Original article
Association between hypophosphatemia and cardiac arrhythmias in the early stages of sepsis

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Abstract

Background: The purpose of this study was to evaluate a possible association between serum phosphate levels and the incidence of cardiac arrhythmias in the early stages of sepsis. Methods: We conducted a prospective, controlled study in the General Intensive Care Unit (GICU) of a university hospital. Sixteen patients with sepsis, but without any previous cardiac disease, were studied during their first 24 h in the GICU. Patients were connected to a continuous ECG recording device. Blood samples for serum phosphate level determinations were drawn during the first 6 h after admission to the unit. Results: Ten of 16 patients had 21 episodes of atrial and ventricular arrhythmias. These patients had higher mean Apache II scores (20.2±6.2) than the six patients without arrhythmias (13.2±1.7; P<0.05) and significantly lower mean phosphate levels (0.73±0.16 vs. 1.02±0.32 mmol/l; P<0.03). No association was found between serum phosphate levels and mortality among patients with arrhythmias, or when all survivors (with and without arrhythmia) were compared to all non-survivors. Conclusions: The results indicate that patients with sepsis and low serum phosphate levels are at a greater risk of developing cardiac arrhythmias. We suggest that phosphate supplementation in the early stages of sepsis may prevent cardiac arrhythmias.

Introduction

Although the hemodynamic complications of sepsis and septic shock are well known, there are few reports regarding cardiac rhythm disturbances during sepsis. Case reports on heart block during severe sepsis have been published [1], [2]. Aderka et al. [3] reported 16 episodes of ventricular arrhythmias recorded in six patients with sepsis, all of whom had had a previous myocardial infarction.

Artucio and Pereira reported that cardiac arrhythmias have a negative effect on the course of patients with sepsis [4], [5], so it is important to identify, as early as possible, patients with sepsis who are at risk of developing cardiac arrhythmias.

In a previous study, we reported the finding of hypophosphatemia in the early stages of sepsis [6], [7]. This hypophosphatemic state of patients with sepsis was related to cytokine secretion and may be used as a diagnostic and prognostic factor [6]. Since phosphate is extremely important to the normal functioning of body organs [8], it has been proposed that cardiac arrhythmias may be associated with hypophosphatemia in the early stages of sepsis.

Section snippets

Material and methods

The study initially included all patients admitted to the five-bed General Intensive Care Unit (GICU) of the Soroka University Medical Center between January and August 1996. Bone’s criteria were used to diagnose sepsis [9]. Patients were entered into the study immediately upon admission to the GICU, where they remained for their first 24 h of hospitalization.

Patients were included in the study if they had clinical evidence of infection and a rectal temperature above 38 °C or below 35 °C, a heart

Results

Two-hundred and twenty-five patients were admitted to the GICU during the study period. Forty-four (20%) were diagnosed with sepsis on admission. Of these, 16 patients (11 surgical and five medical) met all study criteria and were included in the final analyses. The other 28 were excluded in accordance with the exclusion criteria (Table 1).

The etiology of sepsis in the 16 study patients is presented in Table 2. Fourteen of the 16 patients had assisted ventilation during the study period.

Discussion

Previously we reported low serum phosphate levels in patients with sepsis, with and without positive blood cultures [6], [7]. Phosphate levels below 0.64 mmol/l were more prominent in patients with positive blood cultures, especially among those with gram-negative sepsis [11].

In a previous study [6], we demonstrated a significant association between high levels of inflammatory cytokines and serum phosphate levels, especially among patients with positive blood cultures. The results of that study

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