Refining Resuscitation Strategies Using Tissue Oxygen and Perfusion Monitoring in Critical Organ Beds

A faster PISTOL for 1 H MR-based quantitative tissue oximetry

Quantitative mapping of oxygen tension (pO₂ ), noninvasively, could potentially be beneficial in cancer and stroke therapy for monitoring therapy and predicting response to certain therapies. Intracellular pO₂ measurements may also prove useful in tracking the health of labeled cells and understanding the dynamics of cell therapy in vivo. Proton Imaging of Siloxanes to map Tissue Oxygenation Levels (PISTOL) is a relatively new oximetry technique that measures the T₁ of administered siloxanes such as hexamethyldisiloxane (HMDSO), to map the tissue pO₂ at various locations with a temporal resolution of 3.5 minutes. We have now developed a siloxane-selective Look-Locker imaging sequence equipped with an echo planar imaging (EPI) readout to accelerate PISTOL acquisitions. The new tissue oximetry sequence, referred to as PISTOL-LL, enables the mapping of HMDSO T₁ , and hence tissue pO₂ in under one minute. PISTOL-LL was tested and compared with PISTOL in vitro and in vivo. Both sequences were used to record dynamic changes in pO₂ of the rat thigh muscle (healthy Fischer rats, n = 6), and showed similar results (P > 0.05) as the other, with each sequence reporting a significant increase in pO₂ (P < 0.05) under hyperoxia compared with steady state normoxia. This study demonstrates the ability of the new sequence in rapidly and accurately mapping the pO₂ changes and accelerating quantitative ¹ H MR tissue oximetry by approximately 4-fold. The faster PISTOL-LL technique could enable dynamic ¹ H oximetry with higher temporal resolution for assesing tissue oxygentation and tracking the health of transplanted cells labeled with siloxane-based probes. With minor modifications, this sequence can be useful for ¹⁹ F applications as well.

Effects of terlipressin as early treatment for protection of brain in a model of haemorrhagic shock

Introduction

We investigated whether treatment with terlipressin during recovery from hypotension due to haemorrhagic shock (HS) is effective in restoring cerebral perfusion pressure (CPP) and brain tissue markers of water balance, oxidative stress and apoptosis.

Methods

In this randomised controlled study, animals undergoing HS (target mean arterial pressure (MAP) 40 mmHg for 30 minutes) were randomised to receive lactated Ringer’s solution (LR group; n =14; volume equal to three times the volume bled), terlipressin (TERLI group; n =14; 2-mg bolus), no treatment (HAEMO group; n =12) or sham (n =6). CPP, systemic haemodynamics (thermodilution technique) and blood gas analyses were registered at baseline, shock and 5, 30, 60 (T60), 90 and 120 minutes after treatment (T120). After the animals were killed, brain tissue samples were obtained to measure markers of water balance (aquaporin-4 (AQP4)), Na⁺-K⁺-2Cl⁻ co-transporter (NKCC1)), oxidative stress (thiobarbituric acid reactive substances (TBARS) and manganese superoxide dismutase (MnSOD)) and apoptotic damage (Bcl-x and Bax).

Results

Despite the HS-induced decrease in cardiac output (CO) and hyperlactataemia, resuscitation with terlipressin recovered MAP and resulted in restoration of CPP and in cerebral protection expressed by normalisation of AQP4, NKCC1, TBARS and MnSOD expression and Bcl-x/Bax ratio at T60 and T120 compared with sham animals. In the LR group, CO and blood lactate levels were recovered, but the CPP and MAP were significantly decreased and TBARS levels and AQP4, NKCC1 and MnSOD expression and Bcl-x/Bax ratio were significantly increased at T60 and T120 compared with the sham group.

Conclusions

During recovery from HS-induced hypotension, terlipressin was effective in normalising CPP and cerebral markers of water balance, oxidative damage and apoptosis. The role of this pressor agent on brain perfusion in HS requires further investigation.

Tissue oxygen saturation changes during intramedullary nailing of lower-limb fractures

BACKGROUND

The systemic complications of acute intramedullary nailing (IMN) in trauma patients are well known. There are no reliable methods available to predict these adverse outcomes. Noninvasive near-infrared spectroscopy (NIRS) allows measurement of oxygen saturation within muscle tissue (StO2) and quantification of the potential metabolic and microcirculatory effects of IMN in real time. The aim of this study was to characterize tissue oxygenation changes occurring during reamed IMN.

METHODS

Patients undergoing reamed IMN for fixation of a tibia or femur fracture and patients having an open reduction and internal fixation of the ankle (to control for potential effects of anesthesia) had a noninvasive NIRS probe attached to the thenar eminence of the hand. Tissue oxygenation was monitored continuously throughout the operation and digitally recorded for later analysis. Vascular occlusion tests, an established technique with the NIRS device, were performed before canal opening and after nail insertion (at equivalent times in the control group), to establish the presence and nature of changes in systemic microcirculation occurring during the duration of the operation.

RESULTS

Tissue oxygenation data were collected on 23 patients undergoing 26 IMN. (mean [SD] age, 36 [19] years; median Injury Severity Score [ISS], 9; interquartile range, 9-12). The control group consisted of 19 patients (mean [SD] age, 41 [18] years; ISS, 4). Remote muscle tissue desaturated significantly faster after IMN compared with the control operation (mean [SD] difference in IMN desaturation rate, 1.8% per minute [2.6% per minute]; mean [SD] difference in control group desaturation rate, -0.6% per minute [1.5% per minute]; p = 0.014). Near infrared-derived muscle oxygen consumption (NIR VO(2)) was significantly increased during the course of IMN compared with the control (mean [SD] difference in IMN NIR VO(2), 19.9 [32.1]; mean [SD] difference in control NIR VO(2), -4.2 [17.9]; p = 0.041).

