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Critical Care

, 15:R222

First Online: 21 September 2011Received: 28 April 2011Revised: 15 July 2011Accepted: 21 September 2011

Abstract

IntroductionSeptic shock is characterized by altered tissue perfusion associated with persistent arterial hypotension. Vasopressor therapy is generally required to restore organ perfusion but the optimal mean arterial pressure MAP that should be targeted is uncertain. The aim of this study was to assess the effects of increasing MAP using norepinephrine NE on hemodynamic and metabolic variables and on microvascular reactivity in patients with septic shock.

MethodsThis was a single center, prospective, interventional study conducted in the medico-surgical intensive care unit of a university hospital. Thirteen patients in septic shock for less than 48 hours who required NE administration were included. NE doses were adjusted to obtain MAPs of 65, 75, 85 and back to 65 mmHg. In addition to hemodynamic and metabolic variables, we measured thenar muscle oxygen saturation StO2, using near infrared spectroscopy NIRS, with serial vaso-occlusive tests VOTs on the upper arm. We also evaluated the sublingual microcirculation using sidestream dark field SDF imaging in 6 of the patients.

ResultsIncreasing NE dose was associated with an increase in cardiac output from 6.1 to 6.7 l-min, P<0.05 and mixed venous oxygen saturation SvO2, from 70.6 to 75.9%, P<0.05. Oxygen consumption VO2 remained stable, but blood lactate levels decreased. There was a significant increase in the ascending slope of StO2 from 111 to 177%-min, P<0.05 after VOTs. SDF imaging showed an increase in perfused vessel density PVD, from 11.0 to 13.2 n-mm, P<0.05 and in microvascular flow index MFI, from 2.4 to 2.9, P<0.05.

ConclusionsIn this series of patients with septic shock, increasing MAP above 65 mmHg with NE was associated with increased cardiac output, improved microvascular function, and decreased blood lactate concentrations. The microvascular response varied among patients suggesting that individualization of blood pressure targets may be warranted.

AbbreviationsCVPcentral venous pressure

DO2oxygen delivery

FCDfunctional capillary density

MAPmean arterial pressure

MFImicrovascular flow index

NEnorepinephrine

NIRSnear-infrared spectroscopy

nirVO2Ireverse descending slope multiplied by the average tissue hemoglobin index during the first occlusion minute

PPpulse pressure

PVDperfused vessel density

SDFsidestream dark field

StO2thenar muscle oxygen saturation

SvO2mixed venous oxygen saturation

THItissue hemoglobin index

VO2oxygen consumption

VOTvascular occlusion test.

Electronic supplementary materialThe online version of this article doi:10.1186-cc10462 contains supplementary material, which is available to authorized users.

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Autor: Aurélie Thooft - Raphaël Favory - Diamantino Ribeiro Salgado - Fabio S Taccone - Katia Donadello - Daniel De Backer - Ja

Fuente: https://link.springer.com/







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