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

Results: Fluid administration increased the cardiac index (2.6 ± 0.5 vs. 3.3 ± 1.0 L/min/m2, 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/mm2 and 12.3 ± 6.7 vs. 13.0 ± 6.7 mm/mm2). 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.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.Background: This study was performed to compare intestinal and sublingual microcirculation and their response to a fluid challenge.Facultad de Ciencias Médica

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

Results: Fluid administration increased the cardiac index (2.6 ± 0.5 vs. 3.3 ± 1.0 L/min/m2, 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/mm2 and 12.3 ± 6.7 vs. 13.0 ± 6.7 mm/mm2). 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.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.Background: This study was performed to compare intestinal and sublingual microcirculation and their response to a fluid challenge.Facultad de Ciencias Médica

Incremento da depuração renal em pacientes gravemente enfermos: Incidência, fatores associados e efeitos no tratamento com vancomicina

Objective: An augmented renal clearance has been described in some groups of critically ill patients, and it might induce sub-optimal concentrations of drugs eliminated by glomerular filtration, mainly antibiotics. Studies on its occurrence and determinants are lacking. Our goals were to determine the incidence and associated factors of augmented renal clearance and the efects on vancomycin concentrations and dosing in a series of intensive care unit patients. Methods: We prospectively studied 363 patients admitted during 1 year to a clinical-surgical intensive care unit. Patients with serum creatinine >1.3mg/dL were excluded. Creatinine clearance was calculated from a 24-hour urine collection. Patients were grouped according to the presence of augmented renal clearance (creatinine clearance >120mL/min/1.73m2), and possible risk factors were analyzed with bivariate and logistic regression analysis. In patients treated with vancomycin, dosage and plasma concentrations were registered. Results: Augmented renal clearance was present in 103 patients (28%); they were younger (48±15 versus 65±17 years, p>0.0001), had more frequent obstetric (16 versus 7%, p=0.0006) and trauma admissions (10 versus 3%, p=0.016) and fewer comorbidities. The only independent determinants for the development of augmented renal clearance were age (OR 0.95; p<0.0001; 95%CI 0.93-0.96) and absence of diabetes (OR 0.34; p=0.03; 95%CI 0.12-0.92). Twelve of the 46 patients who received vancomycin had augmented renal clearance and despite higher doses, had lower concentrations. Conclusions: In this cohort of critically ill patients, augmented renal clearance was a common finding. Age and absence of diabetes were the only independent determinants. Therefore, younger and previously healthy patients might require larger vancomycin dosing.Facultad de Ciencias Médica

Incremento da depuração renal em pacientes gravemente enfermos: Incidência, fatores associados e efeitos no tratamento com vancomicina

Objective: An augmented renal clearance has been described in some groups of critically ill patients, and it might induce sub-optimal concentrations of drugs eliminated by glomerular filtration, mainly antibiotics. Studies on its occurrence and determinants are lacking. Our goals were to determine the incidence and associated factors of augmented renal clearance and the efects on vancomycin concentrations and dosing in a series of intensive care unit patients. Methods: We prospectively studied 363 patients admitted during 1 year to a clinical-surgical intensive care unit. Patients with serum creatinine >1.3mg/dL were excluded. Creatinine clearance was calculated from a 24-hour urine collection. Patients were grouped according to the presence of augmented renal clearance (creatinine clearance >120mL/min/1.73m2), and possible risk factors were analyzed with bivariate and logistic regression analysis. In patients treated with vancomycin, dosage and plasma concentrations were registered. Results: Augmented renal clearance was present in 103 patients (28%); they were younger (48±15 versus 65±17 years, p>0.0001), had more frequent obstetric (16 versus 7%, p=0.0006) and trauma admissions (10 versus 3%, p=0.016) and fewer comorbidities. The only independent determinants for the development of augmented renal clearance were age (OR 0.95; p<0.0001; 95%CI 0.93-0.96) and absence of diabetes (OR 0.34; p=0.03; 95%CI 0.12-0.92). Twelve of the 46 patients who received vancomycin had augmented renal clearance and despite higher doses, had lower concentrations. Conclusions: In this cohort of critically ill patients, augmented renal clearance was a common finding. Age and absence of diabetes were the only independent determinants. Therefore, younger and previously healthy patients might require larger vancomycin dosing.Facultad de Ciencias Médica

