Effects of Short-term Fenoldopam Infusion on Gastric Mucosal Blood Flow in Septic Shock

Background: Inadequate splanchnic perfusion in septic shock is associated with increased morbidity and mortality. As result of splanchnic ischemia, mucosal permeability increases. Considering the implication of improved mucosal perfusion in terms of maintenance of mucosal barrier integrity, dopamine-1 receptor stimulation could be helpful in septic shock. The goal of the current study was to determine the effects of fenoldopam on systemic hemodynamic parameters and gastric mucosal perfusion in patients with septic shock. Furthermore, the authors tested the hypothesis that the addition of fenoldopam (0.1 [mu]g [middle dot] kg-1 [middle dot] min-1) to a combination of norepinephrine and dobutamine (5 [mu]g [middle dot] kg-1 [middle dot] min-1) may improve gastric mucosal perfusion in septic shock.

Methods: Patients with septic shock were randomized to a double-blind 2-h infusion of fenoldopam (n = 20) or placebo (n = 20). Each group received dobutamine (5 [mu]g [middle dot] kg-1 [middle dot] min-1), and the dosage of norepinephrine was adjusted to achieve a mean arterial pressure between 70 and 80 mmHg. A laser-Doppler probe and tonometer were introduced into the gastric lumen.

Results: A significant increase in gastric mucosal perfusion, detected by laser-Doppler flowmetry, was observed in the group treated with fenoldopam (P < 0.05). In addition, this increase in microcirculatory flow occurred despite the fact that systemic flow remained unchanged. Differences in gastroarterial partial pressure of carbon dioxide values were not statistically significant in the fenoldopam and placebo groups.     

Effects of Vasopressin on Microcirculatory Blood Flow in the Gastrointestinal Tract in Anesthetized Pigs in Septic Shock

Background: Vasopressin increases arterial pressure in septic shock even when [alpha]-adrenergic agonists fail. The authors studied the effects of vasopressin on microcirculatory blood flow in the entire gastrointestinal tract in anesthetized pigs during early septic shock.

Methods: Thirty-two pigs were intravenously anesthetized, mechanically ventilated, and randomly assigned to one of four groups (n = 8 in each; full factorial design). Group S (sepsis) and group SV (sepsis-vasopressin) were made septic by fecal peritonitis. Group C and group V were nonseptic control groups. After 300 min, group V and group SV received intravenous infusion of 0.06 U [middle dot] kg-1 [middle dot] h-1 vasopressin. In all groups, cardiac index and superior mesenteric artery flow were measured. Microcirculatory blood flow was recorded with laser Doppler flowmetry in both mucosa and muscularis of the stomach, jejunum, and colon.

Results: While vasopressin significantly increased arterial pressure in group SV (P < 0.05), superior mesenteric artery flow decreased by 51 +/- 16% (P < 0.05). Systemic and mesenteric oxygen delivery and consumption decreased and oxygen extraction increased in the SV group. Effects on the microcirculation were very heterogeneous; flow decreased in the stomach mucosa (by 23 +/- 10%; P < 0.05), in the stomach muscularis (by 48 +/- 16%; P < 0.05), and in the jejunal mucosa (by 27 +/- 9%; P < 0.05), whereas no significant changes were seen in the colon.     

Effects of Endothelin-1 on Hepatic Blood Flow

Endothelin-1 belongs to a family of potent vasoconstrictors, recently isolated from endothelial cells. Endothelin-1 has a variety of hepatic effects and hepatic clearance from the circulation is important. Elevated plasma concentrations of Endothelin-1 are found after orthotopic liver transplantation and in cirrhosis with ascites.This study in piglets on hepatic bloodflow was designed to compare differences in effects between central venous and intraportal injection of endothelin-1, and to evaluate effects of repeated injections. Central venous injection of endothelin-1 caused a larger reduction in portal vein flow, while intraportal injection caused a larger increase in portal vein pressure. Repeated injections resulted in a reduction in portal vein flow and an increase in portal vein vascular resistance.     

