Conclusion
There is evidence to support the relationship between splanchnic hypoperfusion and multiple organ dysfunction in septic patients, largely related to mucosal injury leading to increased permeability and systemic inflammatory response. As gut mucosal PCO 2 reflects the balance between flow and metabolism, gas tonometry is a valuable tool to monitor the regional effects of hemodynamic interventions and gives insight regarding blood flow heterogeneity in sepsis. The definitive role of gas tonometry to predict outcome and guide therapy for septic patients will be established by large, prospective multicenter trials.
Keywords
Septic Patient Mucosal Blood Flow Splanchnic Blood Flow Gastric Mucosal Blood Flow Gastric Tonometry
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
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References
- 1.Schumacker P, Cain SM. The concept of a critical oxygen delivery. Intensive Care Med 1987; 13:223–229PubMedCrossRefGoogle Scholar
- 2.Ince C, Sinaasappel M. Microcirculatory oxygenation and shunting in sepsis and shock. Crit Care Med 1999; 27:1369–1377PubMedGoogle Scholar
- 3.Vallet B, Lund N, Curtis SE, et al. Gut and muscle tissue PO2 in endotoxemic dogs during shock and resuscitation. J Appl Physiol 1994; 76:793–800PubMedGoogle Scholar
- 4.Marshall JC, Christou NV, Meakins JL. The gastrointestinal tract. The “undrained abscess” of multiple organ failure. Ann Surg 1993; 218:111–119PubMedGoogle Scholar
- 5.Guyton AC, Hall J. General principles of gastrointestinal function — motility, nervous control, and blood circulation. In: Guyton AC, Hall JE (eds) Textbook of Medical Physiology 9th Edition, 1996, pp793–802Google Scholar
- 6.Nelson DP, Samsel RW, Wood LD, Schumacker P. Pathological supply dependence of systemic and intestinal O2 uptake during endotoxemia. J Appl Physiol 1988; 64:2410–2419PubMedGoogle Scholar
- 7.Fink MP. Why the GI tract is pivotal in trauma, sepsis, and MOF. Sepsis 1991; 6:253–276Google Scholar
- 8.Mythen M, Faehnrich J. Monitoring gut perfusion. In: Rombeau JL, Takala J (eds). Gut dysfunction in critical illness. Springer-Verlag, Berlin 1996 pp 246–263Google Scholar
- 9.Fiddian-Green RG. Gastric intramucosal pH, tissue oxygenation and acid-base balance. Br J Anaesth 1995; 74:591–606PubMedGoogle Scholar
- 10.McIver M. Gaseous exchange between the blood and the lumen of the stomach and intestine. Am J Physiol 1926; 76:92–111Google Scholar
- 11.Boda D, Muranyi L. “Gastrotonometry”: an aid to the control of ventilation during artificial respiration. Lancet 1959; 73:181–182Google Scholar
- 12.Bergofsky EH. Determinationof of tissue O2 tensions by hollow visceral tonometers: effects of breathing enriched O2 mixtures. J Clin Invest 1964; 43:193–200PubMedCrossRefGoogle Scholar
- 13.Dawson AM, Trenchard D, Guz A. Small bowel tonometry: Assessment of small gut mucosal oxygen tension in dog and man. Nature 1965; 206(987):943–944PubMedGoogle Scholar
- 14.Creteur J, De Backer D, Vincent JL. Monitoring gastric mucosal carbon dioxide pressure using gas tonometry: in vitro and in vivo validation studies. Anesthesiology 1997; 87:504–510PubMedGoogle Scholar
- 15.Fiddian-Green RG. Tonometry: Theory and applications. Intensive Care World 1992; 9:60–65PubMedGoogle Scholar
