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Jávor P, Donka T, Horváth T, Sándor L, Török L, Szabó A, Hartmann P. Impairment of Mesenteric Perfusion as a Marker of Major Bleeding in Trauma Patients. J Clin Med 2023; 12:jcm12103571. [PMID: 37240677 DOI: 10.3390/jcm12103571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 05/28/2023] Open
Abstract
The majority of potentially preventable mortality in trauma patients is related to bleeding; therefore, early recognition and effective treatment of hemorrhagic shock impose a cardinal challenge for trauma teams worldwide. The reduction in mesenteric perfusion (MP) is among the first compensatory responses to blood loss; however, there is no adequate tool for splanchnic hemodynamic monitoring in emergency patient care. In this narrative review, (i) methods based on flowmetry, CT imaging, video microscopy (VM), measurement of laboratory markers, spectroscopy, and tissue capnometry were critically analyzed with respect to their accessibility, and applicability, sensitivity, and specificity. (ii) Then, we demonstrated that derangement of MP is a promising diagnostic indicator of blood loss. (iii) Finally, we discussed a new diagnostic method for the evaluation of hemorrhage based on exhaled methane (CH4) measurement. Conclusions: Monitoring the MP is a feasible option for the evaluation of blood loss. There are a wide range of experimentally used methodologies; however, due to their practical limitations, only a fraction of them could be integrated into routine emergency trauma care. According to our comprehensive review, breath analysis, including exhaled CH4 measurement, would provide the possibility for continuous, non-invasive monitoring of blood loss.
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Affiliation(s)
- Péter Jávor
- Department of Traumatology, University of Szeged, H-6725 Szeged, Hungary
| | - Tibor Donka
- Department of Traumatology, University of Szeged, H-6725 Szeged, Hungary
| | - Tamara Horváth
- Institute of Surgical Research, University of Szeged, H-6724 Szeged, Hungary
| | - Lilla Sándor
- Department of Traumatology, University of Szeged, H-6725 Szeged, Hungary
| | - László Török
- Department of Traumatology, University of Szeged, H-6725 Szeged, Hungary
- Department of Sports Medicine, University of Szeged, H-6725 Szeged, Hungary
| | - Andrea Szabó
- Institute of Surgical Research, University of Szeged, H-6724 Szeged, Hungary
| | - Petra Hartmann
- Department of Traumatology, University of Szeged, H-6725 Szeged, Hungary
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Maciel AT, Vitorio D, Osawa EA. Urine biochemistry assessment in the sequential evaluation of renal function: Time to think outside the box. Front Med (Lausanne) 2022; 9:912877. [PMID: 35957852 PMCID: PMC9360530 DOI: 10.3389/fmed.2022.912877] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/05/2022] [Indexed: 12/12/2022] Open
Abstract
Urine biochemistry (UB) remains a controversial tool in acute kidney injury (AKI) monitoring, being considered to be of limited value both in terms of AKI diagnosis and prognosis. However, many criticisms can be made to the studies that have established the so called “pre-renal paradigm” (used for decades as the essential physiological basis for UB assessment in AKI) as well as to more recent studies suggesting that UB has no utility in daily clinical practice. The aim of this article is to describe our hypothesis on how to interpret simple and widely recognized urine biochemical parameters from a novel perspective, propose the rationale for their sequential assessment and demonstrate their usefulness in AKI monitoring, especially in the critical care setting.
