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Østergaard L, Granfeldt A, Secher N, Tietze A, Iversen NK, Jensen MS, Andersen KK, Nagenthiraja K, Gutiérrez‐Lizardi P, Mouridsen K, Jespersen SN, Tønnesen EK. Microcirculatory dysfunction and tissue oxygenation in critical illness. Acta Anaesthesiol Scand 2015; 59:1246-59. [PMID: 26149711 PMCID: PMC4758388 DOI: 10.1111/aas.12581] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 05/19/2015] [Accepted: 06/14/2015] [Indexed: 12/19/2022]
Abstract
Severe sepsis is defined by organ failure, often of the kidneys, heart, and brain. It has been proposed that inadequate delivery of oxygen, or insufficient extraction of oxygen in tissue, may explain organ failure. Despite adequate maintenance of systemic oxygen delivery in septic patients, their morbidity and mortality remain high. The assumption that tissue oxygenation can be preserved by maintaining its blood supply follows from physiological models that only apply to tissue with uniformly perfused capillaries. In sepsis, the microcirculation is profoundly disturbed, and the blood supply of individual organs may therefore no longer reflect their access to oxygen. We review how capillary flow patterns affect oxygen extraction efficacy in tissue, and how the regulation of tissue blood flow must be adjusted to meet the metabolic needs of the tissue as capillary flows become disturbed as observed in critical illness. Using the brain, heart, and kidney as examples, we discuss whether disturbed capillary flow patterns might explain the apparent mismatch between organ blood flow and organ function in sepsis. Finally, we discuss diagnostic means of detecting capillary flow disturbance in animal models and in critically ill patients, and address therapeutic strategies that might improve tissue oxygenation by modifying capillary flow patterns.
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Affiliation(s)
- L. Østergaard
- Department of Neuroradiology Aarhus University Hospital Aarhus Denmark
- Center of Functionally Integrative Neuroscience and MINDLab Aarhus University Aarhus Denmark
| | - A. Granfeldt
- Department of Anaesthesia and Intensive Care Medicine Aarhus University Hospital Aarhus Denmark
| | - N. Secher
- Department of Anaesthesia and Intensive Care Medicine Aarhus University Hospital Aarhus Denmark
| | - A. Tietze
- Department of Neuroradiology Aarhus University Hospital Aarhus Denmark
- Center of Functionally Integrative Neuroscience and MINDLab Aarhus University Aarhus Denmark
| | - N. K. Iversen
- Center of Functionally Integrative Neuroscience and MINDLab Aarhus University Aarhus Denmark
| | - M. S. Jensen
- Center of Functionally Integrative Neuroscience and MINDLab Aarhus University Aarhus Denmark
| | - K. K. Andersen
- Department of Anaesthesia and Intensive Care Medicine Aarhus University Hospital Aarhus Denmark
| | - K. Nagenthiraja
- Center of Functionally Integrative Neuroscience and MINDLab Aarhus University Aarhus Denmark
| | - P. Gutiérrez‐Lizardi
- Faculty of Dentistry University of Monterrey Monterrey Mexico
- Critical Care College of Nuevo León Monterrey Mexico
| | - K. Mouridsen
- Center of Functionally Integrative Neuroscience and MINDLab Aarhus University Aarhus Denmark
| | - S. N. Jespersen
- Center of Functionally Integrative Neuroscience and MINDLab Aarhus University Aarhus Denmark
- Department of Physics and Astronomy Aarhus University Aarhus Denmark
| | - E. K. Tønnesen
- Department of Anaesthesia and Intensive Care Medicine Aarhus University Hospital Aarhus Denmark
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Szakmany T, Hauser B, Radermacher P. N-acetylcysteine for sepsis and systemic inflammatory response in adults. Cochrane Database Syst Rev 2012; 2012:CD006616. [PMID: 22972094 PMCID: PMC6517277 DOI: 10.1002/14651858.cd006616.