- 16.Antonsson JB, Engstrom L, Rasmussen I, Wollert S, Haglund UH. Changes in gut intramucosal pH and gut oxygen extraction ratio in a porcine model of peritonitis and hemorrhage. Crit Care Med 1995; 23:1872–1881PubMedGoogle Scholar
- 17.Antonsson JB, Boyle CC, Kruithoff KL, Wang HL, Sacristan E, Rothschild HR et al.. Validation of tonometric measurement of gut intramural pH during endotoxemia and mesenteric occlusion in pigs. Am J Physiol 1990; 259:G519–G523PubMedGoogle Scholar
- 18.Montgomery A, Hartmann M, Jonsson K, Haglund U. Intramucosal pH measurement with tonometers for detecting gastrointestinal ischemia in porcine hemorrhagic shock. Circ Shock 1989; 29:319–327PubMedGoogle Scholar
- 19.Antonsson JB, Haglund UH. Gut intramucosal pH and intraluminal PO2 in a porcine model of peritonitis or haemorrhage. Gut 1995; 37:791–797PubMedGoogle Scholar
- 20.Schlichting E, Lyberg T. Monitoring of tissue oxygenation in shock: an experimental study in pigs. Crit Care Med 1995; 23:1703–1710PubMedGoogle Scholar
- 21.Salzman AL, Strong KE, Wang H, Wollert PS, Vandermeer TJ, Fink MP. Intraluminal balloonless air tonometry: A new method for determination of gastrointestinal mucosal carbon dioxide tension. Crit Care Med 1994; 22:126–134PubMedGoogle Scholar
- 22.Sato Y, Weil MH, Tang W, et al. Esophageal PCO2 as a monitor of perfusion failure during hemorrhagic shock. J Appl Physiol 1997; 82:558–562PubMedGoogle Scholar
- 23.Schlichtig R, Bowles SA. Distinguishing between aerobic and anaerobic appearance of dissolved CO2 in intestine during low flow. J Appl Physiol 1994; 76:2443–2451PubMedGoogle Scholar
- 24.Tang W, Weil MH, Sun SJ, et al.. Gastric intramural PCO2 as a monitor of perfusion failure during hemorrhagic and anaphylatic shock. J Appl Physiol 1994; 76:572–577PubMedGoogle Scholar
- 25.van der Meer JT, Wang H, Fink MP. Endotoxemia causes ileal micosal acidosis in the absence of mucosal hypoxia in a normodynamic porcine model of septic shock. Crit Care Med 1995, 23:1217–1226Google Scholar
- 26.Heino A, Hartikainen J, Merasto M, Alhava E, Takala J. Systemic and regional PCO2 gradients as markers of intestinal ischaemia. Intensive Care Med 1998; 24: 599–604PubMedCrossRefGoogle Scholar
- 27.Knichwitz G, Rotker J, Mollhoff T, Richter KD, Brussel T. Continuous intramucosal PCO2 measurement allows the early detection of intestinal malperfusion. Crit Care Med 1998; 26:1550–1557PubMedGoogle Scholar
- 28.Neviere R, Chagnon JL, Vallet B, et al.. Dobutamine improves gastrointestinal mucosal blood flow in a porcine model of endotoxic shock. Crit Care Med 1997; 25: 1371–1377.PubMedGoogle Scholar
- 29.Neviere R, Mathieu D, Chagnon JL, Lebleu N, Wattel F. The contrasting effects of dobutamine and dopamine on gastric mucosal perfusion in septic patients. Am J Respir Crit Care Med 1996; 154:1684–1688PubMedGoogle Scholar
- 30.Elizalde JI, Hernandez C, Llach J, Monton C, Bordas JM, Pique JM et al.. Gastric intramucosal acidosis in mechanically ventilated patients: Role of mucosal blood flow [see comments]. Crit Care Med 1998; 26:827–832PubMedGoogle Scholar
- 31.Fiddian-Green RG, Pittenger G, Whitehouse WM Jr. Back-diffusion of CO2 and its influence on the intramural pH in gastric mucosa. J Surg Res 1982; 33:39–48PubMedCrossRefGoogle Scholar
