1
|
Nam K, Nam JS, Kim HB, Chung J, Hwang IE, Ju JW, Bae J, Lee S, Cho YJ, Shim JK, Kwak YL, Chin JH, Choi IC, Lee EH, Jeon Y. Effects of intraoperative inspired oxygen fraction (FiO 2 0.3 vs 0.8) on patients undergoing off-pump coronary artery bypass grafting: the CARROT multicenter, cluster-randomized trial. Crit Care 2023; 27:286. [PMID: 37443130 PMCID: PMC10339585 DOI: 10.1186/s13054-023-04558-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND To maintain adequate oxygenation is of utmost importance in intraoperative care. However, clinical evidence supporting specific oxygen levels in distinct surgical settings is lacking. This study aimed to compare the effects of 30% and 80% oxygen in off-pump coronary artery bypass grafting (OPCAB). METHODS This multicenter trial was conducted in three tertiary hospitals from August 2019 to August 2021. Patients undergoing OPCAB were cluster-randomized to receive either 30% or 80% oxygen intraoperatively, based on the month when the surgery was performed. The primary endpoint was the length of hospital stay. Intraoperative hemodynamic data were also compared. RESULTS A total of 414 patients were cluster-randomized. Length of hospital stay was not different in the 30% oxygen group compared to the 80% oxygen group (median, 7.0 days vs 7.0 days; the sub-distribution hazard ratio, 0.98; 95% confidence interval [CI] 0.83-1.16; P = 0.808). The incidence of postoperative acute kidney injury was significantly higher in the 30% oxygen group than in the 80% oxygen group (30.7% vs 19.4%; odds ratio, 1.94; 95% CI 1.18-3.17; P = 0.036). Intraoperative time-weighted average mixed venous oxygen saturation was significantly higher in the 80% oxygen group (74% vs 64%; P < 0.001). The 80% oxygen group also had a significantly greater intraoperative time-weighted average cerebral regional oxygen saturation than the 30% oxygen group (56% vs 52%; P = 0.002). CONCLUSIONS In patients undergoing OPCAB, intraoperative administration of 80% oxygen did not decrease the length of hospital stay, compared to 30% oxygen, but may reduce postoperative acute kidney injury. Moreover, compared to 30% oxygen, intraoperative use of 80% oxygen improved oxygen delivery in patients undergoing OPCAB. Trial registration ClinicalTrials.gov (NCT03945565; April 8, 2019).
Collapse
Affiliation(s)
- Karam Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jae-Sik Nam
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Hye-Bin Kim
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jaeyeon Chung
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Medical Service Corps of the First Logistics Support Command, Wonju, Gangwon State, Republic of Korea
| | - In Eob Hwang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jae-Woo Ju
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jinyoung Bae
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Ajou University Medical Center, Ajou University School of Medicine, Suwon, Gyeonggi Province, Republic of Korea
| | - Seohee Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Youn Joung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young-Lan Kwak
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji-Hyun Chin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - In-Cheol Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Eun-Ho Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
- Hana Anesthesia Clinic, Seoul, Republic of Korea.
| | - Yunseok Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
| |
Collapse
|
2
|
Microvascular reactivity monitored with near-infrared spectroscopy is impaired after induction of anaesthesia in cardiac surgery patients: An observational study. Eur J Anaesthesiol 2018; 34:688-694. [PMID: 28834795 DOI: 10.1097/eja.0000000000000684] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Induction of anaesthesia causes significant macrohaemodynamic changes, but little is known about its effects on the microcirculation. However, alterations in microvascular perfusion are known to be associated with impaired tissue oxygenation and organ dysfunction. Microvascular reactivity can be assessed with vascular occlusion testing, which evaluates the response of tissue oxygen saturation to transient ischaemia and reperfusion. OBJECTIVE The aim of the current study was to evaluate the effects of an opioid-based anaesthesia induction on microvascular reactivity. We hypothesised that despite minimal blood pressure changes, microvascular function would be impaired. DESIGN Prospective, observational study. SETTING Single-centre, tertiary university teaching hospital, Belgium. PATIENTS Thirty-five adult patients scheduled for elective coronary artery bypass grafting surgery. INTERVENTION Microvascular reactivity was assessed before and 30 min after anaesthesia induction by means of vascular occlusion testing and near-infrared spectroscopy. MAIN OUTCOME MEASURES Tissue oxygen saturations, desaturation rate, recovery time (time from release of cuff to the maximum value) and rate of recovery were determined. RESULTS Data are expressed as median (minimum to maximum). Tissue oxygen saturation was higher after induction of anaesthesia [70 (54 to 78) vs. 73 (55 to 94)%, P = 0.015]. Oxygen consumption decreased after induction, appreciable by the higher minimum tissue oxygen saturation [45 (29 to 69) vs. 53 (28 to 81)%, P < 0.001] and the slower desaturation rate [11 (4 to 18) vs. 9 (5 to 16)% min, P < 0.001]. After induction of anaesthesia, recovery times were longer [40 (20 to 120) vs. 48 (24 to 356) s, P = 0.004] and the rate of recovery was lower [114 (12 to 497) vs. 80 (3 to 271)% min, P < 0.001]. CONCLUSION After induction of anaesthesia, oxygen consumption was decreased. The longer recovery times and slower rates of recovery indicate impaired microvascular reactivity after induction of anaesthesia. TRIAL REGISTRATION The research project was registered at ClinicalTrials.gov (NCT02034682).
