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Knotzer H, Hasibeder WR. Microcirculatory function monitoring at the bedside--a view from the intensive care. Physiol Meas 2007; 28:R65-86. [PMID: 17827646 DOI: 10.1088/0967-3334/28/9/r01] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Microcirculatory dysfunction plays a key role in the pathophysiology of various disease states and may consequently impact patient outcome. Until recently, the evaluation of the microcirculation using different measurement techniques has been mostly limited to animal and human research. With technical advances, microcirculatory monitoring nowadays becomes more and more available for application in clinical praxis. Unfortunately, measurements within the microcirculation are mostly limited to easily accessible surfaces, such as skin, muscle and tongue. Due to major differences in the physiologic regulation of microcirculatory blood flow and in metabolism between organs and even within different tissues in one organ, the clinical importance of regional microcirculatory measurements remains to be determined. In addition, technical methods available demonstrate large differences in the measured parameters and sampling volume, making interpretation of data even more difficult. Nonetheless, the monitoring of the microcirculation may, ahead of time, alert physicians that tissue oxygen supply becomes compromised and it may lead to a better understanding of basic pathophysiological aspects of disease. In the present review, we describe available non-invasive microcirculatory measurement techniques which can be applied clinically at the bedside. After a short discussion of physiologic and pathophysiologic basics related to microcirculatory monitoring, the measuring principles, applications, strengths and limitations of different monitoring systems are discussed.
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Affiliation(s)
- Hans Knotzer
- Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria.
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Lange M, Bröking K, Hucklenbruch C, Ertmer C, Van Aken H, Lücke M, Bone HG, Westphal M. Hemodynamic effects of titrated norepinephrine in healthy versus endotoxemic sheep. ACTA ACUST UNITED AC 2007; 13:53-7. [PMID: 17621546 DOI: 10.1177/0968051907078614] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In patients with sepsis and systemic inflammatory response syndrome, hemodynamic support is often complicated by a vascular hyporesponsiveness to exogenously administered norepinephrine. Although norepinephrine tachyphylaxis represents a significant clinical problem, the relationship between norepinephrine dosages and mean arterial pressure (MAP) in the presence of systemic inflammation is still not fully understood. This study was, therefore, designed as a prospective, controlled laboratory trial to elucidate the hemodynamic response to incremental norepinephrine doses in healthy and endotoxemic sheep. ANOVA demonstrated that a significantly higher mean infusion rate of norepinephrine was needed to increase MAP by 20 mmHg in endotoxemic versus healthy control sheep (P = 0.007). Whereas the goal-MAP was reached in 100% of healthy controls, it was achieved in only 80% during endotoxemia. Cardiac index increased significantly in healthy, but not in endotoxemic, sheep. Our findings confirm the presence of vascular hyporesponsiveness to norepinephrine in endotoxemia. In addition, this study demonstrates that the presence of systemic inflammation leads to an early hyporesponsiveness against norepinephrine which was caused by a drug-independent mechanism rather than a tachyphylaxis due to long-term administration of norepinephrine.
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Affiliation(s)
- Matthias Lange
- Department of Anesthesiology and Intensive Care, University of Muenster, Muenster, Germany.
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Träger K, Radermacher P, Debacker D, Vogt J, Jakob S, Ensinger H. Metabolic effects of vasoactive agents. Curr Opin Anaesthesiol 2007; 14:157-63. [PMID: 17016396 DOI: 10.1097/00001503-200104000-00006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
After adequate volume resuscitation, the mainstay of therapy in critically ill patients with shock is treatment with vasoactive substances to restore haemodynamics or to improve regional perfusion. These agents include adrenoceptor agonists with inotropic combined with either vasoconstricting or vasodilating effects, and predominantly vasodilating drugs such as prostacyclin and related compounds. However, vasoactive agents not only affect the cardiovascular system, but also have profound metabolic effects. The interdependence of vasoactive drugs with metabolism may be relevant regarding adequate oxygen and substrate delivery to cover actual organ needs. Therefore, the profiles of these metabolic effects have to be considered during their therapeutic administration.
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Affiliation(s)
- K Träger
- Department of Postoperative Intensive Care Medicine, Clinic for Anaesthesiology, University Medical School, D-89070 Ulm, Germany
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The Impact of Nissen-Rossetti Fundoplication on the Perfusion in Microcirculation of the Gastric Fundus. POLISH JOURNAL OF SURGERY 2007. [DOI: 10.2478/v10035-007-0091-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Bassi G, Radermacher P, Calzia E. Catecholamines and vasopressin during critical illness. Endocrinol Metab Clin North Am 2006; 35:839-57, x. [PMID: 17127150 DOI: 10.1016/j.ecl.2006.09.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This article summarizes the effects of catecholamines and vasopressin on the cardiovascular system, focusing on their metabolic and immunologic properties. Particular attention is dedicated to the septic shock condition.
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Affiliation(s)
- Gabriele Bassi
- Istituto di Anestesiologia e Rianimazione dell'Università degli Studi di Milano, Azienda Ospedaliera, Polo Universitario San Paolo, Via Di Rudini 8, Milano 20100, Italy
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Seguin P, Laviolle B, Guinet P, Morel I, Mallédant Y, Bellissant E. Dopexamine and norepinephrine versus epinephrine on gastric perfusion in patients with septic shock: a randomized study [NCT00134212]. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2006; 10:R32. [PMID: 16507156 PMCID: PMC1550826 DOI: 10.1186/cc4827] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2005] [Revised: 01/23/2006] [Accepted: 01/26/2006] [Indexed: 11/22/2022]
Abstract
Introduction Microcirculatory blood flow, and notably gut perfusion, is important in the development of multiple organ failure in septic shock. We compared the effects of dopexamine and norepinephrine (noradrenaline) with those of epinephrine (adrenaline) on gastric mucosal blood flow (GMBF) in patients with septic shock. The effects of these drugs on oxidative stress were also assessed. Methods This was a prospective randomized study performed in a surgical intensive care unit among adults fulfilling usual criteria for septic shock. Systemic and pulmonary hemodynamics, GMBF (laser-Doppler) and malondialdehyde were assessed just before catecholamine infusion (T0), as soon as mean arterial pressure (MAP) reached 70 to 80 mmHg (T1), and 2 hours (T2) and 6 hours (T3) after T1. Drugs were titrated from 0.2 μg kg-1 min-1 with 0.2 μg kg-1 min-1 increments every 3 minutes for epinephrine and norepinephrine, and from 0.5 μg kg-1 min-1 with 0.5 μg kg-1 min-1 increments every 3 minutes for dopexamine. Results Twenty-two patients were included (10 receiving epinephrine, 12 receiving dopexamine–norepinephrine). There was no significant difference between groups on MAP at T0, T1, T2, and T3. Heart rate and cardiac output increased significantly more with epinephrine than with dopexamine–norepinephrine, whereas. GMBF increased significantly more with dopexamine–norepinephrine than with epinephrine between T1 and T3 (median values 106, 137, 133, and 165 versus 76, 91, 90, and 125 units of relative flux at T0, T1, T2 and T3, respectively). Malondialdehyde similarly increased in both groups between T1 and T3. Conclusion In septic shock, at doses that induced the same effect on MAP, dopexamine–norepinephrine enhanced GMBF more than epinephrine did. No difference was observed on oxidative stress.
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Affiliation(s)
- Philippe Seguin
- Service de Réanimation Chirurgicale INSERM U620, Hôpital de Pontchaillou, Université de Rennes 1, Rennes, France
| | - Bruno Laviolle
- Centre d'Investigation Clinique INSERM 0203, Unité de Pharmacologie Clinique, Hôpital de Pontchaillou, Université de Rennes 1, Rennes, France
| | - Patrick Guinet
- Service de Réanimation Chirurgicale INSERM U620, Hôpital de Pontchaillou, Université de Rennes 1, Rennes, France
| | - Isabelle Morel
- Laboratoire des Urgences & Réanimations, Hôpital de Pontchaillou, Université de Rennes 1, Rennes, France
| | - Yannick Mallédant
- Service de Réanimation Chirurgicale INSERM U620, Hôpital de Pontchaillou, Université de Rennes 1, Rennes, France
| | - Eric Bellissant
- Centre d'Investigation Clinique INSERM 0203, Unité de Pharmacologie Clinique, Hôpital de Pontchaillou, Université de Rennes 1, Rennes, France
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Valverde A, Giguère S, Sanchez LC, Shih A, Ryan C. Effects of dobutamine, norepinephrine, and vasopressin on cardiovascular function in anesthetized neonatal foals with induced hypotension. Am J Vet Res 2006; 67:1730-7. [PMID: 17014324 DOI: 10.2460/ajvr.67.10.1730] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine the effects of dobutamine, norepinephrine, and vasopressin on cardiovascular function and gastric mucosal perfusion in anesthetized foals during isoflurane-induced hypotension. ANIMALS 6 foals that were 1 to 5 days of age. PROCEDURES 6 foals received 3 vasoactive drugs with at least 24 hours between treatments. Treatments consisted of dobutamine (4 and 8 Sang/kg/min), norepinephrine (0.3 and 1.0 Sang/kg/min), and vasopressin (0.3 and 1.0 mU/kg/min) administered IV. Foals were maintained at a steady hypotensive state induced by a deep level of isoflurane anesthesia for 30 minutes, and baseline cardiorespiratory variables were recorded. Vasoactive drugs were administered at the low infusion rate for 15 minutes, and cardiorespiratory variables were recorded. Drugs were then administered at the high infusion rate for 15 minutes, and cardiorespiratory variables were recorded a third time. Gastric mucosal perfusion was measured by tonometry at the same time points. RESULTS Dobutamine and norepinephrine administration improved cardiac index. Vascular resistance was increased by norepinephrine and vasopressin administration but decreased by dobutamine at the high infusion rate. Blood pressure was increased by all treatments but was significantly higher during the high infusion rate of norepinephrine. Oxygen delivery was significantly increased by norepinephrine and dobutamine administration; O2 consumption decreased with dobutamine. The O2 extraction ratio was decreased following norepinephrine and dobutamine treatments. The gastric to arterial CO2 gap was significantly increased during administration of vasopressin at the high infusion rate. CONCLUSION AND CLINICAL RELEVANCE Norepinephrine and dobutamine are better alternatives than vasopressin for restoring cardiovascular function and maintaining splanchnic circulation during isoflurane-induced hypotension in neonatal foals.
