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Tavy ALM, de Bruin AFJ, van der Sloot K, Boerma EC, Ince C, Noordzij PG, Boerma D, van Iterson M. Effects of Thoracic Epidural Anaesthesia on the Serosal Microcirculation of the Human Small Intestine. World J Surg 2019; 42:3911-3917. [PMID: 30097706 DOI: 10.1007/s00268-018-4746-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The effect of thoracic epidural analgesia (TEA) on splanchnic blood flow during abdominal surgery remains unclear. The purpose of this study was to examine whether the hemodynamic effects of TEA resulted in microcirculatory alterations to the intestinal serosa, which was visualized using incident dark-field (IDF) videomicroscopy. METHODS An observational cohort study was performed. In 18 patients, the microcirculation of the intestinal serosa was visualized with IDF. Microcirculatory and hemodynamic measurements were performed prior to (T1) and after administering a bolus of levobupivacaine (T2). If correction of blood pressure was indicated, a third measurement was performed (T3). The following microcirculatory parameters were calculated: microvascular flow index, proportion of perfused vessels, perfused vessel density and total vessel density. Data are presented as median [IQR]. RESULTS Mean arterial pressure decreased from 73 mmHg (68-83) at T1 to 63 mmHg (±11) at T2 (p = 0.001) with a systolic blood pressure of 114 mmHg (98-128) and 87 (81-97), respectively (p = 0.001). The microcirculatory parameters of the bowel serosa, however, were unaltered. In seven patients, blood pressure was corrected to baseline values from a MAP of 56 mmHg (55-57), while microcirculatory parameters remained constant. CONCLUSION We examined the effects of TEA on the intestinal serosal microcirculation during abdominal surgery using IDF imaging for the first time in patients. Regardless of a marked decrease in hemodynamics, microcirculatory parameters of the bowel serosa were not significantly affected. TRIAL REGISTRY NUMBER ClinicalTrials.gov identifier NCT02688946.
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Affiliation(s)
- A L M Tavy
- Department of Anesthesiology, Intensive Care and Pain Medicine, St. Antonius Hospital, Postbus 2500, 3430 EM, Nieuwegein, The Netherlands.
| | - A F J de Bruin
- Department of Anesthesiology, Intensive Care and Pain Medicine, St. Antonius Hospital, Postbus 2500, 3430 EM, Nieuwegein, The Netherlands
| | - K van der Sloot
- Department of Anesthesiology and Pain Medicine, The Hague Medical Center, The Hague, The Netherlands
| | - E C Boerma
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - C Ince
- Department of Translational Physiology, Academic Medical Center, Amsterdam, The Netherlands
| | - P G Noordzij
- Department of Anesthesiology, Intensive Care and Pain Medicine, St. Antonius Hospital, Postbus 2500, 3430 EM, Nieuwegein, The Netherlands
| | - D Boerma
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - M van Iterson
- Department of Anesthesiology, Intensive Care and Pain Medicine, St. Antonius Hospital, Postbus 2500, 3430 EM, Nieuwegein, The Netherlands
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Li Y, Shan Y, Lin X. Effect of acute hypervolemic hemodilution of 6% hydroxyethyl starch 130/0.4 on the EC 50 of propofol at two clinical endpoints in patients. Exp Ther Med 2015; 11:110-116. [PMID: 26889226 PMCID: PMC4726874 DOI: 10.3892/etm.2015.2886] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 06/22/2015] [Indexed: 11/06/2022] Open
Abstract
Preoperative acute hypervolemic hemodilution (AHHD) is a technique used in anesthesia to reduce the number of blood cells lost during intraoperative bleeding. The aim of the present study was to evaluate the effect of the hypervolemic hemodilution of 6% hydroxyethyl starch 130/0.4 on the EC50 of propofol at two clinical endpoints. A total of 20 patients undergoing AHHD following epidural anesthesia were studied, and 20 patients who did not receive hemodilution were used as a control group. All patients were American Society of Anesthesiologists grade I, aged 20-40 years and undergoing hip arthroplasty surgery. In the AHHD group, 10 ml/kg lactated Ringer's solution was infused over 20 min at the same time as the epidural test dose. The infusion was followed by the infusion of 6% hydroxyethyl starch 130/0.4 over 30 min. Patients in the control group received 10 ml/kg Ringer's solution over 50 min. Propofol was then delivered by a Diprifusor target-controlled infusion. The predicted blood and effect-site propofol concentrations were recorded at loss of consciousness (LOC) and return of consciousness (ROC). Probit analysis was used to estimate the values for predicted blood and effect-site concentrations at the two clinical endpoints. The results showed that the potency of propofol was decreased during AHHD. Compared with the controls, the predicted blood and effect-site concentrations of propofol at LOC were higher in patients of the hemodilution group, resulting in higher EC50 values (P=0.001 and 0.025, respectively). At ROC, the effect-site EC50 was 2.9 µg/ml [95% confidence interval (CI), 2.8-3.0] in hemodilution patients and 2.5 µg/ml (95% CI, 2.2-2.6) in control patients (P=0.001). With AHHD, the LOC time was significantly longer and the propofol dose was higher, while ROC times were comparable. In conclusion, AHHD increases the requirement for propofol at LOC and prolongs LOC time. Patients with AHHD recovered consciousness at higher effect-site concentrations of propofol. Thus, the induction dose of propofol should be increased during AHHD.