Collapse
|
3
|
Hasanin A, Mukhtar A, Nassar H. Perfusion indices revisited. J Intensive Care 2017; 5:24. [PMID: 28331621 PMCID: PMC5351209 DOI: 10.1186/s40560-017-0220-5] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 03/07/2017] [Indexed: 12/18/2022] Open
Abstract
Monitoring of tissue perfusion is an essential step in the management of acute circulatory failure. The presence of cellular dysfunction has been a basic component of shock definition even in the absence of hypotension. Monitoring of tissue perfusion includes biomarkers of global tissue perfusion and measures for assessment of perfusion in non-vital organs. The presence of poor tissue perfusion in a shocked patient is usually associated with worse outcome. Persistently impaired perfusion despite adequate resuscitation is also associated with worse outcome. Thus, normalization of some perfusion indices has become one of the resuscitation targets in patients with septic shock. Although the collective evidence shows the clear relation between impaired peripheral perfusion and mortality, the use of different perfusion indices as a resuscitation target needs more research.
Collapse
Affiliation(s)
- Ahmed Hasanin
- Anesthesia and Critical Care Medicine, Cairo University, Giza, Egypt.,Critical Care Department, El-Ameen Hospital, Taif, Kingdom of Saudi Arabia
| | - Ahmed Mukhtar
- Anesthesia and Critical Care Medicine, Cairo University, Giza, Egypt
| | - Heba Nassar
- Anesthesia and Critical Care Medicine, Cairo University, Giza, Egypt
| |
Collapse
|
4
|
Vranken NP, Ganushchak YM, Willigers HM, Maessen JG, Weerwind PW. Vascular Occlusion Test to Dynamically Assess Microcirculation During Normothermic Pulsatile Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2016; 30:979-84. [DOI: 10.1053/j.jvca.2016.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Indexed: 11/11/2022]
|
5
|
Vincent JL, Pelosi P, Pearse R, Payen D, Perel A, Hoeft A, Romagnoli S, Ranieri VM, Ichai C, Forget P, Della Rocca G, Rhodes A. Perioperative cardiovascular monitoring of high-risk patients: a consensus of 12. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:224. [PMID: 25953531 PMCID: PMC4424585 DOI: 10.1186/s13054-015-0932-7] [Citation(s) in RCA: 130] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A significant number of surgical patients are at risk of intra- or post-operative complications or both, which are associated with increased lengths of stay, costs, and mortality. Reducing these risks is important for the individual patient but also for health-care planners and managers. Insufficient tissue perfusion and cellular oxygenation due to hypovolemia, heart dysfunction or both is one of the leading causes of perioperative complications. Adequate perioperative management guided by effective and timely hemodynamic monitoring can help reduce the risk of complications and thus potentially improve outcomes. In this review, we describe the various available hemodynamic monitoring systems and how they can best be used to guide cardiovascular and fluid management in the perioperative period in high-risk surgical patients.