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Affiliation(s)
- Alexander Valverde
- Department of Large Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL 32610, USA
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Lobo SM, Lobo FR, Polachini CA, Patini DS, Yamamoto AE, de Oliveira NE, Serrano P, Sanches HS, Spegiorin MA, Queiroz MM, Christiano AC, Savieiro EF, Alvarez PA, Teixeira SP, Cunrath GS. Prospective, randomized trial comparing fluids and dobutamine optimization of oxygen delivery in high-risk surgical patients [ISRCTN42445141]. Crit Care 2006; 10:R72. [PMID: 16696864 PMCID: PMC1550955 DOI: 10.1186/cc4913] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2006] [Accepted: 04/06/2006] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION Preventing perioperative tissue oxygen debt contributes to a better postoperative recovery. Whether the beneficial effects of fluids and inotropes during optimization of the oxygen delivery index (DO2I) in high-risk patients submitted to major surgeries are due to fluids, to inotropes, or to the combination of the two is not known. We aimed to investigate the effect of DO2I optimization with fluids or with fluids and dobutamine on the 60-day hospital mortality and incidence of complications. METHODS A randomized and controlled trial was performed in 50 high-risk patients (elderly with coexistent pathologies) undergoing major elective surgery. Therapy consisted of pulmonary artery catheter-guided hemodynamic optimization during the operation and 24 hours postoperatively using either fluids alone (n = 25) or fluids and dobutamine (n = 25), aiming to achieve supranormal values (DO2I > 600 ml/minute/m2). RESULTS The cardiovascular depression was an important component in the perioperative period in this group of patients. Cardiovascular complications in the postoperative period occurred significantly more frequently in the volume group (13/25, 52%) than in the dobutamine group (4/25, 16%) (relative risk, 3.25; 95% confidence interval, 1.22-8.60; P < 0.05). The 60-day mortality rates were 28% in the volume group and 8% in the dobutamine group (relative risk, 3.00; 95% confidence interval, 0.67-13.46; not significant). CONCLUSION In patients with high risk of perioperative death, pulmonary artery catheter-guided hemodynamic optimization using dobutamine determines better outcomes, whereas fluids alone increase the incidence of postoperative complications.
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Affiliation(s)
- Suzana M Lobo
- Division of Critical Care Medicine, Departments of Internal Medicine, Anesthesiology and Surgery, Medical School – FUNFARME and Hospital de Base, São José do Rio Preto, São Paulo, Brazil
| | - Francisco R Lobo
- Division of Critical Care Medicine, Departments of Internal Medicine, Anesthesiology and Surgery, Medical School – FUNFARME and Hospital de Base, São José do Rio Preto, São Paulo, Brazil
| | - Carlos A Polachini
- Division of Critical Care Medicine, Departments of Internal Medicine, Anesthesiology and Surgery, Medical School – FUNFARME and Hospital de Base, São José do Rio Preto, São Paulo, Brazil
| | - Daniela S Patini
- Division of Critical Care Medicine, Departments of Internal Medicine, Anesthesiology and Surgery, Medical School – FUNFARME and Hospital de Base, São José do Rio Preto, São Paulo, Brazil
| | - Adriana E Yamamoto
- Division of Critical Care Medicine, Departments of Internal Medicine, Anesthesiology and Surgery, Medical School – FUNFARME and Hospital de Base, São José do Rio Preto, São Paulo, Brazil
| | - Neymar E de Oliveira
- Division of Critical Care Medicine, Departments of Internal Medicine, Anesthesiology and Surgery, Medical School – FUNFARME and Hospital de Base, São José do Rio Preto, São Paulo, Brazil
| | - Patricia Serrano
- Division of Critical Care Medicine, Departments of Internal Medicine, Anesthesiology and Surgery, Medical School – FUNFARME and Hospital de Base, São José do Rio Preto, São Paulo, Brazil
| | - Helder S Sanches
- Division of Critical Care Medicine, Departments of Internal Medicine, Anesthesiology and Surgery, Medical School – FUNFARME and Hospital de Base, São José do Rio Preto, São Paulo, Brazil
| | - Marco A Spegiorin
- Division of Critical Care Medicine, Departments of Internal Medicine, Anesthesiology and Surgery, Medical School – FUNFARME and Hospital de Base, São José do Rio Preto, São Paulo, Brazil
| | - Marcio M Queiroz
- Division of Critical Care Medicine, Departments of Internal Medicine, Anesthesiology and Surgery, Medical School – FUNFARME and Hospital de Base, São José do Rio Preto, São Paulo, Brazil
| | - Antonio C Christiano
- Division of Critical Care Medicine, Departments of Internal Medicine, Anesthesiology and Surgery, Medical School – FUNFARME and Hospital de Base, São José do Rio Preto, São Paulo, Brazil
| | - Elisangela F Savieiro
- Division of Critical Care Medicine, Departments of Internal Medicine, Anesthesiology and Surgery, Medical School – FUNFARME and Hospital de Base, São José do Rio Preto, São Paulo, Brazil
| | - Paula A Alvarez
- Division of Critical Care Medicine, Departments of Internal Medicine, Anesthesiology and Surgery, Medical School – FUNFARME and Hospital de Base, São José do Rio Preto, São Paulo, Brazil
| | - Silvia P Teixeira
- Division of Critical Care Medicine, Departments of Internal Medicine, Anesthesiology and Surgery, Medical School – FUNFARME and Hospital de Base, São José do Rio Preto, São Paulo, Brazil
| | - Geni S Cunrath
- Division of Critical Care Medicine, Departments of Internal Medicine, Anesthesiology and Surgery, Medical School – FUNFARME and Hospital de Base, São José do Rio Preto, São Paulo, Brazil
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Abstract
Microcirculatory dysfunctions play a central role in the pathophysiology of sepsis and shock. Modern methods enable microvascular monitoring in man and offer the possibility to test the effect of novel therapeutical strategies for sepsis. Furthermore, these techniques may be future tools for the monitoring of critically ill patients. In this review, we will describe four microvascular monitoring devices and give an overview of the microcirculatory changes observed during the course of sepsis. Laser Doppler fluxmetry is an easy to use noninvasive technique to measure tissue perfusion enabling monitoring of the effect of different catecholamines on the gastric perfusion during sepsis. Increased microvascular permeability and altered blood flow in septic patients can be quantified by venous congestion plethysmography. Alterations in sublingual microvascular blood flow are detected by intravital microscopy in septic patients and were identified as an outcome predictor. Furthermore, the role of gastrointestinal pCO2-tonometry for microcirculatory monitoring of the perfusion of splanchnic organs during sepsis is discussed. The true clinical value of these techniques has yet to be established and will depend on larger clinical trials showing an impact on diagnostics and patient management.
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Affiliation(s)
- A Bauer
- Klinik für Anaesthesiologie, Klinikum der Universität München-Grosshadern, Marchioninistrasse 15, 81377 München-Grosshadern
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Krejci V, Hiltebrand LB, Sigurdsson GH. Effects of epinephrine, norepinephrine, and phenylephrine on microcirculatory blood flow in the gastrointestinal tract in sepsis*. Crit Care Med 2006; 34:1456-63. [PMID: 16557162 DOI: 10.1097/01.ccm.0000215834.48023.57] [Citation(s) in RCA: 130] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The use of vasopressors for treatment of hypotension in sepsis may have adverse effects on microcirculatory blood flow in the gastrointestinal tract. The aim of this study was to measure the effects of three vasopressors, commonly used in clinical practice, on microcirculatory blood flow in multiple abdominal organs in sepsis. DESIGN Random order, cross-over design. SETTING University laboratory. SUBJECTS Eight sedated and mechanically ventilated pigs. INTERVENTIONS Pigs were exposed to fecal peritonitis-induced septic shock. Mesenteric artery flow was measured using ultrasound transit time flowmetry. Microcirculatory flow was measured in gastric, jejunal, and colon mucosa; jejunal muscularis; and pancreas, liver, and kidney using multiple-channel laser Doppler flowmetry. Each animal received a continuous intravenous infusion of epinephrine, norepinephrine, and phenylephrine in a dose increasing mean arterial pressure by 20%. The animals were allowed to recover for 60 mins after each drug before the next was started. MEASUREMENTS AND MAIN RESULTS During infusion of epinephrine (0.8 +/- 0.2 mug/kg/hr), mean arterial pressure increased from 66 +/- 5 to 83 +/- 5 mm Hg and cardiac index increased by 43 +/- 9%. Norepinephrine (0.7 +/- 0.3 mug/kg/hr) increased mean arterial pressure from 70 +/- 4 to 87 +/- 5 mm Hg and cardiac index by 41 +/- 8%. Both agents caused a significant reduction in superior mesenteric artery flow (11 +/- 4%, p < .05, and 26 +/- 6%, p < .01, respectively) and in microcirculatory blood flow in the jejunal mucosa (21 +/- 5%, p < .01, and 23 +/- 3%, p < .01, respectively) and in the pancreas (16 +/- 3%, p < .05, and 8 +/- 3%, not significant, respectively). Infusion of phenylephrine (3.1 +/- 1.0 mug/kg/min) increased mean arterial pressure from 69 +/- 5 to 85 +/- 6 mm Hg but had no effects on systemic, regional, or microcirculatory flow except for a 30% increase in jejunal muscularis flow (p < .01). CONCLUSIONS Administration of the vasopressors phenylephrine, epinephrine, and norepinephrine failed to increase microcirculatory blood flow in most abdominal organs despite increased perfusion pressure and-in the case of epinephrine and norepinephrine-increased systemic blood flow. In fact, norepinephrine and epinephrine appeared to divert blood flow away from the mesenteric circulation and decrease microcirculatory blood flow in the jejunal mucosa and pancreas. Phenylephrine, on the other hand, appeared to increase blood pressure without affecting quantitative blood flow or distribution of blood flow.
