Skip to main content
SpringerLink
Log in

Microvascular Alterations in Patients with Circulatory Failure

  • Conference paper
Intensive Care Medicine

Abstract

Many patients continue to die from acute circulatory failure despite improvement in whole body hemodynamics. Early optimization of oxygen transport in patients with septic shock can lead to a decrease in morbidity and mortality, but nevertheless a significant proportion of these patients will develop multiple organ failure (MOF) and will ultimately die [1]. Several factors can be implicated in the development of MOF including alterations in blood flow distribution between the various organs but also alterations in metabolic pathways (cytopathic hypoxia). Multiple studies have reported that an imbalance between oxygen demand and supply can occur in the splanchnic area [2, 3], but the most commonly used therapeutic interventions (fluids, inotopic agents, red blood cell [RBC] transfusions) have usually failed to improve regional blood flow alterations in septic patients [4, 5] so that survival was not improved. On the other hand, several studies indicated that metabolic pathways may be directly altered, so that giving more ‘fuel’ to the system would not result in any improvement in tissue oxygenation. Several data support the concept of cytopathic hypoxia. King et al. [6] reported that endotoxin impaired oxygen consumption in mucosal samples in polarographic air-saturated chambers, and related this effect to nitric oxide (NO). In humans, Brealey et al. [7] reported that cytochrome complex I is significantly altered in muscle biopsies obtained in patients with sepsis. Nevertheless, these alterations alone cannot explain all the features observed in patients with septic shock. First, if cytopathic hypoxia were prominent, therapeutic interventions such as early-goal oriented hemodynamic optimalization, as proposed by Rivers et al. [1], would probably not have been successful. Second, cytopathic hypoxia is not compatible with the numerous data reporting increased tissue CO2 in septic shock [4, 5, 9], as CO2 would be rapidly cleared if blood flow was adequate. Hence, it is very likely that all these alterations coexist, the respective part of each of them being undetermined.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 39.99
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 54.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. Rivers E, Nguyen B, Haystadt S, et al (2001) Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345: 1368–1377

    Article  PubMed  CAS  Google Scholar 

  2. Dahn MS, Lange P, Lobdell K, Hans B, Jacobs LA, Mitchell RA (1987) Splanchnic and total body oxygen consumption differences in septic and injured patients. Surgery 101: 69–80

    PubMed  CAS  Google Scholar 

  3. De Backer D, Creteur J, Noordally O, Smail N, Culbis B, Vincent JL (1998) Does hepatosplanchnic V02/D02 dependency exist in critically ill septic patients? Am J Respir Crit Care Med 157: 1219–1225

    Article  PubMed  Google Scholar 

  4. Gomersall CD, Joynt GM, Freebairn RC, Hung V, Buckley TA, OH TE (2000) Resuscitation of critically ill patients based on the results of gastric tonometry: a prospective, randomized, controlled trial. Crit Care Med 28: 607–614

    Article  PubMed  CAS  Google Scholar 

  5. Lebuffe G, Levy B, Neviere R, et al (2002) Dobutamine and gastric-to-arterial carbon dioxide gap in severe sepsis without shock. Intensive Care Med 28: 265–271

    Article  PubMed  Google Scholar 

  6. King CJ, Tytgat S, Delude RL, Fink MP (1999) Ileal mucosal oxygen consumption is decreased in endotoxemic rats but is restored toward normal by treatment with aminoguanidine. Crit Care Med 27: 2518–2524

    Article  PubMed  CAS  Google Scholar 

  7. Brealey D, Brand M, Hargreaves I, et al (2002) Association between mitochondrial dysfunction and severity and outcome of septic shock. Lancet 360: 219–223

    Article  PubMed  CAS  Google Scholar 

  8. Bernard GR, Vincent J-L, Laterre PF, et al (2001) Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 344: 699–709

    Article  PubMed  CAS  Google Scholar 

  9. Friedman G, Berlot G, Kahn RJ, Vincent JL (1995) Combined measurements of blood lactate concentrations and gastric intramucosal pH in patients with severe sepsis. Crit Care Med 23: 1184–1193