Collapse
Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 808 route de Lennik, 1070, Brussels, Belgium.
| | - Paolo Pelosi
- AOU IRCCS San Martino-IST, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Largo Rosanna Benzi 8, 16132, Genoa, Italy.
| | - Rupert Pearse
- Adult Critical Care Unit, Royal London Hospital, Whitechapel Road, London, E1 1BB, UK.
| | - Didier Payen
- Department of Anesthesiology and Critical Care, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris 7 Denis Diderot, 75475, Paris, Cedex 10, France.
| | - Azriel Perel
- Department of Anesthesiology and Intensive Care, Sheba Medical Center, Tel Aviv University, Tel Aviv, 52621, Israel.
| | - Andreas Hoeft
- Department of Anesthesiology and Intensive Care Medicine, University of Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany.
| | - Stefano Romagnoli
- Department of Human Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Largo Giovanni Alessandro Brambilla 3, 50139, Florence, Italy.
| | - V Marco Ranieri
- Department of Anesthesia and Intensive Care Medicine, University of Turin, S.Giovanni Battista Molinette Hospital, 10126, Turin, Italy.
| | - Carole Ichai
- Medico-Surgical Intensive Care Unit, Saint-Roch University Hospital, University of Nice, 5 Rue Pierre Dévoluy, 06006, Nice, France.
| | - Patrice Forget
- Service d'Anesthésiologie, Cliniques Universitaires Saint-Luc, Institute of Neuroscience (IoNS), Université catholique de Louvain, Avenue Hippocrate 10, 1200, Brussels, Belgium.
| | - Giorgio Della Rocca
- Department of Anesthesia and Intensive Care Medicine, University Hospital, Medical School, University of Udine, P. le S. Maria della Misericordia 15, 33100, Udine, Italy.
| | - Andrew Rhodes
- Department of Intensive Care Medicine, St George's Healthcare NHS Trust, Blackshaw Road, London, SW17 0QT, UK.
| |
Collapse
|
6
|
Khanna AK, Laudanski K. Septic shock and anesthesia: Much ado about nothing? J Anaesthesiol Clin Pharmacol 2014; 30:481-3. [PMID: 25425770 PMCID: PMC4234781 DOI: 10.4103/0970-9185.142804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Ashish K Khanna
- Anesthesiology Institute & Outcomes Research, Cleveland Clinic Foundation, Surgical ICU, Cleveland, OH 44195, USA
| | - Krzysztof Laudanski
- Department of Anesthesiology and Critical Care, University of Pennsylvania, PA 19104, USA
| |
Collapse
|
7
|
Silverstein DC, Cozzi EM, Hopkins AS, Keefe TJ. Microcirculatory effects of intravenous fluid administration in anesthetized dogs undergoing elective ovariohysterectomy. Am J Vet Res 2014; 75:809-17. [PMID: 25157884 DOI: 10.2460/ajvr.75.9.809] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess the microcirculatory effects of IV fluid administration in healthy anesthetized dogs undergoing elective ovariohysterectomy. ANIMALS 49 client-owned dogs. PROCEDURES Dogs were sedated, and anesthesia was induced with propofol and diazepam and maintained with isoflurane in oxygen. Dogs received lactated Ringer's solution (LRS) IV at rates of 0, 10, or 20 mL/kg/h. Videomicroscopy was used to assess and record effects of LRS administration on microcirculation in the buccal mucosa. Measurements of microcirculatory (total vessel density, proportion of perfused vessels, microcirculatory flow index, and perfused vessel density by vessel size [< 20 μm, ≥ 20 μm, and all diameters]) and other physiologic variables (heart rate, Doppler-measured blood pressure, oxygen saturation as measured by pulse oximetry, capillary refill time, and body temperature) were compared among groups at baseline (immediately after anesthetic induction), 30 and 60 minutes afterward, and overall. RESULTS Neither the proportion of perfused vessels nor microcirculatory flow index varied among treatment groups at any time point, regardless of vessel size. For vessels < 20 μm in diameter and for all vessels combined, total and perfused vessel density were similar among groups. For vessels ≥ 20 μm in diameter, total vessel density was significantly greater in the 20 mL/kg/h group than in other groups, and perfused vessel density was significantly greater in the 20 mL/kg/h group than in the 0 mL/kg/h group, when all time points were considered. Other physiologic variables were similar among groups. CONCLUSIONS AND CLINICAL RELEVANCE Total and perfused vessel density of vessels ≥ 20 μm in diameter (mostly venules) were greatest in dogs that received 20 mL of LRS/kg/h. Further research is required to evaluate clinical importance of these findings.
