Side effects of positive pressure ventilation on hepatic function and splanchnic circulation

Geiger, K.; Georgieff, Michael; Lutz, H

doi:10.1007/bf01880762

Cited by 12 publications

(5 citation statements)

References 21 publications

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“…The NEOPAIN group were very premature, and all required mechanical ventilation, which may give some clue to the reasons for this difference. Positive pressure ventilation can reduce hepatic blood flow by up to 45% (37), causing reduced clearance in drugs with a high hepatic extraction ratio, for example morphine and lignocaine (38,39). There are neonates who were ventilated and appear to have higher clearances than predicted (Figure 2), which indicates that there must be other unidentified factors accounting for this.…”

Section: Discussionmentioning

confidence: 99%

Prediction of morphine dose in humans

Holford

Anderson

2011

Pediatric Anesthesia

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Section: Discussionmentioning

confidence: 99%

Prediction of morphine dose in humans

Holford

Anderson

2011

Pediatric Anesthesia

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“…Gastric pH i , and consequently splanchnic blood flow, remained stable at PEEP opt and PEEP max when cardiac output and DO2 remained relatively unchanged. Preservation of splanchnic blood flow at PEEP opt and PEEP max was attributed to an increase in oxygen extraction ratio that was sufficient to compensate for the small, insignificant drop in cardiac output and DO 2 that occurred during PEEP titration [ 15 ].…”

Section: Discussionmentioning

confidence: 99%

Gastric intramucosal pH is stable during titration of positive end-expiratory pressure to improve oxygenation in acute respiratory distress syndrome

Akıncı¹,

Çakar²,

Mutlu

et al. 2003

Crit Care

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Correspondence: I Ozkan Akinci, iozkana@yahoo.com R17 ALI = acute lung injury; ARDS = acute respiratory distress syndrome; DO 2 = oxygen delivery; MAP = mean arterial pressure; Pao 2 = partial arterial oxygen tension; P (t-a) CO 2 = gap between partial tissue and arterial carbon dioxide tension; PEEP = positive end-expiratory pressure; pH i = gastric mucosal pH. AbstractBackground Optimal positive end-expiratory pressure (PEEP) is an important component of adequate mechanical ventilation in acute lung injury and acute respiratory distress syndrome (ARDS). In the present study we tested the effect on gastric intramucosal pH of incremental increases in PEEP level (i.e. PEEP titration) to improve oxygenation in ARDS. Seventeen consecutive patients with ARDS, as defined by consensus criteria, were included in this clinical, prospective study. All patients were haemodynamically stable and were not receiving vasopressors. From an initial level of 5 cmH 2 O, PEEP was titrated at 2 cmH 2 O increments until the partial arterial oxygen tension was 300 mmHg or greater, peak airway pressure was 45 cmH 2 O or greater, or mean arterial blood pressure decreased by 20% or more of the baseline value. Optimal PEEP was defined as the level of PEEP that achieved the best oxygenation. The maximum PEEP was the highest PEEP level reached during titration in each patient. Results Gastric mucosal pH was measured using gastric tonometry at all levels of PEEP. The thermodilution technique was used for measurement of cardiac index. Gastric mucosal pH was similar at baseline and at optimal PEEP levels, but it was slightly reduced at maximum PEEP. Cardiac index and oxygen delivery remained stable at all PEEP levels. Conclusion Incremental titration of PEEP based on improvement in oxygenation does not decrease gastric intramucosal perfusion when cardiac output is preserved in patients with ARDS.

