Isoproterenol infusion in septic shock

A 69 year old female with a history of gastric bypass surgery with a recent revision (12 weeks prior to presentation) was admitted from a skilled nursing facility with subacute progressive dyspnea, cough and pleuritic chest pain. On initial assessment her blood pressure was 150/80 mmHg, pulse of 130 beats per minute, with a respiratory rate of 30 per minute and oxygen saturation of 85%. She had evidence of hypoxemic respiratory failure on arterial blood gases, with a PaO2 of 46 mmHg and thus was intubated and sedated before further workup was obtained. A bedside echocardiogram showed preserved left ventricular performance, with an ejection fraction of 65%, but exhibited severe right ventricular enlargement and systolic dysfunction (Figures 1 and 2), with akinesis of the mid-ventricular segments but preserved contractility of the apex (McConnell sign, Figure 3). Right ventricular systolic pressure was estimated to be 50 mmHg by peak tricuspid regurgitant velocity.