Collapse
Affiliation(s)
- Deborah C Silverstein
- Department of Clinical Studies, Matthew J. Ryan Veterinary Hospital, University of Pennsylvania, Philadelphia, PA 19104
| | | | | | | |
Collapse
|
8
|
Habler O, Voss B. [Perioperative management of Jehovah's Witness patients. Special consideration of religiously motivated refusal of allogeneic blood transfusion]. Anaesthesist 2010; 59:297-311. [PMID: 20379694 DOI: 10.1007/s00101-010-1701-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The religious organization of Jehovah's Witnesses numbers more than 7 million members worldwide, including 165,000 members in Germany. Although Jehovah's Witnesses strictly refuse the transfusion of allogeneic red blood cells, platelets and plasma, Jehovah's Witness patients may nevertheless benefit from modern therapeutic concepts including major surgical procedures without facing an excessive risk of death. The present review describes the perioperative management of surgical Jehovah's Witness patients aiming to prevent fatal anemia and coagulopathy. The cornerstones of this concept are 1) education of the patient about blood conservation techniques generally accepted by Jehovah's Witnesses, 2) preoperative optimization of the cardiopulmonary status and correction of preoperative anemia and coagulopathy, 3) perioperative collection of autologous blood, 4) minimization of perioperative blood loss and 5) utilization of the organism's natural anemia tolerance and its acute accentuation in the case of life-threatening anemia.
Collapse
Affiliation(s)
- O Habler
- Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerztherapie, Krankenhaus Nordwest GmbH, Steinbacher Hohl 2-26, 60488 Frankfurt am Main.
| | | |
Collapse
|
9
|
Koch M, De Backer D, Vincent J, Barvais L, Hennart D, Schmartz D. Effects of propofol on human microcirculation. Br J Anaesth 2008; 101:473-8. [DOI: 10.1093/bja/aen210] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
10
|
Sams L, Braun C, Allman D, Hofmeister E. A comparison of the effects of propofol and etomidate on the induction of anesthesia and on cardiopulmonary parameters in dogs. Vet Anaesth Analg 2008; 35:488-94. [PMID: 18713224 DOI: 10.1111/j.1467-2995.2008.00417.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the effects of propofol or etomidate on induction quality, arterial blood pressure, blood gases, and recovery quality in normal dogs. STUDY DESIGN Randomized, blinded trial. ANIMALS Eighteen purpose-bred adult Beagles. METHODS Dogs were randomly assigned to receive propofol at 8 mg kg(-1) or etomidate at 4 mg kg(-1) intravenously (IV) administered to effect. Midazolam was administered at 0.3 mg kg(-1) IV as pre-medication at least 1 minute prior to induction. Direct arterial blood pressure, arterial blood gases, and heart rate were obtained at baseline, before induction, after induction, and for every 5 minutes afterwards until the dog began to swallow and the trachea was extubated. The dogs were allowed to breathe room air with the endotracheal tube in place. RESULTS The systolic arterial pressure (SAP) was higher in the etomidate group compared with the propofol group after induction. The SAP and mean arterial pressure (MAP) were higher in the etomidate group compared with the propofol group at 5 minutes. The recovery quality and ataxia score were worse in the etomidate group compared with the propofol group. Time from extubation to sternal recumbency and sternal recumbency to standing was longer in the etomidate group compared with the propofol group. The heart rate, PaCO(2), and HCO(3) were higher in the propofol group compared with the etomidate group after induction. The PaO(2) and SaO(2) were lower in the propofol group compared with the etomidate group after induction. The SAP and MAP were lower in the propofol group at 5 minutes compared with baseline. CONCLUSION AND CLINICAL RELEVANCE Propofol caused a decrease in SAP and MAP which was not observed with etomidate. Etomidate caused longer and poorer recoveries than propofol.
Collapse
Affiliation(s)
- Lisa Sams
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA, USA.
| | | | | | | |
Collapse
|
11
|
Abstract
Literature about the effects of sedative drugs on the metabolic demand of critically ill patients is relatively old and of relatively poor quality. Most are experimental or observational studies. Level of evidence is therefore relatively low corresponding to "expert opinion". The effects of analgesics and hypnotics on tissue metabolic demand associated remain difficult to be adequately quantified. They are essentially related to a decreased neuro-humoral response to stress. This response involves principally the sympathetic system, which could be effectively blocked by most of the anesthetic agents. Other factors could participate to the observed reduction in tissue metabolic demand, as a decrease in spontaneous muscular activity, a reduction in work of breathing and/or a decrease in body temperature. The relative contribution of these different factors will depend on the clinical situation of the patient. Proper effects of anesthetic agents on cellular metabolism are limited as they can only decrease the functional component of this metabolism especially at the level of the heart and to some extent, at the level of the brain. Although the control of the sympathetic activity may be beneficial in critically ill patient, complete sympathetic blockade could be detrimental. Indeed, when oxygen transport to the tissues is acutely reduced, the sympathetic system plays an important role in the redistribution of blood flow according of local metabolic demand. The complete blunting of the neuro-humoral response to stress and therefore of the sympathetic system alters this physiological mechanism and results in a decrease in tissue oxygen extraction capabilities. An imbalance between tissue oxygen demand and delivery could appear with the development of cellular hypoxia. The institution of sedation in a critically ill patient requires careful evaluation of the sedation level using an appropriate scale. In patients in whom a reduction in metabolic demand is specifically requested, but also in patients with limited oxygen transport, the effects of sedative agents on the oxygen consumption-oxygen delivery relationship must also be monitored. The choice of the different agents to be administered will depend on the predefined objectives. As far as intravenous agents are concerned, there is no evidence than one association is more efficient in reducing patient's metabolic demand.