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Affiliation(s)
- Alexandre T. Maciel
- Research Department, Imed Group, São Paulo, Brazil
- Adult Intensive Care Unit, São Camilo Hospital–Pompéia Unit, São Paulo, Brazil
- *Correspondence: Alexandre T. Maciel,
| | - Daniel Vitorio
- Research Department, Imed Group, São Paulo, Brazil
- Adult Intensive Care Unit, São Camilo Hospital–Pompéia Unit, São Paulo, Brazil
| | - Eduardo A. Osawa
- Research Department, Imed Group, São Paulo, Brazil
- Adult Intensive Care Unit, São Camilo Hospital–Pompéia Unit, São Paulo, Brazil
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Abstract
Tissue hypoperfusion is a major cause of morbidity and mortality in critically ill patients but cannot always be detected by measuring standard whole-body hemodynamic and oxygen-related parameters (e.g., blood pressure, cardiac output, and central venous oxygen saturation). Preclinical and clinical studies have demonstrated that low-flow states are consistently associated with large increases in venous and tissue PCO2. Monitoring regional PCO2 with gastric tonometry (PgCO2) is known to have independent prognostic value for predicting postoperative complications and mortality. The PgCO2 gap might also be of value as a treatment target (endpoint) in critically ill patients. However, this tool has several limitations and has not yet been developed commercially, thus restricting its use. Regional capnography with sublingual and transcutaneous sensors might be an alternative noninvasive option for evaluating the adequacy of tissue perfusion in critically ill patients. However, further studies are needed to determine whether or not this monitoring technique is of value-particularly as an endpoint for guiding resuscitation. Bladder PCO2, has only been evaluated in animal studies, and so remains to be validated in patients.
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Affiliation(s)
- Stéphane Bar
- Anesthesiology and Critical Care Department, Amiens University Hospital, Amiens, France
| | - Marc-Olivier Fischer
- Normandie Univ, UNICAEN, CHU de Caen Normandie, Service d'Anesthésie Réanimation, Caen, France
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Maciel AT. Urine electrolyte measurement as a "window" into renal microcirculatory stress assessment in critically ill patients. J Crit Care 2018; 48:90-96. [PMID: 30176529 DOI: 10.1016/j.jcrc.2018.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/07/2018] [Accepted: 08/14/2018] [Indexed: 12/20/2022]
Abstract
Urine electrolyte assessment has long been used in order to understand electrolyte concentration disturbances in blood and as an easy tool for monitoring renal perfusion and structural tubular damage. In the last few years, great improvement in the pathophysiology of acute kidney injury (AKI) has occurred, and the correlation between urine biochemistry (UB) behavior and renal perfusion was frequently questioned. Many authors have suggested abandoning UB monitoring due to its unclear role in AKI monitoring. Our group has been working in this field in the critically ill population, and we believe that, although UB is indeed very useful, a different point of view regarding the interpretation of the data should be used. The aim of this review is to explain the rationale of these new concepts and make suggestions for their adequate use in daily ICU practice, especially in low-income countries where more sophisticated and expensive AKI biomarker assessments are not available.
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Affiliation(s)
- Alexandre T Maciel
- Imed Research Group, Adult Intensive Care Unit, São Camilo Hospital, São Paulo, Brazil.
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Monitoring Microcirculatory Blood Flow with a New Sublingual Tonometer in a Porcine Model of Hemorrhagic Shock. BIOMED RESEARCH INTERNATIONAL 2015; 2015:847152. [PMID: 26504837 PMCID: PMC4609384 DOI: 10.1155/2015/847152] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 03/23/2015] [Accepted: 03/24/2015] [Indexed: 12/27/2022]
Abstract
Tissue capnometry may be suitable for the indirect evaluation of regional hypoperfusion. We tested the performance of a new sublingual capillary tonometer in experimental hemorrhage. Thirty-six anesthetized, ventilated mini pigs were divided into sham-operated (n = 9) and shock groups (n = 27). Hemorrhagic shock was induced by reducing mean arterial pressure (MAP) to 40 mmHg for 60 min, after which fluid resuscitation started aiming to increase MAP to 75% of the baseline value (60-180 min). Sublingual carbon-dioxide partial pressure was measured by tonometry, using a specially coiled silicone rubber tube. Mucosal red blood cell velocity (RBCV) and capillary perfusion rate (CPR) were assessed by orthogonal polarization spectral (OPS) imaging. In the 60 min shock phase a significant drop in cardiac index was accompanied by reduction in sublingual RBCV and CPR and significant increase in the sublingual mucosal-to-arterial PCO2 gap (PSLCO2 gap), which significantly improved during the 120 min resuscitation phase. There was significant correlation between PSLCO2 gap and sublingual RBCV (r = -0.65, p < 0.0001), CPR (r = -0.64, p < 0.0001), central venous oxygen saturation (r = -0.50, p < 0.0001), and central venous-to-arterial PCO2 difference (r = 0.62, p < 0.0001). This new sublingual tonometer may be an appropriate tool for the indirect evaluation of circulatory changes in shock.
