Dissociation between sublingual and gut microcirculation in the response to a fluid challenge in postoperative patients with abdominal sepsis

Abstract

BackgroundThis study was performed to compare intestinal and sublingual microcirculation and their response to a fluid challenge.MethodsTwenty-two septic patients in the first postoperative day of an intestinal surgery, in which an ostomy had been constructed, were evaluated both before and 20 min after a challenge of 10 mL/kg of 6% hydroxyethylstarch 130/0.4. We measured systemic hemodynamics and sublingual and intestinal microcirculation. Correlations between variables were determined through the Pearson test.ResultsFluid administration increased the cardiac index (2.6 ± 0.5 vs. 3.3 ± 1.0 L/min/m2, P < 0.01) and mean arterial blood pressure (68 ± 11 vs. 82 ± 12 mm Hg, P < 0.0001). The sublingual but not the intestinal red blood cell (RBC) velocity increased (912 ± 270 vs. 1,064 ± 200 μm/s, P < 0.002 and 679 ± 379 vs. 747 ± 419 μm/s, P = 0.12, respectively). The sublingual and intestinal perfused vascular density (PVD) did not change significantly (15.2 ± 2.9 vs. 16.1 ± 1.2 mm/mm2 and 12.3 ± 6.7 vs. 13.0 ± 6.7 mm/mm2). We found no correlation between the basal sublingual and intestinal RBC velocities or between their changes in response to the fluid challenge. The individual changes in sublingual RBC velocity correlated with those in cardiac index and basal RBC velocity. Individual changes in intestinal RBC velocity did not correlate with either the cardiac index modifications or the basal RBC velocity. The same pattern was observed with the sublingual and the intestinal PVDs. The sublingual RBC velocities and PVDs were similar between survivors and nonsurvivors. But the intestinal RBC velocities and PVDs were lower in nonsurvivors.ConclusionsIn this series of postoperative septic patients, we found a dissociation between sublingual and intestinal microcirculation. The improvement in the sublingual microcirculation after fluid challenge was dependent on the basal state and the increase in cardiac output. In contrast, the intestinal microcirculation behaved as an isolated territory.

Intraoperative Incident Dark Field Imaging of the Human Peritoneal Microcirculation

“…This might lead to redistributed flow in the microcirculation. However, since our results regarding quantitative parameters of the sublingual microcirculation are in agreement with previous studies [19, 20, 25, 28], it seems that these differences cannot be attributed to the time point at which the measurements were performed.…”

Is the macrocirculation really dissociated from the microcirculation in septic shock?

“…Thus, assessment of microcirculatory images in non-vital and non-working organs such as the tongue cannot by definition represent other regions in patients with shock. Accordingly, sublingual microcirculation fails to predict gut mucosal microcirculation in septic patients [15]. This fact might have relevant clinical implications since gut mucosal hypoperfusion is considered an important pathogenic determinant of multiple organ failure in sepsis.…”

Principles of Fluid Management

“…Recent observational data have shown that disturbance in sublingual microcirculatory flow failed to correlate with patient survival, possibly because of a significant dissociation observed between sublingual and intestinal microcirculatory perfusion after fluid resuscitation. 27,28 These data reinforce the critical importance of the constant need for clinicians to monitor, reassess, and reevaluate the necessity for and response to ongoing fluid therapy.…”