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Death is common in systemic inflammatory response syndrome (SIRS) or sepsis-induced multisystem organ failure and it has been thought that antioxidants such as N-acetylcysteine could be beneficial. OBJECTIVES We assessed the clinical effectiveness of intravenous N-acetylcysteine for the treatment of patients with SIRS or sepsis. SEARCH METHODS We searched the following databases: Cochrane Central Register of Clinical Trials (CENTRAL) (The Cochrane Library 2011, Issue 12); MEDLINE (January 1950 to January 2012); EMBASE (January 1980 to January 2012); CINAHL (1982 to January 2012); the NHS Trusts Clinical Trials Register and Current Controlled Trials (www.controlled-trials.com); LILACS; KoreaMED; MEDCARIB; INDMED; PANTELEIMON; Ingenta; ISI Web of Knowledge and the National Trials Register to identify all relevant randomized controlled trials available for review. SELECTION CRITERIA We included only randomized controlled trials (RCTs) in the meta-analysis. DATA COLLECTION AND ANALYSIS We independently performed study selection, quality assessment and data extraction. We estimated risk ratios (RR) for dichotomous outcomes. We measured statistical heterogeneity using the I(2) statistic. MAIN RESULTS We included 41 fully published studies (2768 patients). Mortality was similar in the N-acetylcysteine group and the placebo group (RR 1.06, 95% CI 0.79 to 1.42; I(2) = 0%). Neither did N-acetylcysteine show any significant effect on length of stay, duration of mechanical ventilation or incidence of new organ failure. Early application of N-acetylcysteine to prevent the development of an oxidato-inflammatory response did not affect the outcome, nor did late application that is after 24 hours of developing symptoms. Late application was associated with cardiovascular instability. AUTHORS' CONCLUSIONS Overall, this meta-analysis puts doubt on the safety and utility of intravenous N-acetylcysteine as an adjuvant therapy in SIRS and sepsis. At best, N-acetylcysteine is ineffective in reducing mortality and complications in this patient population. At worst, it can be harmful, especially when administered later than 24 hours after the onset of symptoms, by causing cardiovascular depression. Unless future RCTs provide evidence of treatment effect, clinicians should not routinely use intravenous N-acetylcysteine in SIRS or sepsis and academics should not promote its use.
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Affiliation(s)
- Tamas Szakmany
- Department of Anaesthesia, Cwm Taf NHS Trust, Royal Glamorgan Hospital, Llantrisant, UK.
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Oliveira-Junior IS, Brunialti MKC, Koh IHJ, Junqueira VBC, Salomão R. Effect of pentoxifylline on lung inflammation and gas exchange in a sepsis-induced acute lung injury model. Braz J Med Biol Res 2007; 39:1455-63. [PMID: 17146558 DOI: 10.1590/s0100-879x2006001100009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2006] [Accepted: 08/18/2006] [Indexed: 11/22/2022] Open
Abstract
Experimental models of sepsis-induced pulmonary alterations are important for the study of pathogenesis and for potential intervention therapies. The objective of the present study was to characterize lung dysfunction (low PaO2 and high PaCO2, and increased cellular infiltration, protein extravasation, and malondialdehyde (MDA) production assessed in bronchoalveolar lavage) in a sepsis model consisting of intraperitoneal (ip) injection of Escherichia coli and the protective effects of pentoxifylline (PTX). Male Wistar rats (weighing between 270 and 350 g) were injected ip with 10(7) or 10(9) CFU/100 g body weight or saline and samples were collected 2, 6, 12, and 24 h later (N = 5 each group). PaO2, PaCO2 and pH were measured in blood, and cellular influx, protein extravasation and MDA concentration were measured in bronchoalveolar lavage. In a second set of experiments either PTX or saline was administered 1 h prior to E. coli ip injection (N = 5 each group) and the animals were observed for 6 h. Injection of 10(7) or 10(9) CFU/100 g body weight of E. coli induced acidosis, hypoxemia, and hypercapnia. An increased (P < 0.05) cell influx was observed in bronchoalveolar lavage, with a predominance of neutrophils. Total protein and MDA concentrations were also higher (P < 0.05) in the septic groups compared to control. A higher tumor necrosis factor-alpha (P < 0.05) concentration was also found in these animals. Changes in all parameters were more pronounced with the higher bacterial inoculum. PTX administered prior to sepsis reduced (P < 0.05) most functional alterations. These data show that an E. coli ip inoculum is a good model for the induction of lung dysfunction in sepsis, and suitable for studies of therapeutic interventions.