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Vollmer C, Weiß S, Beck C, Bauer I, Picker O. Hypothermia improves oral and gastric mucosal oxygenation during hypoxic challenges. Br J Anaesth 2014; 113:433-42. [PMID: 24390551 DOI: 10.1093/bja/aet462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Therapeutic hypothermia, used primarily for protective effects after hypoxia, improves oral and gastric mucosal microvascular oxygenation (μHbO₂) during additional haemorrhage. Therefore, we questioned whether hypothermia likewise improves μHbO₂ during hypoxic challenges. Since both hypothermia and hypoxia reduce cardiac output (e.g. by myofilament Ca(2+) desensitization), and modulate vasomotor tone via K(+) ATP channels, we hypothesized that the Ca(2+) sensitizer levosimendan and K(+) ATP channel blocker glibenclamide would support the cardiovascular system. METHODS The effects of mild hypothermia (34°C) on μHbO₂ during hypoxia [Formula: see text] were analysed in a cross-over study on five anaesthetized dogs and compared with normothermia (37.5°C) and hypoxia. During hypothermia, but before hypoxia, glibenclamide (0.2 mg kg(-1)) or levosimendan (20 µg kg(-1)+0.25 µg kg(-1) min(-1)) was administered. Systemic haemodynamic variables, gastric and oral mucosal microvascular oxygenation (reflectance spectrophotometry), and perfusion (laser Doppler flowmetry) were recorded continuously. Data are presented as mean (sem), P<0.05. RESULTS Hypoxia during normothermia reduced gastric μHbO₂ by 27 (3)% and oral μHbO₂ by 28 (3)% (absolute change). During hypothermia, this reduction was attenuated to 16 (3)% and 13 (1)% (absolute change). This effect was independent of microvascular flow that did not change during hypoxia and hypothermia. Additional administration of levosimendan during hypothermia restored reduced cardiac output but did not change flow or μHbO₂ compared with hypothermia alone. Glibenclamide did not exert any additional effects during hypothermia. CONCLUSIONS Hypothermia attenuates the decrease in μHbO₂ during additional hypoxic challenges independent of systemic or regional flow changes. A reduction in cardiac output during hypothermia is prevented by Ca(2+) sensitization with levosimendan but not by K(+) ATP channel blockade with glibenclamide.