Collapse
|
12
|
Lin GY, Robben JH, Murrell JC, Aspegrén J, McKusick BC, Hellebrekers LJ. Dexmedetomidine constant rate infusion for 24 hours during and after propofol or isoflurane anaesthesia in dogs. Vet Anaesth Analg 2008; 35:141-53. [DOI: 10.1111/j.1467-2995.2007.00365.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
13
|
Habler O, Meier J, Pape A, Kertscho H, Zwissler B. [Tolerance to perioperative anemia. Mechanisms, influencing factors and limits]. Anaesthesist 2007; 55:1142-56. [PMID: 16826416 PMCID: PMC7095856 DOI: 10.1007/s00101-006-1055-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Die zu erwartende Kostensteigerung im Transfusionswesen (steigender Fremdblutbedarf bei gleichzeitig rückläufiger Spendebereitschaft, Behandlungspflicht transfusionsassoziierter Folgeerkrankungen) erhöht den sozioökonomischen Stellenwert der Entwicklung institutionsspezifischer Transfusionsprogramme. Ein wesentlicher Bestandteil hierbei ist – neben einer schonenden Operationstechnik und der konsequenten perioperativen Anwendung fremdblutsparender Maßnahmen – die Ausschöpfung der natürlicherweise vorhandenen „Anämietoleranz“ des menschlichen Organismus (Toleranz größerer Blutverluste durch Verlust von „verdünntem“ Blut, Hinauszögern des Transfusionsbeginns bis nach chirurgischer Blutstillung, Gewinnung von autologem Blut). In der vorliegenden Übersicht werden die Mechanismen, Einflussgrößen und Grenzen dieser natürlichen Anämietoleranz für den Gesamtorganismus und für einzelne Organsysteme zusammengefasst und die sich daraus ergebende Indikation zur Erythrozytentransfusion abgeleitet. Unter kontrollierten Bedingungen (Narkose, strikte Aufrechterhaltung von Normovolämie, komplette Muskelrelaxierung, Hyperoxämie, Hypothermie) werden von kardiopulmonal gesunden Individuen kurzzeitig auch extreme Grade der Verdünnungsanämie [Hämoglobin- (Hb-)Wert <3 g/dl (<1,86 mmol/l)] ohne Transfusion toleriert. In der klinischen Routine bleibt diese Situation – nicht zuletzt in Ermangelung eines adäquaten Monitorings – jedoch auf spezielle Sonderfälle beschränkt (z. B. unerwartete große Blutverluste bei Zeugen Jehovahs, unerwarteter Engpass bei der Bereitstellung von Fremdblut). Die derzeit geltenden Empfehlungen verschiedener Expertenkommissionen decken sich dahingehend, dass perioperativ (1) bis zu einer Hb-Konzentration von 10 g/dl (6,21 mmol/l) auch bei alten Patienten und Patienten mit kardiopulmonalen Begleiterkrankungen eine Transfusion von Erythrozyten in der Regel nicht notwendig ist und (2) eine Transfusion bei jungen, gesunden Patienten ohne kardiopulmonale Vorerkrankungen (einschließlich Schwangeren und Kindern) erst ab einer Hb-Konzentration von <6 g/dl (<3,72 mmol/l) notwendig wird. Auch beatmete Intensivpatienten mit Polytrauma und Sepsis scheinen nicht von einer Transfusion auf Hb-Konzentration >9 g/dl (>5,59 mmol/l) zu profitieren. Bei massiven Blutverlusten und diffuser Blutungsneigung scheint ein Hb von 10 g/dl (6,21 mmol/l) zur Stabilisierung der Blutgerinnung beizutragen.