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Affiliation(s)
- Vladimir Krejci
- Department of Anesthesiology, University of Berne, Inselspital, Berne, Switzerland
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Sakr Y, Reinhart K, Vincent JL, Sprung CL, Moreno R, Ranieri VM, De Backer D, Payen D. Does dopamine administration in shock influence outcome? Results of the Sepsis Occurrence in Acutely Ill Patients (SOAP) Study. Crit Care Med 2006; 34:589-97. [PMID: 16505643 DOI: 10.1097/01.ccm.0000201896.45809.e3] [Citation(s) in RCA: 240] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The optimal adrenergic support in shock is controversial. We investigated whether dopamine administration influences the outcome from shock. DESIGN Cohort, multiple-center, observational study. SETTING One hundred and ninety-eight European intensive care units. PATIENTS All adult patients admitted to a participating intensive care unit between May 1 and May 15, 2002. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients were followed up until death, until hospital discharge, or for 60 days. Shock was defined as hemodynamic compromise necessitating the administration of vasopressor catecholamines. Of 3,147 patients, 1,058 (33.6%) had shock at any time; 462 (14.7%) had septic shock. The intensive care unit mortality rate for shock was 38.3% and 47.4% for septic shock. Of patients in shock, 375 (35.4%) received dopamine (dopamine group) and 683 (64.6%) never received dopamine. Age, gender, Simplified Acute Physiology Score II, and Sequential Organ Failure Assessment score were comparable between the two groups. The dopamine group had higher intensive care unit (42.9% vs. 35.7%, p=.02) and hospital (49.9% vs. 41.7%, p=.01) mortality rates. A Kaplan-Meier survival curve showed diminished 30 day-survival in the dopamine group (log rank=4.6, p=.032). In a multivariate analysis with intensive care unit outcome as the dependent factor, age, cancer, medical admissions, higher mean Sequential Organ Failure Assessment score, higher mean fluid balance, and dopamine administration were independent risk factors for intensive care unit mortality in patients with shock. CONCLUSIONS This observational study suggests that dopamine administration may be associated with increased mortality rates in shock. There is a need for a prospective study comparing dopamine with other catecholamines in the management of circulatory shock.
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Affiliation(s)
- Yasser Sakr
- Department of Intensive Care, Erasme Hospital, Free University of Brussels, Belgium
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Asfar P, Hauser B, Radermacher P, Matejovic M. Catecholamines and vasopressin during critical illness. Crit Care Clin 2006; 22:131-49, vii-viii. [PMID: 16399024 DOI: 10.1016/j.ccc.2005.08.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In critical care medicine, catecholamines are most widely used to reverse circulatory dysfunction and thus to restore tissue perfusion. However, catecholamines not only influence systemic and regional hemodynamics, but also exert a variety of significant metabolic, endocrine, and immunologic effects. Arginine vasopressin is a vasomodulatory hormone with potency to restore vascular tone in vasodilatory hypotension. Although the evidence supporting the use of low doses of vasopressin or its analogs in vasodilatory shock is increasing, lack of data regarding mortality and morbidity prevent their implementation in critical care protocols.
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Affiliation(s)
- Pierre Asfar
- Département de Réanimation Médicale, Centre Hospitalier Universitaire, 4 rue Larry, 49993 Angers Cedex 9, France
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63
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Creteur J, De Backer D, Sakr Y, Koch M, Vincent JL. Sublingual capnometry tracks microcirculatory changes in septic patients. Intensive Care Med 2006; 32:516-23. [PMID: 16485092 DOI: 10.1007/s00134-006-0070-4] [Citation(s) in RCA: 156] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2005] [Accepted: 11/28/2005] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To test the hypothesis that microcirculatory blood flow is the main determinant of sublingual carbon dioxide pressure in patients with septic shock. DESIGN Prospective, open-label study. SETTING A 31-bed medico-surgical department of intensive care. PATIENTS Eighteen consecutive mechanically ventilated patients with septic shock. INTERVENTIONS A 5 microg/kg x min dobutamine infusion was used to increase blood flow. METHODS Sublingual carbon dioxide pressure was monitored using a microelectrode sensor, and sublingual microcirculation was assessed using orthogonal polarization spectral imaging. The sublingual carbon dioxide pressure gap was calculated as the difference between sublingual and arterial carbon dioxide pressures. In each patient, a nasogastric tonometry catheter was inserted for gastric mucosal carbon dioxide pressure measurement. The gastric carbon dioxide pressure gap was calculated as the difference between gastric mucosal and arterial carbon dioxide pressures. MEASUREMENTS AND RESULTS Dobutamine infusion was associated with increases cardiac index and mixed venous blood oxygen saturation. Dobutamine infusion resulted in decreases in sublingual carbon dioxide pressure gap from 40+/-15 to 17+/-8 mmHg (p<0.01). There was a significant correlation between sublingual and gastric mucosal carbon dioxide pressures (r 2=0.61, p<0.05). At baseline, sublingual carbon dioxide pressure gap correlated with the proportion of well-perfused capillaries (r 2=0.80). The decrease in sublingual carbon dioxide pressure gap paralleled the increase in the proportion of well-perfused capillaries in each patient. CONCLUSIONS Regional microcirculatory blood flow is the main determinant of sublingual carbon dioxide pressure. Sublingual capnometry could represent a simple, non-invasive method to monitor these microcirculatory alterations in septic patients.
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Affiliation(s)
- Jacques Creteur
- Department of Intensive Care, Erasme University Hospital, Route de Lennik 808, 1070, Brussels, Belgium
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De Backer D, Creteur J, Dubois MJ, Sakr Y, Koch M, Verdant C, Vincent JL. The effects of dobutamine on microcirculatory alterations in patients with septic shock are independent of its systemic effects*. Crit Care Med 2006; 34:403-8. [PMID: 16424721 DOI: 10.1097/01.ccm.0000198107.61493.5a] [Citation(s) in RCA: 325] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To evaluate the effects of dobutamine on microcirculatory blood flow alterations in patients with septic shock. DESIGN Prospective, open-label study. SETTING A 31-bed, medico-surgical intensive care unit of a university hospital. PATIENTS Twenty-two patients with septic shock. INTERVENTIONS Intravenous administration of dobutamine (5 mug/kg.min) for 2 hrs (n = 22) followed by the addition of 10 M acetylcholine (topically applied, n = 10). MEASUREMENTS AND MAIN RESULTS Complete hemodynamic measurements were obtained before and after dobutamine administration. In addition, the sublingual microcirculation was investigated with an orthogonal polarization spectral imaging technique before and after dobutamine administration and after topical application of acetylcholine. Dobutamine significantly improved capillary perfusion (from 48 +/- 15 to 67 +/- 11%, p = .001), but with large individual variation, whereas capillary density remained stable. The addition of topical acetylcholine completely restored capillary perfusion (98 +/- 1%, p = .001) and capillary density. The changes in capillary perfusion during dobutamine administration were not related to changes in cardiac index (p = .45) or arterial pressure (p = .29). Interestingly, the decrease in lactate levels was proportional to the improvement in capillary perfusion (y = 0.07 - 0.02x, r = .46, p = .005) but not to changes in cardiac index (p = .55). CONCLUSIONS The administration of 5 mug/kg.min dobutamine can improve but not restore capillary perfusion in patients with septic shock. These changes are independent of changes in systemic hemodynamic variables.
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Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Belgium
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Levy B. Bench-to-bedside review: Is there a place for epinephrine in septic shock? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2005; 9:561-5. [PMID: 16356239 PMCID: PMC1414043 DOI: 10.1186/cc3901] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The use of epinephrine in septic shock remains controversial. Nevertheless, epinephrine is widely used around the world and the reported morbidity and mortality rates with it are no different from those observed with other vasopressors. In volunteers, epinephrine increases heart rate, mean arterial pressure and cardiac output. Epinephrine also induces hyperglycemia and hyperlactatemia. In hyperkinetic septic shock, epinephrine consistently increases arterial pressure and cardiac output in a dose dependent manner. Epinephrine transiently increases lactate levels through an increase in aerobic glycolysis. Epinephrine has no effect on splanchnic circulation in dopamine-sensitive septic shock. On the other hand, in dopamine-resistant septic shock, epinephrine has no effect on tonometric parameters but decreases fractional splanchnic blood flow with an increase in the gradient of mixed venous oxygen saturation (SVO2) and hepatic venous oxygen saturation (SHO2). In conclusion, epinephrine has predictable effects on systemic hemodynamics and is as efficient as norepinephrine in correcting hemodynamic disturbances of septic shock. Moreover, epinephrine is cheaper than other commonly used catecholamine regimens in septic shock. The clinical impact of the transient hyperlactatemia and of the splanchnic effects are not established.
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Affiliation(s)
- Bruno Levy
- Service de Réanimation Médicale, Hôpital Central, 54000 Nancy, France.
