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Arynov A, Kaidarova D, Kabon B. Alternative blood transfusion triggers: a narrative review. BMC Anesthesiol 2024; 24:71. [PMID: 38395758 PMCID: PMC10885388 DOI: 10.1186/s12871-024-02447-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Anemia, characterized by low hemoglobin levels, is a global public health concern. Anemia is an independent factor worsening outcomes in various patient groups. Blood transfusion has been the traditional treatment for anemia; its triggers, primarily based on hemoglobin levels; however, hemoglobin level is not always an ideal trigger for blood transfusion. Additionally, blood transfusion worsens clinical outcomes in certain patient groups. This narrative review explores alternative triggers for red blood cell transfusion and their physiological basis. MAIN TEXT The review delves into the physiology of oxygen transport and highlights the limitations of using hemoglobin levels alone as transfusion trigger. The main aim of blood transfusion is to optimize oxygen delivery, necessitating an individualized approach based on clinical signs of anemia and the balance between oxygen delivery and consumption, reflected by the oxygen extraction rate. The narrative review covers different alternative triggers. It presents insights into their diagnostic value and clinical applications, emphasizing the need for personalized transfusion strategies. CONCLUSION Anemia and blood transfusion are significant factors affecting patient outcomes. While restrictive transfusion strategies are widely recommended, they may not account for the nuances of specific patient populations. The search for alternative transfusion triggers is essential to tailor transfusion therapy effectively, especially in patients with comorbidities or unique clinical profiles. Investigating alternative triggers not only enhances patient care by identifying more precise indicators but also minimizes transfusion-related risks, optimizes blood product utilization, and ensures availability when needed. Personalized transfusion strategies based on alternative triggers hold the potential to improve outcomes in various clinical scenarios, addressing anemia's complex challenges in healthcare. Further research and evidence are needed to refine these alternative triggers and guide their implementation in clinical practice.
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Affiliation(s)
- Ardak Arynov
- Department of Anesthesiology and Intensive Care, Kazakh Institute of Oncology and Radiology, Abay av. 91, Almaty, Kazakhstan.
| | - Dilyara Kaidarova
- Kazakh Institute of Oncology and Radiology, Abay av. 91, Almaty, Kazakhstan
| | - Barbara Kabon
- Department of Anaesthesia, General Intensive Medicine and Pain Medicine Medical, University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
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Martinez-Banaclocha MA. Targeting the Cysteine Redox Proteome in Parkinson's Disease: The Role of Glutathione Precursors and Beyond. Antioxidants (Basel) 2023; 12:1373. [PMID: 37507913 PMCID: PMC10376658 DOI: 10.3390/antiox12071373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 06/22/2023] [Accepted: 06/28/2023] [Indexed: 07/30/2023] Open
Abstract
Encouraging recent data on the molecular pathways underlying aging have identified variants and expansions of genes associated with DNA replication and repair, telomere and stem cell maintenance, regulation of the redox microenvironment, and intercellular communication. In addition, cell rejuvenation requires silencing some transcription factors and the activation of pluripotency, indicating that hidden molecular networks must integrate and synchronize all these cellular mechanisms. Therefore, in addition to gene sequence expansions and variations associated with senescence, the optimization of transcriptional regulation and protein crosstalk is essential. The protein cysteinome is crucial in cellular regulation and plays unexpected roles in the aging of complex organisms, which show cumulative somatic mutations, telomere attrition, epigenetic modifications, and oxidative dysregulation, culminating in cellular senescence. The cysteine thiol groups are highly redox-active, allowing high functional versatility as structural disulfides, redox-active disulfides, active-site nucleophiles, proton donors, and metal ligands to participate in multiple regulatory sites in proteins. Also, antioxidant systems control diverse cellular functions, including the transcription machinery, which partially depends on the catalytically active cysteines that can reduce disulfide bonds in numerous target proteins, driving their biological integration. Since we have previously proposed a fundamental role of cysteine-mediated redox deregulation in neurodegeneration, we suggest that cellular rejuvenation of the cysteine redox proteome using GSH precursors, like N-acetyl-cysteine, is an underestimated multitarget therapeutic approach that would be particularly beneficial in Parkinson's disease.