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Affiliation(s)
- C Vollmer
- Department of Anaesthesiology, University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - S Weiß
- Department of Anaesthesiology, University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - C Beck
- Department of Anaesthesiology, University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - I Bauer
- Department of Anaesthesiology, University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - O Picker
- Department of Anaesthesiology, University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
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Hypothermia improves oral and gastric mucosal microvascular oxygenation during hemorrhagic shock in dogs. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2013; 2013:589606. [PMID: 24327826 PMCID: PMC3845851 DOI: 10.1155/2013/589606] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 09/03/2013] [Accepted: 10/01/2013] [Indexed: 11/30/2022]
Abstract
Hypothermia is known to improve tissue function in different organs during physiological and pathological conditions. The aim of this study was to evaluate the effects of hypothermia on oral and gastric mucosal microvascular oxygenation (μHbO2) and perfusion (μflow) under physiological and hemorrhagic conditions. Five dogs were repeatedly anesthetized. All animals underwent each experimental protocol (randomized cross-over design): hypothermia (34°C), hypothermia during hemorrhage, normothermia, and normothermia during hemorrhage. Microcirculatory and hemodynamic variables were recorded. Systemic (DO2) and oral mucosal (μDO2) oxygen delivery were calculated. Hypothermia increased oral μHbO2 with no effect on gastric μHbO2. Hemorrhage reduced oral and gastric μHbO2 during normothermia (−36 ± 4% and −27 ± 7%); however, this effect was attenuated during additional hypothermia (−15 ± 5% and −11 ± 5%). The improved μHbO2 might be based on an attenuated reduction in μflow during hemorrhage and additional hypothermia (−51 ± 21 aU) compared to hemorrhage and normothermia (−106 ± 19 aU). μDO2 was accordingly attenuated under hypothermia during hemorrhage whereas DO2 did not change. Thus, in this study hypothermia alone improves oral μHbO2 and attenuates the effects of hemorrhage on oral and gastric μHbO2. This effect seems to be mediated by an increased μDO2 on the basis of increased μflow.
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Vollmer C, Schwartges I, Behmke R, Bauer I, Picker O. Hypercapnia counteracts captopril-induced depression of gastric mucosal oxygenation. J Endocrinol 2013; 218:245-53. [PMID: 23757508 DOI: 10.1530/joe-13-0132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hypercapnia (HC) increases systemic oxygen delivery (DO2) and gastric mucosal oxygenation. However, it activates the renin-angiotensin-aldosterone system (RAAS), which conversely reduces mesenteric perfusion. The aims of this study were to evaluate the effect of RAAS inhibition during normocapnia and HC on oral and gastric mucosal oxygenation (μHbO2) and to assess the effect of blood pressure under these circumstances. Five dogs were repeatedly anesthetized to study the effects of ACE inhibition (ACE-I; 5 mg/kg captopril, followed by 0.25 mg/kg per h) on μHbO2 (reflectance spectrophotometry) and hemodynamic variables during normocapnia (end-tidal CO2=35 mmHg) and HC (end-expiratory carbon dioxide (etCO2)=70 mmHg). In the control group, the dogs were subjected to HC alone. To exclude the effects of reduced blood pressure, in one group, blood pressure was maintained at baseline values via titrated phenylephrine (PHE) infusion during HC and additional captopril infusion. ACE-I strongly reduced gastric μHbO2 from 72±2 to 65±2% and mean arterial pressure (MAP) from 64±2 to 48±4 mmHg, while DO2 remained unchanged. This effect was counteracted in the presence of HC, which increased gastric μHbO2 from 73±3 to 79±6% and DO2 from 15±2 to 22±4 ml/kg per min during ACE-I without differences during HC alone. However, MAP decreased similar to that observed during ACE-I alone from 66±3 to 47±5 mmHg, while left ventricular contractility (dPmax) increased from 492±63 to 758±119 mmHg/s. Titrated infusion of PHE had no additional effects on μHbO2. In summary, our data suggest that RAAS inhibition reduces gastric mucosal oxygenation in healthy dogs. HC not only abolishes this effect, but also increases μHbO2, DO2, and dPmax. The increase in μHbO2 during ACE-I under HC is in accordance with our results independent of blood pressure.
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Affiliation(s)
- Christian Vollmer
- Department of Anesthesiology, University Hospital Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany.
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Maciel AT. Breaking old and new paradigms regarding urinary sodium in acute kidney injury diagnosis and management. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:115. [PMID: 23384365 PMCID: PMC4056518 DOI: 10.1186/cc11926] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Urinary sodium (NaU) is one of the oldest parameters used in the evaluation of azotemia and oliguria. Over the past years, however, it has progressively been considered as obsolete and useless, especially in sepsis. It is common sense that NaU frequently does not correlate well with global renal blood flow. If intrarenal microcirculatory changes are more important in acute kidney injury (AKI) than changes in global renal blood flow, we speculate that decreases in NaU may be viewed as a possible marker of microcirculatory impairment in the kidneys. Recent findings by our group (some not yet published) in which sodium retentive capacity is preserved until advanced stages of AKI and the observation of decreases in NaU preceding increases in creatinine bring us to conclude that the new paradigm of abolishing NaU consideration from daily approaches to managing patients at risk for AKI must be reevaluated.