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Szakmany T, Hauser B, Matejovic M, Radermacher P. N-acetylcysteine for sepsis and systemic inflammatory response in adults. Cochrane Database Syst Rev 2007. [DOI: 10.1002/14651858.cd006616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Arrieta O, Rodriguez-Reyna TS, Sotelo J. Pharmacological treatment of septic shock. Expert Opin Ther Pat 2005. [DOI: 10.1517/13543776.10.5.601] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Parker SJ, Brown D, Kenward CE, Watkins PE. Pentoxifylline fails to improve organ dysfunction and survival when used in the resuscitation of a porcine model of haemorrhage and abdominal sepsis. Resuscitation 2000; 44:61-9. [PMID: 10699701 DOI: 10.1016/s0300-9572(99)00166-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Pentoxifylline is a phosphodiesterase inhibitor, known to suppress tumour necrosis factor-alpha production and improve cardiopulmonary parameters and survival in animal models of sepsis. Using a porcine model of abdominal trauma resulting from the combined insults of haemorrhage and infection, a randomised placebo-controlled trial was conducted of pentoxifylline (20 mg/kg bolus followed by 20 mg/kg infusion over 1 h) administered in addition to a colloid resuscitation regimen. Female Large White pigs (45-60 kg) were bled 40% of their blood volume and peritonitis was induced using E. coli (O18: K1: H7) in an autoclaved faecal suspension. Animals were resuscitated with either colloid alone (n=5) or colloid plus pentoxifylline (n=5). Pentoxifylline attenuated increases in mean arterial and pulmonary artery pressures and reduced both systemic and pulmonary vascular resistance. It worsened the lactic acidosis associated with 'septic shock' and failed to reduce serum TNF-alpha levels. Pentoxifylline, in the high doses used in this study, does not have a role as an adjunct to resuscitation in this clinically relevant model of trauma.
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Affiliation(s)
- S J Parker
- Biomedical Sciences, DERA Porton Down, Salisbury, UK.
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Yang S, Zhou M, Koo DJ, Chaudry IH, Wang P. Pentoxifylline prevents the transition from the hyperdynamic to hypodynamic response during sepsis. THE AMERICAN JOURNAL OF PHYSIOLOGY 1999; 277:H1036-44. [PMID: 10484426 DOI: 10.1152/ajpheart.1999.277.3.h1036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The cardiovascular response to sepsis includes an early, hyperdynamic phase followed by a late, hypodynamic phase. Although administration of pentoxifylline (PTX) produces beneficial effects in sepsis, it remains unknown whether this agent prevents the transition from the hyperdynamic to the hypodynamic response during the progression of sepsis. To study this, male adult rats were subjected to polymicrobial sepsis by cecal ligation and puncture (CLP). At 1 h after CLP, PTX (50 mg/kg body wt) or vehicle was infused intravenously over 30 min. At 20 h after CLP (i.e., the late stage of sepsis), cardiac output and organ blood flow were measured by radioactive microspheres. Systemic and regional (i.e., hepatic, intestinal, and renal) oxygen delivery (DO2) and oxygen consumption (VO2) were determined. Moreover, plasma levels of lactate and alanine aminotransferase (ALT) were measured, and histological examinations were performed. In additional animals, the necrotic cecum was excised at 20 h after CLP, and mortality was monitored for 10 days thereafter. The results indicate that cardiac output, organ blood flow, and systemic and regional DO2 decreased by 36-65% (P < 0.05) at 20 h after CLP. Administration of PTX early after the onset of sepsis, however, prevented reduction in measured hemodynamic parameters and increased systemic and regional DO2 and VO(2) by 50-264% (P < 0.05). The elevated levels of lactate (by 173%, P < 0.05) and ALT (by 718%, P < 0.05), as well as the morphological alterations in the liver, small intestine, and kidneys during sepsis were attenuated by PTX treatment. In addition, PTX treatment decreased the mortality rate from 50 to 0% (P < 0.05) after CLP and cecal excision. Because PTX prevents the occurrence of hypodynamic sepsis, this agent appears to be a useful adjunct for maintaining hemodynamic stability and preventing lethality from sepsis.