    Article  PubMed  CAS  Google Scholar 

  10. Cryer HM, Garrison RN, Kaebnick HW, Harris PD, Fink LM (1987) Skeletal microcirculatory responses to hyperdynamic Escherichia coli sepsis in unanesthetized rats. Arch Surg 122: 86–92

    Article  PubMed  CAS  Google Scholar 

  11. Baker CH, Wilmoth FR (1984) Microvascular responses to E. coli endotoxin with altered adrenergic activity. Circ Shock 12: 165–176

    CAS  Google Scholar 

  12. Lam CJ, Tyml K, Martin CM, Sibbald W (1994) Microvascular perfusion is impaired in a rat model of normotensive sepsis. J Clin Invest 94: 2077–2083

    Article  PubMed  CAS  Google Scholar 

  13. Piper RD, Pitt-Hyde ML, Anderson LA, Sibbald WJ, Potter RF (1998) Leukocyte activation and flow behavior in rat skeletal muscle in sepsis. Am J Respir Crit Care Med 157: 129–134

    Article  PubMed  CAS  Google Scholar 

  14. Piper RD, Pitt-Hyde M, Li F, Sibbald WJ, Potter RF (1996) Microcirculatory changes in rat skeletal muscle in sepsis. Am J Respir Crit Care Med 154: 931–937

    Article  PubMed  CAS  Google Scholar 

  15. Farquhar I, Martin CM, Lam C, Potter R, Ellis CG, Sibbald WJ (1996) Decreased capillary density in vivo in bowel mucosa of rats with normotensive sepsis. J Surg Res 61, 190–196

    Article  PubMed  CAS  Google Scholar 

  16. McCuskey RS, Urbaschek R, Urbaschek B (1996) The microcirculation during endotoxemia. Cardiovasc Res 32: 752–763

    PubMed  CAS  Google Scholar 

  17. Drazenovic R, Samsel RW, Wylam ME, Doershuk CM, Schunacker PT (1992) Regulation of perfused capillary density in canine intestinal mucosa during endotoxemia. J Appl Physiol 72: 259–265

    Article  PubMed  CAS  Google Scholar 

  18. Walley KR (1996) Heterogeneity of oxygen delivery impairs oxygen extraction by peripheral tissues: theory. J Appl Physiol 81: 885–894

    PubMed  CAS  Google Scholar 

  19. Humer MF, Phang PT, Friesen BP, et al (1996) Heterogeneity of gut capillary transit times and impaired gut oxygen extraction in endotoxemic pigs. J Appl Physiol 81: 895–904

    PubMed  CAS  Google Scholar 

  20. Ince C, Sinaasappel M (1999) Microcirculatory oxygenation and shunting in sepsis and shock. Crit Care Med 27: 1369–1377

    Article  PubMed  CAS  Google Scholar 

  21. Zuurbier CJ, van Iterson M, Ince C (1999) Functional heterogeneity of oxygen supply-consumption ratio in the heart. Cardiovasc Res 44: 488–497

    Article  PubMed  CAS  Google Scholar 

  22. Vicaut E, Hou X, Payen D, Bousseau A, Tedgui A (1991) Acute effects of tumor necrosis factor on the microcirculation in rat cremaster muscle. J Clin Invest 87: 1537–1540

    Article  PubMed  CAS  Google Scholar 

  23. Groeneveld AB, Hartemink KJ, de Groot MC, Visser J, Thijs LG (1999) Circulating endothelin and nitrate-nitrite relate to hemodynamic and metabolic variables in human septic shock. Shock 11: 160–166

    Article  PubMed  CAS  Google Scholar 

  24. Hollenberg SM, Broussard M, Osman J, Parrillo JE (2000) Increased microvascular reactivity and improved mortality in septic mice lacking inducible nitric oxide synthase. Circ Res 86: 774–778

    Article  PubMed  CAS  Google Scholar 

  25. Diaz NL, Finol HJ, Torres SH, Zambrano CI, Adjounian H (1998) Histochemical and ultra-structural study of skeletal muscle in patients with sepsis and multiple organ failure syndrome (MOFS) Histol Histopathol 13: 121–128