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Mallat J, Rahman N, Hamed F, Hernandez G, Fischer MO. Pathophysiology, mechanisms, and managements of tissue hypoxia. Anaesth Crit Care Pain Med 2022; 41:101087. [PMID: 35462083 DOI: 10.1016/j.accpm.2022.101087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 11/01/2022]
Abstract
Oxygen is needed to generate aerobic adenosine triphosphate and energy that is required to support vital cellular functions. Oxygen delivery (DO2) to the tissues is determined by convective and diffusive processes. The ability of the body to adjust oxygen extraction (ERO2) in response to changes in DO2 is crucial to maintain constant tissue oxygen consumption (VO2). The capability to increase ERO2 is the result of the regulation of the circulation and the effects of the simultaneous activation of both central and local factors. The endothelium plays a crucial role in matching tissue oxygen supply to demand in situations of acute drop in tissue oxygenation. Tissue oxygenation is adequate when tissue oxygen demand is met. When DO2 is severely compromised, a critical DO2 value is reached below which VO2 falls and becomes dependent on DO2, resulting in tissue hypoxia. The different mechanisms of tissue hypoxia are circulatory, anaemic, and hypoxic, characterised by a diminished DO2 but preserved capacity of increasing ERO2. Cytopathic hypoxia is another mechanism of tissue hypoxia that is due to impairment in mitochondrial respiration that can be observed in septic conditions with normal overall DO2. Sepsis induces microcirculatory alterations with decreased functional capillary density, increased number of stopped-flow capillaries, and marked heterogeneity between the areas with large intercapillary distance, resulting in impairment of the tissue to extract oxygen and to satisfy the increased tissue oxygen demand, leading to the development of tissue hypoxia. Different therapeutic approaches exist to increase DO2 and improve microcirculation, such as fluid therapy, transfusion, vasopressors, inotropes, and vasodilators. However, the effects of these agents on microcirculation are quite variable.
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Affiliation(s)
- Jihad Mallat
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA; Normandy University, UNICAEN, ED 497, Caen, France.
| | - Nadeem Rahman
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Fadi Hamed
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontifcia Universidad Católica de Chile, Santiago, Chile
| | - Marc-Olivier Fischer
- Department of Anaesthesiology-Resuscitation and Perioperative Medicine, Normandy University, UNICAEN, Caen University Hospital, Normandy, Caen, France
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Bakker J. Lactate levels and hemodynamic coherence in acute circulatory failure. Best Pract Res Clin Anaesthesiol 2016; 30:523-530. [PMID: 27931655 DOI: 10.1016/j.bpa.2016.11.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 11/04/2016] [Indexed: 12/18/2022]
Abstract
In this review, the relationship between changes in macrohemodynamics during the development and treatment of acute circulatory failure is discussed in the context of coherence with microcirculation and changes in lactate. In models of circulatory failure, coherence between changes in macrocirculatory and microcirculatory perfusion and coherence with subsequent changes in lactate levels are more or less preserved. However, in patients, particularly those with septic shock, these relationships are much less clear. As many factors influence the effect of circulatory failure and infection on microcirculation and on lactate levels, this should not be surprising. Resuscitation should therefore aim at adequate tissue perfusion where systemic hemodynamics, microcirculatory perfusion parameters, and lactate levels should be used in their relevant context. This results in treating the individual patient as an n = 1 experiment.
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Affiliation(s)
- Jan Bakker
- Columbia University Medical Center, Division of Pulmonary, Allergy, and Critical Care Medicine, 622 West 168th St, Room PH 8E-101, Office: PH 8-109, New York, NY 10032, USA; New York University, Department of Pulmonary and Critical Care, 462 First Avenue, New York, NY 10016, USA; Erasmus MC University Medical Center, Department of Intensive Care Adults, PO Box 2040-Room H-625, 3000 CA Rotterdam, Netherlands; Pontificia Universidad Católica de Chile, Department of Intensive Care, Diagonal Paraguay 362, 8330024 Santiago, Chile.