Hemodynamic and Cardiometabolic Effects of Prenalterol in Patients with Gram Negative Septic Shock

The hernodynamic eflects of prenalterol, a new inotropic agent, were investigated in 10 patients with gram negative septic shock. In four of the patients, coronary sinus blood flow (CSF) and myocardial oxygen and lactate extraction were also determined. After baseline hemodynamic measurements, prenalterol was infused intravenously over a 10-min period to a total dose of 150 pg/kg. All patients responded within 15 min after completion of prenalterol infusion by increasing mean arterial pressure from 57±11 to 75 ± 20 mmHg (7.58f 1.46 to 9.97±2.66 kPa), (+32%), ( P<0.01 ) and cardiac index from 2.65±0.40 to 3.80±0.47 l min^-l m^-2 (+44%) ( P < 0.001). There was no change in heart rate or systemic vascular resistance, nor were any arrhythmias recorded. The urinary output increased significantly. After prenalterol, CSF increased from 185kl 4 to 246±14 ml.min-¹, (+33%), (P<0.001) and myocardial oxygen and lactate extraction rose from 19.8±2.1to26.6±2.1 ml O₂.min^-1, (+ 34%) (P<0.00l) andfrom33.2±2.3 to44.7k2.1 μmol.min^-1, (+35%), (P<0.001), respectively. The total body oxygen consumption increased from 287f 13 to 348±23 ml O₂.min^-1, (+21 %), ( P<0.01 ) and the arterial lactate concentration decreased from 5.61±0.55 to 3.94±0. 16 mmol.l^-1, (- 30%), (P<0.01), suggesting improved tissue perfusion. The results demonstrate that prenalterol is a potent, highly selective inotropic agent inducing the same magnitude of increase in blood pressure and cardiac output as reported for dopamine in septic shock.     

胆道感染性休克病人凝血变化的观察

急性梗阻性化脓性胆管炎的病人发病急，病死率高，为外科治疗中较棘手问题本文主要观察ＡＯＳＣ伴休克的病人凝血方面的变化，观察对象为６例ＡＯＳＣ伴有休克的病人，另选择２０例胆囊结石手术病人作为对照组，结果表明：ＡＯＳＣ伴休克组血浆中脂多糖含量增高，ＴＰ和ＫＰＴＴ延长，血小板计数减少，均较对照组有非常显著差异（Ｐ＜０．０１）；纤维蛋白原显著低于对照组（Ｐ＜０．０５），ＡＯＳＣ组中有５例，低于１．５ｇ／Ｌ；     

外科脓毒血症病人血磷水平变化的初步研究

目的:研究外科危重病人在全身炎症反应综合征(SIRS)、脓毒血症和脓毒性休克阶段血磷水平变化的趋势。方法:回顾性研究2003年1月到2003年4月在瑞金医院外科ICU连续入住病人的血磷值,比较不同病程阶段(非重症、SIRS、脓毒血症和脓毒性休克)病人的血磷水平。结果:在外科ICU非重症病人中,血磷水平都正常;而在SIRS阶段病人,部分标本的血磷水平降低(占标本数30.4%),但平均值仍属正常。脓毒血症阶段病人的血磷水平则明显降低,平均为(0.66±0.17)mmol/L,显示低磷血症的标本数占90.9%;脓毒性休克时病人的血磷降低更为明显,平均为(0.48±0.22)mmol/L。方差分析显示各组间两两比较都有显著差异。结论:外科危重病人中,随着疾病从SIRS加重到脓毒性休克,其血磷降低程度亦逐渐加重。     

Regional Cerebral Blood Flow Autoregulation in Patients With Fulminant Hepatic Failure

