Die Wirkung von Noradrenalin, Adrenalin, Isoproterenol und Adenosin auf die Durchblutung der Leber und des Splanchnicusgebietes des Hundes

Effect of intravenous low-dose norepinephrine on blood loss in non-tourniquet total knee arthroplasty under general anesthesia: a randomized, double-blind, controlled, single-center trial

OBJECTIVE

This prospective trial aimed to evaluate the effects of low-dose intravenous norepinephrine (NE) on intraoperative blood loss and bleeding from osteotomy sites during non-tourniquet total knee arthroplasty (TKA) under general anesthesia.

METHODS

A total of 120 patients who underwent TKA between December 2020 and May 2022 were enrolled and randomly assigned to the intravenous low-dose NE Group (NE Group) or the control group (C Group). During surgery, NE Group received 0.05-0.1 μg/(kg min) of NE intravenously to raise and maintain the patient's mean arterial pressure (MAP). C Group received the same dose of saline as placebo. Intraoperative blood loss, bleeding score at osteotomy sites, Δlactate levels (Lac), postoperative complications, and transfusion rate during hospitalization were compared between groups.

RESULTS

Intraoperative and osteotomy blood loss was significantly lower in the NE Group than in the C Group (P < 0.001). No significant difference was observed in ΔLac between groups (P > 0.05). There was no significant difference in complications between the groups 3 days after surgery (P > 0.05). In addition, there was no significant difference in blood transfusion rates between the two groups during hospitalization (P > 0.05).

CONCLUSION

In non-tourniquet TKA under general anesthesia, low-dose intravenous NE safely and effectively reduced intraoperative blood loss and provided a satisfactory osteotomy site while maintaining a higher MAP.

Negative impact of systemic catecholamine administration on hepatic blood perfusion after porcine liver transplantation

Catecholamines are often administered during and after liver transplantation (LTx) to support systemic perfusion and to increase organ oxygen supply. Some vasoactive agents can compromise visceral organ perfusion. We followed the hypothesis that the vasculature of transplanted livers presents with a higher sensitivity, which leads to an increased vulnerability for flow derangement after application of epinephrine (Epi) or norepinephrine (NorEpi). Hepatic macroperfusion and microperfusion during systemic Epi or NorEpi infusion were measured by Doppler flow and thermodiffusion probes in porcine native, denervated, and transplanted livers (n = 16 in each group). Epi or NorEpi were infused (n = 8 in each subgroup) in predefined dosages (low dose = 5 microg/kg/minute and high dose = 10 microg/kg/minute) over 240 minutes. Systemic cardiocirculatory parameters were monitored continuously. Hepatic perfusion data were compared between all groups at comparable time points and dosages. In all native, denervated, and transplanted liver groups, Epi and NorEpi induced an inconsistent rise of mean arterial pressure and heart rate shortly after onset of infusion in both dosages compared with baseline. No significant differences of cardiovascular parameters at comparable time points were observed. In native livers, Epi and NorEpi induced only temporary alterations of hepatic macrocirculation and microcirculation, which returned to baseline 2 hours after onset of infusion. No significant alterations of hepatic blood flow were detected after isolated surgical denervation of the liver. By contrast, transplanted livers showed a progressive decline of hepatic macrocirculation (33-75% reduction) and microcirculation (39-58% reduction) during catecholamine infusions in a dose-dependent fashion. Characteristics of liver blood flow impairment were comparable for both vasoactive agents. In conclusion, pronounced disturbances of hepatic macrocirculation and microcirculation were observed during systemic Epi and NorEpi infusion after LTx compared with native and denervated livers. Microcirculation disturbances after LTx might be explained by impairment of hepatic blood flow regulation caused by an increased sensitivity of hepatic vasculature after ischemia-reperfusion and by lengthening of vasopressor effects caused by reduced hepatocyte metabolism. Clinicians should be aware of this potentially hazardous effect. Therefore, application of catecholamines after clinical LTx should be indicated carefully.