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Cecconi M, De Backer D, Antonelli M, Beale R, Bakker J, Hofer C, Jaeschke R, Mebazaa A, Pinsky MR, Teboul JL, Vincent JL, Rhodes A. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med 2014; 40:1795-815. [PMID: 25392034 PMCID: PMC4239778 DOI: 10.1007/s00134-014-3525-z] [Citation(s) in RCA: 937] [Impact Index Per Article: 93.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 10/18/2014] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Circulatory shock is a life-threatening syndrome resulting in multiorgan failure and a high mortality rate. The aim of this consensus is to provide support to the bedside clinician regarding the diagnosis, management and monitoring of shock. METHODS The European Society of Intensive Care Medicine invited 12 experts to form a Task Force to update a previous consensus (Antonelli et al.: Intensive Care Med 33:575-590, 2007). The same five questions addressed in the earlier consensus were used as the outline for the literature search and review, with the aim of the Task Force to produce statements based on the available literature and evidence. These questions were: (1) What are the epidemiologic and pathophysiologic features of shock in the intensive care unit? (2) Should we monitor preload and fluid responsiveness in shock? (3) How and when should we monitor stroke volume or cardiac output in shock? (4) What markers of the regional and microcirculation can be monitored, and how can cellular function be assessed in shock? (5) What is the evidence for using hemodynamic monitoring to direct therapy in shock? Four types of statements were used: definition, recommendation, best practice and statement of fact. RESULTS Forty-four statements were made. The main new statements include: (1) statements on individualizing blood pressure targets; (2) statements on the assessment and prediction of fluid responsiveness; (3) statements on the use of echocardiography and hemodynamic monitoring. CONCLUSIONS This consensus provides 44 statements that can be used at the bedside to diagnose, treat and monitor patients with shock.
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Affiliation(s)
- Maurizio Cecconi
- Anaesthesia and Intensive Care, St George's Hospital and Medical School, SW17 0QT, London, UK,
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Bakker J, Nijsten MW, Jansen TC. Clinical use of lactate monitoring in critically ill patients. Ann Intensive Care 2013; 3:12. [PMID: 23663301 PMCID: PMC3654944 DOI: 10.1186/2110-5820-3-12] [Citation(s) in RCA: 209] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 04/16/2013] [Indexed: 12/13/2022] Open
Abstract
Increased blood lactate levels (hyperlactataemia) are common in critically ill patients. Although frequently used to diagnose inadequate tissue oxygenation, other processes not related to tissue oxygenation may increase lactate levels. Especially in critically ill patients, increased glycolysis may be an important cause of hyperlactataemia. Nevertheless, the presence of increased lactate levels has important implications for the morbidity and mortality of the hyperlactataemic patients. Although the term lactic acidosis is frequently used, a significant relationship between lactate and pH only exists at higher lactate levels. The term lactate associated acidosis is therefore more appropriate. Two recent studies have underscored the importance of monitoring lactate levels and adjust treatment to the change in lactate levels in early resuscitation. As lactate levels can be measured rapidly at the bedside from various sources, structured lactate measurements should be incorporated in resuscitation protocols.
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Affiliation(s)
- Jan Bakker
- Department of Intensive Care Adults, Erasmus MC University Medical Center, PO Box 2040, Room H625, Rotterdam, CA 3000, Netherlands.
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Vincent JL, De Backer D. Oxygen transport-the oxygen delivery controversy. Intensive Care Med 2004; 30:1990-6. [PMID: 15258731 DOI: 10.1007/s00134-004-2384-4] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2003] [Accepted: 06/24/2004] [Indexed: 12/22/2022]
Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Route de Lennik 808, 1070 Brussels, Belgium.