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Abstract
PURPOSE OF REVIEW Tissue dysoxia is now widely regarded as the major factor leading to organ dysfunction in critically ill patients. Recent data suggests that early aggressive resuscitation of critically ill patients, which limits and/or reverses tissue dysoxia may prevent progression to organ dysfunction and improve outcome. The traditional clinical and laboratory markers used to assess tissue dysoxia are, however, insensitive and have numerous limitations. Regional carbon dioxide monitoring appears to be ideally suited to monitoring the adequacy of resuscitation. This review provides an update on this evolving technology. RECENT FINDINGS Gastric intramucosal carbon dioxide as measured by gastric tonometry has proven to be useful as a prognostic marker, in evaluating the response to specific therapeutic interventions and as an end point of resuscitation. Gastric tonometry is, however, cumbersome and has a number of limitations that may have prevented its widespread adoption. The measurement of carbon dioxide in the sublingual mucosa by sublingual capnometry is technically simple, noninvasive, and provides near instantaneous information. Clinical studies have demonstrated a good correlation between gastric intramucosal carbon dioxide and sublingual mucosa carbon dioxide. Sublingual mucosa carbon dioxide responds more rapidly to therapeutic interventions than does gastric intramucosal carbon dioxide and may be a better prognostic marker. SUMMARY Sublingual capnometry may be the ideal technology for guiding early goal directed therapy. This technology may be useful for monitoring tissue oxygenation, titrating therapeutic interventions, and as an end point for resuscitation in critically ill and injured patients.
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Affiliation(s)
- Paul E Marik
- Pulmonary and Critical Care Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA.
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Trzeciak S, Rivers EP. Clinical manifestations of disordered microcirculatory perfusion in severe sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2005; 9 Suppl 4:S20-6. [PMID: 16168070 PMCID: PMC3226160 DOI: 10.1186/cc3744] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Microcirculatory dysfunction plays a pivotal role in the development of the clinical manifestations of severe sepsis. Prior to the advent of new imaging technologies, clinicians had been limited in their ability to assess the microcirculation at the bedside. Clinical evidence of microcirculatory perfusion has historically been limited to physical examination findings or surrogates that could be derived from global parameters of oxygen transport. This review explores: (1) the clinical manifestations of severe sepsis that can be linked to microcirculatory dysfunction; (2) the relationship between conventional hemodynamic parameters and microcirculatory blood flow indices; (3) the incorporation of microcirculatory function into the definition of 'shock' in the sepsis syndrome; (4) the role of the microcirculation in oxygen transport; and (5) the potential impact of novel sepsis therapies on microcirculatory flow. Although the study of the microcirculation has long been the domain of basic science, newly developed imaging technologies, such as orthogonal polarization spectral imaging, have now given us the ability to directly visualize and analyze microcirculatory blood flow at the bedside, and see the microcirculatory response to therapeutic interventions. Disordered microcirculatory flow can now be associated with systemic inflammation, acute organ dysfunction, and increased mortality. Using new technologies to directly image microcirculatory blood flow will help define the role of microcirculatory dysfunction in oxygen transport and circulatory support in severe sepsis.
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Affiliation(s)
- Stephen Trzeciak
- Section of Critical Care Medicine and the Department of Emergency Medicine, UMDNJ-Robert Wood Johnson Medical School at Camden, Cooper University Hospital, Camden, New Jersey, USA.
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Morelli A, De Castro S, Teboul JL, Singer M, Rocco M, Conti G, De Luca L, Di Angelantonio E, Orecchioni A, Pandian NG, Pietropaoli P. Effects of levosimendan on systemic and regional hemodynamics in septic myocardial depression. Intensive Care Med 2005; 31:638-44. [PMID: 15812624 DOI: 10.1007/s00134-005-2619-z] [Citation(s) in RCA: 215] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2004] [Accepted: 03/04/2005] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Calcium desensitization plays an important part in the pathophysiology of septic myocardial depression. We postulated that levosimendan, a new calcium sensitizer, would be beneficial in sepsis-induced cardiac dysfunction. DESIGN AND SETTING Prospective, randomized, controlled study in two university hospital intensive care units. PATIENTS AND PARTICIPANTS Twenty-eight patients with persisting left ventricular dysfunction related to septic shock after 48 h of conventional treatment including dobutamine (5 microg/kg per minute). INTERVENTIONS After 48 h of conventional treatment patients were randomized to receive a 24-h infusion of either levosimendan (0.2 microg/kg per minute, n=15) or dobutamine (5 microg/kg per minute, n=13). MEASUREMENTS AND RESULTS Data from right heart catheterization, echocardiography, gastric tonometry, laser-Doppler flowmetry, and lactate concentrations and creatinine clearance were obtained before and after the 24-h drug infusion. Dobutamine did not change systemic or regional hemodynamic variables. By contrast, at the same mean arterial pressure levosimendan decreased pulmonary artery occlusion pressure and increased cardiac index. Levosimendan decreased left ventricular end-diastolic volume and increased left ventricular ejection fraction. Levosimendan increased gastric mucosal flow, creatinine clearance, and urinary output while it decreased lactate concentrations. CONCLUSIONS These findings show that levosimendan improves systemic hemodynamics and regional perfusion in patients with septic cardiac dysfunction under conditions where administration of 5 microg/kg dobutamine per minute is no longer efficacious. Accordingly, our results suggest that levosimendan can be an alternative to the strategy of increasing the dose of dobutamine under such conditions.
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Affiliation(s)
- Andrea Morelli
- Department of Anesthesiology and Intensive Care, University of Rome La Sapienza, Rome, Italy.
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Affiliation(s)
- Elizabeth J. Bridges
- Elizabeth Bridges was formerly the deputy commander of the 59th Clinical Research Squadron and a senior nurse researcher at the 59th Medical Wing, Lackland Air Force Base, San Antonio, Tex. She is now an assistant professor at the University of Washington School of Nursing and a clinical nurse researcher at the University of Washington Medical Center, Seattle, Wash
| | - Susan Dukes
- Susan Dukes is a critical care clinical nurse specialist in the 759th Surgical Operations Squadron, Wilford Hall Medical Center, at Lackland Air Force Base
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Martikainen TJ, Tenhunen JJ, Giovannini I, Uusaro A, Ruokonen E. Epinephrine induces tissue perfusion deficit in porcine endotoxin shock: evaluation by regional CO(2) content gradients and lactate-to-pyruvate ratios. Am J Physiol Gastrointest Liver Physiol 2005; 288:G586-92. [PMID: 15513952 DOI: 10.1152/ajpgi.00378.2004] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Epinephrine is widely used as a vasoconstrictor or inotrope in shock, although it may typically induce or augment lactic acidosis. Ongoing debate addresses the question of whether hyperlactatemia per se is a sign of tissue perfusion deficit or aerobic glycolysis. We wanted to test the hypothesis that epinephrine has selective detrimental effects on visceral perfusion and metabolism. We performed rigorous regional venous blood gas analyses as well as intraperitoneal microdialysis. We used a mathematical model to calculate regional arteriovenous CO(2) content gradients and estimated the magnitude of the Haldane effect in a porcine model of prolonged hypotensive shock induced by endotoxin infusion (mean arterial blood pressure < 60 mmHg). Subsequently, vasopressors (epinephrine or norepinephrine) were administered and adjusted to maintain systemic mean arterial pressure > 70 mmHg for 4 h. Epinephrine caused systemic hyperlactatemia and acidosis. Importantly, both systemic and regional venous lactate-to-pyruvate ratios increased. Epinephrine was associated with decreasing portal blood flow despite apparently maintained total splanchnic blood flow. Epinephrine increased gastric venous-to-arterial Pco(2) gradients and CO(2) content gradients with decreasing magnitude of the Haldane effect, and the regional gastric respiratory quotient remained higher after epinephrine as opposed to norepinephrine infusion. In addition, epinephrine induced intraperitoneal lactate and glycerol release. We did not observe these adverse hemodynamic or metabolic changes related to norepinephrine with the same arterial pressure goal. We conclude that high CO(2) content gradients with decreasing magnitude of the Haldane effect pinpoint the most pronounced perfusion deficiency to the gastric wall when epinephrine, as opposed to norepinephrine, is used in experimental endotoxin shock.
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Affiliation(s)
- Tero J Martikainen
- Department of Anesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland
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72
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Guérin JP, Levraut J, Samat-Long C, Leverve X, Grimaud D, Ichai C. EFFECTS OF DOPAMINE AND NOREPINEPHRINE ON SYSTEMIC AND HEPATOSPLANCHNIC HEMODYNAMICS, OXYGEN EXCHANGE, AND ENERGY BALANCE IN VASOPLEGIC SEPTIC PATIENTS. Shock 2005; 23:18-24. [PMID: 15614126 DOI: 10.1097/01.shk.0000150549.45338.6c] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Dopamine is widely used to improve systemic and hepatosplanchnic hemodynamics and oxygenation during sepsis. However, some studies have suggest that norepinephrine may have beneficial effects on regional blood flow and metabolism, whereas dopamine might have deleterious effects related to redistribution of blood flow away from the intestinal mucosa or by decreasing directly the cell redox state. In 12 vasoplegic septic patients, we compared the effects of norepinephrine and dopamine on systemic and hepatosplanchnic hemodynamics, oxygenation, and energy metabolism. Catecholamines were administered in a crossover randomized order to maintain mean arterial pressure (MAP) at 80 mmHg. Hepatosplanchnic blood flow (Qspl) was determined using a continuous infusion of indocyanine green dye. Despite a similar MAP, the cardiac index was higher with dopamine than with norepinephrine (6.3 [5.3-7.3] vs. 4.3 [3.8-4.9] L.min.m) (P <0.001). Qspl was similar with both catecholamines, but the ratio of Qspl to cardiac output was significantly lower with dopamine (23.9% [17.5-33.5]) than with norepinephrine (33.5% [25.8-37]) (P <0.05). Although global O2 delivery and O2 consumption were higher with dopamine (782 [707-859] vs. 553 [512-629] mL.min.m, P <0.001 and 164 [134-192] vs. 128 [111-149] mL.min.m, P <0.001, respectively), hepatosplanchnic O2 delivery and consumption were not different. Hepatic lactate uptake was lower (0.47 [0.3-0.89] vs. 1.01 [0.69-1.34] mmol.min) (P <0.01), and hepatic venous lactate-to-pyruvate ratio was higher (15.3 [7.6-21.1] vs. 11.2 [6.6-15.1], P <0.05) with dopamine than with norepinephrine. In vasoplegic septic patients, maintaining mean arterial pressure, hepatosplanchnic hemodynamics, and oxygen exchange with dopamine requires a consequent increased cardiac output, which is responsible for an increased global oxygen demand when compared with norepinephrine. In addition, dopamine impairs the hepatic energy balance. Its position as a preferential treatment compared with norepinephrine in this context may therefore be questionable.
