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Reisinger KW, Willigers HM, Jansen J, Buurman WA, Von Meyenfeldt MF, Beets GL, Poeze M. Doppler-guided goal-directed fluid therapy does not affect intestinal cell damage but increases global gastrointestinal perfusion in colorectal surgery: a randomized controlled trial. Colorectal Dis 2017; 19:1081-1091. [PMID: 29028286 DOI: 10.1111/codi.13923] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 05/17/2017] [Indexed: 01/13/2023]
Abstract
AIM Individualized, goal-directed fluid therapy (GDFT), based on Doppler measurements of stroke volume, has been proposed as a treatment strategy in terms of reducing complications, mortality and length of hospital stay in major bowel surgery. We studied the effect of Doppler-guided GDFT on intestinal damage as compared with standard postoperative fluid replacement. METHOD Patients undergoing elective colorectal resection for malignancy were randomized either to standard intra- and postoperative fluid therapy or to standard fluid therapy with additional Doppler-guided GDFT. The primary outcome was intestinal epithelial cell damage measured by plasma levels of intestinal fatty acid-binding protein (I-FABP). Global gastrointestinal perfusion was measured by gastric tonometry, expressed as regional (gastric) minus arterial CO2 -gap (Pr-a CO2 -gap). RESULTS I-FABP levels were not significantly different between the intervention group and the control group (respectively, 440.8 (251.6) pg/ml and 522.4 (759.9) pg/ml, P = 0.67). Mean areas under the curve (AUCs) of intra-operative Pr-a CO2 -gaps were significantly lower in the intervention group than in the control group (P = 0.01), indicating better global gastrointestinal perfusion in the intervention group. Moreover, the mean intra-operative Pr-a CO2 -gap peak in the intervention group was 0.5 (1.0) kPa, which was significantly lower than the mean peak in the control group, of 1.4 (1.4) kPa (P = 0.03). CONCLUSION Doppler-guided GDFT during and in the first hours after elective colorectal surgery for malignancy increases global gastrointestinal perfusion, as measured by Pr-a CO2 -gap.
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Affiliation(s)
- K W Reisinger
- Department of Surgery, Maastricht University Medical Center & Nutrim School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, the Netherlands
| | - H M Willigers
- Department of Anaesthesiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - J Jansen
- Department of Anaesthesiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - W A Buurman
- School for Mental Health and Neuroscience (MHeNS), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - M F Von Meyenfeldt
- Department of Surgery, Maastricht University Medical Center & Nutrim School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, the Netherlands
| | - G L Beets
- Department of Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - M Poeze
- Department of Surgery, Maastricht University Medical Center & Nutrim School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, the Netherlands
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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] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Indexed: 11/11/2022]
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Derikx JPM, van Waardenburg DA, Thuijls G, Willigers HM, Koenraads M, van Bijnen AA, Heineman E, Poeze M, Ambergen T, van Ooij A, van Rhijn LW, Buurman WA. New Insight in Loss of Gut Barrier during Major Non-Abdominal Surgery. PLoS One 2008; 3:e3954. [PMID: 19088854 PMCID: PMC2599890 DOI: 10.1371/journal.pone.0003954] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2008] [Accepted: 11/05/2008] [Indexed: 12/15/2022] Open
Abstract
Background Gut barrier loss has been implicated as a critical event in the occurrence of postoperative complications. We aimed to study the development of gut barrier loss in patients undergoing major non-abdominal surgery. Methodology/Principal Findings Twenty consecutive children undergoing spinal fusion surgery were included. This kind of surgery is characterized by long operation time, significant blood loss, prolonged systemic hypotension, without directly leading to compromise of the intestines by intestinal manipulation or use of extracorporeal circulation. Blood was collected preoperatively, every two hours during surgery and 2, 4, 15 and 24 hours postoperatively. Gut mucosal barrier was assessed by plasma markers for enterocyte damage (I-FABP, I-BABP) and urinary presence of tight junction protein claudin-3. Intestinal mucosal perfusion was measured by gastric tonometry (PrCO2, Pr-aCO2-gap). Plasma concentration of I-FABP, I-BABP and urinary expression of claudin-3 increased rapidly and significantly after the onset of surgery in most children. Postoperatively, all markers decreased promptly towards baseline values together with normalisation of MAP. Plasma levels of I-FABP, I-BABP were significantly negatively correlated with MAP at ½ hour before blood sampling (−0.726 (p<0.001), −0.483 (P<0.001), respectively). Furthermore, circulating I-FABP correlated with gastric mucosal PrCO2, Pr-aCO2-gap measured at the same time points (0.553 (p = 0.040), 0.585 (p = 0.028), respectively). Conclusions/Significance This study shows the development of gut barrier loss in children undergoing major non-abdominal surgery, which is related to preceding hypotension and mesenterial hypoperfusion. These data shed new light on the potential role of peroperative circulatory perturbation and intestinal barrier loss.