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Zhang H, De Jongh R, De Backer D, Cherkaoui S, Vray B, Vincent JL. Effects of alpha - and beta -adrenergic stimulation on hepatosplanchnic perfusion and oxygen extraction in endotoxic shock. Crit Care Med 2001; 29:581-8. [PMID: 11373424 DOI: 10.1097/00003246-200103000-00020] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the effects of adrenergic stimulation on hepatosplanchnic perfusion, oxygen extraction, and tumor necrosis factor-alpha production during endotoxic shock. DESIGN In vivo, prospective, randomized, controlled, repeated-measures, experimental study. SETTING Experimental physiology laboratory in a university teaching hospital. SUBJECTS Twenty-one anesthetized and mechanically ventilated dogs. INTERVENTIONS An intrapericardial catheter was positioned. Catheters for blood sampling were inserted into the right femoral artery, hepatic vein, portal vein, and pulmonary artery. Ultrasonic flow probes were placed around the portal vein, the hepatic artery, the mesenteric artery, the left renal artery, and the left femoral artery. Animals received 2 mg/kg of Escherichia coli endotoxin, followed by fluid resuscitation. Seven dogs received intravenous isoproterenol (0.1 microg/kg x min(-1)), seven received phenylephrine (1 microg/kg x min(-1)), and seven served as controls. Thirty minutes later, cardiac tamponade was introduced to study organ perfusion and tissue oxygen extraction capabilities. MAIN RESULTS The isoproterenol group had a higher cardiac index and stroke index and lower systemic vascular resistance than the other groups. The phenylephrine group had a higher arterial pressure but a lower cardiac index than the isoproterenol group. The isoproterenol group had a higher hepatic artery blood flow than the other groups and a higher portal and mesenteric flow than the control group. Liver and gut mucosal blood flow was greater in the isoproterenol than in the phenylephrine group. The isoproterenol group had a lower global critical oxygen delivery than the other groups (8.8 +/- 1.3 vs. 13.1 +/- 2.0 (control) and 11.8 +/- 3.3 mL/kg x min(-1) (phenylephrine); both p < .05) and a higher liver critical oxygen extraction ratio than the control group. Isoproterenol tended to attenuate, but phenylephrine significantly increased, blood tumor necrosis factor levels. CONCLUSIONS During endotoxic shock, beta-stimulation can improve hepatosplanchnic perfusion and enhance tissue oxygen extraction capabilities, whereas alpha-stimulation does not. In addition, alpha-adrenergic stimulation can increase tumor necrosis factor levels.
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Affiliation(s)
- H Zhang
- Division of Respiratory Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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Van der Linden P, De Hert S, Bélisle S, De Groote F, Mathieu N, d'Eugenio S, Julien V, Huynh C, Mélot C. Comparative effects of red blood cell transfusion and increasing blood flow on tissue oxygenation in oxygen supply-dependent conditions. Am J Respir Crit Care Med 2001; 163:1605-8. [PMID: 11401881 DOI: 10.1164/ajrccm.163.7.2001003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Red blood cell (RBC) transfusion is usually administered to improve oxygen delivery (DO(2)) in order to sustain tissue oxygen demand. However, this practice is not supported by firm clinical or experimental data. Using a randomized two-period crossover design, this study compared the efficacy of "fresh" RBC transfusion and increased blood flow to restore tissue oxygenation in oxygen supply-dependent conditions. In 12 ketamine-anesthetized mongrel dogs submitted to nonpulsatile normothermic cardiopulmonary bypass, DO(2) was reduced by a progressive decrease in pump flow. DO(2) dependency was defined as an O(2) uptake (V O(2)) decrease by more than 15% from baseline value. Then, intervention consisted of a 40% increase in DO(2) obtained either by transfusion of "fresh" dog's RBC (stored < 3 d) or by increase in pump flow. Animals received both interventions sequentially in a random order, while O(2) saturation was maintained constant. In O(2) supply-dependent conditions, rising pump flow from 1.6 +/- 0.4 to 2.7 +/- 0.7 L/ min increased DO(2) from 5.4 +/- 1.1 to 9.0 +/- 1.3 ml/kg/min (p < 0.01) and V O(2) from 3.5 +/- 0.4 to 4.1 +/- 0.5 ml/kg/min (p = 0.02). "Fresh" RBC transfusion, which increased the hemoglobin concentration from 6.4 +/- 0.9 to 11.1 +/- 1.3 g/dl, increased DO(2) from 5.4 +/- 1.2 to 9.0 +/- 1.4 ml/kg/min (p < 0.01) and V O(2) from 3.6 +/- 0.4 to 4.1 +/- 0.5 ml/kg/min (p = 0.02). There was no difference in V O(2) resulting from both interventions. In oxygen supply-dependent conditions, "fresh" RBC transfusion and increased blood flow are equally effective in restoring tissue oxygenation.