The absence of cerebral blood flow autoregulation in patients with fulminant hepatic failure (FHF) implies that changes in arterial pressure directly influence cerebral perfusion. It is assumed that dilatation of cerebral arterioles is responsible for the impaired autoregulation. Recently, frontal blood flow was reported to be lower compared with other brain regions, indicating greater arteriolar tone and perhaps preserved regional cerebral autoregulation. In patients with severe FHF (6 women, 1 man; median age, 46 years; range, 18 to 55 years), we tested the hypothesis that perfusion in the anterior cerebral artery would be less affected by an increase in mean arterial pressure compared with the brain area supplied by the middle cerebral artery. Relative changes in cerebral perfusion were determined by transcranial Doppler–measured mean flow velocity (V_mean ), and resistance was determined by pulsatility index in the anterior and middle cerebral arteries. Cerebral autoregulation was evaluated by concomitant measurements of mean arterial pressure and V_mean in the anterior and middle cerebral arteries during norepinephrine infusion. Baseline V_mean was lower in the brain area supplied by the anterior cerebral artery compared with the middle cerebral artery (median, 47 cm/s; range, 21 to 62 cm/sv 70 cm/s; range 43 to 119 cm/s, respectively;P < .05). Also, vascular resistance determined by pulsatility index was greater in the anterior than middle cerebral artery (median, 1.02; range 1.00 to 1.37 v 0.87; range 0.75 to 1.48; P < .01). When arterial pressure was increased from 84 mm Hg (range 57 to 95 mm Hg) to 115 mm Hg (range, 73 to 130 mm Hg) during norepinephrine infusion, V_mean remained unchanged in 2 patients in the anterior cerebral artery, whereas it increased in the middle cerebral artery in all 7 patients. In the remaining patients, V_mean increased approximately 25% in both the anterior and middle cerebral arteries. Thus, this study could only partially confirm the hypothesis that autoregulation is preserved in the brain regions supplied by the anterior cerebral artery in patients with FHF. Although the findings of this small study need to be further evaluated, one should consider that autoregulation may be impaired not only in the brain region supplied by the middle cerebral artery, but also in the area corresponding to the anterior cerebral artery. (Liver Transpl 2000;6:795-800.)     

连续性血液净化联合乌司他丁治疗重症脓毒症的临床研究

目的:探讨连续血液净化(CBP)联合鸟司他丁治疗重症脓毒症的疗效。方法:选择重症脓毒症患者120例,随机分为对照组和观察组。两组均给予常规抗感染、液体复苏、穿刺引流控制感染灶,应用多巴胺、去甲肾上腺素等血管活性药物,必要时给予机械通气。同时两组在确诊脓毒症4 h内均采用CBP治疗。在此基础上,观察组静脉注射乌司他丁50万IU/d,连续应用7 d。检测入院时和入院后第1、3、5天取血检测血浆C反应蛋白(CRP)、血清乳酸(Lac)、血清降钙素原(PCT)、白细胞介素-10(IL-10)水平。在患者入院时及入院后第1、3、5天分别进行序贯器官衰竭评估(SOFA)和急性生理学与慢性健康状况评分Ⅱ(APACHE II)。结果:两组患者治疗后第1、3、5天的CRP、Lac、PCT、IL-10均低于治疗前(均P<0.05);且观察组治疗后各时点的CRP、Lac、PCT和IL-10显著低于对照组。两组患者治疗后第1、3、5天的SOFA评分和APACHElI评分均显著低于治疗前;且观察组在入院第1、3、5天的SOFA评分和APACHElI评分均显著低于对照组,差异有统计学意义(均P<0.05)。结论:CBP联合乌司他丁能够清除炎症介质、纠正机体缺血缺氧、改善组织细胞和器官低灌注,维持血流动力学稳定,减少器官的损伤,值得重症脓毒症患者早期应用。     

乳酸测定在严重感染和感染性休克患者中的临床价值

目的：探讨全身性感染患者血乳酸浓度与急性生理学和慢性健康状况评分系统Ⅱ（APACHEⅡ）评分．动脉血氧分压（PaO2）及预后的相互关系。通过测定乳酸浓度以判断病情及指导治疗。方法：调查严重感染或感染性休克患者30例,记录入住时及入住后12h．24h、48h的血乳酸浓度,婀对记录PaO2,并进行APAcHEⅡ评分。结果：所有患者入住时及入住后12h、24h。48h乳酸浓度较正常对照组明显升高．两组比较差异有统计学意义（P〈0.05）,且存活组和死亡组入住时及入住后12h．24h．48h乳酸浓度亦明显高于正常对照组（P〈0．05）。存活组患者入住时及入住后12h、24h．48h的血乳酸浓度与死亡组比较差异有统计学意义（P〈0．05）。所有患者入住时乳酸浓度与APACHEⅡ评分呈显著正相关（r=0,67．P〈0.05）,且存活组、死亡组患者APACHEⅡ评分与入住时乳酸浓度亦呈显著正相关（r=0.75,P〈0.05;r=085,P〈0.05）。经治疗乳酸浓度下降幅度越大．预后越好。结论：血乳酸的测定是评估严重藏染或感染性休克的良好指标,动态监测可了解疾病的发展过程,同时结合APACHEⅡ评分,有助于指导严重感染及感染性休克患者的治疗,对判断病情的严重程度、病情的发展和预后有重要的临床意义。     