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Holley A, Lukin W, Paratz J, Hawkins T, Boots R, Lipman J. Review article: Part two: Goal-directed resuscitation--which goals? Perfusion targets. Emerg Med Australas 2012; 24:127-35. [PMID: 22487661 DOI: 10.1111/j.1742-6723.2011.01515.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Haemodynamic targets, such as cardiac output, mean arterial blood pressure and central venous oxygen saturations, remain crude predictors of tissue perfusion and oxygen supply at a cellular level. Shocked patients may appear adequately resuscitated based on normalization of global vital signs, yet they are still experiencing occult hypoperfusion. If targeted resuscitation is employed, appropriate use of end-points is critical. In this review, we consider the value of directing resuscitation at the microcirculation or cellular level. Current technologies available include sublingual capnometry, video microscopy of the microcirculation and near-infrared spectroscopy providing a measure of tissue oxygenation, whereas base deficit and lactate potentially provide a surrogate measure of the adequacy of global perfusion. The methodology and evidence for these technologies guiding resuscitation are considered in this narrative review.
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Affiliation(s)
- Anthony Holley
- Departments of Intensive Care Medicine Emergency Medicine, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD 4029, Australia.
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Mayevsky A, Walden R, Pewzner E, Deutsch A, Heldenberg E, Lavee J, Tager S, Kachel E, Raanani E, Preisman S, Glauber V, Segal E. Mitochondrial function and tissue vitality: bench-to-bedside real-time optical monitoring system. JOURNAL OF BIOMEDICAL OPTICS 2011; 16:067004. [PMID: 21721825 DOI: 10.1117/1.3585674] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND The involvement of mitochondria in pathological states, such as neurodegenerative diseases, sepsis, stroke, and cancer, are well documented. Monitoring of nicotinamide adenine dinucleotide (NADH) fluorescence in vivo as an intracellular oxygen indicator was established in 1950 to 1970 by Britton Chance and collaborators. We use a multiparametric monitoring system enabling assessment of tissue vitality. In order to use this technology in clinical practice, the commercial developed device, the CritiView (CRV), is tested in animal models as well as in patients. METHODS AND RESULTS The new CRV enables the optical monitoring of four different parameters, representing the energy balance of various tissues in vivo. Mitochondrial NADH is measured by surface fluorometry/reflectometry. In addition, tissue microcirculatory blood flow, tissue reflectance and oxygenation are measured as well. The device is tested both in vitro and in vivo in a small animal model and in preliminary clinical trials in patients undergoing vascular or open heart surgery. In patients, the monitoring is started immediately after the insertion of a three-way Foley catheter (urine collection) to the patient and is stopped when the patient is discharged from the operating room. The results show that monitoring the urethral wall vitality provides information in correlation to the surgical procedure performed.
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Affiliation(s)
- Avraham Mayevsky
- Bar-Ilan University, The Mina & Everard Goodman Faculty of Life-Sciences, Ramat-Gan, 52900 Israel.