Fluidos no período pós-operatório: efeitos da falta de ajuste ao peso corpóreo Líquidos en el período postoperatorio: efectos de la falta de ajuste al peso corporal Fluids in the postoperative period: effects of lack of adjustment to body weight

OBJETIVO: Comparar as diferenças no equilíbrio hídrico e eletrolítico em pacientes com baixo e alto peso corpóreo no primeiro dia pós-operatório. MÉTODOS: Em um período de 18 meses avaliamos prospectivamente 150 pacientes durante as primeiras 24 horas após cirurgia, na unidade de terapia intensiva de um hospital universitário. Pacientes com baixo (<60 kg) e alto peso corpóreo (>90 kg) foram comparados em termos de fornecimento e eliminação de fluidos. RESULTADOS: Não foram observadas diferenças significantes em termos de volume (4,334 ± 1,097 em versus 4,644 ± 1,957 mL/24 horas) e composição dos fluidos administrados (481 ± 187 versus 586 ± 288 mEq [Na+]administrados em 24 horas). O débito urinário em 24 horas foi similar (2,474 ± 1,597 versus 2,208 ± 678 mL/24 horas), porém o grupo com baixo peso teve uma maior eliminação de eletrólitos (296 ± 195 versus 192 ± 117 mEq [Na+]urina/24 horas, p=0.0246). Quando os fluidos administrados foram ajustados ao peso corpóreo, o volume e quantidade de eletrólitos dos fluidos administrados foram maiores no grupo com baixo peso (79 ± 21 versus 47 ± 22 mL/ kg/24 horas, p<0.0001 e 8,8 ± 3,4 versus 5,8 ± 3,3 mEq [Na+]administrado/kg/24 horas, p=0,017, respectivamente). Este grupo também demonstrou maior débito urinário e eliminação de eletrólitos (45 ± 28 versus 22 ± 7 mL/kg/24 horas; p=0,0002 e 5.3 ± 3.5 vs. 1.8 ± 1.2 mEq [Na+]urina/ kg/24 horas; p<0,0001, respectivamente). CONCLUSÕES: A falta de ajuste da terapia hídrica ao peso corpóreo determinou que os pacientes com peso baixo recebessem mais líquidos do que os pacientes com peso elevado, de acordo com o peso corpóreo. A sobrecarga hídrica poderia ser compensada pelo aumento do débito urinário e eliminação de eletrólitos.<br>OBJETIVO: Comparar las diferencias en el equilibrio de líquidos y electrolitos en los pacientes con bajo y alto peso en el primer día postoperatorio. MÉTODOS: Durante un período de 18 meses, evaluamos prospectivamente 150 pacientes, en las primeras 24 horas después de la cirugía, en una unidad de cuidados intensivos de un hospital escuela afiliado auna universidad. Se compararon pacientes con bajo (< 60 kg) y alto peso corporal (> 90 Kg) en términos de ingesta y excreción urinariade agua y electrolitos. RESULTADOS: No se observaron diferencias significativas en el volumen (4,334 ± 1,097 vs. 4,644 ± 1,957 ml/24 hs.) y la composición de los líquidos administrados (481 ± 187 vs. 586 ± 288 mEq [Na +]administrado/24 hs). El volumen de La diuresis en24 horas fue similar (2,474 ± 1,597 vs 2208 ± 678 ml/24 hs.), pero el grupo de bajo peso mostró una mayor eliminación de electrolitos (296 ± 195 vs. 192 ± 117 mEq [Na +]orina/ 24 hs., p = 0,0246). Cuando los líquidos administrados fueron ajustados por peso corporal, el volumen y cantidad de electrolitos fueron mayores en el grupo de bajo peso (79 ± 21 vs. 47 ± 22 ml/kg/24h, p <0,0001 y 8,8 ± 3,4 vs. 5,8 ± 3,3 mEq [Na +]administrado/kg/24 hs., p = 0,017, respectivamente). Este grupo también mostró mayores producción de orina y eliminación de electrolitos (45 ± 28 vs. 22 ± 7 ml/kg/24 hs., p = 0,0002 y 5,3 ± 3,5 frente a 1,8 ± 1,2 mEq [Na+]orina/kg/24 hs., p <0,0001, respectivamente). CONCLUSIONES: La falta de ajuste de la terapia con fluidos al peso corporal determinó que los pacientes de bajo peso recibieran más líquidos que los pacientes de alto peso, de acuerdo a su peso corporal. Esta sobrecarga de líquidos pudo ser compensada por el aumento de la diuresis y la eliminación de electrolitos.<br>OBJECTIVE: To compare the differences in fluid and electrolyte balance in patients with low and high weight in the first postoperative day. METHODS: Over a period of 18 months, we prospectively evaluated 150 patients in the first 24 hours after surgery, in a university-affiliated hospital intensive care unit. Patients with low weight (< 60 kg) and high body weight (> 90 Kg) were compared in terms of fluid intake and output. RESULTS: No significant differences were observed in the volume (4334 ± 1097 vs. 4644 ± 1957 ml/24 h) and composition of the fluids administered (481 ± 187 vs. 586 ± 288 mEq [Na+]administered/24 h). The 24 h urine output was similar (2474 ± 1597 vs.2208 ± 678 ml/24 h) but low weight group showed higher electrolyte elimination (296 ± 195 vs.192 ± 117 mEq [Na+]urine /24 h, p = 0.0246). When the administered fluids were adjusted for body weight, the volume and amount of electrolytes of fluids administered were higher in the low weight group (79 ± 21 vs. 47 ± 22 ml/kg/24 h, p < 0.0001 and 8.8 ± 3.4 vs. 5.8 ± 3.3 mEq [Na+]administered/kg/24 h, p = 0.017, respectively). This group also showed higher urine output and electrolyte elimination (45 ± 28 vs. 22 ± 7 ml/kg/24 h, p = 0.0002 and 5.3 ± 3.5 vs. 1.8 ± 1.2 mEq [Na+]urine/kg/24 h, p < 0.0001, respectively). CONCLUSIONS: The lack of adjustment of the fluid therapy to body weight determined that low weight patients received more fluid than high weight patients according to their body weight. This fluid overload could be compensated by increased urine output and electrolyte elimination