Collapse
Affiliation(s)
- O Habler
- Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerztherapie, Krankenhaus Nordwest GmbH, Steinbacher Hohl 2-26, 60488 Frankfurt am Main.
| | | | | | | | | |
Collapse
|
14
|
Habler O, Meier J, Pape A, Kertscho H, Zwissler B. [Tolerance to perioperative anemia. Mechanisms, influencing factors and limits]. Urologe A 2007; 46:W543-56; quiz W557-8. [PMID: 17429601 PMCID: PMC7095997 DOI: 10.1007/s00120-007-1344-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Die zu erwartende Kostensteigerung im Transfusionswesen erhöht den sozioökonomischen Stellenwert der Entwicklung institutionsspezifischer Transfusionsprogramme. Ein wesentlicher Bestandteil hierbei ist – neben einer schonenden Operationstechnik und der konsequenten perioperativen Anwendung fremdblutsparender Maßnahmen – die Ausschöpfung der natürlichen „Anämietoleranz“ des menschlichen Organismus. Im vorliegenden Beitrag werden die Mechanismen, Einflussgrößen und Grenzen dieser Anämietoleranz für den Gesamtorganismus und für einzelne Organsysteme zusammengefasst und die sich daraus ergebende Indikation zur Erythrozytentransfusion abgeleitet. Die derzeit geltenden Empfehlungen decken sich dahingehend, dass bis zu einer Hämoglobinkonzentration von 10 g/dl (6,21 mmol/l) auch bei alten Patienten oder kardiopulmonalen Begleiterkrankungen eine perioperative Transfusion in der Regel nicht notwendig ist und bei jungen, gesunden Patienten ohne kardiopulmonale Vorerkrankungen (einschließlich Schwangeren und Kindern) erst ab <6 g/dl (<3,72 mmol/l) notwendig wird. Auch beatmete Intensivpatienten mit Polytrauma und Sepsis scheinen nicht von einer Transfusion auf eine Hämoglobinkonzentration >9 g/dl (>5,59 mmol/l) zu profitieren. Bei massiven Blutverlusten und diffuser Blutungsneigung scheint ein Wert von 10 g/dl (6,21 mmol/l) zur Stabilisierung der Blutgerinnung beizutragen.
Collapse
Affiliation(s)
- O Habler
- Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerztherapie, Krankenhaus Nordwest GmbH, Steinbacher Hohl 2-26, 60488 Frankfurt a.M.
| | | | | | | | | |
Collapse
|
15
|
Annecke T, Kubitz JC, Kahr S, Hilberath JM, Langer K, Kemming GI, Rehm M, Bittmann I, Conzen PF. Effects of sevoflurane and propofol on ischaemia–reperfusion injury after thoracic-aortic occlusion in pigs. Br J Anaesth 2007; 98:581-90. [PMID: 17371775 DOI: 10.1093/bja/aem049] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Thoraco-abdominal-aneurysm surgery predicts high mortality. Propofol and sevoflurane are commonly used anaesthetics for this procedure. Halogenated anaesthetics induce organ protection similar to ischaemic preconditioning. We investigated which anaesthetic regimen would lead to a better protection against ischaemia-reperfusion injury induced by temporary thoracic-aortic occlusion. METHODS Following initial fentanyl-midazolam anaesthesia for surgical preparation, 18 pigs were randomly assigned to two groups: group one received propofol (n=9) and group two sevoflurane (n=9) before, during, and after lower body ischaemia in an investigator blinded fashion. Ten animals without aortic occlusion served as time controls (propofol, n=5; sevoflurane, n=5). For induction of ischaemia, the thoracic aorta was occluded by a balloon-catheter for 90 min. After 120 min of reperfusion, the study anaesthetics were discontinued and fentanyl-midazolam re-established for an additional 180 min. Goal-directed therapy was performed during reperfusion. Fluid and catecholamine requirements were assessed. Serum samples and intestinal tissue specimens were obtained. RESULTS Severe declamping shock occurred in both study groups. While norepinephrine requirements in the sevoflurane group were significantly reduced during reperfusion (P<0.05), allowing cessation of catecholamine support in 4/9 animals, all 9/9 animals were still catecholamine dependent at the end of the experiment in the propofol group. Serum activities of lactate dehydrogenase, aspartate transaminase, and alanine aminotransferase were lower with sevoflurane (P<0.05). Small intestine tissue specimens did not differ histologically. CONCLUSIONS Use of sevoflurane compared with propofol attenuated the haemodynamic sequelae of reperfusion injury in our model. Release of serum markers of cellular injury was also attenuated.