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Affiliation(s)
- S Yang
- Center for Surgical Research and Department of Surgery, Brown University School of Medicine and Rhode Island Hospital, Providence, Rhode Island 02903, USA
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Spapen H, Zhang H, Verhaeghe V, Smail N, Vincent JL. The platelet-activating factor antagonist BB-882 does not improve tissue oxygen extraction in endotoxic shock. J Crit Care 1998; 13:81-90. [PMID: 9627275 DOI: 10.1016/s0883-9441(98)80006-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE We investigated whether BB-882, a novel potent PAF antagonist, could influence systemic and pulmonary hemodynamics and oxygen extraction capabilities during an acute reduction in blood flow induced by cardiac tamponade after endotoxin challenge. MATERIALS AND METHODS Twenty-one anesthetized, ventilated, and endotoxin-shocked (2 mg/kg i.v. Escherichia coli endotoxin) dogs were randomly divided in three groups. One group (N = 7) served as control. A second group (N = 7) received BB-882 as a single bolus dose of 5 mg/kg, 30 minutes before endotoxin administration. A third group (N = 7) received BB-882 as a continuous infusion of 5 mg/kg x h, started 30 minutes after endotoxin. Hemodynamic and gazometric measurements were obtained in all dogs 30 minutes after endotoxin injection and repeated 30 minutes after cardiac filling pressures were restored to baseline by generous saline infusion. Saline infusion rate was then set at 20 mL/kg x h and tamponade was induced by repeated bolus injections of warm saline into the pericardial sac. RESULTS Compared with controls, pretreatment with BB-882 attenuated the early endotoxin-induced decrease in arterial pressure (70 +/- 17 v 51 +/- 14 mm Hg, P < .05), cardiac index (118 +/- 29 v 91 +/- 15 mL/ kg x min, P < .05), stroke index (1.0 +/- 0.2 v 0.7 +/- 0.3 mL/kg, P < .05), and left ventricular stroke work index (0.9 +/- 0.3 v 0.4 +/- 0.2 g x m/kg, P < .05), but these effects were not sustained after fluid resuscitation. In contrast, BB-882 post-treatment maintained arterial pressure and improved cardiac performance at lower filling pressures in the later phase of endotoxic shock. BB-882 did not influence pulmonary hemodynamics. Treatment with BB-882 did not influence oxygen extraction at critical oxygen delivery (51.5 +/- 9.9% and 52.8 +/- 13.9% v 46.6 +/- 9.0%, respectively BB-882 pretreatment and post-treatment v control). CONCLUSIONS We conclude that in this model of endotoxic shock the administration of BB-882, either before or after endotoxin challenge, has time-related beneficial hemodynamic and cardiac effects but does not improve global oxygen extraction capabilities. The potential benefit of adjunctive treatment with a platelet-activating factor antagonist in sepsis remains doubtful.
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Affiliation(s)
- H Spapen
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Belgium
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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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Wang P, Ba ZF, Chaudry IH. Pentoxifylline maintains hepatocellular function and improves cardiac performance during early sepsis. THE JOURNAL OF TRAUMA 1997; 42:429-35; discussion 435-6. [PMID: 9095110 DOI: 10.1097/00005373-199703000-00010] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Although pentoxifylline (PTX) produces various beneficial effects after endotoxemia, it remains unknown whether this agent attenuates the depressed hepatocellular function and improves heart performance during early sepsis. The aim of this study, therefore, was to determine whether PTX maintains hepatocellular function and improves cardiac function during the early hyperdynamic stages of polymicrobial sepsis. DESIGN, MATERIALS, AND METHODS Rats were subjected to sepsis by cecal ligation and puncture (CLP). At 1 hour after CLP, PTX (50 mg/kg body weight), or an equal volume of saline, was infused intravenously over 30 minutes. At 2 or 5 hours after CLP (i.e., early hyperdynamic stages of sepsis), hepatocellular function was assessed by in vivo indocyanine green clearance. Cardiac output was determined by dye dilution. Left ventricular performance parameters such as maximal rates of left ventricular pressure rise and fall (+/-dP/dtmax), ventricular peak systemic pressure, etc., were determined using a heart performance analyzer. RESULTS The results indicate that hepatocellular function was significantly depressed at 2 and 5 hours after CLP. Administration of PTX, however, maintained hepatocellular function to sham levels. Although cardiac output increased after CLP with or without PTX treatment, this agent markedly improved cardiac performance as evidenced by significantly higher + dP/dtmax and ventricular peak systemic pressure as well as other heart performance parameters. CONCLUSIONS Pentoxifylline appears to be a useful adjunct for maintaining hepatocellular function and improving cardiac performance during the early hyperdynamic stages of polymicrobial sepsis.