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Affiliation(s)
- Joep P. M. Derikx
- Department of Surgery, University Hospital Maastricht & Nutrition and Toxicology Research Institute (NUTRIM), Maastricht University, Maastricht, the Netherlands
- * E-mail:
| | | | - Geertje Thuijls
- Department of Surgery, University Hospital Maastricht & Nutrition and Toxicology Research Institute (NUTRIM), Maastricht University, Maastricht, the Netherlands
| | - Henriëtte M. Willigers
- Department of Anaesthesiology, University Hospital Maastricht, Maastricht, the Netherlands
| | - Marianne Koenraads
- Department of Surgery, University Hospital Maastricht & Nutrition and Toxicology Research Institute (NUTRIM), Maastricht University, Maastricht, the Netherlands
| | - Annemarie A. van Bijnen
- Department of Surgery, University Hospital Maastricht & Nutrition and Toxicology Research Institute (NUTRIM), Maastricht University, Maastricht, the Netherlands
| | - Erik Heineman
- Department of Surgery, University Hospital Maastricht & Nutrition and Toxicology Research Institute (NUTRIM), Maastricht University, Maastricht, the Netherlands
| | - Martijn Poeze
- Department of Surgery, University Hospital Maastricht & Nutrition and Toxicology Research Institute (NUTRIM), Maastricht University, Maastricht, the Netherlands
| | - Ton Ambergen
- Department of Methodology and Statistics, University of Maastricht, Maastricht, the Netherlands
| | - André van Ooij
- Department of Orthopaedic Surgery, University Hospital Maastricht, Maastricht, the Netherlands
| | - Lodewijk W. van Rhijn
- Department of Orthopaedic Surgery, University Hospital Maastricht, Maastricht, the Netherlands
| | - Wim A. Buurman
- Department of Surgery, University Hospital Maastricht & Nutrition and Toxicology Research Institute (NUTRIM), Maastricht University, Maastricht, the Netherlands
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Willigers HM, Prinzen FW, Roekaerts PMHJ. The Effects of Esmolol and Dexmedetomidine on Myocardial Oxygen Consumption During Sympathetic Stimulation in Dogs. J Cardiothorac Vasc Anesth 2006; 20:364-70. [PMID: 16750737 DOI: 10.1053/j.jvca.2006.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2005] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The purpose of this study was to compare the potential of the beta(1)-adrenergic receptor blocker esmolol and the alpha(2)-adrenergic receptor agonist dexmedetomidine to suppress the cardiovascular and neuroendocrine response to a sympathetic stimulus. DESIGN Experimental study. SETTING Laboratory of university. PARTICIPANTS Eleven anesthetized dogs. INTERVENTIONS Catheters for arterial and coronary venous blood sampling and calculation of myocardial oxygen consumption were inserted. Pressure sensors were placed in the aorta, left ventricle, and a carotid artery. Flow probes were placed around the aortic root and around the left anterior descending coronary artery. Esmolol was infused (loading dose of 1 mg/kg, infusion of 0.3 mg/kg/h), and the adequacy of beta-blockade was checked. Thirty minutes after stopping esmolol, dexmedetomidine infusion was started (loading dose of 1 microg/kg, infusion of 1.5 microg/kg/min). Occlusion of both carotid arteries was used as a sympathetic stimulus before and during infusion of esmolol and before and during infusion of dexmedetomidine. MEASUREMENTS AND MAIN RESULTS The variables were measured just before and during sympathetic stimulation, and changes were calculated. Both drugs suppressed the increase in dPdT(max). Dexmedetomidine suppressed the increase in plasma norepinephrine and the increase in systemic vascular resistance (dexmedetomidine 4% +/- 4% and esmolol 25% +/- 19% increase, p = 0.02). Esmolol attenuated the heart rate response (esmolol 2% +/- 2% and dexmedetomidine 20% +/- 18% increase, p = 0.02). However, dexmedetomidine decreased baseline heart rate more than esmolol; therefore, the absolute maximal heart rate during sympathetic stimulation was lower in the presence of dexmedetomidine (dexmedetomidine 119 +/- 14 and esmolol 141 +/- 15 beats/min, p = 0.01). Neither drug suppressed the increase in myocardial oxygen consumption. CONCLUSIONS Both esmolol and dexmedetomidine have the potential to suppress some of the cardiovascular and neuroendocrine changes to a sympathetic stimulus but neither drug abolished the increase in myocardial oxygen consumption.