- 32.Heard SO, Helmsoortel CM, Kent JC, et al.. Gastric tonometry in health volunteers:effect of ranitidine on calculated intramural pH. Crit Care Med 1991; 19:271–274PubMedGoogle Scholar
- 33.Kolkman JJ, Groeneveld AB, Meuwissen SG. Effect of ranitidine on basal and bicarbonate enhanced intragastric PCO2: a tonometric study. Gut 1994; 35:737–741PubMedGoogle Scholar
- 34.Stevens MH, Thirlby RC, Feldman M. Mechanisms for high PCO2 in gastric juice:roles of bicarbonate secretion and CO2 diffusion. Am J Physiol 1987; 253:G527–G530PubMedGoogle Scholar
- 35.Driks MR, Graven DE, Celli BR, et al. Nosocomial pneumonia in intubated patients given sucralfate as compared with antacids or histamine type 2 blockers: the role of gastric colonization. N Engl J Med 1987; 317:1376–1382PubMedCrossRefGoogle Scholar
- 36.Jin X, Weil MH, Sun S, Tang W, Bisera J, Mason EJ. Decreases in organ blood flows associated with increases in sublingual PCO2 during hemorrhagic shock. J Appl Physiol 1998; 85:2360–2364PubMedGoogle Scholar
- 37.Weil MH, Nakagawa Y, Tang W, et al. Sublingual capnometry: a new noninvasive measurement for diagnosis and quantitation of severity of circulatory shock. Crit Care Med 1999; 27:1225–1229PubMedGoogle Scholar
- 38.Nakagawa Y, Weil MH, Tang W, et al. Sublingual capnometry for diagnosis and quantitation of circulatory shock. Am J Respir Crit Care Med 1998; 157:1838–1843PubMedGoogle Scholar
- 39.Lang JD, Evans D, Poli de Figueiredo L, Hays S, Mathru M, Kramer G. A novel approach to monitor tissue perfusion: bladder mucosal PCO2, PO2, and pHi during ischemia and reperfusion in pigs. J Intensive Care 1999; 14:93–98Google Scholar
- 40.Kette F, Weil MH, Gazmuri RJ, et al. Intramyocardial hyperbaric acidosis during cardiac arrest and resuscitation. Crit Care Med 1993; 21:901–906PubMedGoogle Scholar
- 41.Takala J, Parviainen I, Siloaho M, Ruokonen E, Hamalainen E. Saline PCO2 is an important source of error in the assessment of gastric intramucosal pH. Crit Care Med 1994; 22:1877–1879PubMedCrossRefGoogle Scholar
- 42.Riddington D, Venkatesh B, Clutton-Brock T, Bion J, Venkatesh KB. Measuring carbon dioxide tension in saline and alternative solutions: quantification of bias and precision in two blood gas analyzers. Crit Care Med 1994; 22:96–100PubMedGoogle Scholar
- 43.Knichwitz G, Kuhmann M, Brodner G, Mertes N, Goeters C, Brussel T. Gastric tonometry: precision and reliability are improved by a phosphate buffered solution. Crit Care Med 1996; 24:512–516PubMedGoogle Scholar
- 44.Guzman JA, Kruse JA. Gut mucosal-arterial PCO2 gradient as an indicator of splanchnic perfusion during systemic hypo-and hypercapnia. Crit Care Med 1999; 27:2760–2765PubMedGoogle Scholar
- 45.Schlichtig R, Mehta N, Gayowski TJ. Tissue-arterial PCO2 difference is a better marker of ischemia than intramural pH (pHi) or arterial pH-pHi difference. J Crit Care 1996; 11:51–56PubMedCrossRefGoogle Scholar
- 46.Vincent JL, Creteur J. Gastric mucosal pH is definitely obsolete—please, tell us more about gastric mucosal PCO2. Crit Care Med 1998; 26:1479–1481PubMedGoogle Scholar
- 47.Guzman JA, Kruse JA. Development and validation of a technique for continuous monitoring of gastric intramucosal pH. Am J Respir Crit Care Med 1996; 153:694–700PubMedGoogle Scholar
