1
|
Chandrasekhar A, Padrós-Valls R, Pallarès-López R, Palanques-Tost E, Houstis N, Sundt TM, Lee HS, Sodini CG, Aguirre AD. Tissue perfusion pressure enables continuous hemodynamic evaluation and risk prediction in the intensive care unit. Nat Med 2023; 29:1998-2006. [PMID: 37550417 DOI: 10.1038/s41591-023-02474-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 06/27/2023] [Indexed: 08/09/2023]
Abstract
Treatment of circulatory shock in critically ill patients requires management of blood pressure using invasive monitoring, but uncertainty remains as to optimal individual blood pressure targets. Critical closing pressure, which refers to the arterial pressure when blood flow stops, can provide a fundamental measure of vascular tone in response to disease and therapy, but it has not previously been possible to measure this parameter routinely in clinical care. Here we describe a method to continuously measure critical closing pressure in the systemic circulation using readily available blood pressure monitors and then show that tissue perfusion pressure (TPP), defined as the difference between mean arterial pressure and critical closing pressure, provides unique information compared to other hemodynamic parameters. Using analyses of 5,988 admissions to a modern cardiac intensive care unit, and externally validated with 864 admissions to another institution, we show that TPP can predict the risk of mortality, length of hospital stay and peak blood lactate levels. These results indicate that TPP may provide an additional target for blood pressure optimization in patients with circulatory shock.
Collapse
Affiliation(s)
- Anand Chandrasekhar
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Raimon Padrós-Valls
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA
| | - Roger Pallarès-López
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA
| | - Eric Palanques-Tost
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA
| | - Nicholas Houstis
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Healthcare Transformation Lab, Massachusetts General Hospital, Boston, MA, USA
| | - Thoralf M Sundt
- Cardiac Surgery Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hae-Seung Lee
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Charles G Sodini
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Aaron D Aguirre
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA.
- Healthcare Transformation Lab, Massachusetts General Hospital, Boston, MA, USA.
- Center for Systems Biology, Massachusetts General Hospital, Boston, MA, USA.
| |
Collapse
|
2
|
Berger D, Moller PW, Weber A, Bloch A, Bloechlinger S, Haenggi M, Sondergaard S, Jakob SM, Magder S, Takala J. Effect of PEEP, blood volume, and inspiratory hold maneuvers on venous return. Am J Physiol Heart Circ Physiol 2016; 311:H794-806. [DOI: 10.1152/ajpheart.00931.2015] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 07/13/2016] [Indexed: 11/22/2022]
Abstract
According to Guyton's model of circulation, mean systemic filling pressure (MSFP), right atrial pressure (RAP), and resistance to venous return (RVR) determine venous return. MSFP has been estimated from inspiratory hold-induced changes in RAP and blood flow. We studied the effect of positive end-expiratory pressure (PEEP) and blood volume on venous return and MSFP in pigs. MSFP was measured by balloon occlusion of the right atrium (MSFPRAO), and the MSFP obtained via extrapolation of pressure-flow relationships with airway occlusion (MSFPinsp_hold) was extrapolated from RAP/pulmonary artery flow (QPA) relationships during inspiratory holds at PEEP 5 and 10 cmH2O, after bleeding, and in hypervolemia. MSFPRAO increased with PEEP [PEEP 5, 12.9 (SD 2.5) mmHg; PEEP 10, 14.0 (SD 2.6) mmHg, P = 0.002] without change in QPA [2.75 (SD 0.43) vs. 2.56 (SD 0.45) l/min, P = 0.094]. MSFPRAO decreased after bleeding and increased in hypervolemia [10.8 (SD 2.2) and 16.4 (SD 3.0) mmHg, respectively, P < 0.001], with parallel changes in QPA. Neither PEEP nor volume state altered RVR ( P = 0.489). MSFPinsp_hold overestimated MSFPRAO [16.5 (SD 5.8) vs. 13.6 (SD 3.2) mmHg, P = 0.001; mean difference 3.0 (SD 5.1) mmHg]. Inspiratory holds shifted the RAP/QPA relationship rightward in euvolemia because inferior vena cava flow (QIVC) recovered early after an inspiratory hold nadir. The QIVC nadir was lowest after bleeding [36% (SD 24%) of preinspiratory hold at 15 cmH2O inspiratory pressure], and the QIVC recovery was most complete at the lowest inspiratory pressures independent of volume state [range from 80% (SD 7%) after bleeding to 103% (SD 8%) at PEEP 10 cmH2O of QIVC before inspiratory hold]. The QIVC recovery thus defends venous return, possibly via hepatosplanchnic vascular waterfall.