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Mesquida J, Borrat X, Lorente JA, Masip J, Baigorri F. [Objectives of hemodynamic resuscitation]. Med Intensiva 2011; 35:499-508. [PMID: 21208691 DOI: 10.1016/j.medin.2010.10.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Accepted: 10/18/2010] [Indexed: 01/01/2023]
Abstract
Cardiovascular failure or shock, of any etiology, is characterized by ineffective perfusion of body tissues, inducing derangements in the balance between oxygen delivery and consumption. Impairment in oxygen availability on the cellular level causes a shift to anaerobic metabolism, with an increase in lactate and hydrogen ion production that leads to lactic acidosis. The degree of hyperlactatemia and metabolic acidosis will be directly correlated to the development of organ failure and poor outcome of the individuals. The amount of oxygen available at the tissues will depend fundamentally on an adequate level of perfusion pressure and oxygen delivery. The optimization of these two physiologic parameters can re-establish the balance between oxygen delivery and consumption on the cellular level, thus, restoring the metabolism to its aerobic paths. Monitoring variables such as lactate and oxygen venous saturations (either central or mixed) during the initial resuscitation of shock will be helpful to determine whether tissue hypoxia is still present or not. Recently, some new technologies have been developed in order to evaluate local perfusion and microcirculation, such as gastric tonometry, near-infrared spectroscopy and videomicroscopy. Although monitoring these regional parameters has demonstrated its prognostic value, there is a lack of evidence regarding to its usefulness during the resuscitation process. In conclusion, hemodynamic resuscitation is still based on the rapid achievement of adequate levels of perfusion pressure, and then on the modification of oxygen delivery variables, in order to restore physiologic values of ScvO(2)/SvO(2) and resolve lactic acidosis and/or hyperlactatemia.
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Affiliation(s)
- J Mesquida
- Área de Críticos, Hospital de Sabadell, Institut Universitari Parc Taulí, Sabadell, Barcelona, España.
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1H-NMR-based metabolic signatures of clinical outcomes in trauma patients--beyond lactate and base deficit. ACTA ACUST UNITED AC 2010; 69:31-40. [PMID: 20622576 DOI: 10.1097/ta.0b013e3181e043fe] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The determination of reliable biomarkers capable to predict clinical outcome of a trauma patient remains essential toward better therapeutic management of the patient in the intensive care unit. Assessment of global metabolic profiling using quantitative nuclear magnetic resonance (NMR)-based metabolomics offers an attractive modern methodology for fast and comprehensive determination of multiple circulating metabolites and for establishing metabolic phenotype of survivors versus nonsurvivors. Multivariate data analysis on 43 quantitative metabolic parameters identified three lipid metabolites, triacylglycerol, glycerol heads of phospholipids, and monounsaturated fatty acids, as being the most discriminative markers to separate survivors versus nonsurvivors at the time of admission. Glucose and glutamate were intermediate predictors, followed by lactate and hydroxybutyrate as two low-weight predictors. Ultimately, cellular and subcellular failure in nonsurviving trauma patients results in multiple systemic biochemical effects and in changes in circulating metabolites in the blood that are characteristic for decreased lipid synthesis and urea cycle activity in the liver, and for increased hyperglycemia, lactic, and ketoacidosis.
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Abstract
The microcirculation plays an essential role in health and disease. Microvascular perfusion can be assessed directly using laser Doppler flowmetry and various imaging techniques or indirectly using regional capnometry and measurement of indicators of mismatch between oxygen delivery and oxygen consumption or indices of disturbed cellular oxygen utilization. Assessment of microvascular oxygen availability implies measurement of oxygen pressure or measurement of hemoglobin oxygen saturation. Microvascular function is assessed using other methods, including venous plethysmography. In this paper, I review current knowledge concerning assessment of the microcirculation with special emphasis on methods that could be used at the bedside.
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Affiliation(s)
- Yasser Sakr
- Department of Anesthesiology and Intensive Care, Friedrich Schiller University Hospital, Erlanger Allee 101, Jena 07743, Germany.
