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Effects of changes in arterial pressure on organ perfusion during septic shock.doc

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Effects of changes in arterial pressure on organ perfusion during septic shock

Thooftetal.CriticalCare2011,15:R222 /content/15/5/R222 RESEARCH OpenAccess Effectsofchangesinarterialpressureonorgan perfusionduringsepticshock AurélieThooft,Rapha?lFavory,DiamantinoRibeiroSalgado,FabioSTaccone,KatiaDonadello,DanielDeBacker, JacquesCreteurandJean-LouisVincent* Abstract Introduction:Septicshockischaracterizedbyalteredtissueperfusionassociatedwithpersistentarterial hypotension.Vasopressortherapyisgenerallyrequiredtorestoreorganperfusionbuttheoptimalmeanarterial pressure(MAP)thatshouldbetargetedisuncertain.Theaimofthisstudywastoassesstheeffectsofincreasing MAPusingnorepinephrine(NE)onhemodynamicandmetabolicvariablesandonmicrovascularreactivityin patientswithsepticshock. Methods:Thiswasasinglecenter,prospective,interventionalstudyconductedinthemedico-surgicalintensive careunitofauniversityhospital.Thirteenpatientsinsepticshockforlessthan48hourswhorequiredNE administrationwereincluded.NEdoseswereadjustedtoobtainMAPsof65,75,85and(backto)65mmHg.In additiontohemodynamicandmetabolicvariables,wemeasuredthenarmuscleoxygensaturation(StO2 ),using nearinfraredspectroscopy(NIRS),withserialvaso-occlusivetests(VOTs)ontheupperarm.Wealsoevaluatedthe sublingualmicrocirculationusingsidestreamdarkfield(SDF)imagingin6ofthepatients. Results:IncreasingNEdosewasassociatedwithanincreaseincardiacoutput(from6.1to6.7l/min,P0.05)and mixedvenousoxygensaturation(SvO2,from70.6to75.9%,P0.05).Oxygenconsumption(VO2)remainedstable, butbloodlactatelevelsdecreased.TherewasasignificantincreaseintheascendingslopeofStO2(from111to 177%/min,P0.05)afterVOTs.SDFimagingshowedanincreaseinperfusedvesseldensity(PVD,from11.0to13.2 n/mm,P0.05)andinmicrovascularflowindex(MFI,from2.4to2.9,P0.05). Conclusions:Inthisseriesofpatientswithsepticshock,increasingMAPabove65mmHgwithNEwasassociated withincreasedcardiacoutput,improvedmicrovascularfunction,anddecreasedbloodlactateconcentrations.The microvascularresponsevariedamongpatientssuggestingthatindividualizationofbloodpressuretargetsmaybe warranted. Introd