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Llitjos JF, Mira JP, Duranteau J, Cariou A. Hyperoxia toxicity after cardiac arrest: What is the evidence? Ann Intensive Care 2016; 6:23. [PMID: 27003426 PMCID: PMC4803714 DOI: 10.1186/s13613-016-0126-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 03/08/2016] [Indexed: 01/08/2023] Open
Abstract
This review gives an overview of current knowledge on hyperoxia pathophysiology and examines experimental and human evidence of hyperoxia effects after cardiac arrest. Oxygen plays a pivotal role in critical care management as a lifesaving therapy through the compensation of the imbalance between oxygen requirements and supply. However, growing evidence sustains the hypothesis of reactive oxygen species overproduction-mediated toxicity during hyperoxia, thus exacerbating organ failure by various oxidative cellular injuries. In the cardiac arrest context, evidence of hyperoxia effects on outcome is fairly conflicting. Although prospective data are lacking, retrospective studies and meta-analysis suggest that hyperoxia could be associated with an increased mortality. However, data originate from retrospective, heterogeneous and inconsistent studies presenting various biases that are detailed in this review. Therefore, after an original and detailed analysis of all experimental and clinical studies, we herein provide new ideas and concepts that could participate to improve knowledge on oxygen toxicity and help in developing further prospective controlled randomized trials on this topic. Up to now, the strategy recommended by international guidelines on cardiac arrest (i.e., targeting an oxyhemoglobin saturation of 94–98 %) should be applied in order to avoid deleterious hypoxia and potent hyperoxia.
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Affiliation(s)
- Jean-François Llitjos
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaires Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France. .,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'école de Médecine, 75006, Paris, France.
| | - Jean-Paul Mira
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaires Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'école de Médecine, 75006, Paris, France
| | - Jacques Duranteau
- Anesthesia and Intensive Care Department, Bicêtre Hospital, Assistance Publique des Hôpitaux de Paris, 94275, Le Kremlin-Bicêtre, France.,Université Paris Sud XI, Orsay, France
| | - Alain Cariou
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaires Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'école de Médecine, 75006, Paris, France
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52
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Smit B, Smulders YM, de Waard MC, Boer C, Vonk ABA, Veerhoek D, Kamminga S, de Grooth HJS, García-Vallejo JJ, Musters RJP, Girbes ARJ, Oudemans-van Straaten HM, Spoelstra-de Man AME. Moderate hyperoxic versus near-physiological oxygen targets during and after coronary artery bypass surgery: a randomised controlled trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:55. [PMID: 26968380 PMCID: PMC4788916 DOI: 10.1186/s13054-016-1240-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 02/10/2016] [Indexed: 01/21/2023]
Abstract
Background The safety of perioperative hyperoxia is currently unclear. Previous studies in patients undergoing coronary artery bypass surgery suggest reduced myocardial damage when avoiding extreme perioperative hyperoxia (>400 mmHg). In this study we investigated whether an oxygenation strategy from moderate hyperoxia to a near-physiological oxygen tension reduces myocardial damage and improves haemodynamics, organ dysfunction and oxidative stress. Methods This was a single-blind, single-centre, open-label, randomised controlled trial in patients undergoing elective coronary artery bypass surgery. Fifty patients were randomised to a partial pressure of oxygen in arterial blood (PaO2) target of 200–220 mmHg during cardiopulmonary bypass and 130–150 mmHg during intensive care unit (ICU) admission (control group) versus lower targets of 130–150 mmHg during cardiopulmonary bypass and 80–100 mmHg at the ICU (conservative group). Primary outcome was myocardial injury (CK-MB and Troponin-T) at ICU admission and 2, 6 and 12 hours thereafter. Results Weighted PaO2 during cardiopulmonary bypass was 220 mmHg (interquartile range (IQR) 211–233) vs. 157 (151–162) in the control and conservative group, respectively (P < 0.0001). During ICU admission, weighted PaO2 was 107 mmHg (86–141) vs. 90 (84–98) (P = 0.03), respectively. Area under the curve of CK-MB was median 23.5 μg/L/h (IQR 18.4–28.1) vs. 21.5 (15.8–26.6) (P = 0.35) and 0.30 μg/L/h (0.25–0.44) vs. 0.39 (0.24–0.43) (P = 0.81) for Troponin-T. Cardiac index, systemic vascular resistance index, creatinine, lactate and F2-isoprostane levels were not different between groups. Conclusions Compared to moderate hyperoxia, a near-physiological oxygen strategy does not reduce myocardial damage in patients undergoing coronary artery bypass surgery. Conservative oxygen administration was not associated with increased lactate levels or hypoxic events. Trial registration Netherlands Trial Registry NTR4375, registered on 30 January 2014 Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1240-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bob Smit
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands.