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Dubin A, Edul VSK, Ince C. Determinants of Tissue PCO2 in Shock and Sepsis: Relationship to the Microcirculation. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Barie PS, Eachempati SR. Monitoring of Cardiovascular and Respiratory Function. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Fu SL, Bluth MH. Monitoring efficacy of red blood cell transfusion in sepsis by sublingual microvascular perfusion: a tongue speaks without words. Crit Care Med 2007; 35:1773-4. [PMID: 17581359 DOI: 10.1097/01.ccm.0000269396.54140.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
As outlined in Table 1, the nonthermodilution techniques available to measure cardiac output are noninvasive and clinically applicable to a variable degree. The truly noninvasive monitors are bioimpedance and CO2 re-breathing. The latter, however, requires the patient to be intubated, and the former continues to be evaluated with regard to correlation with the thermodilution standard. Esophageal Doppler devices are relatively noninvasive in that they do not require vascular cannulation, but they do require an immobile patient and some user expertise. Pulse contour analysis requires an arterial catheter, and two of the three available monitors require external calibration, while the third has not been validated adequately. The reader can see that all four approaches continue to be refined, with new analysis algorithms and monitors continuing to appear on the market. In the absence of true tissue oxygenation monitors, it seems likely that some or all of these alternatives to thermodilution will play a greater role in the care of patients where measurement of cardiac output is desired.
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Affiliation(s)
- James Ramsay
- Anesthesiology Critical Care Medicine, Emory University School of Medicine, Emory University Hospital, 1364 Clifton Road, Atlanta, GA 30322, USA.
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Abstract
PURPOSE OF REVIEW Tissue hypoperfusion is a common pathophysiologic process leading to multiple organ dysfunction and death. Increases in tissue PCO2 can reflect an abnormal oxygen supply to the cells, so that monitoring tissue PCO2 by the use of gastric or sublingual capnometry may help identify circulatory abnormalities and guide their correction. This review provides an update on these technologies. RECENT FINDINGS Gastric tonometry aims at monitoring PCO2 in the stomach, an organ that becomes ischemic quite early when the circulatory status is jeopardized. Despite substantial initial enthusiasm, this technique has never been widely implemented due to methodological problems. The measurement of sublingual mucosal PCO2 (PslCO2) by sublingual capnometry is technically simple and noninvasive. Experimental studies have suggested that PslCO2 is a reliable marker of tissue perfusion. Clinical studies have demonstrated that high PslCO2 values are associated with impaired microcirculatory blood flow and a worse prognosis in critically ill patients. SUMMARY Gastric tonometry was proposed for regional PCO2 monitoring, but it is prone to a number of technical limitations. Sublingual capnometry could offer a valuable alternative for tissue PCO2 monitoring in clinical practice, representing a simple, noninvasive method to monitor tissue perfusion and titrate therapeutic interventions in critically ill patients.
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Affiliation(s)
- Jacques Creteur
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Belgium.
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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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Abstract
Over the last 100 years, huge advances have been made in the field of sepsis in terms of pathophysiology, epidemiology, diagnosis, monitoring, and therapeutics. Here, we offer our perspective of the key changes and current situation in each of these areas. Despite these changes, mortality rates remain unacceptably high and continued progress, particularly in early diagnosis and therapy, is urgently needed.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Brussels, Belgium 1070.
