Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1016/j.bjane.2015.10.002
Brazilian Journal of Anesthesiology
Scientific Article

Effects of the positive end-expiratory pressure increase on sublingual microcirculation in patients with acute respiratory distress syndrome

Efeitos do aumento de pressão positiva ao final da expiração sobre a microcirculação sublingual em pacientes com síndrome do desconforto respiratório agudo

Nathaly Fonseca Nunes; Antônio Tonete Bafi; Eduardo Souza Pacheco; Luciano Cesar Pontes de Azevedo; Flavia Ribeiro Machado; Flávio Geraldo Rezende Freitas

http://dx.doi.org/10.1016/j.bjane.2015.10.002 Braz J Anesthesiol, vol.67, n3, p.278-283, 2017
PDF English
PDF Português
Downloads: 0
Views: 666

Abstract

Abstract Objective: The aim of this study was to evaluate the impact of increased positive end-expiratory pressure on the sublingual microcirculation. Methods: Adult patients who were sedated, under mechanical ventilation, and had a diagnosis of circulatory shock and acute respiratory distress syndrome were included. The positive end-expiratory pressure level was settled to obtain a plateau pressure of 30 cm H2O and then maintained at this level for 20 minutes. Microcirculatory (obtained by videomicroscopy) and hemodynamic variables were collected at baseline and compared with those at the end of 20 min. Results: Twelve patients were enrolled. Overall, the microcirculation parameters did not significantly change after increasing the positive end-expiratory pressure. However, there was considerable interindividual variability. There was a negative, moderate correlation between the changes in the De Backer score (r = -0.58, p = 0.048), total vessel density (r = -0.60, p = 0.039) and baseline values. The changes in total vessel density (r = 0.54, p = 0.07) and perfused vessel density (r = 0.52, p = 0.08) trended toward correlating with the changes in the mean arterial pressure. Conclusion: Overall, the microcirculation parameters did not significantly change after increasing the positive end-expiratory pressure. However, at individual level, such response was heterogeneous. The changes in the microcirculation parameters could be correlated with the baseline values and changes in the mean arterial pressure.

Keywords

Adult respiratory distress syndrome, Positive end-expiratory pressure, Microcirculation, Hemodynamics, Shock, Mechanical ventilators

Resumo

Resumo Objetivo: O objetivo deste estudo foi avaliar o impacto do aumento de pressão positiva no fim da expiração (PEEP) sobre a microcirculação sublingual. Métodos: Os pacientes adultos que foram sedados, sob ventilação mecânica, com diagnóstico de choque circulatório e síndrome do desconforto respiratório agudo foram incluídos. O nível da PEEP foi estabelecido para obter uma pressão de platô de 30 cmH2O e depois mantido nesse nível por 20 minutos. As variáveis de microcirculação (obtida por microscopia de vídeo) e hemodinâmica foram registradas na fase basal e comparadas com aquelas no fim de 20 min. Resultados: Doze pacientes foram incluídos. Em geral, os parâmetros da microcirculação não apresentaram alterações significativas após o aumento da PEEP. Porém, houve considerável variabilidade interindividual. Houve uma correlação negativa, moderada, entre as alterações no escore de De Backer (r = -0,58, p = 0,048), na densidade total do vaso (r = -0,60, p = 0,039) e nos valores basais. As alterações na densidade total do vaso (r = 0,54, p = 0,07) e na densidade do vaso perfundido (r = 0,52, p = 0,08) apresentaram tendência de correlação com as alterações na pressão arterial média. Conclusão: Em geral, os parâmetros da microcirculação não apresentaram alterações significativas após o aumento da PEEP. No entanto, individualmente, essa resposta foi heterogênea. As alterações nos parâmetros da microcirculação puderam ser correlacionadas com os valores basais e alterações na pressão arterial média.

Palavras-chave

Síndrome do desconforto respiratório do adulto, Pressão positiva expiratória final, Microcirculação, Hemodinâmica, Choque, Ventiladores mecânicos

References

Dellinger RP, Levy MM, Rhodes A. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;39:165-228.

Briel M, Meade M, Mercat A. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA. 2010;303:865-73.

De Backer D. The effects of positive end-expiratory pressure on the splanchnic circulation. Intensive Care Med. 2000;26:361-3.

Harrois A, Dupic L, Duranteau J. Targeting the microcirculation in resuscitation of acutely unwell patients. Curr Opin Crit Care. 2011;17:303-7.

De Backer D, Orbegozo Cortes D, Donadello K. Pathophysiology of microcirculatory dysfunction and the pathogenesis of septic shock. Virulence. 2014;5:73-9.