Quantitative assessment of the microcirculation in healthy volunteers and in patients with septic shock.

International audienceOBJECTIVE: The microcirculation of septic patients has been characterized only semiquantitatively. Our goal was to characterize the sublingual microcirculation in healthy volunteers and patients with septic shock quantitatively. Our hypotheses were that 1) hyperdynamic blood flow is absent in septic shock; 2) nonsurvivors show more severe alterations than survivors; and 3) quantitative and semiquantitative microcirculatory parameters have a similar performance. DESIGN: Prospective, observational study. SETTING: Teaching intensive care unit in a university-affiliated hospital. SUBJECTS: Twenty-five normal volunteers and 25 patients with septic shock. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The sublingual microcirculation was evaluated by means of sidestream dark field imaging. Semiquantitative and quantitative microcirculatory parameters were determined through the use of applied software. Septic patients showed decreased perfused capillary density (13.2±4.4 mm/mm² vs. 16.6±1.6 mm/mm²), proportion of perfused capillaries (0.78±0.23 vs. 1.00±0.01), microvascular flow index (2.15±0.61 vs. 2.97±0.03), and red blood cell velocity (830±183 µm/sec vs. 1332±187 µm/sec) along with increased heterogeneity flow index (1.64±1.14 vs. 0.25±0.19) compared with controls. No differences were found in total capillary density (16.9±2.2 vs. 16.7±1.6). Only 4% of capillaries analyzed showed red blood cell velocities>75th percentile of the velocities of the normal volunteers. The nonsurvivors exhibited decreased perfused capillary density, proportion of perfused capillaries, and microvascular flow index along with increased heterogeneity flow index compared with the survivors. The correlations between microvascular flow index and proportion of perfused capillaries, total capillary density and number of grid-crossing capillaries, and red blood cell velocities and microvascular flow index gave high R values (0.92, 0.65, and 0.52, respectively; p<.0001 for all). CONCLUSIONS: The main characteristics of sublingual microcirculation in patients with septic shock are hypoperfusion and increased flow heterogeneity. Hyperdynamic microvascular blood flow was not found. Nonsurvivors showed more severe alterations than survivors. Quantitative and semiquantitative microcirculatory variables displayed similar behaviors