The effect of caffeine on postprandial hypotension in the elderly

In a double-blind, randomized trial the effects of caffeinated and decaffeinated drinks on postprandial hemodynamic and neurohumoral changes were studied in seven fit, elderly subjects after a standard 2.4MJ meal. There was a significant difference in supine postprandial systolic blood pressure between the placebo and caffeine phases (P less than 0.01); at 60 minutes, supine systolic blood pressure had fallen 14 mmHg [95% confidence interval (CI)-7 to-21 mmHg, p less than 0.01) after placebo, but was unchanged after caffeine (+9 mmHg, CI 0 to 18 mmHg, NS]. Similar differences between placebo and caffeine were seen in erect systolic and diastolic blood pressure (P less than 0.01), although orthostatic tolerance was maintained throughout each study period. Postprandial plasma noradrenaline levels were higher (P less than 0.02) and the increase greater (P less than 0.02) after caffeine than after placebo. Caffeine administered at the end of a standard test meal prevents the postprandial fall in blood pressure in fit, elderly subjects. The clinical relevance of this finding has yet to be determined, but it may offer a simple remedy for patients with symptomatic postprandial hypotension.

Liver blood flow measurement in the rat. The electromagnetic versus the microsphere and the clearance methods

This study describes the simultaneous measurement of hepatic arterial and portal venous blood flow in the pentobarbital anesthetized rat by means of electromagnetic flowmeters. Hepatic arterial flow was 0.21 +/- 0.02 mL/min/g liver, and portal venous flow was 1.53 +/- 0.19 mL/min/g liver (n = 20). Flows remained stable for more than 3 hr. A clear advantage of the electromagnetic technique is that it allows the continuous simultaneous separate measurement of hepatic arterial and portal venous blood flow. Simultaneous measurement of hepatic blood flow by the electromagnetic method and the microsphere method yielded almost identical results. Adenosine infusion (100 micrograms/min) did not affect hepatic blood flow measured electromagnetically nor via the microsphere technique. The suitability of indocyanine green (ICG) as an indicator of hepatic blood flow was evaluated by comparing the ICG clearance at steady-state conditions to the values of liver flow obtained by direct electromagnetic measurement. ICG clearance was only 30% of the electromagnetically measured blood flow. These data strongly suggest that ICG clearance does not reflect liver flow in the rat. Intravenous infusion of the vasoactive agents phenylephrine (2, 4, 10 micrograms/min during 5 min) and adenosine (20, 40, 200 micrograms/min) did not affect portal venous nor hepatic arterial flow, measured by the electromagnetic method, although brisk effects on mean arterial blood pressure were observed. This suggests autoregulatory responses of the hepatic vascular bed. The data suggest that electromagnetic flowmeters may be used to measure portal venous and hepatic arterial flow simultaneously in anesthetized rats. The continuous measurement of both flows simultaneously offers a clear advantage over other methods of hepatic flow measurement.

Hepatic adenosine in rats fed ethanol: effect of acute hyperoxia or hypoxia

The level of adenosine was measured in monthly biopsied livers from rats fed ethanol and a high fat/low protein diet in order to test a hypothesis that hepatic adenosine is increased due to enhanced breakdown of adenine nucleotides in which ATP and total adenylate pool were decreased by chronic ethanol feeding. The ethanol-fed rats showed a significantly higher average level of adenosine compared to the pair-fed controls. When investigated monthly, however, adenosine in ethanol-fed rats increased only after the decrease in ATP had stabilized and AMP remained unchanged, indicating that these changes were not temporarily related. The average percentage of change in adenosine after acute hyperoxia or hypoxia were variable both in ethanol-fed and pair-fed rats. There was a tendency for a positive correlation between the percentage of change of adenosine and AMP after hyperoxia regardless of ethanol feeding. A negative correlation between the percentage of change of adenosine and energy charge, and a positive correlation between the percentage of change of adenosine and AMP were seen after hypoxia regardless of ethanol feeding. Adenosine levels changed rapidly in response to changes in systemic of pO2 in both the ethanol-fed and control rats, indicating that the liver maintained its normal response to the changes in energy state. The results indicate that chronic ethanol feeding does increase the level of adenosine in the liver and that this level remains responsive to acute changes in pO2.(ABSTRACT TRUNCATED AT 250 WORDS)