| | - Yvo M Smulders
- Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Monique C de Waard
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Christa Boer
- Department of Anaesthesiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Alexander B A Vonk
- Department of Cardiothoracic Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Dennis Veerhoek
- Department of Cardiothoracic Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Suzanne Kamminga
- Department of Anaesthesiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Harm-Jan S de Grooth
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Juan J García-Vallejo
- Department of Molecular Cell Biology & Immunology, VU University Medical Center, Amsterdam, The Netherlands
| | - Rene J P Musters
- Department of Physiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Armand R J Girbes
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands
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53
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Journal of Clinical Monitoring and Computing 2015 end of year summary: tissue oxygenation and microcirculation. J Clin Monit Comput 2016; 30:141-6. [PMID: 26897032 PMCID: PMC4792340 DOI: 10.1007/s10877-016-9846-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 02/14/2016] [Indexed: 12/29/2022]
Abstract
Last year we started this series of end of year summaries of papers published in the 2014 issues of the Journal Of Clinical Monitoring And Computing with a review on near infrared spectroscopy (Scheeren et al. in J Clin Monit Comput 29(2):217-220, 2015). This year we will broaden the scope and include papers published in the field of tissue oxygenation and microcirculation, or a combination of both entities. We present some promising new technologies that might enable a deeper insight into the (patho)physiology of certain diseases such as sepsis, but also in healthy volunteers. These may help researchers and clinicians to evaluate both tissue oxygenation and microcirculation beyond macro-hemodynamic measurements usually available at the bedside.
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54
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Milstein DMJ, Helmers R, Hackmann S, Belterman CNW, van Hulst RA, de Lange J. Sublingual microvascular perfusion is altered during normobaric and hyperbaric hyperoxia. Microvasc Res 2016; 105:93-102. [PMID: 26851620 DOI: 10.1016/j.mvr.2016.02.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 02/02/2016] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
Abstract
Hyperoxia and hyperbaric oxygen therapy can restore oxygen tensions in tissues distressed by ischemic injury and poor vascularization and is believed to also yield angiogenesis and regulate tissue perfusion. The aim of this study was to develop a model in which hyperoxia-driven microvascular changes could be quantified and to test the hypothesis that microcirculatory responses to both normobaric (NB) and hyperbaric (HB) hyperoxic maneuvers are reversible. Sublingual mucosa microcirculation vessel density, proportion of perfused vessels, vessel diameters, microvascular flow index, macrohemodynamic, and blood gas parameters were examined in male rabbits breathing sequential O2/air mixtures of 21%, 55%, 100%, and return to 21% during NB (1.0 bar) and HB (2.5 bar) conditions. The results indicate that NB hyperoxia (55% and 100%) produced significant decreases in microvascular density and vascular diameters (p<0.01 and p<0.05, respectively) accompanied by significant increases in systolic and mean arterial blood pressure (p<0.05, respectively) with no changes in blood flow indices when compared to NB normoxia. HB normoxia/hyperoxia resulted in significant decreases in microvascular density (p<0.05), a transient rise in systolic blood pressure at 55% (p<0.01), and no changes in blood vessel diameter and blood flow indices when compared to NB hyperoxia. All microcirculation parameters reverted back to normal values upon return to NB normoxia. We conclude that NB/HB hyperoxia-driven changes elicit reversible physiological control of sublingual mucosa blood perfusion in the presence of steady cardiovascular function and that the absence of microvascular vasoconstriction during HB conditions suggests a beneficial mechanism associated with maintaining peak tissue perfusion states.