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Affiliation(s)
- Henriëtte M Willigers
- Department of Anesthesiology, University Hospital, Maastricht, Maastricht, the Netherlands
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Abstract
UNLABELLED The sympatholytic effect of the alpha(2)-adrenergic agonist dexmedetomidine may decrease emergence-related myocardial ischemic load in patients. However, a direct measure of myocardial ischemia, such as myocardial lactate release, is difficult to obtain in patients. Therefore, we studied mongrel dogs and measured myocardial lactate release, myocardial oxygen supply, hemodynamic variables, and neurohumoral indices of the stress response. After the induction of a standardized degree of borderline myocardial ischemia, either dexmedetomidine (dexmed group, n = 9) or normal saline (control group, n = 9) was infused. Measurements were repeated at the end of the anesthetic period and every 10 min during the 90-min emergence period. In the dexmed group, the cumulative emergence-related lactate release was 46% less than in the control group (95% confidence interval, 20%-80%; P = 0.02). Simultaneously, dexmedetomidine increased the endo-/epicardial blood flow ratio by 35% (control group, 0.4 +/- 0.1; dexmed group, 0.6 +/- 0.1; P = 0.03). These antiischemic effects of dexmedetomidine were accompanied by reduced plasma concentrations of norepinephrine (126 versus 577 pg/mL) and epinephrine (158 versus 1909 pg/mL) and a slower heart rate (123 +/- 6 versus 160 +/- 10 bpm, dexmed versus control). The antiischemic effect of dexmedetomidine started before emergence, as evidenced by a decreased prevalence of myocardial lactate release at that time (zero of eight dogs in the dexmed group and four of seven dogs in the control group had lactate release before emergence; P = 0.03). IMPLICATIONS Dexmedetomidine decreases plasma catecholamines and heart rate during emergence from anesthesia. In dogs with a coronary stenosis, these sympatholytic effects decrease myocardial lactate release and, therefore, minimize emergence-related myocardial ischemia.
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Affiliation(s)
- Henriëtte M Willigers
- *Department of Anesthesiology, University Hospital Maastricht; and †Department of Physiology, Maastricht University, Maastricht, The Netherlands
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Roekaerts PM, Prinzen FW, Willigers HM, De Lange S. The effects of alpha 2-adrenergic stimulation with mivazerol on myocardial blood flow and function during coronary artery stenosis in anesthetized dogs. Anesth Analg 1996; 82:702-11. [PMID: 8615484 DOI: 10.1097/00000539-199604000-00005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The central sympatholytic effect of alpha 2 agonists may be beneficial during myocardial ischemia, but could be opposed by their peripheral vasoconstrictive effect. We studied the effects of mivazerol during periods of moderate coronary artery stenosis in anesthetized dogs. Mivazerol decreased heart rate (from 125 +/- 6 to 106 +/- 6 bpm) and cardiac output (from 4.4 +/- 0.6 to 1.8 +/- 0.2L/min) under normal conditions, while mean arterial pressure did not change. Mivazerol reduced blood flow in nonischemic myocardium and in the ischemic epicardial layer, but blood flow was preserved in the ischemic midmyocardial and subendocardial layer. Mivazerol had no effect on myocardial oxygen extraction during the stenoses, and regional myocardial oxygen consumption was unchanged. However, mivazerol decreased myocardial oxygen demand from 4.51 +/- 0.51 to 3.17 +/- 0.24 mumol.min-1.g-1, thereby reducing oxygen deficiency of ischemic myocardium to values significantly lower than in the placebo group (from 1.07 +/- 0.32 to 0.47 +/- 0.41 mumol.min-1.g-1). Mivazerol had no effect on myocardial lactate production during the stenoses. We conclude that mivazerol reduced myocardial oxygen demand while blood flow was preserved in the inner layers of ischemic myocardium.
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Affiliation(s)
- P M Roekaerts
- Department of Anesthesiology, University Hospital of Maastricht, The Netherlands
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Van Oosterhout MF, Willigers HM, Reneman RS, Prinzen FW. Fluorescent microspheres to measure organ perfusion: validation of a simplified sample processing technique. Am J Physiol 1995; 269:H725-33. [PMID: 7653638 DOI: 10.1152/ajpheart.1995.269.2.h725] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A disadvantage of nonradioactive microsphere techniques is that the processing of samples is time-consuming and complex. We developed and validated a simplified processing method for the fluorescent microsphere (FM) technique. In seven anesthetized dogs with coronary artery stenosis up to six different FM and five different radioactivity labeled microspheres (RM) were injected. Two FM and two RM labels were injected simultaneously to enable inter- and intramethod comparison. After gamma-counting samples of blood, myocardium (n = 168), and other organs (n = 59) were digested in test tubes with 2 N ethanolic KOH (60 degrees C, 48 h), microspheres were sedimented by centrifugation, dye was extracted in the same tube, and fluorescence was measured. With this processing method, recovery of FM was approximately 100%. Good correlations for inter- and intramethod comparisons were found [r = 0.985 +/- 0.01 (mean +/- SD)]. The lower intermethod correlation for blue microspheres (r = 0.958) indicates that the use of this label is less desirable. RM and FM endocardial-to-epicardial blood flow ratios correlated well (r = 0.974). With this one-vessel centrifugal sedimentation method and at least five fluorescently labeled microspheres, blood flow can be reliably measured in various organs, including ischemic myocardium.
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Affiliation(s)
- M F Van Oosterhout
- Department of Physiology, University of Limburg, Maastricht, The Netherlands
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Koehler PJ, Bongers KM, Willigers HM. [Facial pain in a thoracic disease]. Ned Tijdschr Geneeskd 1992; 136:2035-6. [PMID: 1407197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Affiliation(s)
- K M Bongers
- Department of Neurology, De Wever Hospital, Heerlen, The Netherlands
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