The role of vasoactive agents in the resuscitation of microvascular perfusion and tissue oxygenation in critically ill patients

E Christiaan Boerma, Can Ince, E Christiaan Boerma, Can Ince

Abstract

Purpose: The clinical use of vasoactive drugs is not only intended to improve systemic hemodynamic variables, but ultimately to attenuate derangements in organ perfusion and oxygenation during shock. This review aims (1) to discuss basic physiology with respect to manipulating vascular tone and its effect on the microcirculation, and (2) to provide an overview of available clinical data on the relation between vasoactive drugs and organ perfusion, with specific attention paid to recent developments that have enabled direct in vivo observation of the microcirculation and concepts that have originated from it.

Methods: A MedLine search was conducted for clinical articles in the English language over the last 15 years pertainig to shock, sepsis, organ failure, or critically ill patients in combination with vasoactive drugs and specific variables of organ perfusion/oxygenation (e.g., tonometry, indocyanine clearance, laser Doppler, and sidestream dark field imaging).

Results: Eighty original papers evaluating the specific relationship between organ perfusion/oxygenation and the use of vasoactive drugs were identified and are discussed in light of physiological theory of vasomotor tone.

Conclusions: Solid clinical data in support of the idea that increasing blood pressure in shock improves microcirculatory perfusion/oxygenation seem to be lacking, and such a concept might not be in line with physiological theory of microcirculation as a low-pressure vascular compartment. In septic shock no beneficial effect on microcirculatory perfusion above a mean arterial pressure of 65 mmHg has been reported, but a wide range in inter-individual effect seems to exist. Whether improvement of microcirculatory perfusion is associated with better patient outcome remains to be elucidated.

Figures

Fig. 1
Fig. 1
Left panel arteriolar vasodilation increases the opening pressure of the microcirculation as result of a decrease in pressure drop prior to the microvascular compartment. Right panel combined arteriolar and venular increment of vascular tone reduces the net driving pressure over the microvascular compartment (from [17] by permission)
Fig. 2
Fig. 2
Convective transport of oxygen through the capillaries depends on red blood cell velocity, capillary hematocrit and oxygen saturation. Oxygen transport from the capillary to the cell via diffusion is inversely related to the diffusion distance (D1 and D2) according to Fick’s law
Fig. 3
Fig. 3
Under experimental conditions with a systemic hematocrit (HA) of 50%, capillary hematocrit (Hcap) ranges from 6.8% under vasoconstriction to 38% under vasodilation. (From [20] by permission)

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Source: PubMed

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