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Affiliation(s)
- Dan M J Milstein
- Department of Oral & Maxillofacial Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands.
| | - Renée Helmers
- Department of Oral & Maxillofacial Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
| | - Sanne Hackmann
- Department of Large Laboratory Animals, Animal Research Institute Academic Medical Center (ARIA), University of Amsterdam, Meibergdreef 31, 1105 AZ, The Netherlands
| | - Charly N W Belterman
- Department of Experimental Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
| | - Robert A van Hulst
- Department of Hyperbaric Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands; Diving Medical Center, Royal Netherlands Navy, PO Box 10000, 1780 CA Den Helder, The Netherlands; Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Department of Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
| | - Jan de Lange
- Department of Oral & Maxillofacial Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
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55
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
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56
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Ince C. Hemodynamic coherence and the rationale for monitoring the microcirculation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19 Suppl 3:S8. [PMID: 26729241 PMCID: PMC4699073 DOI: 10.1186/cc14726] [Citation(s) in RCA: 299] [Impact Index Per Article: 33.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This article presents a personal viewpoint of the shortcoming of conventional hemodynamic resuscitation procedures in achieving organ perfusion and tissue oxygenation following conditions of shock and cardiovascular compromise, and why it is important to monitor the microcirculation in such conditions. The article emphasizes that if resuscitation procedures are based on the correction of systemic variables, there must be coherence between the macrocirculation and microcirculation if systemic hemodynamic-driven resuscitation procedures are to be effective in correcting organ perfusion and oxygenation. However, in conditions of inflammation and infection, which often accompany states of shock, vascular regulation and compensatory mechanisms needed to sustain hemodynamic coherence are lost, and the regional circulation and microcirculation remain in shock. We identify four types of microcirculatory alterations underlying the loss of hemodynamic coherence: type 1, heterogeneous microcirculatory flow; type 2, reduced capillary density induced by hemodilution and anemia; type 3, microcirculatory flow reduction caused by vasoconstriction or tamponade; and type 4, tissue edema. These microcirculatory alterations can be observed at the bedside using direct visualization of the sublingual microcirculation with hand-held vital microscopes. Each of these alterations results in oxygen delivery limitation to the tissue cells despite the presence of normalized systemic hemodynamic variables. Based on these concepts, we propose how to optimize the volume of fluid to maximize the oxygen-carrying capacity of the microcirculation to transport oxygen to the tissues.
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Hafner S, Beloncle F, Koch A, Radermacher P, Asfar P. Hyperoxia in intensive care, emergency, and peri-operative medicine: Dr. Jekyll or Mr. Hyde? A 2015 update. Ann Intensive Care 2015; 5:42. [PMID: 26585328 PMCID: PMC4653126 DOI: 10.1186/s13613-015-0084-6] [Citation(s) in RCA: 123] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 11/02/2015] [Indexed: 12/22/2022] Open
Abstract
This review summarizes the (patho)-physiological effects of ventilation with high FiO2 (0.8–1.0), with a special focus on the most recent clinical evidence on its use for the management of circulatory shock and during medical emergencies. Hyperoxia is a cornerstone of the acute management of circulatory shock, a concept which is based on compelling experimental evidence that compensating the imbalance between O2 supply and requirements (i.e., the oxygen dept) is crucial for survival, at least after trauma. On the other hand, “oxygen toxicity” due to the increased formation of reactive oxygen species limits its use, because it may cause serious deleterious side effects, especially in conditions of ischemia/reperfusion. While these effects are particularly pronounced during long-term administration, i.e., beyond 12–24 h, several retrospective studies suggest that even hyperoxemia of shorter duration is also associated with increased mortality and morbidity. In fact, albeit the clinical evidence from prospective studies is surprisingly scarce, a recent meta-analysis suggests that hyperoxia is associated with increased mortality at least in patients after cardiac arrest, stroke, and traumatic brain injury. Most of these data, however, originate from heterogenous, observational studies with inconsistent results, and therefore, there is a need for the results from the large scale, randomized, controlled clinical trials on the use of hyperoxia, which can be anticipated within the next 2–3 years. Consequently, until then, “conservative” O2 therapy, i.e., targeting an arterial hemoglobin O2 saturation of 88–95 % as suggested by the guidelines of the ARDS Network and the Surviving Sepsis Campaign, represents the treatment of choice to avoid exposure to both hypoxemia and excess hyperoxemia.
