both p < 0.001, a relative risk ratio of 1.17 (1.03–1.33), p = 0.023. The odds ratio (95%CI) of pulmonary complications after pressure‐controlled ventilation compared with volume‐controlled ventilation at driving pressures of < 19 cmH ₂ O was 1.37 (1.27–1.48), p < 0.001, and 1.16 (1.04–1.30) when ≥ 19 cmH ₂ O, p = 0.011, a relative risk ratio of 1.18 (1.07–1.30), p = 0.016. Our data support volume‐controlled ventilation during surgery, particularly for patients more likely to suffer postoperative pulmonary complications.

Pre-operatively diagnosed patent foramen ovale (PFO) is associated with an increased risk of ischaemic stroke within 30 days after surgery. This study aimed to assess the PFO-attributable ischaemic stroke risk beyond the perioperative period. This observational study of adult patients without history of stroke undergoing non-cardiac surgery with general anaesthesia examined the association of PFO with ischaemic stroke 1 and 2 years after surgery using multivariable logistic regression. Of the 144 563 patients included, a total of 1642 (1.1%) and 2376 (1.6%) ischaemic strokes occurred within 1 and 2 years after surgery, 54 (4.7%) and 76 (6.6%) among patients with PFO, and 1588 (1.1%) and 2300 (1.6%) among patients without PFO, respectively. The odds of ischaemic stroke within 1 and 2 years after surgery were increased in patients with PFO: adjusted odds ratio (aOR) 2.01, 95% confidence interval (CI) 1.51-2.69; P < 0.001 and aOR 2.10, 95% CI 1.64-2.68; P < 0.001, respectively. Among patients who underwent contrast transoesophageal echocardiography, the frequency of PFO was 27%, and the increased stroke risk in patients with PFO was robust (aOR 3.80, 95% CI 1.76-8.23; P = 0.001 for year 1). The PFO-attributable risk was mitigated by post-operative prescription of combination antithrombotic therapy (odds ratio 0.41, 95% CI 0.22-0.75; P for interaction = 0.004). Patients with PFO are vulnerable to ischaemic stroke for an extended period of time after surgery. Physicians should consider implementing PFO screening protocols in patients scheduled for major non-cardiac surgery.