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Affiliation(s)
- P Van der Linden
- Department of Experimental Anesthesia, Erasme University Hospital, Brussels, Belgium.
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Vincent JL, van der Linden P. Physiology of VO2/DO2. UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 1997. [DOI: 10.1007/978-3-642-60696-0_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Vincent JL. Determination of oxygen delivery and consumption versus cardiac index and oxygen extraction ratio. Crit Care Clin 1996; 12:995-1006. [PMID: 8902380 DOI: 10.1016/s0749-0704(05)70288-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Measuring cardiac output without knowledge of the oxygen extraction by the tissues is of limited value. Instead of calculating oxygen consumption and oxygen delivery, a diagram relating cardiac index to the oxygen extraction ratio is proposed to interpret hemodynamic data at the bedside. This diagram is particularly helpful in interpreting cardiac index in the presence of changes in hemoglobin or oxygen demands and in evaluating the effects of therapy.
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Affiliation(s)
- J L Vincent
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Belgium
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Samsel RW, Lewis TH, Sanders WM, Wood LD, Schumacker PT. The effect of adrenergic agonists on the systemic response to hemorrhage. J Crit Care 1994; 9:25-33. [PMID: 8199651 DOI: 10.1016/0883-9441(94)90030-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE Systemic blood loss elicits a variety of reflex cardiovascular responses, which preserve cardiac output as possible and preserve arterial blood pressure when cardiac output decreases. When compensatory venoconstriction is exhausted, hemorrhage reduces oxygen delivery (QO2), and systemic vasoconstriction competes with local metabolic vasodilation to preserve tissue oxygen uptake (VO2). Through their effects on vascular tone and blood flow distribution, adrenergic agents might interfere with the physiological responses to reduced O2 delivery. This study was designed to determine the effects of dobutamine and norepinephrine on oxygen extraction and systemic vascular resistance during progressive hemorrhage. METHODS We infused dobutamine or norepinephrine into anesthetized, ventilated dogs and measured the systemic vascular resistance, oxygen consumption, and oxygen extraction ratio as oxygen delivery (blood flow) was reduced by blood withdrawal. Four groups were compared: control (saline), dobutamine (10 micrograms/kg/min), high-dose norepinephrine (1.0 microgram/kg/min), and low-dose norepinephrine (0.1 microgram/kg/min). RESULTS High-dose norepinephrine increased oxygen demand but did not alter extraction significantly at the critical point. Neither low-dose norepinephrine nor dobutamine affected oxygen extraction during hemorrhage. Dobutamine and norepinephrine both ablated the increase in systemic vascular resistance that accompanies hemorrhage. Low-dose norepinephrine was not different from control. CONCLUSIONS Norepinephrine and dobutamine appear to block reflex vasoconstriction, and mechanistic explanations for this finding remain speculative. Despite inhibition of reflex vasoconstriction, neither dobutamine nor norepinephrine significantly impaired oxygen extraction during hemorrhage.
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Affiliation(s)
- R W Samsel
- Department of Medicine, University of Chicago, Illinois
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