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Affiliation(s)
- Sebastian Hafner
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Helmholtzstrasse 8-1, 89081, Ulm, Germany. .,Klinik für Anästhesiologie, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany.
| | - François Beloncle
- Département de Réanimation Médicale et de Médecine Hyperbare, Centre Hospitalier Universitaire, 4 rue Larrey, Cedex 9, 49933, Angers, France. .,Laboratoire de Biologie Neurovasculaire et Mitochondriale Intégrée, CNRS UMR 6214-INSERM U1083, Université Angers, PRES L'UNAM, Nantes, France.
| | - Andreas Koch
- Sektion Maritime Medizin, Institut für Experimentelle Medizin, Christian-Albrechts-Universität, 24118, Kiel, Germany. .,Schifffahrtmedizinisches Institut der Marine, 24119, Kronshagen, Germany.
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Helmholtzstrasse 8-1, 89081, Ulm, Germany.
| | - Pierre Asfar
- Département de Réanimation Médicale et de Médecine Hyperbare, Centre Hospitalier Universitaire, 4 rue Larrey, Cedex 9, 49933, Angers, France. .,Laboratoire de Biologie Neurovasculaire et Mitochondriale Intégrée, CNRS UMR 6214-INSERM U1083, Université Angers, PRES L'UNAM, Nantes, France.
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58
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Affiliation(s)
- K O Pryor
- Department of Anesthesiology, Weill Cornell Medical College, 525 East 68th Street, New York, NY 10065, USA
| | - M M Berger
- Department of Anesthesiology, Perioperative and General Critical Care Medicine, Salzburg General Hospital, Paracelsus Medical University, Müllner Haupstraße 48, Salzburg 5020, Austria
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Kemmler J, Bindl R, McCook O, Wagner F, Gröger M, Wagner K, Scheuerle A, Radermacher P, Ignatius A. Exposure to 100% Oxygen Abolishes the Impairment of Fracture Healing after Thoracic Trauma. PLoS One 2015; 10:e0131194. [PMID: 26147725 PMCID: PMC4492600 DOI: 10.1371/journal.pone.0131194] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 05/30/2015] [Indexed: 12/22/2022] Open
Abstract
In polytrauma patients a thoracic trauma is one of the most critical injuries and an important trigger of post-traumatic inflammation. About 50% of patients with thoracic trauma are additionally affected by bone fractures. The risk for fracture malunion is considerably increased in such patients, the pathomechanisms being poorly understood. Thoracic trauma causes regional alveolar hypoxia and, subsequently, hypoxemia, which in turn triggers local and systemic inflammation. Therefore, we aimed to unravel the role of oxygen in impaired bone regeneration after thoracic trauma. We hypothesized that short-term breathing of 100% oxygen in the early post-traumatic phase ameliorates inflammation and improves bone regeneration. Mice underwent a femur osteotomy alone or combined with blunt chest trauma 100% oxygen was administered immediately after trauma for two separate 3 hour intervals. Arterial blood gas tensions, microcirculatory perfusion and oxygenation were assessed at 3, 9 and 24 hours after injury. Inflammatory cytokines and markers of oxidative/nitrosative stress were measured in plasma, lung and fracture hematoma. Bone healing was assessed on day 7, 14 and 21. Thoracic trauma induced pulmonary and systemic inflammation and impaired bone healing. Short-term exposure to 100% oxygen in the acute post-traumatic phase significantly attenuated systemic and local inflammatory responses and improved fracture healing without provoking toxic side effects, suggesting that hyperoxia could induce anti-inflammatory and pro-regenerative effects after severe injury. These results suggest that breathing of 100% oxygen in the acute post-traumatic phase might reduce the risk of poorly healing fractures in severely injured patients.
