Sublingual microcirculatory changes during high-volume hemofiltration in hyperdynamic septic shock patients

Carolina Ruiz, Glenn Hernandez, Cristian Godoy, Patricio Downey, Max Andresen, Alejandro Bruhn, Carolina Ruiz, Glenn Hernandez, Cristian Godoy, Patricio Downey, Max Andresen, Alejandro Bruhn

Abstract

Introduction: Previous studies have suggested that high volume hemofiltration (HVHF) may contribute to revert hypotension in severe hyperdynamic septic shock patients. However, arterial pressure stabilization occurs due to an increase in systemic vascular resistance, which could eventually compromise microcirculatory blood flow and perfusion. The goal of this study was to determine if HVHF deteriorates sublingual microcirculation in severe hyperdynamic septic shock patients.

Methods: This was a prospective, non-randomized study at a 16-bed, medical-surgical intensive care unit of a university hospital. We included 12 severe hyperdynamic septic shock patients (norepinephrine requirements > 0.3 μg/kg/min and cardiac index > 3.0 L/min/m2) who underwent a 12-hour HVHF as a rescue therapy according to a predefined algorithm. Sublingual microcirculation (Microscan for NTSC, Microvision Medical), systemic hemodynamics and perfusion parameters were assessed at baseline, at 12 hours of HVHF, and 6 hours after stopping HVHF.

Results: Microcirculatory flow index increased after 12 hours of HVHF and this increase persisted 6 hours after stopping HVHF. A similar trend was observed for the proportion of perfused microvessels. The increase in microcirculatory blood flow was inversely correlated with baseline levels. There was no significant change in microvascular density or heterogeneity during or after HVHF. Mean arterial pressure and systemic vascular resistance increased while lactate levels decreased after the 12-hour HVHF.

Conclusions: The use of HVHF as a rescue therapy in patients with severe hyperdynamic septic shock does not deteriorate sublingual microcirculatory blood flow despite the increase in systemic vascular resistance.

Figures

Figure 1
Figure 1
Effects of high-volume hemofiltration (HVHF) on sublingual microvascular density. The graphs present the individual evolution of total vascular density (upper graph) and perfused vascular density (lower graph) of small vessels (< 20 μm) at baseline, at the end of the 12-hour period of HVHF, and 6 hours after stopping HVHF. There was no significant change. Density is expressed as the number of vessels divided by the total length of the gridline in millimeters.
Figure 2
Figure 2
Effects of high-volume hemofiltration (HVHF) on sublingual microvascular flow. The graphs present the individual evolution of flow assessed by the percentage of perfused vessels (upper graph) and by the microvascular flow index (lower graph) of small vessels (< 20 μm) at baseline, at the end of the 12-hour period of HVHF, and 6 hours after stopping HVHF. *P < 0.05 compared with baseline.
Figure 3
Figure 3
Relationship between baseline sublingual microcirculatory parameters and their change during the 12-hour high-volume hemofiltration (HVHF). The upper graph shows a significant correlation between baseline values of perfused vascular density (PVD) and their variation during the 12-hour HVHF. The lower graph shows a similar correlation between the baseline values of the percentage of perfused vessels (PPV) and their variation during the 12-hour HVHF. Both PVD and PPV were calculated for small vessels (< 20 μm). Density is expressed as the number of vessels divided by the total length of the gridline in millimeters.