Angiotensin II infusion during beta-adrenergic stimulation by isoproterenol. Effects on hepatic, splenic and cardiac blood volumes and on the magnitude and distribution of cardiac output in the dog

The cardiac and peripheral vascular adjustments to angiotensin II (0.1-0.2 microgram kg-1 min-1 i.v.) during high beta-adrenergic activity by a continuous isoproterenol infusion (0.2-0.3 microgram kg-1 min-1 i.v.) were examined in anaesthetized, atropinized dogs. Hepatic, splenic and left ventricular (LV) volume changes were estimated by an ultrasonic technique, and the blood flow distribution was measured by injecting radioactive microspheres and by electromagnetic flowmetry on the caval veins, the hepatic artery and the portal vein. During isoproterenol infusion, angiotensin II increased the systolic LV pressure by 45 +/- 3 mmHg and the stroke volume by 17 +/- 6%. Concomitantly, the hepatic and splenic blood volumes declined by 29 +/- 4 and 14 +/- 6 ml, respectively, and the LV end-diastolic segment length increased by 3 +/- 1%. The flow through the inferior caval vein increased by 39 +/- 9%, whereas the superior vena caval flow remained unchanged. The hepatic arterial flow more than doubled. Thus, at high inotropy by isoproterenol infusion, angiotensin II relocates blood from the liver and the spleen towards the heart. By activating the Frank-Starling mechanism, cardiac output is increased and conducted through the lower body, especially through the hepatic artery, because of the poor autoregulation of flow through this vessel.

Cardiovascular effects of adenosine

The results, briefly summarized above, indicate that adenosine could be a physiologically important modulator of several aspects of cardiovascular regulation. Most cells are equipped with adenosine receptors. These receptors are of at least two subtypes which can be defined by the relative agonist potency. At these adenosine receptors, methylxanthines, including caffeine and theophylline, act as competitive antagonists. The role of adenosine antagonism, as a mechanism behind the cardiovascular effects of these xanthines, was recently reviewed (Fredholm, 1984). The concentrations of adenosine are low during resting conditions, but may be raised substantially by, for example, hypoxia, ischaemia and increased mechanical or biochemical work. The adenosine levels can also be raised by drugs, including uptake inhibitors such as dipyridamole. Already the concentrations of adenosine that occur during basal conditions are sufficient to produce significant effects, for example, on blood-flow. When the concentrations are raised the importance of endogenous adenosine becomes even greater. Adenosine may not only be of physiological significance but may also be pharmacologically important. First, there are several drugs that may act by affecting the levels of adenosine or by influencing its receptors. Second, the possibility exists that adenosine itself could be used clinically. For example, adenosine may be an attractive alternative to sodium nitroprusside or nitroglycerin when controlled hypotension is to be achieved. Adenosine may also be used to preserve blood platelets during extracorporal circulation or to produce selective regional vasodilatation. Both the physiological and pharmacological aspects are subject to intense study in several laboratories.

Hemodynamic and humoral effects of caffeine in autonomic failure. Therapeutic implications for postprandial hypotension