- 48.Guzman JA, Kruse JA. Continuous assessment of gastric intramucosal PCO2 and pH in hemorrhagic shock using capnometric recirculating gas tonometry. Crit Care Med 1997; 25:533–537PubMedGoogle Scholar
- 49.Heinonen PO. Validation of air tonometric measurement of gastric regional concentration of CO2 in critically ill septic patients. Intensive Care Med 1997; 23:524–529PubMedCrossRefGoogle Scholar
- 50.Bowles SA, Schlichtig R, Kramer DJ, Klions HA. Arteriovenous pH and partial pressure of carbon dioxide detect critical oxygen delivery during progressive haemorrhage in dogs. J Crit Care 1992; 7:95–105Google Scholar
- 51.Van Der Linden P, Rausin I, Deltell A, et al. Detection of tissue hypoxia by arteriovenous gradient for PCO2 and pH in anesthetized dogs during progressive hemorrhage. Anesth Analg 1995; 80:269–275PubMedGoogle Scholar
- 52.Zhang H, Vincent JL. Arteriovenous difference in PCO2 and pH are good indicators of critical hypoperfusion. Am Rev Respir Dis 1993; 148:867–871PubMedGoogle Scholar
- 53.Teboul JL, Michard F, Richard C. Critical analysis of venoarterial CO2 gradient as a marker of tissue hypoxia. In: Vincent JL (ed) Yearbook of Intensive Care and Emergency Medicine. Springer-Verlag, Berlin, 1996 pp 296–307Google Scholar
- 54.Vallet B, Teboul JL, Cain SM, Curtis SE. Veno-arterial CO2 difference during regional ischemic or hypoxic hypoxia. J Appl Physiol 2000; 89:1317–1321PubMedGoogle Scholar
- 55.Vallet B, Durinck JL, Chagnon JL, Neviere R. Effects of hypoxic hypoxia on veno and gut mucosal arterial PCO2 difference in pigs. Anesthesiology 1996; 85:A607 (Abst)Google Scholar
- 56.Temmesfeld-Wollbruck B, Szalay A, Mayer K, Olschewski H, Seeger W, Grimminger F. Abnormalities of gastric mucosal oxygenation in septic shock: partial responsiveness to dopexamine. Am J Respir Crit Care Med 1998; 157:1586–1592PubMedGoogle Scholar
- 57.Revelly JP, Ayuse A, Brienza N, et al. Endotoxic shock alters distribution of blood flow within the intestinal wall. Crit Care Med 1996; 24:1345–1351PubMedGoogle Scholar
- 58.Jakob SM, Kosonen P, Ruokonen E, Parviainen I, Takala J. The Haldane effect — an alternative explanation for increasing gastric mucosal PCO2 gradients? Br J Anaesth 1999; 83:740–746PubMedGoogle Scholar
- 59.Maynard N, Bihari D, Beale R, et al. Assessment of splanchnic oxygenation by gastric tonometry in patients with acute circulatory failure. JAMA 1993; 270:1203–1210PubMedCrossRefGoogle Scholar
- 60.Maynard ND, Bihari DJ, Dalton RN, Smithies MN, Mason RC. Increasing splanchnic blood flow in the critically ill. Chest 1995; 108:1648–1654PubMedGoogle Scholar
- 61.Lagoa C, Cruz Jr R, Poli de Figueiredo L, Silva E, Rocha e Silva M. Systemic and splanchnic hemodynamics, metabolism and pCO2-gap during septic shock induced by live E. coli infusion in dogs. Crit Care Forum 2000; 4:S88 (Abst)Google Scholar
- 62.Creteur J, De Backer D, Vincent JL. Does gastric tonometry monitor splanchnic perfusion? Crit Care Med 1999; 27:2480–2484PubMedGoogle Scholar
- 63.Silva E, Creteur J, De Backer D, Vincent JL. Effects of norepinephrine and epinephrine on splanchnic oxygen utilization in septic shock patients. Crit Care Med 1998; 26:A63 (Abst)Google Scholar
- 64.Doglio GR, Pusajo JF, Egurrola MA, et al. Gastric mucosal pH as a prognostic index of mortality in critically ill patients. Crit Care Med 1991; 19:1037–1040PubMedGoogle Scholar