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Dubin A, Pozo MO, Edul VSK, Murias G, Canales HS, Barán M, Maskin B, Ferrara G, Laporte M, Estenssoro E. Urinary bladder partial carbon dioxide tension during hemorrhagic shock and reperfusion: an observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2005; 9:R556-61. [PMID: 16277718 PMCID: PMC1297623 DOI: 10.1186/cc3797] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2005] [Revised: 07/20/2005] [Accepted: 07/25/2005] [Indexed: 11/24/2022]
Abstract
Introduction Continuous monitoring of bladder partial carbon dioxide tension (PCO2) using fibreoptic sensor technology may represent a useful means by which tissue perfusion may be monitored. In addition, its changes might parallel tonometric gut PCO2. Our hypothesis was that bladder PCO2, measured using saline tonometry, will be similar to ileal PCO2 during ischaemia and reperfusion. Method Six anaesthetized and mechanically ventilated sheep were bled to a mean arterial blood pressure of 40 mmHg for 30 min (ischaemia). Then, blood was reinfused and measurements were repeated at 30 and 60 min (reperfusion). We measured systemic and gut oxygen delivery and consumption, lactate and various PCO2 gradients (urinary bladder–arterial, ileal–arterial, mixed venous–arterial and mesenteric venous–arterial). Both bladder and ileal PCO2 were measured using saline tonometry. Results After bleeding systemic and intestinal oxygen supply dependency and lactic acidosis ensued, along with elevations in PCO2 gradients when compared with baseline values (all values in mmHg; bladder ΔPCO2 3 ± 3 versus 12 ± 5, ileal ΔPCO2 9 ± 5 versus 29 ± 16, mixed venous–arterial PCO2 5 ± 1 versus 13 ± 4, and mesenteric venous–arterial PCO2 4 ± 2 versus 14 ± 4; P < 0.05 versus basal for all). After blood reinfusion, PCO2 gradients returned to basal values except for bladder ΔPCO2, which remained at ischaemic levels (13 ± 7 mmHg). Conclusion Tissue and venous hypercapnia are ubiquitous events during low flow states. Tonometric bladder PCO2 might be a useful indicator of tissue hypoperfusion. In addition, the observed persistence of bladder hypercapnia after blood reinfusion may identify a territory that is more susceptible to reperfusion injury. The greatest increase in PCO2 gradients occurred in gut mucosa. Moreover, the fact that ileal ΔPCO2 was greater than the mesenteric venous–arterial PCO2 suggests that tonometrically measured PCO2 reflects mucosal rather than transmural PCO2. Ileal ΔPCO2 appears to be the more sensitive marker of ischaemia.
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Affiliation(s)
- Arnaldo Dubin
- Medical Director, Intensive Care Unit, Sanatorio Otamendi y Miroli, Buenos Aires, Argentina
| | - Mario O Pozo
- Staff physician, Intensive Care Unit, Clínicas Bazterrica y Santa Isabel, Buenos Aires, Argentina
| | - Vanina S Kanoore Edul
- Research Fellow, Cátedra de Farmacología, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, La Plata, Argentina
| | - Gastón Murias
- Staff physician, Intensive Care Unit, Clínicas Bazterrica y Santa Isabel, Buenos Aires, Argentina
| | - Héctor S Canales
- Staff physician, Intensive Care Unit, Hospital San Martín de La Plata, Argentina
| | - Marcelo Barán
- Medical Director, Renal Transplantation Unit, CRAI Sur, CUCAIBA, Argentina
| | - Bernardo Maskin
- Medical Director, Intensive Care Unit, Hospital Posadas, Buenos Aires, Argentina
| | - Gonzalo Ferrara
- Resident, Intensive Care Unit, Hospital San Martín de La Plata, Argentina
| | - Mercedes Laporte
- Medical Director, Clinical Chemistry Laboratory, Hospital San Martín de La Plata, Argentina
| | - Elisa Estenssoro
- Medical Director, Intensive Care Unit, Hospital San Martín de La Plata, Argentina
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Gutierrez G. Blood flow, not hypoxia, determines intramucosal PCO2. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2005; 9:149-50. [PMID: 15774068 PMCID: PMC1175940 DOI: 10.1186/cc3489] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Monitoring tissue hypoxia in critically ill patients is a challenging task. Tissue PCO2 has long been proposed as a marker of tissue hypoxia, although there is considerable controversy on whether the rise in CO2 with hypoxia is caused by anaerobic metabolism and excess CO2 production or by the accumulation of aerobically produced CO2 in the setting of blood flow stagnation. The prevention of increases in intestinal PCO2 in aggressively resuscitated septic animals supports the notion that tissue CO2 accumulation is a function of decreases in blood flow, not of tissue hypoxia.
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Affiliation(s)
- Guillermo Gutierrez
- Pulmonary and Critical Care Medicine Division, Department of Medicine, The George Washington University Medical Center, Washington, DC, USA.
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