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      Dissociation between sublingual and gut microcirculation in the response to a fluid challenge in postoperative patients with abdominal sepsis

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          Abstract

          Background

          This study was performed to compare intestinal and sublingual microcirculation and their response to a fluid challenge.

          Methods

          Twenty-two septic patients in the first postoperative day of an intestinal surgery, in which an ostomy had been constructed, were evaluated both before and 20 min after a challenge of 10 mL/kg of 6% hydroxyethylstarch 130/0.4. We measured systemic hemodynamics and sublingual and intestinal microcirculation. Correlations between variables were determined through the Pearson test.

          Results

          Fluid administration increased the cardiac index (2.6 ± 0.5 vs. 3.3 ± 1.0 L/min/m 2, P < 0.01) and mean arterial blood pressure (68 ± 11 vs. 82 ± 12 mm Hg, P < 0.0001). The sublingual but not the intestinal red blood cell (RBC) velocity increased (912 ± 270 vs. 1,064 ± 200 μm/s, P < 0.002 and 679 ± 379 vs. 747 ± 419 μm/s, P = 0.12, respectively). The sublingual and intestinal perfused vascular density (PVD) did not change significantly (15.2 ± 2.9 vs. 16.1 ± 1.2 mm/mm 2 and 12.3 ± 6.7 vs. 13.0 ± 6.7 mm/mm 2). We found no correlation between the basal sublingual and intestinal RBC velocities or between their changes in response to the fluid challenge. The individual changes in sublingual RBC velocity correlated with those in cardiac index and basal RBC velocity. Individual changes in intestinal RBC velocity did not correlate with either the cardiac index modifications or the basal RBC velocity. The same pattern was observed with the sublingual and the intestinal PVDs. The sublingual RBC velocities and PVDs were similar between survivors and nonsurvivors. But the intestinal RBC velocities and PVDs were lower in nonsurvivors.

          Conclusions

          In this series of postoperative septic patients, we found a dissociation between sublingual and intestinal microcirculation. The improvement in the sublingual microcirculation after fluid challenge was dependent on the basal state and the increase in cardiac output. In contrast, the intestinal microcirculation behaved as an isolated territory.

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          Most cited references11

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          American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis.

          (1992)
          To define the terms "sepsis" and "organ failure" in a precise manner. Review of the medical literature and the use of expert testimony at a consensus conference. American College of Chest Physicians (ACCP) headquarters in Northbrook, IL. Leadership members of ACCP/Society of Critical Care Medicine (SCCM). An ACCP/SCCM Consensus Conference was held in August of 1991 with the goal of agreeing on a set of definitions that could be applied to patients with sepsis and its sequelae. New definitions were offered for some terms, while others were discarded. Broad definitions of sepsis and the systemic inflammatory response syndrome were proposed, along with detailed physiologic variables by which a patient could be categorized. Definitions for severe sepsis, septic shock, hypotension, and multiple organ dysfunction syndrome were also offered. The use of severity scoring methods were recommended when dealing with septic patients as an adjunctive tool to assess mortality. Appropriate methods and applications for the use and testing of new therapies were recommended. The use of these terms and techniques should assist clinicians and researchers who deal with sepsis and its sequelae.
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            The effects of dobutamine on microcirculatory alterations in patients with septic shock are independent of its systemic effects.

            To evaluate the effects of dobutamine on microcirculatory blood flow alterations in patients with septic shock. Prospective, open-label study. A 31-bed, medico-surgical intensive care unit of a university hospital. Twenty-two patients with septic shock. Intravenous administration of dobutamine (5 mug/kg.min) for 2 hrs (n = 22) followed by the addition of 10 M acetylcholine (topically applied, n = 10). Complete hemodynamic measurements were obtained before and after dobutamine administration. In addition, the sublingual microcirculation was investigated with an orthogonal polarization spectral imaging technique before and after dobutamine administration and after topical application of acetylcholine. Dobutamine significantly improved capillary perfusion (from 48 +/- 15 to 67 +/- 11%, p = .001), but with large individual variation, whereas capillary density remained stable. The addition of topical acetylcholine completely restored capillary perfusion (98 +/- 1%, p = .001) and capillary density. The changes in capillary perfusion during dobutamine administration were not related to changes in cardiac index (p = .45) or arterial pressure (p = .29). Interestingly, the decrease in lactate levels was proportional to the improvement in capillary perfusion (y = 0.07 - 0.02x, r = .46, p = .005) but not to changes in cardiac index (p = .55). The administration of 5 mug/kg.min dobutamine can improve but not restore capillary perfusion in patients with septic shock. These changes are independent of changes in systemic hemodynamic variables.
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              Measurement of functional microcirculatory geometry and velocity distributions using automated image analysis

              This study describes a new method for analyzing microcirculatory videos. It introduces algorithms for quantitative assessment of vessel length, diameter, the functional microcirculatory density distribution and red blood-cell (RBC) velocity in individual vessels as well as its distribution. The technique was validated and compared to commercial software. The method was applied to the sublingual microcirculation in a healthy volunteer and in a patient during cardiac surgery. Analysis time was reduced from hours to minutes compared to previous methods requiring manual vessel identification. Vessel diameter was detected with high accuracy (>80%, d > 3 pixels). Capillary length was estimated within 5 pixels accuracy. Velocity estimation was very accurate (>95%) in the range [2.5, 1,000] pixels/s. RBC velocity was reduced by 70% during the first 10 s of cardiac luxation. The present method has been shown to be fast and accurate and provides increased insight into the functional properties of the microcirculation.
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                Author and article information

                Contributors
                Journal
                Ann Intensive Care
                Ann Intensive Care
                Annals of Intensive Care
                Springer
                2110-5820
                2014
                4 December 2014
                : 4
                : 39
                Affiliations
                [1 ]Academic Medical Center, Department of Translational Physiology, Amsterdam, Netherlands
                [2 ]Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Cátedra de Farmacología Aplicada, Calle 42 N° 577 (1900), La Plata, Argentina
                [3 ]Sanatorio Otamendi y Miroli, Servicio de Terapia Intensiva, Buenos Aires, Argentina
                Article
                s13613-014-0039-3
                10.1186/s13613-014-0039-3
                4298674
                25625013
                fa4a3a3b-c191-490d-b80c-103112339343
                Copyright © 2014 Edul et al.; licensee Springer.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.

                History
                : 12 October 2014
                : 18 November 2014
                Categories
                Research

                Emergency medicine & Trauma
                microcirculation,tissue perfusion,fluid challenge,septic shock,intestine,sublingual,abdominal surgery

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