Effects of phenylephrine on the sublingual microcirculation during cardiopulmonary bypass

Maier, Stephan; Hasibeder, Walter; Hengl, C.; Pajk, Werner; Schwarz, Birgit; Margreiter, Josef; Ulmer, Hanno; Engl, Julia; Knotzer, Hans

doi:10.1093/bja/aep018

Cited by 61 publications

(42 citation statements)

References 27 publications

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“…50,51 Indeed, a 20-mmHg increase in systemic blood pressure by phenylephrine was associated with depressed sublingual smallvessel blood flow while medium-sized vessels were unaffected. 52 However, from this study, it was unclear whether this increase in blood pressure also was associated with augmentation of cardiac output. Others showed an increase in local gastric mucosal blood flow after dopamine infusion, whereas systemic flow remained stable.…”

Section: Blood Pressure and Cardiac Outputmentioning

confidence: 70%

“…[80][81][82] In contrast, Maier et al demonstrated that initiation of CPB did not alter sublingual microcirculatory perfusion, while an additional phenylephrine-induced systemic blood pressure increase reduced small vessel blood flow and augmented tissue hemoglobin oxygenation. 52 Others showed that the rectal microvascular flow index and the proportion of perfused vessels was almost normal at 30 minutes following cardiac surgery. 23…”

Section: Cardiac Surgery With Cardiopulmonary Bypassmentioning

confidence: 99%

See 1 more Smart Citation

Changes in Microcirculatory Perfusion and Oxygenation During Cardiac Surgery With or Without Cardiopulmonary Bypass

Koning

Atasever

Vonk

et al. 2014

Journal of Cardiothoracic and Vascular Anesthesia

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Section: Blood Pressure and Cardiac Outputmentioning

confidence: 70%

Section: Cardiac Surgery With Cardiopulmonary Bypassmentioning

confidence: 99%

Changes in Microcirculatory Perfusion and Oxygenation During Cardiac Surgery With or Without Cardiopulmonary Bypass

Koning

Atasever

Vonk

et al. 2014

Journal of Cardiothoracic and Vascular Anesthesia

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“…Of all patients, 54% required at least one postoperative hemodialysis (median 1, range [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17]. Grafts with delayed function had a longer Cit (mean 11 h 36 min) compared with those not requiring any postoperative hemodialysis (mean 7 h 45 min)(P < 0.05).…”

Section: Postoperative Kidney Functionmentioning

confidence: 98%

Prognostic value of intraoperative renal tissue oxygenation measurement on early renal transplant function

Scheeren¹,

Martin²,

Maruschke³

et al. 2011

Transplant International

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Summary Ischemia time is a prognostic factor in renal transplantation for postoperative graft function and survival. Kidney transplants from living donors have a higher survival rate than deceased donor kidneys probably because of shorter ischemia time. We hypothesized that measurement of intraoperative kidney oxygenation (μHbO2) and microvascular perfusion predicts postoperative graft function. We measured microvascular hemoglobin oxygen saturation by reflectance spectrophotometry and microcirculatory kidney perfusion by laser Doppler flowmetry 5 and 30 min after kidney reperfusion on the organ surface in 53 renal transplant patients including 19 grafts from living donors. These values were related to systemic hemodynamics, cold ischemia time (cit), early postoperative graft function and length of hospital stay. μHbO2 improved 30 min after reperfusion compared to 5 min (from 67% to 71%, P < 0.05). μHbO2 correlated with mean arterial blood pressure and central venous pH (P < 0.01). Most importantly, μHbO2 was significantly higher in kidneys from living compared with deceased donors (74% vs. 63%) and in kidneys without vs. with biopsy‐proven postoperative rejection (71% vs. 45%, P < 0.001). Finally, μHbO2 correlated positively with cit and postoperative creatinine clearance and negatively with postoperative plasma creatinine, need for hemodialysis and length of hospital stay. Our results suggest higher oxygen extraction and thus oxygen demand of the grafts shortly after reperfusion. The intraoperative measurement of tissue oxygenation in kidney transplants is predictive of early postoperative graft function. Future studies should evaluate the potential effect of intraoperative therapeutic maneuvers to improve organ tissue oxygenation in renal transplantation.