Collapse
Affiliation(s)
- T Annecke
- Clinic of Anaesthesiology, Institute for Surgical Research, Ludwig-Maximilians-University, University Hospital, Munich, Germany
| | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Haskins SC. Comparative cardiovascular and pulmonary effects of sedatives and anesthetic agents and anesthetic drug selection for the trauma patient. J Vet Emerg Crit Care (San Antonio) 2006. [DOI: 10.1111/j.1476-4431.2006.00188.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
17
|
García-Martínez D, Portilla-de Buen E, Leal C, Santillán P, Muñiz J. THE IMMEDIATE RESPONSE TO SEVERE SHOCK IN A CANINE MODEL WITH A COMBINATION OF HYPERTONIC-HYPERONCOTIC SOLUTION WITH NALOXONE. Shock 2006; 26:379-85. [PMID: 16980885 DOI: 10.1097/01.shk.0000226339.48033.8b] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To evaluate the acute hemodynamic and acid-base balance effects of hypertonic-hyperoncotic solution (HHS) combined with naloxone in the treatment of hemorrhagic shock in 45 male splenectomized adult mongrel dogs, a severe controlled hemorrhagic shock (20 mmHg mean arterial pressure during 30 min) was established in the groups (n=6) no treatment, shed blood reinfusion, hypertonic-hyperoncotic (saline-dextran) solution alone, naloxone alone (NX), or combination. Interventions included propiopromazine-pentobarbital anesthesia and installation of Swan-Ganz, femoral arterial, and urethral catheters, and exsanguination at 20 mmHg mean arterial pressure during 30 min followed by treatment and observation for 160 min. Fifteen (33%) dogs died before completing the 30-min shock period. Another 33% from the no-treatment group died during the following 90 min. Shed blood improved the cardiac index, arterial pressure, and acid-base balance. NX restored the cardiac index to less than 60% of baseline and reduced vascular resistance. Additionally, NX produced no improvement in acidosis, with 1 dog dead at 95 min posttreatment. HHS restored the cardiac index for 45 min and increased vascular resistance and arterial pressure. Acidosis was not improved. Single-dose HHS combined with naloxone resulted in a high cardiac index, oxygen consumption, and urine output with low peripheral vascular resistance (and no acute mortality) compared with untreated or single-dose groups.
Collapse
Affiliation(s)
- David García-Martínez
- Surgical Research Division, Centro de Investigación Biomédica de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México
| | | | | | | | | |
Collapse
|
18
|
De Blasi RA, Palmisani S, Alampi D, Mercieri M, Romano R, Collini S, Pinto G. Microvascular dysfunction and skeletal muscle oxygenation assessed by phase-modulation near-infrared spectroscopy in patients with septic shock. Intensive Care Med 2005; 31:1661-8. [PMID: 16205889 DOI: 10.1007/s00134-005-2822-y] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2004] [Accepted: 09/08/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Sepsis is now considered a disease of the microcirculation. Little is known about the various sepsis-induced changes responsible for microvascular dysfunction. We investigated human microvascular function, regulation, oxygenation, and cellular metabolism during subacute septic shock. DESIGN AND SETTING Prospective case-control study in a nine-bed polyvalent surgical ICU of a university hospital. PATIENTS AND PARTICIPANTS A prospectively enrolled group of 26 patients (13 with septic shock, 13 nonseptic postsurgical patients) and 15 healthy volunteer controls. MEASUREMENTS AND RESULTS The absolute tissue hemoglobin concentrations (oxygenated hemoglobin and deoxyhemoglobin) were measured noninvasively in arterioles, capillaries, and venules by phase-modulation near-infrared spectroscopy in the human brachioradial muscle during a series of venous occlusions and an arterial occlusion (ischemia) induced by applying a pneumatic cuff. These measurements were used to calculate tissue blood volume, postischemic hemoglobin resaturation time, microvascular compliance, and O2 consumption. Patients with sepsis had significantly higher tissue blood volume values and lower compliance than healthy controls. They also had longer postischemic hemoglobin resaturation times than the other two groups and blunted resaturation curves. O2 consumption was lower in patients with sepsis than in healthy controls. In patients with septic shock cuff-induced ischemia left O2 consumption unchanged, whereas in healthy volunteers it reduced O2 consumption to values almost matching those of patients with septic shock. CONCLUSIONS These findings show that septic shock alters microvascular muscle function and regulation. Diminished local VO2 presumably reflects maldistribution and faulty autoregulation of local blood flow.
