Effect of early goal directed therapy on tissue perfusion in patients with septic shock

Abstract

BACKGROUND:This study aimed to observe the effect of early goal directed therapy (EGDT) on tissue perfusion, microcirculation and tissue oxygenation in patients with septic shock.METHODS:Patients with early septic shock (<24 hours) who had been admitted to the ICU of Zhongda Hospital Affiliated to Southeast University from September 2009 through May 2011 were enrolled (research time: 12 months), and they didn’t meet the criteria of EGDT. Patients who had one of the following were excluded: stroke, brain injury, other types of shock, severe heart failure, acute myocardial infarction, age below 18 years, pregnancy, end-stage disease, cardiac arrest, extensive burns, oral bleeding, difficulty in opening the mouth, and the onset of septic shock beyond 24 hours. Patients treated with the standard protocol of EGDT were included. Transcutaneous pressure of oxygen and carbon dioxide (PtcO2, PtcCO2) were monitored and hemodynamic measurements were obtained. Side-stream dark field (SDF) imaging device was applied to obtain sublingual microcirculation. Hemodynamics, tissue oxygen, and sublingual microcirculation were compared before and after EGDT. If the variable meets the normal distribution, Student's t test was applied. Otherwise, Wilcoxon's rank-sum test was used. Correlation between variables was analyzed with Pearson's product-moment correlation coefficient method.RESULTS:Twenty patients were involved, but one patient wasn’t analyzed because he didn’t meet the EGDT criteria. PtcO2 and PtcCO2 were monitored in 19 patients, of whom sublingual microcirculation was obtained. After EGDT, PtcO2 increased from 62.7±24.0 mmHg to 78.0±30.9 mmHg (P<0.05) and tissue oxygenation index (PtcO2/FiO2) was 110.7±60.4 mmHg before EGDT and 141.6±78.2 mmHg after EGDT (P<0.05). The difference between PtcCO2 and PCO2 decreased significantly after EGDT (P<0.05). The density of perfused small vessels (PPV) and microcirculatory flow index of small vessels (MFI) tended to increase, but there were no significant differences between them (P>0.05). PtcO2, PtcO2/FiO2, and PtcCO2 were not linearly related to central venous saturation, lactate, oxygen delivery, and oxygen consumption (P>0.05).CONCLUSION:Peripheral perfusion was improved after EGDT in patients with septic shock, and it was not exactly reflected by the index of systemic perfusion.

Microcirculatory Perfusion During Different Perioperative Hemodynamic Strategies

“…Lu et al . did not find an improvement of microcirculatory perfusion in septic patients treated with early goal‐directed therapy based on central venous pressure, MAP, and SvO 2 . While Bansch, Flisberg, and Bentzer showed only minor alterations in sublingual microcirculatory perfusion during major abdominal surgery , Jhanji et al .…”

Presepsin as a novel sepsis biomarker

“…There are many reported biological markers such as procalcitonin (PCT), interleukins, pro-vasopressin, C-reactive protein (CRP) and myeloid cells expressing triggering receptor-1 (TREM-1). [5][6][7][8] The studies of these biomarkers on sepsis concerning the diagnosis, assessment, antibiotic treatment, and prognosis have attracted extensive attention from researchers. Except PCT, however, the clinical values of the other biomarkers are still uncertain or controversial.…”

Relationship between Microcirculatory Perfusion and Arterial Elastance: A Pilot Study

“…We found only a weak correlation between PPV and arterial elastance. Similarly, other studies showed a weak, and often transitory, correlation between PPV and macrohemodynamic parameters (e.g., cardiac output, oxygen delivery, and venous oxygen saturation) in septic patients [20, 21]. It could be also speculated that arterial elastance may be more influenced by the arteriolar tone, while other factors, such as tissue edema, neural perivascular activity, and changes in red blood cells deformability, may impact on capillary density and perfusion.…”