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“…Cela dit, la même équipe, en randomisant les patients à recevoir initialement soit de la phényléphrine, soit de la noradrénaline, ne retrouve pas de différence entre les deux groupes concernant les mêmes paramètres [39]. Chez des patients hémodynamiquement stables après pontage aortocoronaire, le MFI capillaire sublingual est abaissé après traitement par phényléphrine, malgré une augmentation de la saturation tissulaire en oxygène (StO 2 ) [NIRS), et une accé-lération du débit sanguin microcirculatoire est mesurée en laser échographie-doppler évoquant l'aggravation d'un shunt microcirculatoire [40].…”

Section: Phényléphrineunclassified

“…Phényléphrine -Aggravation clairance ICG, clairance créatinine, lactate, dans une étude en crossing-over avec la noradrénaline [38] -Pas de modification dans une étude randomisée [39] -Aggravation de l'indice de flux microcirculatoire [40] Noradrénaline -Amélioration non significative de la proportion de capillaires perfusés [35] Adrénaline -Crossing-over en addition de dobutamine-noradrénaline, diminution du pH muqueux, du flux splanchnique augmentation du lactate dans la veine hépatique (Meier-Hellmann 1997) En effet, certaines études ont porté sur la microcirculation splanchnique (jéjunale, iléale ou colique), le plus souvent par doppler laser ou vidéomicroscopie (débit, densité capillaire fonctionnelle, hétérogénéité) [42][43][44]. D'autres études ont mesuré l'oxygénation microcirculatoire (StO 2 , HbO 2 ou gradient PO 2 muqueuse/PO 2 artérielle) de la muqueuse et de la sous-muqueuse intestinale par électrodes dédiées [45].…”

Section: Sepsis Périopératoireunclassified

Effets des vasoconstricteurs sur la microcirculation

et al. 2015

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Les théories physiologiques et les modèles animaux nous prédisent souvent un effet néfaste de l'obtention d'une vasoconstriction importante sur la microcirculation. La diminution de la pression capillaire (avec au maximum une fermeture des capillaires en cas de pression extramurale trop forte), de l'hématocrite microcirculatoire, possiblement du débit, et de la densité capillaire possible en sont autant de raisons. En fait, les effets des vasoconstricteurs à disposition sont impossibles à prévoir : la noradrénaline par exemple provoque un effet alphapositif entraînant une augmentation des résistances artériolaires, mais aussi veineuses, avec un effet possible d'augmentation du débit cardiaque par effet précharge et/ou par bêtastimulation. Les effets sur la perfusion intestinale, rénale et microcirculatoire (le plus souvent sublinguale) sont souvent neutres, voire positifs pour la noradrénaline et la terlipressine au décours du choc septique, pour peu qu'une hypovolémie importante ait été traitée auparavant et que les objectifs de pression artérielle moyenne ne dépassent pas 75 mmHg. La phényléphrine semble être difficile d'utilisation et dangereuse pour la microcirculation. La vasopressine requiert probablement des études complémentaires concernant la microcirculation. Enfin, la titration et la décrémentation en cas de signe de dysoxie tissulaire (marbrures cutanées, augmentation du lactate) semblent être de bon sens. Mots clés Microcirculation · Vasoconstricteurs · Sepsis · Noradrénaline · Terlipressine · Adrénaline · Vasopressine · PhényléphrineAbstract Physiology and animal models often predict microvascular negative effects of excessive vasoconstriction. The following are among them: a drop in capillary pressure (even closure of capillaries), a drop in microvascular haematocrit, a possible drop in flow, a possible decrease in capillary density. In fact, the impact of usual vasoconstrictors is difficult to predict, e.g. norepinephrine is an alpha agonist, which simultaneously increases arteriolar but also venular resistances together with a possible increase in cardiac output by beta stimulation or thanks to preload effect. Concerning norepinephrine and probably terlipressin, the effects on splanchnic, renal and most often sublingual microcirculation are globally either positive or neutral if a deep hypovolemia is treated before perfusion of the drug and if mean arterial pressure goal is below 75 mmHg. Phenylephrine seems deleterious and difficult to use. Vasopressin requires more studies concerning microcirculation. Careful titration and even decrementation of the drugs in case of tissue dysoxia (mottling of the skin, the increase of lactate levels) seems to be common sense.

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Effects of phenylephrine on the sublingual microcirculation during cardiopulmonary bypass

Abstract: Our data demonstrate that an increased perfusion pressure produced by phenylephrine at constant CPB flow may decrease microcirculatory blood flow in the sublingual mucosal microcirculation due to microvascular blood flow shunting.

Cited by 61 publications

References 27 publications

Changes in Microcirculatory Perfusion and Oxygenation During Cardiac Surgery With or Without Cardiopulmonary Bypass

Changes in Microcirculatory Perfusion and Oxygenation During Cardiac Surgery With or Without Cardiopulmonary Bypass

Prognostic value of intraoperative renal tissue oxygenation measurement on early renal transplant function

Effets des vasoconstricteurs sur la microcirculation

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