References

    1. Honore PM, Jamez J, Wauthier M, Lee PA, Dugernier T, Pirenne B, Hanique G, Matson JR. Prospective evaluation of short-term, high-volume isovolemic hemofiltration on the hemodynamic course and outcome in patients with intractable circulatory failure resulting from septic shock. Crit Care Med. 2000;28:3581–3587. doi: 10.1097/00003246-200011000-00001.
    1. Cornejo R, Downey P, Castro R, Romero C, Regueira T, Vega J, Castillo L, Andresen M, Dougnac A, Bugedo G, Hernandez G. High-volume hemofiltration as salvage therapy in severe hyperdynamic septic shock. Intensive Care Med. 2006;32:713–722. doi: 10.1007/s00134-006-0118-5.
    1. Sprung CL, Annane D, Keh D, Moreno R, Singer M, Freivogel K, Weiss YG, Benbenishty J, Kalenka A, Forst H, Laterre PF, Reinhart K, Cuthbertson BH, Payen D, Briegel J. Hydrocortisone therapy for patients with septic shock. N Engl J Med. 2008;358:111–124. doi: 10.1056/NEJMoa071366.
    1. Lopez A, Lorente JA, Steingrub J, Bakker J, McLuckie A, Willatts S, Brockway M, Anzueto A, Holzapfel L, Breen D, Silverman MS, Takala J, Donaldson J, Arneson C, Grove G, Grossman S, Grover R. Multiple-center, randomized, placebo-controlled, double-blind study of the nitric oxide synthase inhibitor 546C88: effect on survival in patients with septic shock. Crit Care Med. 2004;32:21–30. doi: 10.1097/01.CCM.0000105581.01815.C6.
    1. Levy B, Gibot S, Franck P, Cravoisy A, Bollaert PE. Relation between muscle Na+K+ ATPase activity and raised lactate concentrations in septic shock: a prospective study. Lancet. 2005;365:871–875. doi: 10.1016/S0140-6736(05)71045-X.
    1. Buchele GL, Silva E, Ospina-Tascon GA, Vincent JL, De Backer D. Effects of hydrocortisone on microcirculatory alterations in patients with septic shock. Crit Care Med. 2009;37:1341–1347. doi: 10.1097/CCM.0b013e3181986647.
    1. De Backer D, Creteur J, Dubois MJ, Sakr Y, Koch M, Verdant C, Vincent JL. The effects of dobutamine on microcirculatory alterations in patients with septic shock are independent of its systemic effects. Crit Care Med. 2006;34:403–408. doi: 10.1097/01.CCM.0000198107.61493.5A.
    1. De Backer D, Verdant C, Chierego M, Koch M, Gullo A, Vincent JL. Effects of drotrecogin alfa activated on microcirculatory alterations in patients with severe sepsis. Crit Care Med. 2006;34:1918–1924. doi: 10.1097/01.CCM.0000220498.48773.3C.
    1. Boerma EC, Koopmans M, Konijn A, Kaiferova K, Bakker AJ, van Roon EN, Buter H, Bruins N, Egbers PH, Gerritsen RT, Koetsier PM, Kingma WP, Kuiper MA, Ince C. Effects of nitroglycerin on sublingual microcirculatory blood flow in patients with severe sepsis/septic shock after a strict resuscitation protocol: A double-blind randomized placebo controlled trial. Crit Care Med. 2010;38:93–100. doi: 10.1097/CCM.0b013e3181b02fc1.
    1. Sykora R, Chvojka J, Krouzecky A, Radej J, Karvunidis T, Varnerova V, Novak I, Matejovic M. High versus standard-volume haemofiltration in hyperdynamic porcine peritonitis: effects beyond haemodynamics? Intensive Care Med. 2009;35:371–380. doi: 10.1007/s00134-008-1318-y.
    1. Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Intensive Care Med. 2004;30:536–555. doi: 10.1007/s00134-004-2398-y.
    1. Castro R, Regueira T, Aguirre ML, Llanos OP, Bruhn A, Bugedo G, Dougnac A, Castillo L, Andresen M, Hernandez G. An evidence-based resuscitation algorithm applied from the emergency room to the ICU improves survival of severe septic shock. Minerva Anestesiol. 2008;74:223–231.