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Affiliation(s)
- Jean-Philippe Guérin
- Département d'Anesthésie-Réanimation Est, University Hospital Nice, 06000 Nice, France
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73
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Hsu DZ, Liu MY. Involvement of nitric oxide in gastric protection of epinephrine in endotoxin intoxication in rats. Toxicology 2004; 204:203-8. [PMID: 15388246 DOI: 10.1016/j.tox.2004.06.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2004] [Revised: 03/21/2004] [Accepted: 06/23/2004] [Indexed: 11/19/2022]
Abstract
Reduction in blood pressure may cause gastric mucosal hypoxia and injury during endotoxin intoxication. Epinephrine is found to increase gastric mucosal perfusion while managing hypotension. Nitric oxide plays an important role in regulating gastric mucosal perfusion and maintaining gastric integrity. The aim of this study was to investigate the involvement of nitric oxide in the gastric protection of epinephrine by determining gastric mucosal lipid peroxidation, ulceration, and hemorrhage levels in endotoxin intoxication in rats. Epinephrine significantly increased gastric mucosal nitrite levels, decreased gastric mucosal lipid peroxidation levels, and ameliorated gastric ulceration and hemorrhage in endotoxin-treated rats. Furthermore, nitric oxide synthase inhibitors potently reversed the effects of epinephrine on gastric mucosa in endotoxin-treated rats. It was suggested that nitric oxide might be involved in the protective effect of epinephrine on gastric mucosal injury in endotoxin intoxication in rats.
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Affiliation(s)
- Dur-Zong Hsu
- Department of Environmental and Occupational Health, and Institute of Basic Medical Sciences, National Cheng Kung University Medical College, 138 Sheng-Li Road, Tainan 704, Taiwan
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d'Acampora AJ, Ortellado DK, Carvalho ROM, Serafim JDM, Farias DCD, Tramonte R. Atrofia mucosa/translocação bacteriana na sepse experimental em ratos Wistar. Acta Cir Bras 2004. [DOI: 10.1590/s0102-86502004000500005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Avalizar a relação entre lesão mucosa e translocação bacteriana. MÉTODO: Utilizou-se 50 ratos distribuídos em 5 grupos: 1.Controle: injeção de inóculo padrão de Pseudomonas aeruginosa, 2.Dreno: injeção do inóculo padrão e drenagem da cavidade abdominal, após 6 horas, 3.Lavado: injeção do inóculo padrão e lavagem da cavidade abdominal, após 6 horas, 4.Lavado + dreno: injeção do inóculo padrão e após 6 horas, drenagem e lavagem da cavidade, 5.Normal: avaliação histológica da parede intestinal normal. Após o óbito, realizou-se hemocultura e cultura peritoneal. Realizou-se medida da espessura total da parede do jejuno e da camada mucosa em vilosidades seccionadas de forma longitudinal. RESULTADOS: Na hemocultura, houve crescimento de Pseudomonas aeruginosa e Escherichia coli em 90% e 52,5% dos animais. Na cultura peritoneal, houve crescimento de P. aeruginosa, E. coli e Klebsiella sp em 87,5%, 85% e 5% dos animais. Quanto a altura da camada mucosa e da parede intestinal, não houve alteração estatisticamente significativa entre os 5 grupos. CONCLUSÃO: A sepse aguda não causou alteração na camada mucosa do intestino delgado e a translocação ocorrida não pode ser considerada como decorrente de uma lesão da mucosa intestinal.
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Abstract
Successful treatment with inotropes and vasopressors depends on an understanding of the interplay of flow, pressure, and resistance in the cardiovascular system and an appreciation of the pathophysiologic mechanisms leading to inadequate tissue perfusion. Any treatment strategy is necessarily a compromise between the requirements of different vascular beds.Furthermore. the underlying hemodynamic derangements can change rapidly. Therefore. inotropes and vasopressors should be titrated to measures of improved hemodynamic status, and the treatments should be frequently reviewed.
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Affiliation(s)
- Kevin T T Corley
- Neonatal Foal Intensive Care Programme, Royal Veterinary College, University of London, Hawkshead Lane, North Mymms, Hertfordshire AL9 7TA, United Kingdom.
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Hollenberg SM, Ahrens TS, Annane D, Astiz ME, Chalfin DB, Dasta JF, Heard SO, Martin C, Napolitano LM, Susla GM, Totaro R, Vincent JL, Zanotti-Cavazzoni S. Practice parameters for hemodynamic support of sepsis in adult patients: 2004 update. Crit Care Med 2004; 32:1928-48. [PMID: 15343024 DOI: 10.1097/01.ccm.0000139761.05492.d6] [Citation(s) in RCA: 372] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To provide the American College of Critical Care Medicine with updated guidelines for hemodynamic support of adult patients with sepsis. DATA SOURCE Publications relevant to hemodynamic support of septic patients were obtained from the medical literature, supplemented by the expertise and experience of members of an international task force convened from the membership of the Society of Critical Care Medicine. STUDY SELECTION Both human studies and relevant animal studies were considered. DATA SYNTHESIS The experts articles reviewed the literature and classified the strength of evidence of human studies according to study design and scientific value. Recommendations were drafted and graded levels based on an evidence-based rating system described in the text. The recommendations were debated, and the task force chairman modified the document until <10% of the experts disagreed with the recommendations. CONCLUSIONS An organized approach to the hemodynamic support of sepsis was formulated. The fundamental principle is that clinicians using hemodynamic therapies should define specific goals and end points, titrate therapies to those end points, and evaluate the results of their interventions on an ongoing basis by monitoring a combination of variables of global and regional perfusion. Using this approach, specific recommendations for fluid resuscitation, vasopressor therapy, and inotropic therapy of septic in adult patients were promulgated.
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Asfar P, De Backer D, Meier-Hellmann A, Radermacher P, Sakka SG. Clinical review: influence of vasoactive and other therapies on intestinal and hepatic circulations in patients with septic shock. Crit Care 2004; 8:170-9. [PMID: 15153235 PMCID: PMC468887 DOI: 10.1186/cc2418] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The organs of the hepatosplanchnic system are considered to play a key role in the development of multiorgan failure during septic shock. Impaired oxygenation of the intestinal mucosa can lead to disruption of the intestinal barrier, which may promote a vicious cycle of inflammatory response, increased oxygen demand and inadequate oxygen supply. Standard septic shock therapy includes supportive treatment such as fluid resuscitation, administration of vasopressors (adrenergic and nonadrenergic drugs), and respiratory and renal support. These therapies may have beneficial or detrimental effects not only on systemic haemodynamics but also on splanchnic haemodynamics, at both the macrocirculatory and microcirculatory levels. This clinical review focuses on the splanchnic haemodynamic and metabolic effects of standard therapies used in patients with septic shock, as well as on the recently described nonconventional therapies such as vasopressin, prostacyclin and N-acetyl cysteine.
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Affiliation(s)
- Pierre Asfar
- Staff Physician, Département de Réanimation Médicale, Centre Hospitalier Universitaire, Angers, France
| | - Daniel De Backer
- Staff Physician, Département de Réanimation Médicale, Hôpital Erasme, Université Libre, Bruxelles, Belgium
| | - Andreas Meier-Hellmann
- Head, Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, Helios Klinikum, Erfurt, Germany
| | - Peter Radermacher
- Section Head, Sektion Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Ulm, Germany
| | - Samir G Sakka
- Staff Physician, Department of Anesthesiology and Intensive Care Medicine, Friedrich-Schiller University, Jena, Germany
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Effects of volume resuscitation on splanchnic perfusion in canine model of severe sepsis induced by live Escherichia coli infusion. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2004; 8:R221-8. [PMID: 15312221 PMCID: PMC522840 DOI: 10.1186/cc2871] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2003] [Revised: 04/14/2004] [Accepted: 04/21/2004] [Indexed: 12/20/2022]
Abstract
INTRODUCTION We conducted the present study to investigate whether early large-volume crystalloid infusion can restore gut mucosal blood flow and mesenteric oxygen metabolism in severe sepsis. METHODS Anesthetized and mechanically ventilated male mongrel dogs were challenged with intravenous injection of live Escherichia coli (6 x 10(9) colony-forming units/ml per kg over 15 min). After 90 min they were randomly assigned to one of two groups - control (no fluids; n = 13) or lactated Ringer's solution (32 ml/kg per hour; n = 14) - and followed for 60 min. Cardiac index, mesenteric blood flow, mean arterial pressure, systemic and mesenteric oxygen-derived variables, blood lactate and gastric carbon dioxide tension (PCO2; by gas tonometry) were assessed throughout the study. RESULTS E. coli infusion significantly decreased arterial pressure, cardiac index, mesenteric blood flow, and systemic and mesenteric oxygen delivery, and increased arterial and portal lactate, intramucosal PCO2, PCO2 gap (the difference between gastric mucosal and arterial PCO2), and systemic and mesenteric oxygen extraction ratio in both groups. The Ringer's solution group had significantly higher cardiac index and systemic oxygen delivery, and lower oxygen extraction ratio and PCO2 gap at 165 min as compared with control animals. However, infusion of lactated Ringer's solution was unable to restore the PCO2 gap. There were no significant differences between groups in mesenteric oxygen delivery, oxygen extraction ratio, or portal lactate at the end of study. CONCLUSION Significant disturbances occur in the systemic and mesenteric beds during bacteremic severe sepsis. Although large-volume infusion of lactated Ringer's solution restored systemic hemodynamic parameters, it was unable to correct gut mucosal PCO2 gap.