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Affiliation(s)
- Yuhong Li
- Department of Anesthesiology, Shaoxing People's Hospital, Shaoxing, Zhejiang 312000, P.R. China; Department of Anesthesiology, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310000, P.R. China
| | - Yue Shan
- Department of Anesthesiology, Shaoxing People's Hospital, Shaoxing, Zhejiang 312000, P.R. China
| | - Xuezheng Lin
- Department of Anesthesiology, Taizhou Central Hospital, Taizhou, Zhejiang 318000, P.R. China
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Effects of ketanserin on microcirculatory alterations in septic shock: An open-label pilot study. J Crit Care 2015; 30:1156-62. [PMID: 26264259 DOI: 10.1016/j.jcrc.2015.07.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 06/17/2015] [Accepted: 07/07/2015] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Microcirculatory alterations in sepsis are associated with increased morbidity and mortality. These alterations occur despite macrohemodynamic resuscitation. Alternative pro-microcirculatory strategies, including vasodilatory drugs, have been suggested to improve capillary blood flow. Ketanserin, a serotonin receptor antagonist, is an attractive candidate because of its vasodilatory, antithrombotic, and anti-inflammatory effects. METHODS This is an open-label pilot study on the effect of ketanserin administration on microcirculatory alterations in septic shock, defined as microvascular flow index (MFI)≤2.5 after a strict macrohemodynamic resuscitation protocol. Sidestream dark-field imaging was applied to assess the microcirculation. A stepwise incremental dose regiment was applied until an MFI>2.9, the primary end point, was reached. RESULTS Ten patients (Acute Physiology and Chronic Health Evaluation IV scores of 115 [100-136]) were included. Baseline MFI was 1.71 (1.31-2.32) and was significantly increasing to 2.96 (2.54-3.00; P=.021) during the ketanserin infusion. The total ketanserin dose was 0.09 (0.08-0.13) mg/kg per patient in 60 (30-60) minutes. In 3 patients (30%), the ketanserin infusion was discontinued due to refractory hypotension. CONCLUSION An improvement in microcirculatory perfusion was observed during ketanserin administration in patients with septic shock after macrohemodynamic resuscitation. This finding needs further exploration in a placebo-controlled setting.
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Weber MA, Milstein DMJ, Ince C, Oude Rengerink K, Roovers JPWR. Vaginal microcirculation: Non-invasive anatomical examination of the micro-vessel architecture, tortuosity and capillary density. Neurourol Urodyn 2014; 34:723-9. [PMID: 25212383 DOI: 10.1002/nau.22662] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 07/04/2014] [Indexed: 11/05/2022]
Abstract
AIM To describe the vaginal microcirculatory architecture and capillary density parameters using sidestream dark-field imaging (SDFI), and determine feasibility and reliability of this method. METHODS In nine healthy female volunteers SDFI measurements were performed at two different time points in the luteal phase of the menstrual cycle. Non-invasive tissue micro-angioarchitecture and vaginal capillary density measurements were assessed independently by two observers. Agreement was expressed with mean differences between the measurements of both observers and the limits of agreement. Inter- and intra-observer agreement was quantified with the intra-class correlation coefficient (ICC). RESULTS Vaginal microcirculatory assessment with the SDFI device was easy in use, painless and well accepted by the participants. Morphologically, the vaginal microcirculation revealed an array of single hairpin-shaped capillary loops distributed homogeneously across an imaged tissue segment. The intra-observer assessment of the capillary density measurements (comparing two measurement time points of one observer) showed good agreement with an ICC ranging from 0.62 to 0.85. The inter-observer assessments of the capillary density measurements (comparing assessments of two observers at one time point) revealed very good agreement, with small differences between observers and an ICC of more than 0.9. CONCLUSIONS This is the first report on both microcirculatory architecture and quantitative microcirculatory parameters of the vagina with the use of SDFI. Micro-vessels of the vagina show a recognizable pattern in our study population of young, healthy women. SDFI gives a reproducible assessment of the vaginal microcirculation offering the researcher a wide field of applications.