肾素-血管紧张素系统在感染性休克患者中的变化和意义

目的:探讨感染性休克患者中肾素-血管紧张素系统的变化和意义。方法:对21例感染性休克患者和24例非感染性休克患者分别测定血浆肾素活性(PRA)和AngⅡ浓度,以及血乳酸水平(LAC),并进行急性生理及慢性健康状况(APACHE)Ⅱ评分和序贯器官功能衰竭评分(SOFA),计算病死率,进一步将患者按预后分为死亡组和存活组进行分析,对结果进行比较,并对PRA、AngⅡ浓度和APACHEⅡ评分、SOFA评分、LAC进行相关分析。结果:与非感染性休克组相比,感染性休克组患者PRA、AngⅡ、APACHEⅡ、SOFA评分、LAC和病死率明显增高;与存活组患者相比,死亡组患者PRA、AngⅡ、APACHEⅡ、SOFA评分、LAC明显升高(P<0.05)。相关分析结果,PRA和APACHEⅡ、SOFA、LAC之间相关系数分别为0.409、0.601和0.671(P<0.01);AngⅡ和APACHEⅡ、SOFA、LAC之间相关系数分别为0.491、0.776和0.690(P<0.01)。结论:感染性休克激活了肾素-血管紧张素系统,PRA和AngⅡ浓度明显升高,过度激活的肾素-血管紧张素系统可能参与器官功能损伤过程,PRA和AngⅡ水平与病情严重程度相关性较好,对病情预后和严重程度判断有重要作用。     

脉搏指示连续心排血量监测（PiCCO）在脓毒症休克患者血流动力学监测中的临床价值

目的探讨脉搏指示连续心排血量监测技术（pulse indicator continuous cardiac output,Pjcc0）在脓毒症休克患者血流动力学监测中的临床价值。方法2012年1～8月,前瞻性队列研究比较常规监测（n=12）与Hcc0监测（n=19）脓毒症休克患者的血流动力学,应用PiccO监测指导脓毒症休克患者的液体复苏、血管收缩药和正性肌力药物的使用。结果2组脓毒症休克患者性别、年龄、原发病、既往病史、多器官功能不全综合征（MODs）的发生和发生MODs器官数、急性生理学及慢性健康状况评分系统（APAcHE）Ⅱ、脓毒症相关器官衰竭评分（s0FA）、应用去甲肾上腺素剂量和入Icu后7天总的输液量差异均无显著性,Picc0组初始平均动脉压（MAP）明显低于常规组[（52．00±5．00）mmHgvs．（59．58±3．42）mmHg,k4．603,P=O．000],而对于Picco组存在心功能损害的患者应用正性肌力药治疗后达到与常规组相同的MAP达标值[（68．00±2．43）mmHgvs．（68．58±2．88）mmHg,t=0．607,P=0．549],2组MAP达标值差异无显著性。结论在Picco监测指导下,可以对于存在心功能损害的患者应用正性肌力药物,而不是仅应用血管收缩药升高血压。     

Assessment of Effective Hepatic Blood Flow in Critically Ill Patients by Noninvasive Pulse Dye-Densitometry