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Tramonte R, Carvalho ROM, Farias DCD, Serafim JDM, Ortellado DK, d'Acampora AJ. Alterações da mucosa intestinal em ratos: estudo morfométrico em três diferentes tratamentos após indução experimental de sepse abdominal aguda. Acta Cir Bras 2004. [DOI: 10.1590/s0102-86502004000200007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Verificar as possíveis alterações morfológicas da parede intestinal provocadas pela contaminação de uma monocultura bacteriana na cavidade abdominal de ratos, após tratamento por drenagem, lavagem e a combinação destes dois processos. MÉTODOS: Foram utilizados 50 ratos fêmeas da linhagem Wistar, foram distribuídos em 5 subgrupos: grupo Controle (C) - recebeu um inóculo padrão com 1,2.10(9) de Pseudomonas aeruginosa, intraperitonial, sem nenhum tipo de tratamento; grupo Dreno (D) - inóculo padrão e realizada a drenagem da cavidade abdominal; grupo Lavado (L) - inóculo e realizada a lavagem da cavidade abdominal com solução salina; grupo L+D - inóculo e submetido aos dois tipos de tratamentos; grupo Normal (N) sem nenhum tipo de inoculação ou tratamento. Realizou-se a análise morfométrica das lâminas coradas por H.E da mucosa intestinal e hemocultura. RESULTADOS: Não houve diferenças estatisticamente significantes na espessura da mucosa intestinal entre os 5 subgrupos de ratos analisados no período de 24 horas após a injeção do inóculo. 37 animais que receberam o inóculo evoluíram para o óbtito entre 5,83 e 28 horas, com 2 animais do grupo L sobrevivendo por um período de 28 horas. CONCLUSÃO: A sepse aguda não causou alterações morfológicas mensuráveis através desta metodologia na parede intestinal.
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Morelli A, Rocco M, Conti G, Orecchioni A, De Gaetano A, Cortese G, Coluzzi F, Vernaglione E, Pelaia P, Pietropaoli P. Effects of terlipressin on systemic and regional haemodynamics in catecholamine-treated hyperkinetic septic shock. Intensive Care Med 2003; 30:597-604. [PMID: 14673520 DOI: 10.1007/s00134-003-2094-3] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2003] [Accepted: 11/03/2003] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the effects of an intravenous bolus dose of a vasopressin analogue, terlipressin (1 mg), on systemic haemodynamic parameters and gastric mucosal perfusion (GMP) in patients with catecholamine-treated septic shock using a gastric tonometry and laser-Doppler flowmetry technique. DESIGN Prospective open label study. SETTINGS Two multidisciplinary intensive care units. PATIENTS Fifteen patients with norepinephrine-treated septic shock. INTERVENTIONS Every patient with mean arterial pressure between 50 and 55 mmHg treated with high dose norepinephrine received an intravenous bolus dose of terlipressin as last resort therapy. A laser-Doppler probe and tonometer were introduced into the gastric lumen. MEASUREMENTS AND MAIN RESULTS Terlipressin produced a decrease in cardiac output ( p<0.05), a progressive increase in mean arterial pressure ( p<0.05) and in GMP, detected by laser-Doppler flowmetry ( p<0.05) over 30 min and sustained for at least 24 h. The ratio of GMP to systemic oxygen delivery increased after terlipressin bolus dose ( p<0.05). The gradient between gastric mucosal and arterial PCO(2) tended to be lower after terlipressin, and the difference was statistically significant ( p<0.05) after 8 h. Terlipressin administration significantly increased ( p<0.05) urine output compared to baseline and higher values were found at each set of measurement. The terlipressin-induced increase in urine output was associated with a significantly increased creatinine clearance ( p<0.05). Reduction of the high-dose norepinephrine was observed in all patients ( p<0.05). CONCLUSIONS Our findings showed that, in patients with norepinephrine-treated septic shock, terlipressin increased GMP, urine output and creatinine clearance by an increase in mean arterial pressure.
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Affiliation(s)
- Andrea Morelli
- Department of Anaesthesiology and Intensive Care, University of Rome La Sapienza, Viale del Policlinico 155, 00161 Rome, Italy.
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81
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van Haren FMP, Rozendaal FW, van der Hoeven JG. The Effect of Vasopressin on Gastric Perfusion in Catecholamine-Dependent Patients in Septic Shock. Chest 2003; 124:2256-60. [PMID: 14665508 DOI: 10.1378/chest.124.6.2256] [Citation(s) in RCA: 135] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE To study the effect of continuous infusion of vasopressin on the splanchnic circulation in patients with severe septic shock. DESIGN Prospective clinical study. SETTING ICU in a teaching hospital. PATIENTS Eleven consecutive patients with documented septic shock who remained hypotensive despite norepinephrine infusion at a rate > or =0.2 microg/kg/min. INTERVENTIONS Insertion of a gastric tonometry catheter, and continuous infusion of vasopressin 0.04 U/min during 4 h. MEASUREMENTS AND MAIN RESULTS Difference between gastric and arterial CO(2) partial pressure (P[g-a]CO(2) gap), mean arterial pressure, and cardiac index were recorded at baseline and after 15 min, 30 min, 60 min, 120 min, and 240 min. RESULTS The median P(g-a)CO(2) gap increased from 5 mm Hg at baseline to 19 mm Hg after 4 h (p = 0.022). Mean arterial pressure increased from 61 +/- 13 mm Hg at baseline to 68 +/- 9 mm Hg after 4 h (p = 0.055). No significant changes in cardiac index were noted. CONCLUSIONS In norepinephrine-dependent patients in septic shock, continuous infusion of low-dose vasopressin results in a significant increase of the P(g-a)CO(2) gap compatible with GI hypoperfusion.
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Affiliation(s)
- Frank M P van Haren
- Department of Intensive Care Medicine, Jeroen Bosch Hospital, PO Box 90153, 5200 ME 's-Hertogenbosch, the Netherlands.
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De Backer D, Creteur J, Silva E, Vincent JL. Effects of dopamine, norepinephrine, and epinephrine on the splanchnic circulation in septic shock: which is best? Crit Care Med 2003; 31:1659-67. [PMID: 12794401 DOI: 10.1097/01.ccm.0000063045.77339.b6] [Citation(s) in RCA: 221] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To assess the effects of different doses of dopamine, norepinephrine, and epinephrine on the splanchnic circulation in patients with septic shock. DESIGN Prospective, randomized, open-label study. SETTING A 31-bed, medicosurgical intensive care unit of a university hospital. PATIENTS Convenience sample of 20 patients with septic shock, separated into two groups according to whether (moderate shock group, n = 10) or not (severe shock, n = 10) dopamine alone was able maintain mean arterial pressure >65 mm Hg. INTERVENTIONS Dopamine was progressively withdrawn and replaced successively by norepinephrine and then epinephrine (the order of the two agents was randomly determined) to maintain mean arterial pressure constant (moderate shock) or to increase mean arterial pressure above 65 mm Hg (severe shock). MEASUREMENTS AND MAIN RESULTS Systemic circulation (pulmonary artery catheter) and splanchnic circulation (indocyanine green dilution and hepatic vein catheter) and gastric mucosal Pco(2) (gas tonometry) were measured during dopamine (moderate shock only), norepinephrine, and epinephrine administration (both groups). Data were analyzed with nonparametric tests and are presented as median [percentiles 25-75]. In moderate shock, cardiac index was similar to dopamine and norepinephrine (3.1 [2.7-3.8] vs. 2.9 [2.7-4.1] L/min.m2, p = nonsignificant) but greater with epinephrine (4.1 [3.5-4.4] p <.01 vs. dopamine and norepinephrine). Splanchnic blood flow was similar with the three agents (732 [413-1483] vs. 746 [470-1401] vs. 653 [476-1832] mL/min.m, p = nonsignificant). The gradient between mixed-venous and hepatic venous oxygen saturations was lower with dopamine than with norepinephrine and epinephrine, but the Pco(2) gap was similar with the three agents. In severe shock, cardiac index was higher, but splanchnic blood flow was lower, with epinephrine than with norepinephrine (4.6 [3.7-5.3] vs. 3.4 [3.0-4.1] L/min.m2, p <.01 and 860 [684-1334] vs. 977 [806-1802] mL/min.m2, p <.05, respectively). Epinephrine increased the mixed-venous and hepatic venous oxygen saturation gradient but did not alter Pco(2) gap. CONCLUSIONS Dopamine and norepinephrine have similar hemodynamic effects, but epinephrine can impair splanchnic circulation in severe septic shock.
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Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Route de Lennik 808, B-1070 Brussels, Belgium.
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84
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Abstract
Controversy exists as to the best means to monitor the critically ill patient and the appropriate end points of therapy. Use of global hemodynamic or metabolic parameters may be normal in the patient who has not been completely or adequately resuscitated. Decreased perfusion to the gut is not well tolerated and may contribute to the development of the multiple organ dysfunction syndrome. Gastric tonometry is a minimally invasive way to monitor splanchnic perfusion in the critically ill patient. Data suggest that tonometry is useful for outcome prognostication and for detection of early hypovolemia. In addition, use of gastric intramucosal pH or mucosal-arterial CO(2) gap as end points of resuscitation may be superior to other conventional whole-body parameters. For these reasons, gastric tonometry must be considered the hemodynamic monitor of choice.
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Affiliation(s)
- Stephen O Heard
- Department of Anesthesiology, University of Massachusetts Medical School, Worcester 01655, USA.