CONCLUSION

IMN causes significant remote microcirculatory changes. The responsiveness of the microcirculation could be a predictor of secondary organ dysfunction.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Bladder tissue oxygen tension monitoring in pigs subjected to a range of cardiorespiratory and pharmacological challenges

PURPOSE

A fall in tissue oxygen tension (tPO(2)) is an early indicator of organ hypoxia in both patients and animal models. We previously demonstrated the utility of bladder tPO(2) in various rodent shock models. As a prelude to clinical testing, we aimed to provide further validation of bladder tPO(2) monitoring in a large animal model undergoing a range of cardiorespiratory insults and vasoactive drug interventions.

METHODS

Anaesthetized, mechanically ventilated, instrumented female pigs (n = 8) were subjected to a range of short-term cardiorespiratory (changes in inspired oxygen concentration (FiO(2)), haemorrhage, positive end-expiratory pressure) and pharmacologic (inotrope, pressor) challenges. Global haemodynamics, arterial and pulmonary blood gases and bladder tPO(2) were measured before and after each challenge.

RESULTS

Bladder tPO(2) values fell in line with increasing degrees of hypoxaemia and haemorrhage, and were restored during resuscitation. These changes often preceded those seen in global haemodynamics, arterial base excess and lactate. The rise in bladder tPO(2) with hyperoxia, performed as an oxygen challenge test, was incrementally blunted by progressive haemorrhage. Dobutamine and norepinephrine both increased cardiac output and global O(2) delivery, but had no effect on bladder tPO(2) or lactataemia in these healthy pigs.

CONCLUSIONS

In this pig model bladder tPO(2) provides a sensitive indicator of organ hypoxia compared to traditional biochemical markers during various cardiorespiratory challenges. This technique offers a potentially useful tool for clinical monitoring.

A novel technique for monitoring of fast variations in brain oxygen tension using an uncoated fluorescence quenching probe (Foxy AL-300)

BACKGROUND

A novel uncoated fluorescence quenching probe allows fast measurement of oxygen tension in vessels and tissue. The present study reports the first use of the technology for dual measurements of arterial (paO(2)) and brain tissue oxygen tension (ptiO(2)) during hypoxic challenge in a pig model.

METHODS

Eight pigs were anesthetized using fentanyl and propofol. Fluorescence quenching pO(2) probes (Foxy AL-300, Ocean Optics, Dunedin, FL) were placed in the ascending aorta (Foxy-paO(2)) and subcortically at 14 mm in brain tissue (Foxy-ptiO(2)). As reference, a clark-type electrode probe (Licox-ptiO(2)) was placed into brain tissue close to the Foxy probe (Licox, Integra Neurosciences, Plainsboro, NJ). Measurements were taken at baseline (FiO(2) 1.0), during episodes of apnea, and during recovery (FiO(2) 1.0).

STATISTICS

descriptive results.

RESULTS

Individual Foxy-paO(2), Foxy-ptiO(2), and Licox-ptiO(2) courses were related to episodes of apnea. The response time of the Foxy measurements was 10 Hz. Baseline values at FiO(2) 1.0 were Foxy-paO(2) 520±120 mm Hg, Foxy-ptiO(2) 62±24 mm Hg, and Licox-ptiO(2) 55±29 mm Hg; apnea values were Foxy-paO(2) 64±10 mm Hg, Foxy-ptiO(2) 37±12 mm Hg, and Licox-ptiO(2) 31±16 mm Hg; recovery values at FiO(2) 1.0 were Foxy-paO(2) 478±98 mm Hg, Foxy-ptiO(2) 78±26 mm Hg, and Licox-ptiO(2) 62±32 mm Hg.

CONCLUSIONS

The present study demonstrates the feasibility of pO(2) measurements in macrocirculation and cerebral microcirculation using a novel uncoated fluorescence quenching probe. The technology allows for real-time investigation of pO(2) changes at a temporal resolution of 0.05 to 10 Hz.

Quantitative tissue oxygen measurement in multiple organs using 19F MRI in a rat model

Measurement of individual organ tissue oxygen levels can provide information to help evaluate and optimize medical interventions in many areas including wound healing, resuscitation strategies, and cancer therapeutics. Echo planar (19) F MRI has previously focused on tumor oxygen measurement at low oxygen levels (pO(2)) <30 mmHg. It uses the linear relationship between spin-lattice relaxation rate (R(1)) of hexafluorobenzene (HFB) and pO(2). The feasibility of this technique for a wider range of pO(2) values and individual organ tissue pO(2) measurement was investigated in a rat model. Spin-lattice relaxation times (T(1) = 1/R(1)) of hexafluorobenzene were measured using (19) F saturation recovery echo planar imaging. Initial in vitro studies validated the linear relationship between R(1) and pO(2) from 0 to 760 mmHg oxygen partial pressure at 25, 37, and 41°C at 7 Tesla for hexafluorobenzene. In vivo experiments measured rat tissue oxygen (ptO2) levels of brain, kidney, liver, gut, muscle, and skin during inhalation of both 30 and 100% oxygen. All organ ptO(2) values significantly increased with hyperoxia (P < 0.001). This study demonstrates that (19) F MRI of hexafluorobenzene offers a feasible tool to measure regional ptO2 in vivo, and that hyperoxia significantly increases ptO2 of multiple organs in a rat model.

Early identification of shock in critically ill patients

Emergency providers must be experts in the resuscitation and stabilization of critically ill patients, and the rapid recognition of shock is crucial to allow aggressive targeted intervention and reduce morbidity and mortality. This article reviews the physiologic definition of shock, the importance of early intervention, and the clinical and diagnostic signs that emergency department providers can use to identify patients in shock.