    1. 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. Crit Care Med. 1992;20:864–874. doi: 10.1097/00003246-199206000-00025.
    1. De Backer D, Hollenberg S, Boerma C, Goedhart P, Buchele G, Ospina-Tascon G, Dobbe I, Ince C. How to evaluate the microcirculation: report of a round table conference. Crit Care. 2007;11:R101. doi: 10.1186/cc6118.
    1. Cole L, Bellomo R, Journois D, Davenport P, Baldwin I, Tipping P. High-volume haemofiltration in human septic shock. Intensive Care Med. 2001;27:978–986. doi: 10.1007/s001340100963.
    1. Honore PM, Joannes-Boyau O, Boer W, Collin V. High-volume hemofiltration in sepsis and SIRS: current concepts and future prospects. Blood Purif. 2009;28:1–11. doi: 10.1159/000210031.
    1. Sakr Y, Dubois MJ, De Backer D, Creteur J, Vincent JL. Persistent microcirculatory alterations are associated with organ failure and death in patients with septic shock. Crit Care Med. 2004;32:1825–1831. doi: 10.1097/01.CCM.0000138558.16257.3F.
    1. De Backer D, Creteur J, Preiser JC, Dubois MJ, Vincent JL. Microvascular blood flow is altered in patients with sepsis. Am J Respir Crit Care Med. 2002;166:98–104. doi: 10.1164/rccm.200109-016OC.
    1. Trzeciak S, Dellinger RP, Parrillo JE, Guglielmi M, Bajaj J, Abate NL, Arnold RC, Colilla S, Zanotti S, Hollenberg SM. Early microcirculatory perfusion derangements in patients with severe sepsis and septic shock: relationship to hemodynamics, oxygen transport, and survival. Ann Emerg Med. 2007;49:88–98. doi: 10.1016/j.annemergmed.2006.08.021. 98 e81-82.
    1. Dubin A, Pozo MO, Casabella CA, Palizas F Jr, Murias G, Moseinco MC, Kanoore Edul VS, Palizas F, Estenssoro E, Ince C. Increasing arterial blood pressure with norepinephrine does not improve microcirculatory blood flow: a prospective study. Crit Care. 2009;13:R92. doi: 10.1186/cc7922.
    1. Jhanji S, Stirling S, Patel N, Hinds CJ, Pearse RM. The effect of increasing doses of norepinephrine on tissue oxygenation and microvascular flow in patients with septic shock. Crit Care Med. 2009;37:1961–1966. doi: 10.1097/CCM.0b013e3181a00a1c.
    1. Morelli A, Ertmer C, Lange M, Dunser M, Rehberg S, Van Aken H, Pietropaoli P, Westphal M. Effects of short-term simultaneous infusion of dobutamine and terlipressin in patients with septic shock: the DOBUPRESS study. Br J Anaesth. 2008;100:494–503. doi: 10.1093/bja/aen017.
    1. Sakr Y, Chierego M, Piagnerelli M, Verdant C, Dubois MJ, Koch M, Creteur J, Gullo A, Vincent JL, De Backer D. Microvascular response to red blood cell transfusion in patients with severe sepsis. Crit Care Med. 2007;35:1639–1644. doi: 10.1097/01.CCM.0000269936.73788.32.
    1. Boerma EC, van der Voort PH, Spronk PE, Ince C. Relationship between sublingual and intestinal microcirculatory perfusion in patients with abdominal sepsis. Crit Care Med. 2007;35:1055–1060. doi: 10.1097/01.CCM.0000259527.89927.F9.
    1. Verdant CL, De Backer D, Bruhn A, Clausi CM, Su F, Wang Z, Rodriguez H, Pries AR, Vincent JL. Evaluation of sublingual and gut mucosal microcirculation in sepsis: a quantitative analysis. Crit Care Med. 2009;37:2875–2881. doi: 10.1097/CCM.0b013e3181b029c1.

Source: PubMed

Sponsorer og samarbeidspartnere

Medisinsk tilstand

Legemiddelintervensjoner

3
Abonnere