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85
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Abstract
In 1914, Schottmueller wrote "Septicemia is a state of microbial invasion from a portal of entry into the blood stream which causes signs of illness." In the last few decades, the evidence that sepsis results from an exaggerated systemic inflammatory host response induced by infecting organisms is compelling; inflammatory mediators are the key players in the pathogenesis of septic shock and multiorgan failure. Sepsis and its sequelae represent a continuum of clinical syndrome encompassing systemic inflammation, coagulopathy, and hemodynamic abnormalities. Severe sepsis and septic shock continue to be the major causes of morbidity and mortality in the United States; sepsis deaths currently match mortality from myocardial infarction. Despite significant advances in our understanding of the pathophysiology and technological innovations in the supportive management, mortality from septic shock remains excessive. After many disappointments with strategies to manipulate the inflammatory response, modulation of coagulation cascade to decrease sepsis mortality has become a clinical reality. This review will highlight and discuss recent advances in the pathophysiology and management of sepsis.
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Affiliation(s)
- Sat Sharma
- Section of Pulmonary Care Medicine, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
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86
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Abstract
Norepinephrine (NE) is mostly used to treat severe hypotension. However, NE has potentially adverse vasoconstrictive effects on regional vascular beds of kidney, liver, and gut, with a potential for ensuing organ dysfunction. NE therefore is considered as a last reserve in otherwise refractory hypotension. During sepsis, a loss of catecholamine responsiveness occurs that is often interpreted as down-regulation of catecholamine receptors. Therefore, the doses of NE needed to maintain or restore blood pressure may be extremely high. Surprisingly, no adverse vasoconstriction with subsequent hypoperfusion occurs during sepsis, despite the high doses of NE administered. Instead, NE rather causes an increase in blood flow and oxygen delivery.
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Affiliation(s)
- Gregor Theilmeier
- Klinik und Poliklinik für Anästhesiologie und operative Intensivmedizin, Westfälische Wilhelms-Universität, Albert-Schweitzer-Str. 33, 48129 Münster, Germany
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Levy B, Mansart A, Bollaert PE, Franck P, Mallie JP. Effects of epinephrine and norepinephrine on hemodynamics, oxidative metabolism, and organ energetics in endotoxemic rats. Intensive Care Med 2003; 29:292-300. [PMID: 12594589 DOI: 10.1007/s00134-002-1611-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2002] [Accepted: 11/13/2002] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine whether epinephrine increases lactate concentration in sepsis through hypoxia or through a particular thermogenic or metabolic pathway. DESIGN Prospective, controlled experimental study in rats. SETTING Experimental laboratory in a university teaching hospital. INTERVENTIONS Three groups of anesthetized, mechanically ventilated male Wistar rats received an intravenous infusion of 15 mg/kg Escherichia coli O127:B8 endotoxin. Rats were treated after 90 min by epinephrine ( n=14), norepinephrine ( n=14), or hydroxyethyl starch ( n=14). Three groups of six rats served as time-matched control groups and received saline, epinephrine, or norepinephrine from 90 to 180 degrees min. Mean arterial pressure, aortic, renal, mesenteric and femoral blood flow, arterial blood gases, lactate, pyruvate, and nitrate were measured at baseline and 90 and 180 min after endotoxin challenge. At the end of experiments biopsy samples were taken from the liver, heart, muscle, kidney, and small intestine for tissue adenine nucleotide and lactate/pyruvate measurements. MEASUREMENTS AND RESULTS Endotoxin induced a decrease in mean arterial pressure and in aortic, mesenteric, and renal blood flow. Plasmatic and tissue lactate increased with a high lactate/pyruvate (L/P) ratio. ATP decreased in liver, kidney, and heart. The ATP/ADP ratio did not change, and phosphocreatinine decreased in all organs. Epinephrine and norepinephrine increased mean arterial pressure to baseline values. Epinephrine increased aortic blood flow while renal blood low decreased with both drugs. Plasmatic lactate increased with a stable L/P ratio with epinephrine and did not change with norepinephrine compared to endotoxin values. Nevertheless epinephrine and norepinephrine when compared to endotoxin values did not change tissue L/P ratios or ATP concentration in muscle, heart, gut, or liver. In kidney both drugs decreased ATP concentration. CONCLUSIONS Our data demonstrate in a rat model of endotoxemia that epinephrine-induced hyperlactatemia is not related to cellular hypoxia.
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Affiliation(s)
- Bruno Levy
- Réanimation Médicale, Hôpital Central, 54035, Nancy Cedex, France.
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89
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Asfar P, Pierrot M, Veal N, Moal F, Oberti F, Croquet V, Douay O, Gallois Y, Saumet JL, Alquier P, Calès P. Low-dose terlipressin improves systemic and splanchnic hemodynamics in fluid-challenged endotoxic rats. Crit Care Med 2003; 31:215-20. [PMID: 12545018 DOI: 10.1097/00003246-200301000-00033] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Vasopressin has been used to treat arterial hypotension associated with hyperdynamic vasoplegic states, but detrimental effects on splanchnic circulation have been reported. We tested the effects of a low-dose vasopressin analogue, terlipressin (6 microg/kg), on systemic and splanchnic hemodynamics in fluid-challenged endotoxic rats (lipopolysaccharide, 30 mg/kg in 1 hr). DESIGN Prospective, randomized, controlled experimental study with repeated measures. SETTING Investigational animal laboratory. SUBJECTS A total of 77 rats were divided into five groups: group C, control (17 rats); group E, LPS (18 rats); group EF, LPS plus fluid challenge (18 rats); group EFT, LPS plus fluid challenge plus terlipressin (18 rats); and group ET, LPS plus terlipressin (seven rats). INTERVENTIONS Rats were anesthetized, mechanically ventilated, and instrumented to measure heart rate, mean arterial pressure, and abdominal aortic and mesenteric vein indexed blood flows; ileal microcirculation was assessed by laser Doppler. After LPS infusion, rats experienced an endotoxic shock and were resuscitated after the allocation group. The fluid challenge was targeted to maintain mean arterial pressure of >90 mm Hg and aortic blood flow at baseline values. MEASUREMENTS AND MAIN RESULTS Terlipressin significantly (p <.05) increased mean arterial pressure without decreasing indexed aortic blood flow and heart rate in the fluid-challenged endotoxic rats (EFT) compared with EF rats and had detrimental effects in hypodynamic endotoxic rats (ET). Fluid challenge significantly (p <.05) increased mesenteric vein blood flow in both the EF and EFT groups, and terlipressin had no detrimental effect on mesenteric blood flow. Terlipressin significantly (p <.05) increased ileal microcirculation in fluid-challenged endotoxic rats (EF and EFT) but not in hypodynamic endotoxic rats (E and ET). CONCLUSION Low-dose terlipressin in fluid-challenged endotoxic rats improved systemic and splanchnic hemodynamics and improved the ileal microcirculation.
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Abstract
An estimated 750,000 cases of severe sepsis occur annually in the United States, and the mortality rate is about 30%. As a condition that disproportionately affects the elderly and is related to invasive and immunosuppressive healthcare, increases in the frequency of sepsis are anticipated. The complex pathophysiology of sepsis encompasses the interplay of pro- and anti-inflammatory mediators, activated circulating and resident inflammatory cells, disrupted coagulation, endothelial activation and injury, vasodilatation and vascular hyporesponsiveness to vasoactive mediators, cardiac dysfunction, and cellular dysoxia. Current management of severe sepsis includes eradication of infection through source control and antimicrobial therapy, aggressive and targeted shock resuscitation that includes fluid administration, correction of anemia, vasopressor support, modest inotropic therapy, infusion of human recombinant activated protein C to selected patients, and compulsive supportive care to manage organ dysfunction and to avoid complications.
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Affiliation(s)
- Curtis N Sessler
- Division of Pulmonary and Critical Care Medicine and Medical Respiratory Intensive Care Unit, Medical College of Virginia, Virginia Commonwealth University Health System, Richmond, VA 23289, USA.
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Silva E, Figueiredo LFPD, Cruz Jr RJ, Silva MRE. Gas tonometry for evaluation of gastrointestinal mucosal perfusion: experimental and clinical sepsis¹. part 2. Acta Cir Bras 2002. [DOI: 10.1590/s0102-86502002000500003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Substantial clinical and animal evidences indicate that the mesenteric circulatory bed, particularly the gut mucosa, is highly vulnerable to reductions in oxygen supply and prone to early injury in the course of hemodynamic changes induced by sepsis and septic shock. Gut hypoxia or ischemia is one possible contributing factor to gastrointestinal tract barrier dysfunction that may be associated with the development of systemic inflammatory response and multiple organ dysfunction syndrome, the principal cause of death after sepsis. Monitoring gut perfusion during experimental and clinical sepsis may provide valuable insights over new interventions and therapies highly needed to reduce multiple organ dysfunction and sepsis-related morbidity and mortality. We present our experience with gas tonometry as a monitor of the adequacy of gastrointestinal mucosal perfusion in experimental models sepsis and with the use of vasoactive agents for hemodynamic management in patients with septic shock.
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Andel H, Rab M, Andel D, Felfernig M, Hörauf K, Felfernig D, Schramm W, Zimpfer M. Impact of early high caloric duodenal feeding on the oxygen balance of the splanchnic region after severe burn injury. Burns 2001; 27:389-93. [PMID: 11348751 DOI: 10.1016/s0305-4179(00)00134-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Early enteral nutrition is recommended in burned patients. Depending on the amount administered, enteral feeding causes an increase of intestinal oxygen-demand. Although early moderate enteral nutrition has been shown to be beneficial, early high calorie enteral nutrition might lead to an imbalance of the O(2)-balance of the gut since intestinal perfusion is decreased after major burns. In 20 severely burned patients during the first 48 h of early high caloric duodenal feeding an assessment of the CO(2)-gap between the arterial and the gastric CO(2), as parameter for the intestinal O(2)-balance, was performed. Time points were prior to starting the enteral nutrition (BASE) subsequently every 30 min after increasing the amount of nutrition administered and from the 11th to the 48th h after beginning of nutrition in intervals of 6 h. In none of the patients was the CO(2)-gap increased during the rapid increase of enteral nutrition. On the contrary the CO(2)-gap decreased significantly. We conclude that high caloric duodenal feeding in the early hypodynamic postburn phase does not have adverse effects on the oxygen balance of the intestine.