De Backer D, Creteur J, Dubois MJ. Microvascular alterations in patients with acute severe heart failure and cardiogenic shock. Am Heart J. 2004;147:91-9.

Trzeciak S, Dellinger RP, Parrillo JE. 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.

Jhanji S, Lee C, Watson D. Microvascular flow and tissue oxygenation after major abdominal surgery: association with post-operative complications. Intensive Care Med. 2009;35:671-7.

De Backer D, Creteur J, Preiser JC. Microvascular blood flow is altered in patients with sepsis. Am J Respir Crit Care Med. 2002;166:98-104.

Sakr Y, Dubois MJ, De Backer D. Persistent microcirculatory alterations are associated with organ failure and death in patients with septic shock. Crit Care Med. 2004;32:1825-31.

Trager K, Radermacher P, Georgieff M. PEEP and hepatic metabolic performance in septic shock. Intensive Care Med. 1996;22:1274-5.

Bruhn A, Hernandez G, Bugedo G. Effects of positive end-expiratory pressure on gastric mucosal perfusion in acute respiratory distress syndrome. Crit Care. 2004;8:R306-11.

Kiefer P, Nunes S, Kosonen P. Effect of positive end-expiratory pressure on splanchnic perfusion in acute lung injury. Intensive Care Med. 2000;26:376-83.

Ranieri VM, Rubenfeld GD, Thompson BT. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012;307:2526-33.

De Backer D, Hollenberg S, Boerma C. How to evaluate the microcirculation: report of a round table conference. Crit Care. 2007;11:R101.

Maddison L, Karjagin J, Buldakov M. Sublingual microcirculation in patients with intra-abdominal hypertension: a pilot study in 15 critically ill patients. J Crit Care. 2014;29.

Nanas S, Magder S. Adaptations of the peripheral circulation to PEEP. Am Rev Respir Dis. 1992;146:688-93.

Orbegozo Cortes D, Puflea F, Donadello K. Normobaric hyperoxia alters the microcirculation in healthy volunteers. Microvasc Res. 2014;98c:23-8.

Vellinga NA, Ince C, Boerma EC. Elevated central venous pressure is associated with impairment of microcirculatory blood flow in sepsis: a hypothesis generating post hoc analysis. BMC Anesthesiol. 2013;13:17.

Bersten AD, Gnidec AA, Rutledge FS. Hyperdynamic sepsis modifies a PEEP-mediated redistribution in organ blood flows. Am Rev Respir Dis. 1990;141(Pt 1):1198-208.

Fry BC, Roy TK, Secomb TW. Capillary recruitment in a theoretical model for blood flow regulation in heterogeneous microvessel networks. Physiol Rep. 2013;1:e00050.

Putensen C, Wrigge H, Hering R. The effects of mechanical ventilation on the gut and abdomen. Curr Opin Crit Care. 2006;12:160-5.

Dubin A, Pozo MO, Casabella CA. Increasing arterial blood pressure with norepinephrine does not improve microcirculatory blood flow: a prospective study. Crit Care. 2009;13:R92.

De Backer D, Creteur J, Dubois MJ. The effects of dobutamine on microcirculatory alterations in patients with septic shock are independent of its systemic effects. Crit Care Med. 2006;34:403-8.

Silva S, Teboul JL. Defining the adequate arterial pressure target during septic shock: not a 'micro' issue but the microcirculation can help. Crit Care. 2011;15:1004.

Thooft A, Favory R, Salgado DR. Effects of changes in arterial pressure on organ perfusion during septic shock. Crit Care. 2011;15:R222.

Pottecher J, Deruddre S, Teboul JL. Both passive leg raising and intravascular volume expansion improve sublingual microcirculatory perfusion in severe sepsis and septic shock patients. Intensive Care Med. 2010;36:1867-74.

Linden A. Assessing regression to the mean effects in health care initiatives. BMC Med Res Methodol. 2013;13:119.

Ruiz C, Hernandez G, Godoy C. Sublingual microcirculatory changes during high-volume hemofiltration in hyperdynamic septic shock patients. Crit Care. 2010;14:R170.

Sakr Y, Chierego M, Piagnerelli M. Microvascular response to red blood cell transfusion in patients with severe sepsis. Crit Care Med. 2007;35:1639-44.

5dcd4eb60e8825a05cbf58f1 rba Articles
Links & Downloads
2352-2291 (Electronic) 0104-0014 (Printed)
Braz J Anesthesiol ©2024 All rights reserved.

Braz J Anesthesiol

Share this page
Page Sections