    CAS  Google Scholar 

  26. Schneider J (1993) Fibrin-specific lysis of microthrombosis in endotoxemic rats by saruplase. Thromb Res 72: 71–82

    Article  PubMed  CAS  Google Scholar 

  27. Drost EM, Kassabian G, Meiselman HJ, Gelmont D, Fisher TC (1999) Increased rigidity and priming of polymorphonuclear leukocytes in sepsis. Am J Respir Crit Care Med 159: 1696–1702

    Article  PubMed  CAS  Google Scholar 

  28. Astiz ME, DeGent GE, Lin RY, Rackow EC (1995) Microvascular function and rheologic changes in hyperdynamic sepsis. Crit Care Med 23: 265–271

    Article  PubMed  CAS  Google Scholar 

  29. Kirschenbaum LA, Astiz ME, Rackow EC, Saha DC, Lin R (2000) Microvascular response in patients with cardiogenic shock. Crit Care Med 28: 1290–1294

    Article  PubMed  CAS  Google Scholar 

  30. Eichelbronner O, Sielenkamper A, Cepinskas G, Sibbald WJ, Chin-Yee IM (2000) Endotoxin promotes adhesion of human erythrocytes to human vascular endothelial cells under conditions of flow. Crit Care Med 28: 1865–1870

    Article  PubMed  CAS  Google Scholar 

  31. De Backer D, Dubois MJ (2001) Assessment of the microcirculatory flow in patients in the intensive care unit. Curr Opin Crit Care 7: 200–203

    Article  PubMed  Google Scholar 

  32. Freedlander SO, Lenhart CH (1922) Clinical observations on the capillary circulation. Arch Intern Med 29: 12–32

    Article  Google Scholar 

  33. Young JD, Cameron EM (1995) Dynamics of skin blood flow in human sepsis. Intensive Care Med 21: 669–674

    Article  PubMed  CAS  Google Scholar 

  34. Stucker M, Steinberg J, Memmel U, et al (2001) Differences in the two-dimensionally measured laser Doppler flow at different skin localisations. Skin Pharmacol Appl Skin Physiol 14: 44–51

    Article  PubMed  CAS  Google Scholar 

  35. Nevière R, Mathieu D, Chagnon JL, Lebleu N, Millien JP, Wattel F (1996) Skeletal muscle microvascular blood flow and oxygen transport in patients with severe sepsis. Am J Respir Crit Care Med 153: 191–195

    Article  PubMed  Google Scholar 

  36. Groner W, Winkelman JW, Harris AG, et al (1999) Orthogonal polarization spectral imaging: a new method for study of the microcirculation. Nat Med 5: 1209–1212

    Article  PubMed  CAS  Google Scholar 

  37. Mathura KR, Vollebregt KC, Boer K, De Graaf JC, Ubbink DT, Ince C (2001) Comparison of OPS imaging and conventional capillary microscopy to study the human microcirculation. J Appl Physiol 91: 74–78

    PubMed  CAS  Google Scholar 

  38. Langer S, von Dobschuetz E, Harris AG, et al (2000) Validation of the orthogonal polarization spectral imaging technique on solid organs. In: Messmer K (ed) Orthogonal polarization spectral imaging. Progress in Applied Microcirculation, vol 24. Karger, Basel, pp 3246

    Google Scholar 

  39. Laemmel E, Tadayoni R, Sinitsina I, et al (2000) Using orthogonal polarization spectral imaging for the experimental study of microcirculation: comparison with intravital microscopy. In: Messmer K (ed) Orthogonal polarization spectral imaging. Progress in Applied Microcirculation, vol 24. Karger, Basel, pp 50–60

    Chapter  Google Scholar 

  40. Harris AG, Sinitsina I, Messmer K (2000) The Cytoscan(TM) Model E-II, a new reflectance microscope for intravital microscopy: Comparison with the standard fluorescence method. J Vasc Res 37: 469–476

    Google Scholar 

  41. De Backer D, Creteur J, Preiser JC, Dubois MJ, Vincent JL (2002) Microvascular blood flow is altered in patients with sepsis. Am J Respir Crit Care Med 166: 98–104