Collapse
Affiliation(s)
- Roberto Alberto De Blasi
- Department of Anaesthesiology and Intensive Care II, Faculty of Medicine, University of Rome La Sapienza, S. Andrea Hospital, Via di Grottarossa 1035, 00189, Rome, Italy.
| | | | | | | | | | | | | |
Collapse
|
19
|
Guzman JA, Rosado AE, Kruse JA. Dopamine-1 receptor stimulation impairs intestinal oxygen utilization during critical hypoperfusion. Am J Physiol Heart Circ Physiol 2003; 284:H668-75. [PMID: 12399258 DOI: 10.1152/ajpheart.00636.2002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Effects of a dopamine-1 (DA-1) receptor agonist on systemic and intestinal oxygen delivery (Do(2))-uptake relationships were studied in anesthetized dogs during sequential hemorrhage. Control (group 1) and experimental animals (group 2) were treated similarly except for the addition of fenoldopam (1.0 microg x kg(-1) x min(-1)) in group 2. Both groups had comparable systemic critical Do(2) (Do(2crit)), but animals in group 2 had a higher gut Do(2crit) (1.12 +/- 1.13 vs. 0.80 +/- 0.09 ml. kg(-1) x min(-1), P < 0.05). At the mucosal level, a clear biphasic delivery-uptake relationship was not observed in group 1; thus oxygen consumption by the mucosa may be supply dependent under physiological conditions. Group 2 demonstrated higher peak mucosal blood flow and lack of supply dependency at higher mucosal Do(2) levels. Fenoldopam resulted in a more conspicuous biphasic relationship at the mucosa and a rightward shift of overall splanchnic Do(2crit) despite increased splanchnic blood flow. These findings suggest that DA-1 receptor stimulation results in increased gut perfusion heterogeneity and maldistribution of perfusion, resulting in increased susceptibility to ischemia.
Collapse
Affiliation(s)
- Jorge A Guzman
- Division of Pulmonary, Critical Care, and Sleep Medicine, Wayne State University School of Medicine, Detroit, Michigan 48201, USA
| | | | | |
Collapse
|
20
|
Smithline HA, Ward KR, Chiulli DA, Blake HC, Rivers EP. Whole body oxygen consumption and critical oxygen delivery in response to prolonged and severe carbon monoxide poisoning. Resuscitation 2003; 56:97-104. [PMID: 12505745 DOI: 10.1016/s0300-9572(02)00272-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Carbon monoxide (CO) poisoning remains the leading cause of death by poisoning in the world. One of the major proposed mechanisms for CO toxicity is the binding of CO to cytochrome oxidase and interference with cellular oxygen utilization but evidence for this is inconclusive. AIM OF STUDY This study examined the effects of prolonged CO exposure on the dynamics of whole body oxygen consumption (VO(2)) and oxygen delivery (DO(2)) in an attempt to observe if CO exposure results in a defect of oxygen utilization defect as determined by a reduction in VO(2) during the course of poisoning prior to reaching the point where VO(2) is directly dependent on DO(2). This critical level of DO(2) (DO(2)crit) produced by CO poisoning was compared to historical values produced by other insults, which decrease global body DO(2). METHODS Five small dogs were ventilated for 2 h with 0.25% CO and room air followed by 0.5% CO until death. Cardiac index (Q), DO(2), VO(2), oxygen extraction ratio (OER), and systemic lactate were measured every 15 min until death. RESULTS Carboxyhemoglobin (COHb) levels increased linearly over 2.5 h to values above 80% until death. VO(2) remained constant and not significantly different from baseline below a COHb of 80%. At COHb levels above 80%, VO(2) precipitously dropped. Similarly lactate levels were not significantly elevated from baseline until VO(2) dropped. DO(2) decreased by 78% (from 23+/-6 ml/kg/min to 5+/-4 ml/kg/min) over time despite an increase in Q by 58% until levels of COHb were above 80%. OER increased from 19+/-5% to 50+/-11% until death. The calculated DO(2)crit was 10.7+/-4 ml/min/kg, which is not significantly different from values ranging from 7 to 13 ml/min/kg reported in the literature due to other insults, which reduce DO(2). CONCLUSION In this canine model of prolonged CO exposure, no gradual reduction in VO(2) or increase in systemic lactate prior to reaching DO(2)crit was noted. In addition, CO exposure does not appear to change the DO(2)crit. The combination of these findings does not support the theory that CO produces a whole body intracellular defect in oxygen utilization.
Collapse
Affiliation(s)
- Howard A Smithline
- Baystate Medical Center, Department of Emergency Medicine, Baystate, MA, USA
| | | | | | | | | |
Collapse
|