- 65.Mohsenifar Z. Gastric intramucosal acidosis during weaning from mechanical ventilation. Adv Exp Med Biol 1994; 361:333–343PubMedGoogle Scholar
- 66.Gutierrez G, Palizas F, Doglio G, et al. Gastric intramucosal pH as a therapeutic index of tissue oxygenation in critically ill patients. Lancet 1992; 339:195–199PubMedGoogle Scholar
- 67.Marik PE. Gastric intramucosal pH. A better predictor of multiorgan dysfunction syndrome and death than oxygen-derived variables in patients with sepsis. Chest 1993; 104:225–229PubMedGoogle Scholar
- 68.Joynt GM, Lipman J, Gomersall CD, Tan I, Scribante J. Gastric intramucosal pH blood lactate in severe sepsis. Anaesthesia 1997; 52:726–732PubMedGoogle Scholar
- 69.Silva E, Blecher S, Kai MH, et al. Gastric-arterial PCO2 gradient, but not lactate levels, is related to multiple organ dysfunction assessed by SOFA score in septic patients n septic shock. Crit Care Forum 2000; 4:S88 (Abst)Google Scholar
- 70.De Backer D, Zhang H, Manikis P, Vincent JL. Regional effects of dobutamine in endotoxic shock. J Surg Res 1996; 65:93–100PubMedGoogle Scholar
- 71.Forrest DM, Baigorri F, Chittock DR, Spinelli JJ, Russell JA. Volume expansion using pentastarch does not change gastric arterial CO2 gradient or gastric intramucosal pH in patients who have sepsis syndrome. Crit Care Med 2000; 28:2254–2258PubMedGoogle Scholar
- 72.Silva E, De Backer D, Creteur L, Vincent JL. Effects of fluid challenge on gastric-arterial CO2 gradient in septic patients. Crit Care Med 1998; 26:A136 (Abst)Google Scholar
- 73.Silva E, DeBacker D, Creteur J, Vincent JL. Effects of vasoactive drugs on gastric intramucosal pH. Crit Care Med 1998; 26:1749–1758PubMedGoogle Scholar
- 74.Creteur J, De Backer D, Vincent JL. A dobutamine test can disclose hepatosplanchnic hypoperfusion in septic patients. Am J Respir Crit Care Med 1999; 160:839–845PubMedGoogle Scholar
- 75.Duranteau J, Sitbon P, Teboul JL, et al. Effects of epinephrine, norepinephrine, or the combination of norepinephrine and dobutamine on gastric mucosa in septic shock. Crit Care Med 1999; 27:893–900PubMedGoogle Scholar
- 76.Levy B, Bollaert PE, Luchelli J-P, Sadoune L-D, Larcan A. Dobutamine improves the adequacy of gastric mucosal perfusion in epinephrine-treated septic shock. Crit Care Med 1997;25:1649–1654PubMedGoogle Scholar
- 77.Levy B, Nace L, Bollaert PE, Dousset B, Mallie JP, Larcan A. Comparison of systemic and regional effects of dobutamine and dopexamine in norepinephrine-treated septic shock. Intensive Care Med 1999; 25:942–948PubMedCrossRefGoogle Scholar
- 78.Gutierrez G, Palizas F, Doglio G, Wainsztein N, Gallesio A, Pacin J et al.. Gastric intramucosal pH as a therapeutic index of tissue oxygenation in critically ill patients [see comments]. Lancet 1992; 339(8787): 195–199PubMedCrossRefGoogle Scholar
- 79.Gomersall CD, Joynt GM, Freebairn RC, Hung V, Buckley TA, Oh TE. Resuscitation of critically ill patients based on the results of gastric tonometry: a prospective, randomized, controlled trial. Crit Care Med 2000; 28:607–614PubMedGoogle Scholar
- 80.Chapman M, Mythen MG, Webb AR, Vincent JL. Report from the meeting: gastrointestinal tonometry: state of the art. Intensive Care Med 2000; 26:613–622PubMedCrossRefGoogle Scholar
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