Collapse
Affiliation(s)
- David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Per W. Moller
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Alberto Weber
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Bloch
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Bloechlinger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and
| | - Matthias Haenggi
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Soren Sondergaard
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Stephan M. Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sheldon Magder
- Department of Critical Care, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
3
|
Kato R, Pinsky MR. Personalizing blood pressure management in septic shock. Ann Intensive Care 2015; 5:41. [PMID: 26573630 PMCID: PMC4646890 DOI: 10.1186/s13613-015-0085-5] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 11/02/2015] [Indexed: 12/29/2022] Open
Abstract
This review examines the available evidence for targeting a specific mean arterial pressure (MAP) in sepsis resuscitation. The clinical data suggest that targeting an MAP of 65-70 mmHg in patients with septic shock who do not have chronic hypertension is a reasonable first approximation. Whereas in patients with chronic hypertension, targeting a higher MAP of 80-85 mmHg minimizes renal injury, but it comes with increased risk of arrhythmias. Importantly, MAP alone should not be used as a surrogate of organ perfusion pressure, especially under conditions in which intracranial, intra-abdominal or tissue pressures may be elevated. Organ-specific perfusion pressure targets include 50-70 mmHg for the brain based on trauma brain injury as a surrogate for sepsis, 65 mmHg for renal perfusion and >50 mmHg for hepato-splanchnic flow. Even at the same MAP, organs and regions within organs may have different perfusion pressure and pressure-flow relationships. Thus, once this initial MAP target is achieved, MAP should be titrated up or down based on the measures of organ function and tissue perfusion.
Collapse
Affiliation(s)
- Ryotaro Kato
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 606 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 606 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
| |
Collapse
|
4
|
Yu Y, Chen J, Si Z, Zhao G, Xu S, Wang G, Ding F, Luan L, Wu L, Pang Q. The Hemodynamic Response of the Cerebral Bridging Veins to Changes in ICP. Neurocrit Care 2009; 12:117-23. [DOI: 10.1007/s12028-009-9299-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
5
|
Bracht H, Takala J, Tenhunen JJ, Brander L, Knuesel R, Merasto-Minkkinen M, Jakob SM. Hepatosplanchnic blood flow control and oxygen extraction are modified by the underlying mechanism of impaired perfusion. Crit Care Med 2005; 33:645-53. [PMID: 15753759 DOI: 10.1097/01.ccm.0000156445.59009.49] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the effects of low hepatosplanchnic blood flow on regional blood flow control and oxygenation. DESIGN Three randomized, controlled animal experiments. SETTING Two university experimental research laboratories. SUBJECTS Pigs of either gender. INTERVENTIONS Isolated abdominal blood flow reduction: An extracorporeal shunt with reservoir and roller pump was inserted between proximal and distal aorta in 11 pigs. Abdominal aortic blood flow was reduced by 50% by activating the shunt. Mesenteric ischemia: In seven pigs, superior mesenteric arterial flow was reduced to 4 mL.kg.min for 4 hrs. Cardiac tamponade: In 12 pigs, aortic blood flow was reduced by cardiac tamponade to 50 mL (moderate tamponade) and further to 30 mL.kg.min (severe tamponade) for 1 hr each. In each experimental condition, the same number of control animals was used. MEASUREMENTS AND MAIN RESULTS Abdominal blood flow reduction, acute mesenteric ischemia, and moderate tamponade resulted in a portal venous flow (QPV) reduction to 51 +/- 23%, 52 +/- 18%, and 61 +/- 25% (mean +/- sd) of baseline flow, respectively. During abdominal blood flow reduction, QPV and hepatic arterial flow (QHA) decreased proportionally, whereas in moderate tamponade and acute mesenteric ischemia QPV reduction was associated with an increase in QHA of 30 +/- 39% and 102 +/- 108%, respectively (p = .001 and .018). Prolonged mesenteric ischemia restored total hepatic blood flow (Qliver) completely. During all conditions, decreasing mesenteric oxygen consumption was partly prevented by increased mesenteric oxygen extraction (p < .001 for all conditions). In contrast, decreasing hepatic oxygen delivery was associated with increased oxygen extraction in tamponade (p = .009) but not in abdominal blood flow reduction. CONCLUSIONS Blood flow redistribution can restore Qliver totally when mesenteric blood flow is reduced selectively, partially when cardiac output is reduced, and not at all during abdominal blood flow reduction. Since hepatic oxygen extraction does not increase in abdominal blood flow reduction, hepatic oxygenation is at risk in this condition.