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“…Mean PEEP in our cohort was correlated to GGT on day 10 though, but only with a low effect level. Above that, linear regression did not find causation of increased GGT levels for PEEP alone, nor for the combination of PEEP and prone position, both factors that have been reported to reduce splanchnic perfusion [ 24 , 40 , 41 ]. These results largely exclude ischemic hypoxia as a cause of the GGT profile we found in our cohort but suggest that the increase and rise in GGT must be caused by another mechanism.…”

Section: Discussionmentioning

confidence: 98%

“…The underlying mechanism here could be due to splanchnic perfusion impairments due to increased levels of PEEP (ischemic hypoxia) rather than due to gas exchange impairments. Increased PEEP levels could lead to a mechanically conditioned form of decreased splanchnic perfusion [ 24 , 40 , 41 ]. In this scenario, an increase in PEEP would consecutively increase intraabdominal pressure, leading to a partial functional mechanical obstruction of the liver supplying vessels of the liver; this effect could even be aggravated by prone positioning [ 41 ].…”

Section: Discussionmentioning

confidence: 99%

“…Increased PEEP levels could lead to a mechanically conditioned form of decreased splanchnic perfusion [ 24 , 40 , 41 ]. In this scenario, an increase in PEEP would consecutively increase intraabdominal pressure, leading to a partial functional mechanical obstruction of the liver supplying vessels of the liver; this effect could even be aggravated by prone positioning [ 41 ]. Another mechanism with the same result of reduced hepatic perfusion is hepatic congestion due to increased levels of PEEP and consecutive increased intrathoracic pressure.…”

Section: Discussionmentioning

confidence: 99%

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Biomarkers of Cholestasis and Liver Injury in the Early Phase of Acute Respiratory Distress Syndrome and Their Pathophysiological Value

et al. 2021

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Background: Impaired liver function and cholestasis are frequent findings in critically ill patients and are associated with poor outcomes. We tested the hypothesis that hypoxic liver injury and hypoxic cholangiocyte injury are detectable very early in patients with ARDS, may depend on the severity of hypoxemia, and may be aggravated by the use of rescue therapies (high PEEP level and prone positioning) but could be attenuated by extracorporeal membrane oxygenation (ECMO). Methods: In 70 patients with ARDS, aspartate-aminotransferase (AST), alanin-aminotransferase (ALT) and gamma glutamyltransferase (GGT) were measured on the day of the diagnosis of ARDS and three more consecutive days (day 3, day 5, day 10), total bile acids were measured on day 0, 3, and 5. Results: AST levels increased on day 0 and remained constant until day 5, then dropped to normal on day 10 (day 0: 66.5 U/l; day 3: 60.5 U/l; day 5: 63.5 U/l, day 10: 32.1 U/l), ALT levels showed the exact opposite kinetic. GGT was already elevated on day 0 (91.5 U/l) and increased further throughout (day 3: 163.5 U/l, day 5: 213 U/l, day 10: 307 U/l), total bile acids levels increased significantly from day 0 to day 3 (p = 0.019) and day 0 to day 5 (p < 0.001), but not between day 3 and day 5 (p = 0.217). Total bile acids levels were significantly correlated to GGT on day 0 (p < 0.001), day 3 (p = 0.02), and in a trend on day 5 (p = 0.055). PEEP levels were significantly correlated with plasma levels of AST (day 3), ALT (day 5) and GGT (day 10). Biomarker levels were not associated with the use of ECMO, prone position, the cause of ARDS, and paO2. Conclusions: We found no evidence of hypoxic liver injury or hypoxic damage to cholangiocytes being caused by the severity of hypoxemia in ARDS patients during the very early phase of the disease. Additionally, mean PEEP level, prone positioning, and ECMO treatment did not have an impact in this regard. Nevertheless, GGT levels were elevated from day zero and rising, this increase was not related to paO2, prone position, ECMO treatment, or mean PEEP, but correlated to total bile acid levels.

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Side effects of positive pressure ventilation on hepatic function and splanchnic circulation

Cited by 12 publications

References 21 publications

Prediction of morphine dose in humans

Prediction of morphine dose in humans

Gastric intramucosal pH is stable during titration of positive end-expiratory pressure to improve oxygenation in acute respiratory distress syndrome

Biomarkers of Cholestasis and Liver Injury in the Early Phase of Acute Respiratory Distress Syndrome and Their Pathophysiological Value

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