    Article  PubMed  Google Scholar 

  42. Buwalda M, Ince C (2002) Opening the microcirculation: can vasodilators be useful in sepsis? Intensive Care Med 28: 1208–1217

    Article  PubMed  Google Scholar 

  43. Spronk PE, Ince C, Gardien MJ, et al (2002) Nitroglycerin in septic shock after intravascular volume resuscitation. Lancet 360: 1395–1396

    Article  PubMed  Google Scholar 

  44. De Backer D, Creteur J, Vincent J-L (2000) Microcirculatory alterations in cardiogenic and septic shock. Intensive Care Med 26: S334 (abst)

    Google Scholar 

  45. Dubois MJ, De Backer D, Schmartz D, et al (2002) Microcirculatory alterations in cardiac surgery with and without cardiopulmonary bypass. Intensive Care Med 28: S76 (abst)

    Google Scholar 

  46. Zhao KS, Junker D, Delano FA, Zweifach BW (1985) Microvascular adjustments during irreversible hemorrhagic shock in rat skeletal muscle. Microvasc Res 30: 143–153

    Article  PubMed  CAS  Google Scholar 

  47. Kerger H, Waschke KF, Ackern KV, Tsai AG, Intaglietta M (1999) Systemic and microcirculatory effects of autologous whole blood resuscitation in severe hemorrhagic shock. Am J Physiol 276: H2035 - H2043

    PubMed  CAS  Google Scholar 

  48. Sakr Y, Dubois MJ, De Backer D, et al (2002) Time course alterations in patients with septic shock. Intensive Care Med 28: 515 (abst)

    Google Scholar 

  49. Nakagawa Y, Weil MH, Tang W, et al (1998) Sublingual capnometry for diagnosis and quantitation of circulatory shock. Am J Respir Crit Care Med 157: 1838–1843

    Article  PubMed  CAS  Google Scholar 

  50. Weil MH, Nakagawa Y, Tang W, et al (1999) Sublingual capnometry: a new noninvasive measurement for diagnosis and quantitation of severity of circulatory shock. Crit Care Med 27: 1225–1229

    Article  PubMed  CAS  Google Scholar 

  51. Povoas HP, Weil MH, Tang W, Moran B, Kamohara T, Bisera J (2000) Comparisons between sublingual and gastric tonometry during hemorrhagic shock. Chest 118: 1127–1132

    Article  PubMed  CAS  Google Scholar 

  52. Jin X, Weil MH, Sun S, Tang W, Bisera J, Mason EJ (1998) Decreases in organ blood flows associated with increases in sublingual PCO2 during hemorrhagic shock. J Appl Physiol 85: 2360–2364

    PubMed  CAS  Google Scholar 

  53. Creteur J, De Backer D, Sakr Y, et al (2003) Sublingual PCO2 monitoring in patients with septic shock. Crit Care Med (abst) (in press)

    Google Scholar 

Download references

Authors
  1. D. De Backer
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. J. Creteur
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. M. J. Dubois
    View author publications

    You can also search for this author in PubMed Google Scholar

Editor information

Editors and Affiliations

  1. Department of Intensive Care, Erasme Hospital, Free University of Brussels, Route de Lennik 808, B-1070, Brussels, Belgium

    Jean-Louis Vincent MD, PhD, FCCM, FCCP (Head) (Head)

Rights and permissions

Reprints and permissions

Copyright information

© 2003 Springer-Verlag Berlin Heidelberg

About this paper

Cite this paper

De Backer, D., Creteur, J., Dubois, M.J. (2003). Microvascular Alterations in Patients with Circulatory Failure. In: Vincent, JL. (eds) Intensive Care Medicine. Springer, New York, NY. https://doi.org/10.1007/978-1-4757-5548-0_50

Download citation

  • DOI: https://doi.org/10.1007/978-1-4757-5548-0_50

  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-1-4757-5550-3

  • Online ISBN: 978-1-4757-5548-0

  • eBook Packages: Springer Book Archive

Publish with us

Policies and ethics

Search

Navigation