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Affiliation(s)
- H Andel
- Department of Anesthesiology and Intensive Care, Vienna Medical School, University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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94
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Abstract
Infection is problematic because it affects many patients (adults and children), is a major cause of death in intensive care units (ICU) worldwide, and uses a large amount of hospital resources. The mortality rate among patients with septic shock varies but approximates 40% in infected patients admitted to ICUs. Because of the large number of adults dying of sepsis, many resources are expended. Children are physiologically different from adults, but nonetheless, many similarities exist with respect to the response to septic shock.
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Affiliation(s)
- W Butt
- Pediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, Australia
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De Backer D, Dubois MJ. Assessment of the microcirculatory flow in patients in the intensive care unit. Curr Opin Crit Care 2001; 7:200-3. [PMID: 11436528 DOI: 10.1097/00075198-200106000-00010] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Various techniques have been used at bedside to assess the microcirculation of critically ill patients, including nailfold videomicroscopy, laser doppler techniques, and orthogonal polarization spectral imaging. Nailfold videomicroscopy was introduced first, but its value may be limited by the extreme sensitivity of nailfold microcirculation to external temperature or vasoconstrictive agents. Laser Doppler techniques can measure gastric or jejunal mucosal blood flow as well as skin and muscle blood flow, but do not take into account blood flow heterogeneity, a major parameter of microcirculation. The recent introduction of orthogonal polarization spectral imaging techniques allows direct visualization of microcirculation in critically ill patients, opening a new area for the investigation of the pathophysiologic processes involved in the hemodynamic alterations of shock states.
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Affiliation(s)
- D De Backer
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Route de Lennik, 808 B-1070 Brussels, Belgium.
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96
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Abstract
Gastric tonometry has proved to be a sensitive but not specific predictor of outcome in the critically ill. The data accumulated to date indicate that those patients able to achieve or maintain a normal gastric mucosal pH do better than those who do not. In addition, therapy aimed at improving an abnormal gastric mucosal pH has proved to be less successful. These findings may simply indicate that tonometry identifies those "responders" and "nonresponders," as becomes increasingly apparent in populations of critical care patients receiving interventional therapy. Gastric tonometry has undergone a number of methodologic changes over the last decade, seeing a switch from saline to automated gas tonometry. Along with this switch of methodology has come a deeper scrutiny of the indices used to assess gut perfusion. Most studies (including all the interventional ones) have used gastric mucosal pH. The newer indices of gut luminal PCO2 (PgCO2) referenced to arterial CO2 (PgCO2-PaCO2) or end tidal CO2 (PgCO2-PeCO2), although relatively well validated, remain to be proven as predictors of outcome or guides to interventional therapy. If we take a fresh look at the interventional trials in intensive care patients, there is a very definite trend toward benefit in the protocol groups, although they are generally reported as negative studies. There is much to be accomplished, however, before we accept the gastric tonometer as a routine tool with which to guide therapy based on gastrointestinal perfusion, including a greater understanding of gastrointestinal physiology and, as ever, the call for an adequately powered prospective randomized controlled trial to evaluate the clinical utility of gas tonometry.
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Affiliation(s)
- M A Hamilton
- Center for Anesthesia, Middlesex Hospital, and Center for Anesthesia, University College, London, UK
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97
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Eshel GM, Safar P, Stezoski W. The role of the gut in the pathogenesis of death due to hyperthermia. Am J Forensic Med Pathol 2001; 22:100-4. [PMID: 11444654 DOI: 10.1097/00000433-200103000-00022] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pathologic data from the gastrointestinal tract in heat-stroke victims, although documented, are confusing. The object of this study was to document the gastrointestinal changes observed during induced total body hyperthermia (42 degrees C) followed by cooling. An established heat-stroke model was used in a university animal laboratory. Group A underwent immersion hyperthermia for 1 hour, followed by cooling to normothermia. Group B underwent hyperthermia to cardiac arrest, followed by resuscitation plus cooling to normothermia. The postmortem findings in the gastrointestinal tract were evaluated. In group A, several hours after return to normothermia and stable vital signs, delayed secondary deterioration with massive gastrointestinal bleeding occurred. The postmortem findings revealed bleeding into the whole intestine and serosanguineous fluid in the peritoneal cavity. In group B, an adynamic gut was observed after 165 +/- 21 minutes (range 125-174) of heating when mean arterial pressure (MAP) decreased to 38 +/- 21 mm Hg (range 30-70). Cardiac arrest occurred at 178 +/- 26 minutes (range 140-208) of immersion. Eight monkeys could be resuscitated to spontaneous circulation with return of normal gut motility, then they rearrested at 158 +/- 68 minutes (range 45-228). The postmortem findings resembled those in group A. The Postmortem findings in the four monkeys in which restoration of spontaneous circulation failed, revealed only some intestinal wall edema and occasional petechial hemorrhages. It is concluded that after a hyperthermic event, tissue injury continues to develop. The pathologic findings are related to the time lapse between hyperthermia, cooling, and death. The similarity to the descriptions of septic shock, multiple organ failure, and the gut reperfusion syndrome is striking. An immunologic response as a mechanism for all these syndromes is discussed.
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Affiliation(s)
- G M Eshel
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pennsylvania, USA
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98
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Träger K, Radermacher P, Brinkmann A, Calzia E, Kiefer P. Gastrointestinal tract resuscitation in critically ill patients. Curr Opin Clin Nutr Metab Care 2001; 4:131-5. [PMID: 11224658 DOI: 10.1097/00075197-200103000-00009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Particular research interest is currently focusing on the resuscitation of the gastrointestinal tract, because the gut is regarded to be both the "canary of the body", i.e. a sentinel organ during situations of compromised oxygen or substrate supply, as well as the "motor of multiple organ failure". Several therapeutic strategies have recently been proposed for the resuscitation of this organ system, aimed primarily at the augmentation of blood flow and oxygenation but also integrating nutritional or metabolic support and antioxidant administration.
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Affiliation(s)
- K Träger
- Postoperative Intensive Care Medicine, University Medical School, D-89073 Ulm, Germany
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Salak N, Pajk W, Knotzer H, Hofstötter H, Schwarz B, Mayr A, Labeck B, Kafka R, Ulmer H, Mutz N, Hasibeder W. Effects of epinephrine on intestinal oxygen supply and mucosal tissue oxygen tension in pigs. Crit Care Med 2001; 29:367-73. [PMID: 11246318 DOI: 10.1097/00003246-200102000-00027] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To study the effects of increasing dosages of epinephrine given intravenously on intestinal oxygen supply and, in particular, mucosal tissue oxygen tension in an autoperfused, innervated jejunal segment. DESIGN Prospective, randomized experimental study. SETTING Animal research laboratory. SUBJECTS Domestic pigs. INTERVENTIONS Sixteen pigs were anesthetized, paralyzed, and normoventilated. A small segment of the jejunal mucosa was exposed by midline laparotomy and antimesenteric incision. Mucosal oxygen tension was measured by using Clark-type surface oxygen electrodes. Microvascular hemoglobin oxygen saturation and microvascular blood flow (perfusion units) were determined by tissue reflectance spectrophotometry and laser-Doppler velocimetry. Systemic hemodynamics, mesenteric-venous acid-base and blood gas variables, and systemic acid-base and blood gas variables were recorded. Measurements were performed after a resting period and at 20-min intervals during infusion of increasing dosages of epinephrine (n = 8; 0.01, 0.05, 0.1, 0.5, 1, and 2 microg x kg(-1) x min(-1)) or without treatment (n = 8). In addition, arterial and mesenteric-venous lactate concentrations were measured at baseline and at 60 and 120 mins. MEASUREMENTS AND MAIN RESULTS Epinephrine infusion led to significant tachycardia; an increase in cardiac output, systemic oxygen delivery, and oxygen consumption; and development of lactic acidosis. Epinephrine significantly increased jejunal microvascular blood flow (baseline, 267 +/- 39 perfusion units; maximum value, 443 +/- 35 perfusion units) and mucosal oxygen tension (baseline, 36 +/- 2.0 torr [4.79 +/- 0.27 kPa]; maximum value, 48 +/- 2.8 torr [6.39 +/- 0.37 kPa]) and increased hemoglobin oxygen saturation above baseline. Epinephrine increased mesenteric venous lactate concentration (baseline, 2.9 +/- 0.6 mmol x L(-1); maximum value, 5.5 +/- 0.2 mmol x L(-1)) without development of an arterial-mesenteric venous lactate concentration gradient. CONCLUSIONS Epinephrine increased jejunal microvascular blood flow and mucosal tissue oxygen supply at moderate to high dosages. Lactic acidosis that develops during infusion of increasing dosages of epinephrine is not related to development of gastrointestinal hypoxia.
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Affiliation(s)
- N Salak
- Division of General and Surgical Intensive Care Medicine, Department of Anesthesia and Critical Care Medicine, The Leopold Franzens University of Innsbruck, Innsbruck, Austria
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Corley K, McKenzie H, Amoroso L, Furr M. Initial Experience with Norepinephrine Infusion in Hypotensive Critically III Foals. J Vet Emerg Crit Care (San Antonio) 2000. [DOI: 10.1111/j.1476-4431.2000.tb00012.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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