We examined the effects of caffeine and meals on blood pressure and heart rate in 12 patients with autonomic failure. The influence of caffeine on plasma norepinephrine, epinephrine, and renin activity was also studied. Caffeine 250 mg, raised blood pressure by 12/6 mm Hg, from 129 +/- 25/78 +/- 12 (mean +/- S.D.) to a maximum of 141 +/- 30/84 +/- 16 mm Hg at 45 minutes (P less than 0.01), but did not change heart rate, levels of norepinephrine, or epinephrine, or plasma renin activity. Blood pressure fell by 28/18 mm Hg after a standardized meal, from 133 +/- 32/80 +/- 15 to a minimum of 105 +/- 21/62 +/- 12 mm Hg at 60 minutes (P less than 0.01). After pretreatment with 250 mg of caffeine, the standardized meal induced a fall of only 11/10 mm Hg, from 140 +/- 33/79 +/- 7 to 129 +/- 31/69 +/- 13 mm Hg at 60 minutes (P less than 0.05 vs. values after the control per day for seven days) in five patients, postprandial blood pressures remained higher after caffeine than after placebo (P less than 0.05). We conclude that caffeine is a pressor agent and attenuates postprandial hypotension in autonomic failure, and that this effect is not primarily due to elevations in sympathoadrenal activity or activation of the renin-angiotensin system. Caffeine may be useful in the treatment of orthostatic hypotension due to autonomic failure, especially in the postprandial state.

The effects of adenosine-5'-ethylcarboxamide on liver blood flow and hepatic glucose, lactate and pyruvate balances in dogs

The actions of adenosine-5'-ethylcarboxamide (744-96), a long-acting adenosine analogue, on liver, portal and intestinal balances of glucose, lactate and pyruvate and on hepatic and portal blood flow were investigated in 6 chloralose-anaesthetized mongrel dogs. 744-96 led to an increase in portal and hepatic blood flow. Glucose release by the liver and glucose uptake by the non-hepatic splanchnic area (portal balance) were markedly increased by 744-96. Hepatic lactate and pyruvate balances were reversed from uptake to release by the adenosine analogue. The changes in glucose balances compare closely to the actions of glucagon, which is known to be released by 744-96. Apart from these possible glucagon-mediated actions, a direct action of the adenosine analogue must be assume from the changes in lactate metabolism. The results of this study are indicative of a substrate-mobilising action of adenosine in addition to its well-known vasodilatory action.

Hemodynamic effects of norepinephrine and isoprenaline in various regions of the canine splanchnic area

Responses to norepinephrine (NE) and isoprenaline (ISO) (1-1024 ng/kg i.v.) were assessed by electromagnetic flowmetry on 18 arteries of the splanchnic region in anesthetized dogs. Measurements were judged according to the 2 criteria: 1. direction of effect; 2.sensitivity of vascular areas to catecholamines, expressed as D50 (i.e. the calculated dose inducing 50% of the maximum effect). NE decreased flow in all arteries (40-80%), but caused additionally an increase in the celiac, splenic and splenic artery proper. Thus changes in the spleen are responsible for the increase with NE. Flow reduction in the pancreatic branch of the cranial mesenteric artery was small. All flow reductions induced by NE had a similar D50 (about 30 ng/kg), except that in the hepatic artery (100 ng/kg).

The vasodilator actions of isoprenaline, histamine, prostaglandin E2, glucagon and secretin on the hepatic arterial vascular bed of the dog

The sympathetically-innervated arterial vascular bed of the dog's liver was perfused from a femoral artery. Arterial blood flow and perfusion pressure were measured continuously, and the hepatic arterial vascular resistance calculated. The preparation provided a means of assessing hepatic arterial vasodilatation quantitatively. 2 Isoprenaline, histamine, prostaglandin E2, glucagon and secretin were injected intra-arterially and all evoked dose-dependent vasodilatation of the hepatic arterial vascular bed. 3 The maximum reduction in the calculated hepatic arterial vascular resistance of 37-38% was the same for each of the five substances. 4 Comparisons on a weight basis revealed that prostaglandin E2 was the most potent, followed in potency order by secretin, isoprenaline, histamine and glucagon. 5 Comparisons on a molar basis showed that secretin and prostaglandin E3 were intrinsically considerably more potent than isoprenaline, histamine or glucagon. 6 The onset of the vasodilatator responses to secretin, isoprenaline, histamine and prostaglandin E2, was rapid, and the duration of their actions was brief. 7 The onset of the vasodilator effects of glucagon was slow and its duration of action very prolonged. 8 The implications of these observations with respect to the physiological control of the hepatic arterial vascular bed of the dog are discussed.