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Affiliation(s)
- Julia Kemmler
- Institute of Orthopaedic Research and Biomechanics, Center of Musculoskeletal Research, University of Ulm, Ulm, Germany
| | - Ronny Bindl
- Institute of Orthopaedic Research and Biomechanics, Center of Musculoskeletal Research, University of Ulm, Ulm, Germany
| | - Oscar McCook
- Institute of Pathophysiological Anaesthesiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
| | - Florian Wagner
- Institute of Pathophysiological Anaesthesiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
| | - Michael Gröger
- Institute of Pathophysiological Anaesthesiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
| | - Katja Wagner
- Institute of Pathophysiological Anaesthesiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
| | | | - Peter Radermacher
- Institute of Pathophysiological Anaesthesiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
| | - Anita Ignatius
- Institute of Orthopaedic Research and Biomechanics, Center of Musculoskeletal Research, University of Ulm, Ulm, Germany
- * E-mail:
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Silva H, Ferreira H, Bujan MJ, Rodrigues LM. Regarding the quantification of peripheral microcirculation--Comparing responses evoked in the in vivo human lower limb by postural changes, suprasystolic occlusion and oxygen breathing. Microvasc Res 2015; 99:110-7. [PMID: 25872021 DOI: 10.1016/j.mvr.2015.04.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 04/05/2015] [Accepted: 04/06/2015] [Indexed: 11/25/2022]
Abstract
The human skin is an interesting model to explore microcirculation, particularly if using noninvasive technologies such as LDF (Laser Doppler Flowmetry) and tc (transcutaneous) gasimetry and methods as near as possible from the normal physiological state. In this study, we combined those technologies with three classical approaches--leg raising from supine, suprasystolic occlusion (in the ankle), and normobaric oxygen breathing to explore distal peripheral circulation in the foot. These methods are often cited, but a comparative assessment has not been done. The goal of this study was to identify relevant flow related descriptors, method-related advantages and pitfalls, and eventually, to find the best experimental approach. Volunteers (both genders, 22.1 ± 3.7 years old) were subjected to these methods and variables registered during basal, challenge and stabilization phases. Descriptive and comparative statistics were obtained, adopting a 95% confidence level. All flow-related quantitative descriptors potentially useful for the analysis were identified and compared. As expected, male patients consistently showed higher LDF levels and transepidermal water loss (TEWL) and lower tcpO2 values. However, lower results were recorded in the supine position, suggesting a postural dependence. Both leg raising and suprasystolic occlusion produced a hyperemic response after provocation, although different in magnitude, significantly reducing LDF and tcpO2 during provocation. The oxygen breathing method provided the most patient-friendly protocol, consistently reducing LDF (potentially by the inhibition of production of local vasodilators). TEWL increased during the provocation phase in all protocols, although not significantly. Baseline tcpO2 was found to correlate positively with the peak tcpO2 during oxygen breathing and basal LDF with peak flow during leg raising and suprasystolic occlusion. No statistical correlation between TEWL and LDF could be demonstrated under the current experimental conditions. We conclude that although equally useful considering the purpose, these methods involve very different practicalities and do not provide the same information. Also noteworthy, LDF is a highly sensitive indicator that could be further explored to look deeper into blood flow regulating mechanisms.
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Affiliation(s)
- Henrique Silva
- CBIOS - Universidade Lusófona's Research Center for Biosciences and Health Technologies, Lisboa, Portugal; Pharmacol. Sc Depart - Universidade de Lisboa, Faculty of Pharmacy, Lisboa, Portugal
| | - Hugo Ferreira
- IBEB - Biophysics and Biomedical Engineering Institute, Universidade de Lisboa Faculty of Sciences, Lisboa, Portugal
| | - Ma Julia Bujan
- Dept Medicine and Medical Specialities, CIBER-BBN Alcalá de Henares, Madrid, Spain
| | - Luis Monteiro Rodrigues
- CBIOS - Universidade Lusófona's Research Center for Biosciences and Health Technologies, Lisboa, Portugal; Pharmacol. Sc Depart - Universidade de Lisboa, Faculty of Pharmacy, Lisboa, Portugal.
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