Abstact. Purpose: Effective hepatic blood flow (EHBF) is thought to reflect splanchnic perfusion and the metabolic state of the liver. This study was conducted to examine the relationship between cardiac output (CO) and EHBF using pulse dye-densitometry (PDD) in nonseptic and septic patients, and to assess the prognostic value of this relationship. Methods: The subjects were 33 critically ill patients, 16 of whom met the criteria for sepsis. Indocyanine green (ICG) was given via a central venous catheter to each patient. CO (l/min) and EHBF (l/min) were assessed with PDD. Results: CO and EHBF were significantly correlated in the nonseptic patients (r = 0.92, P < 0.001), but not in the septic patients (r = 0.38, P = 0.15). The ratio of EHBF to CO (EHBF/CO) in the septic patients was significantly lower than that in the nonseptic patients (0.08 ± 0.04 vs 0.22 ± 0.05; P < 0.001). Moreover, in the septic patients, the EHBF/CO ratios of nonsurvivors were significantly lower than those of survivors (0.06 ± 0.04 vs 010 ± 0.02; P < 0.01). Conclusions: In nonseptic patients, the EHBF decreased in relation to the CO. However, the EHBF/CO ratio of septic patients was lower than that of nonseptic patients, suggesting that inadequate splanchnic perfusion or metabolic change occurs in septic patients. Furthermore, the lower EHBF/CO ratio was related with a fatal outcome in septic patients. PDD could be a clinically useful method of assessing splanchnic conditions in critically ill patients. Received: February 4, 2002 / Accepted: July 2, 2002 Reprint requests to: Y. Mizushima     

慢性肝病患者肝叶切除术凝血-纤溶活性检测的意义

目的探讨慢性肝病患者行肝叶切除术围手术期凝血-纤溶活性的变化及其意义。方法将2003年1月至2004年2月重庆医科大学附属第二医院肝胆外科收治的35例伴乙肝肝硬变的手术患者根据疾病和手术的不同分为肝叶切除术组（n=18）和非肝叶切除术组（n=17），并分别于术前、术毕和术后24h采集外周静脉血，测定其凝血酶原时间（PT）、活化部分凝血活酶时间（APTT）、凝血酶时间（TT）、纤维蛋白原（Fbg）和D-二聚体（D-D）含量。结果非肝叶切除组患者的PT、APTT和TT在手术前后不同时相间比较差异无统计学意义（P〉0．05）；肝叶切除组PT水平术前明显高于术毕和术后，并明显高于非肝叶切除组（P〈0．01），APTT术后则明显高于术前和术毕，也高于非肝叶切除组（P〈0．01），而TT在组内不同时相间及与非肝叶切除组相应时间比较差异无统计学意义（P〉0．05）。2组患者Fbg和D-D水平术后均较术前和术毕明显升高（P〈0．05），但2组间比较差异无统计学意义（P〉0．05）。结论慢性肝病患者实施肝叶切除术时，血液处于低凝和继发性纤溶亢进状态，提示有潜在出血的危险，应加强围手术期处理。     

芬太尼复合诱导气管插管对神经外科病人大脑中动脉血流速率的影响

目的应用经颅多普勒(TCD)研究不同剂量芬太尼和依托咪酯复合诱导气管插管对神经外科病人脑血流动力学的影响。方法20例病人随机分成两组(每组10例)F5组,芬太尼5μg／kg;F10组,芬太尼10μg／kg。余诱导用药相同安定0．1mg／kg、依托咪酯0．3mg／kg、维库溴铵0．1mg／kg。采用TCD监测双侧大脑中动脉血流速率(V-MCA),同时监测BP、HR、记录麻醉诱导前、插管前和插管后3分钟的变化。结果与麻醉前比,插管前和插管后3分钟,两组V-MCA均明显降低(P＜0．01);血压在插管前降低(P＜0．01),插管后恢复麻醉前水平。但两组间的变化差异无显著意义。结论芬太尼和依托咪酯复合诱导能抑制插管刺激引起的脑血流量增加和心血管反应,减少脑血流量。     

Effect of Controlled Halothane Anaesthesia on Splanchnic Blood Flow and Cardiac Output in the Dog

Effects of halothane anaesthesia on aplanchnic blood flow and cardiac output were studied in six dogs. Blood flows in the hepatic artery, the superior mesenteric artery and the portal vein were measured electromagnetically. Cardiac output was measured by thermodilution. Depth of anaesthesia, ventilation, acid-base state and body temperature were controlled. Cardiac output and blood flows in the hepatic artery, the superior mesenteric artery and the portal vein decreased significantly to 73%, 54%, 59% and 60% of control values, respectively. Total peripheral vascular resistance decreased significantly, while mesenteric and portal resistance remained essentially unchanged and hepatic arterial resistance showed a significant increase. It is suggested that the difference between the various vascular responses may be caused by a differentiated release from baroreceptor inhibition in various parts of the bulbar vasomotor center.