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

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 mu m/s, P <0.002 and 679 +/- 379 vs. 747 +/- 419 mu m/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 territor

Similar Microcirculatory Alterations in Patients with Normodynamic and Hyperdynamic Septic Shock

Rationale: In normodynamic septic shock, the quantitative assessment of sublingual microcirculation has shown decreases in perfused vascular density and red blood cell velocity. However, no studies have been performed in hyperdynamic septic shock. Objectives: To characterize the microcirculatory patterns and rule out the presence of fast red blood cell velocity in patients with hyperdynamic septic shock. Methods: We prospectively evaluated the sublingual microcirculation in healthy volunteers (n = 20) and in patients with hyperdynamic (n = 20) and normodynamic (n = 20) septic shock. Hyperdynamic septic shock was defined by a cardiac index >4.0 L/min/m(2). The microcirculation was assessed with sidestream dark field imaging and AVA 3.0 software. Measurements and Main Results: There were no differences in perfused vascular density, proportion of perfused vessels, or microvascular flow index between patients with hyperdynamic and normodynamic septic shock, but these variables were reduced compared with those of healthy volunteers, A similar pattern was observed in red blood cell velocity (9126291, 9686204, and 13036 120 mm/s, respectively; P <0.0001) and its coefficient of variation. In both types of septic shock, no microvessel had a red blood cell velocity higher than the 100th percentile value for healthy volunteers. Conclusions: Patients with hyperdynamic septic shock showed microcirculatory alterations similar to those of patients with normal cardiac output. Both groups of patients had reduced perfused vascular density and red blood cell velocity and increased flow heterogeneity compared with that of healthy subjects. Fast red blood cell velocity was not found, even in patients with high cardiac output. These results support the conclusion that microcirculatory function is frequently dissociated from systemic hemodynamic derangements in septic shoc

Systemic and microcirculatory effects of dobutamine in patients with septic shock

Purpose: The aim of this study was to characterize the cardiovascular responses to dobutamine and their predictors. Our hypotheses were that dobutamine mainly produces tachycardia and vasodilation and fails to improve the microcirculation of patients with septic shock. Materials and Methods: Systemic hemodynamics and sublingual microcirculation were evaluated with dobutamine (0, 2.5, 5.0, and 10.0 mu g kg(-1) min(-1)) in 23 patients with septic shock. Results: Dobutamine increased heart rate, cardiac index, and stroke volume index (SVI). Mean blood pressure was unchanged, and systemic vascular resistance decreased. Individual responses were heterogeneous. Stroke volume index increased in 52% of the patients. These patients showed lower changes in mean blood pressure (3 +/- 16 mm Hg vs -10 +/- 6 mm Hg, P <.05) and higher increases in cardiac index (1.47 +/- 0.93 L m(-1) m(-2) vs 0.20 +/- 0.5 L m(-1) m(-2)) than did nonresponders. Changes in SVI significantly correlated with echocardiographic left ventricular ejection fraction (r = 0.55). In the whole group, perfused capillary density remained unchanged (14.0 +/- 4.3 mm/mm(2) vs 14.8 +/- 3.7 mm/mm(2)), but improved if basal values were 12 mm/mm(2) or less (9.1 +/- 4.3 mm/mm(2) vs 12.5 +/- 4.8 mm/mm(2)). Conclusions: Dobutamine produced variable hemodynamic effects. Systolic dysfunction was the only variable associated with increases in SVI. Finally, dobutamine only improved sublingual microcirculation when severe alterations were found at baseline. (C) 2012 Elsevier Inc. All rights reserve