Collapse
Affiliation(s)
- Hendrik Bracht
- Department of Intensive Care Medicine, University Hospital Bern, Switzerland
| | | | | | | | | | | | | |
Collapse
|
6
|
Schipke JD, Heusch G, Sanii AP, Gams E, Winter J. Static filling pressure in patients during induced ventricular fibrillation. Am J Physiol Heart Circ Physiol 2003; 285:H2510-5. [PMID: 12907428 DOI: 10.1152/ajpheart.00604.2003] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The static pressure resulting after the cessation of flow is thought to reflect the filling of the cardiovascular system. In the past, static filling pressures or mean circulatory filling pressures have only been reported in experimental animals and in human corpses, respectively. We investigated arterial and central venous pressures in supine, anesthetized humans with longer fibrillation/defibrillation sequences (FDSs) during cardioverter/defibrillator implantation. In 82 patients, the average number of FDSs was 4 +/- 2 (mean +/- SD), and their duration was 13 +/- 2 s. In a total of 323 FDSs, arterial blood pressure decreased with a time constant of 2.9 +/- 1.0 s from 77.5 +/- 34.4 to 24.2 +/- 5.3 mmHg. Central venous pressure increased with a time constant of 3.6 +/- 1.3 s from 7.5 +/- 5.2 to 11.0 +/- 5.4 mmHg (36 points, 141 FDS). The average arteriocentral venous blood pressure difference remained at 13.2 +/- 6.2 mmHg. Although it slowly decreased, the pressure difference persisted even with FDSs lasting 20 s. Lack of true equilibrium pressure could possibly be due to a waterfall mechanism. However, waterfalls were identified neither between the left ventricle and large arteries nor at the level of the diaphragm in supine patients. We therefore suggest that static filling pressures/mean circulatory pressures can only be directly assessed if the time after termination of cardiac pumping is adequate, i.e., >20 s. For humans, such times are beyond ethical options.
Collapse
Affiliation(s)
- J D Schipke
- Research Group Experimental Surgery, Department of Surgery I, University Hospital Dusseldorf, D 40225, Germany.
| | | | | | | | | |
Collapse
|
7
|
Bellomo R, Kellum JA, Wisniewski SR, Pinsky MR. Effects of norepinephrine on the renal vasculature in normal and endotoxemic dogs. Am J Respir Crit Care Med 1999; 159:1186-92. [PMID: 10194164 DOI: 10.1164/ajrccm.159.4.9802055] [Citation(s) in RCA: 137] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Septic shock is often complicated by systemic hypotension despite normal or increased cardiac output. Restoration of arterial pressure usually requires the administration of systemic vasopressor agents, such as norepinephrine. However, because norepinephrine induces vasoconstriction in other vascular beds, it may decrease visceral blood flow, impairing visceral organ function. Because sepsis is often associated with impaired peripheral vascular responsiveness, we hypothesized that, unlike in normal circulatory conditions, norepinephrine would improve visceral organ blood flow in sepsis by selectively increasing organ perfusion pressure. Thus, in nine pentobarbital-anesthetized, mechanically ventilated dogs, we measured the effect of norepinephrine infusion (0.3 microgram/kg/min) on renal, hepatic, and portal steady-state pressure-flow relations (P/Q) and the dynamic vascular P/Q, created by transient inferior vena caval occlusion, under basal and endotoxic conditions. Norepinephrine increased organ perfusion pressures during both control and endotoxemic conditions. However, even after controlling for the pressure effect using a general linear model, NE was associated with an increase in renal blood flow both before and after endotoxin administration. We conclude that, unlike the effects of administering norepinephrine under baseline conditions, norepinephrine infusion during endotoxic shock actually increases renal blood flow and that this effect is not the result of an increase in perfusion pressure alone.
Collapse
Affiliation(s)
- R Bellomo
- Cardiopulmonary Research Laboratory, Division of Critical Care Medicine, Department of Anesthesiology University of Pittsburgh Medical Center, Pittsburg, PA, USA
| | | | | | | |
Collapse
|