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Affiliation(s)
- Maaike A Weber
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, The Netherlands
| | - Dan M J Milstein
- Department of Oral & Maxillofacial Surgery, Academic Medical Center, Amsterdam, The Netherlands.,Department of Translational Physiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Can Ince
- Department of Translational Physiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Katrien Oude Rengerink
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jan-Paul W R Roovers
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, The Netherlands
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Pranskunas A, Vellinga NA, Pilvinis V, Koopmans M, Boerma EC. Microcirculatory changes during open label magnesium sulphate infusion in patients with severe sepsis and septic shock. BMC Anesthesiol 2011; 11:12. [PMID: 21672227 PMCID: PMC3134422 DOI: 10.1186/1471-2253-11-12] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Accepted: 06/14/2011] [Indexed: 01/10/2023] Open
Abstract
Background Microcirculatory alterations play a pivotal role in sepsis and persist despite correction of systemic hemodynamic parameters. Therefore it seems tempting to test specific pro-microcirculatory strategies, including vasodilators, to attenuate impaired organ perfusion. As opposed to nitric oxide donors, magnesium has both endothelium-dependent and non-endothelium-dependent vasodilatory pathways. Methods In a single-center open label study we evaluated the effects of magnesium sulphate (MgS) infusion on the sublingual microcirculation perfusion in fluid resuscitated patients with severe sepsis and septic shock within the first 48 hours after ICU admission. Directly prior to and after 1 hour of magnesium sulphate (MgS) infusion (2 gram) systemic hemodynamic variables, sublingual SDF images and standard laboratory tests, were obtained. Results Fourteen patients (12 septic shock, 2 severe sepsis) with a median APACHE II score of 20 were enrolled. No significant difference of the systemic hemodynamic variables was found between baseline and after MgS infusion. We did not observe any significant difference pre and post MgS infusion in the primary endpoint microvascular flow index (MFI) of small vessels: 2.25(1.98-2.69) vs. 2.33(1.96-2.62), p = 0.65. Other variables of microcirculatory perfusion were also unaltered. In the overall unchanged microvascular perfusion there was a non-significant trend to an inverse linear relationship between the changes of MFI and its baseline value (y = -0.7260 × + 1.629, r2 = 0.270, p = 0.057). The correlation between baseline Mg concentrations and the change in MFI pre- and post MgS infusion was non-significant (rs = -0.165, p = 0.67). Conclusions In the setting of severe sepsis and septic shock sublingual microcirculatory alterations were observed despite fulfillment of sepsis resuscitation guidelines. After infusion of a limited and fixed dose of MgS, microcirculatory perfusion did not improve over time. Trial registration ClinicalTrials.gov NTC01332734.
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Affiliation(s)
- Andrius Pranskunas
- Department of Intensive Care Medicine, Medical Center Leeuwarden, Henri Dunantweg 2, Leeuwarden, 8901 BR, the Netherlands.
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YURUK KORAY, ALMAC EMRE, INCE CAN. Hydroxyethyl starch solutions and their effect on the microcirculation and tissue oxygenation. ACTA ACUST UNITED AC 2007. [DOI: 10.1111/j.1778-428x.2007.00076.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Knotzer H, Hasibeder WR. Microcirculatory function monitoring at the bedside--a view from the intensive care. Physiol Meas 2007; 28:R65-86. [PMID: 17827646 DOI: 10.1088/0967-3334/28/9/r01] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Microcirculatory dysfunction plays a key role in the pathophysiology of various disease states and may consequently impact patient outcome. Until recently, the evaluation of the microcirculation using different measurement techniques has been mostly limited to animal and human research. With technical advances, microcirculatory monitoring nowadays becomes more and more available for application in clinical praxis. Unfortunately, measurements within the microcirculation are mostly limited to easily accessible surfaces, such as skin, muscle and tongue. Due to major differences in the physiologic regulation of microcirculatory blood flow and in metabolism between organs and even within different tissues in one organ, the clinical importance of regional microcirculatory measurements remains to be determined. In addition, technical methods available demonstrate large differences in the measured parameters and sampling volume, making interpretation of data even more difficult. Nonetheless, the monitoring of the microcirculation may, ahead of time, alert physicians that tissue oxygen supply becomes compromised and it may lead to a better understanding of basic pathophysiological aspects of disease. In the present review, we describe available non-invasive microcirculatory measurement techniques which can be applied clinically at the bedside. After a short discussion of physiologic and pathophysiologic basics related to microcirculatory monitoring, the measuring principles, applications, strengths and limitations of different monitoring systems are discussed.
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Affiliation(s)
- Hans Knotzer
- Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria.
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