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Affiliation(s)
- P Wang
- Center for Surgical Research, Brown University School of Medicine, Providence, Rhode Island, USA
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Wang P, Wood TJ, Ba ZF, Chaudry IH. Pentoxifylline maintains vascular endothelial cell function during hyperdynamic and hypodynamic sepsis. Surgery 1996; 120:367-73. [PMID: 8751606 DOI: 10.1016/s0039-6060(96)80311-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Although pentoxifylline produces various beneficial effects after endotoxemia or sepsis occurs, it is not known whether this agent attenuates the depressed endothelial cell function during sepsis. Therefore the aim of this study was to determine whether pentoxifylline maintains vascular endothelial cell function (i.e., improves the release of endothelium-derived nitric oxide) during hyperdynamic and hypodynamic stages of polymicrobial sepsis. METHODS Rats were subjected to sepsis by cecal ligation and puncture (CLP), after which 3 ml/100 gm body wt normal saline solution was injected subcutaneously in these and rats in a sham-operated group. At 1 hour after the onset of sepsis, pentoxifylline (50 mg/kg body wt) or an equal volume of normal saline solution was infused intravenously during a 30 minute period. At 10 and 20 hours after CLP was performed (10-hour CLP, hyperdynamic sepsis; 20-hour CLP, hypodynamic sepsis), the thoracic aorta was isolated, cut into rings, and placed in organ chambers. Norepinephrine (2 x 10(-7) mol/L) was used to achieve near maximal tension. Dose responses for an endothelium-dependent vasodilator, acetylcholine, and an endothelium-independent vasodilator, nitroglycerine, were carried out. The changes in percentage relaxation in the aortic rings by these agonists were then determined. RESULTS Endothelium-dependent (acetylcholine-induced) vascular relaxation decreased significantly at 10 and 20 hours after CLP. Administration of pentoxifylline, however, maintained acetylcholine-induced vascular relaxation at both time points. In contrast, no significant reduction in nitroglycerine-induced vascular relaxation was seen in rats with sepsis irrespective of pentoxifylline treatment. CONCLUSIONS Because pentoxifylline prevented endothelial cell dysfunction at 10 and 20 hours after CLP occurred, this agent appears to be a useful agent for maintaining vascular endothelial function during the hyperdynamic and hypodynamic stages of polymicrobial sepsis.
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Affiliation(s)
- P Wang
- Department of Surgery, Michigan State University, East Lansing, USA
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Vincent JL. End-points of resuscitation: arterial blood pressure, oxygen delivery, blood lactate, or...? Intensive Care Med 1996; 22:3-5. [PMID: 8857431 DOI: 10.1007/bf01728324] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Vincent JL, De Backer D. Oxygen uptake/oxygen supply dependency: fact or fiction? ACTA ANAESTHESIOLOGICA SCANDINAVICA. SUPPLEMENTUM 1995; 107:229-37. [PMID: 8599284 DOI: 10.1111/j.1399-6576.1995.tb04364.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
More than a decade ago, observations of co-variance between VO2 and DO2 led to the identification of a condition known as pathological O2 supply dependency. This condition was subsequently observed in critically ill patients with sepsis and acute circulatory failure. More recently, other authors have challenged the existence of this condition, often citing methodologic problems or mathematical coupling to account for spurious observations in the earlier studies. Here, we review the evidence for and against pathological O2 supply dependency. We find that many of the arguments have some validity but only in specific circumstances. We conclude, therefore, that pathological O2 supply dependency is a hallmark of acute circulatory failure and that an effective therapeutic approach should be based on an evaluation of organ system function in each individual case. Parameters such as blood lactate, pHi and veno-arterial PCO2 may be useful in this respect.
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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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Vincent JL, De Backer D. Delivery-dependent oxygen consumption: what was the question? Crit Care Med 1995; 23:211-2. [PMID: 8001375 DOI: 10.1097/00003246-199501000-00034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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