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Morelli A, Donati A, Ertmer C, Rehberg S, Kampmeier T, Orecchioni A, Di Russo A, D'Egidio A, Landoni G, Lombrano MR, Botticelli L, Valentini A, Zangrillo A, Pietropaoli P, Westphal M. Effects of vasopressinergic receptor agonists on sublingual microcirculation in norepinephrine-dependent septic shock. Crit Care 2011; 15:R217. [PMID: 21929764 PMCID: PMC3334762 DOI: 10.1186/cc10453] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Revised: 07/28/2011] [Accepted: 09/19/2011] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION The present study was designed to determine the effects of continuously infused norepinephrine (NE) plus (1) terlipressin (TP) or (2) arginine vasopressin (AVP) or (3) placebo on sublingual microcirculation in septic shock patients. The primary study end point was a difference of ≥ 20% in the microvascular flow index of small vessels among groups. METHODS The design of the study was a prospective, randomized, double-blind clinical trial. NE was titrated to maintain mean arterial pressure (MAP) between 65 and 75 mmHg after establishment of normovolemia in 60 septic shock patients. Thereafter patients (n = 20 per group) were randomized to receive continuous infusions of either TP (1 μg/kg/hour), AVP (0.04 U/minute) or placebo (isotonic saline). In all groups, open-label NE was adjusted to maintain MAP within threshold values if needed. The sublingual microcirculatory blood flow of small vessels was assessed by sidestream dark-field imaging. All measurements, including data from right heart catheterization and norepinephrine requirements, were obtained at baseline and 6 hours after randomization. RESULTS TP and AVP decreased NE requirements at the end of the 6-hour study period. The data are medians (25th and 75th interquartile ranges (IQRs)): 0.57 μg/kg/minute (0.29 to 1.04) vs. 0.16 μg/kg/minute (0.03 to 0.37) for TP and 0.40 μg/kg/minute (0.20 to 1.05) vs. 0.23 μg/kg/minute (0.03 to 0.77) for AVP, with statistical significance of P < 0.05 vs. baseline and vs. placebo. There were no differences in sublingual microcirculatory variables, systemic hemodynamics, oxygen transport and acid-base homeostasis among the three study groups during the entire observation period. The proportions of perfused vessels increased in relation to baseline within all study groups, and there were no significant differences between groups. The specific data were as follows (median (IQR)): 9.7% (2.6 to 19.8) for TP, 8.9% (0.0 to 17.8) for AVP, and 6.9% (3.5 to 10.1) for placebo (P < 0.05 vs. baseline for each comparison), as well as perfused vessel density 18.6% (8.6 to 36.9) for TP, 20.2% (-3.0 to 37.2) for AVP, and 11.4% (-3.0 to 19.4) for placebo (P < 0.05 vs. baseline for each comparison). CONCLUSIONS The present study suggests that to achieve a MAP of 65 to 75 mmHg in septic patients treated with NE, the addition of continuously infused low-dose TP or AVP does not affect sublingual microcirculatory blood flow. In addition, our results suggest that microcirculatory flow abnormalities are mainly related to other factors (for example, volume status, timing, hemodynamics and progression of the disease) rather than to the vasopressor per se. TRIAL REGISTRATION ClinicalTrial.gov NCT00995839.
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Affiliation(s)
- Andrea Morelli
- Department of Anesthesiology and Intensive Care, University of Rome, "La Sapienza," Viale del Policlinico 155, Rome I-00161, Italy
| | - Abele Donati
- Department of Neuroscience-Anesthesia and Intensive Care Unit, Università Politecnica delle Marche, Via Tronto 10, Torrette di Ancona I-60020, Italy
| | - Christian Ertmer
- Department of Anesthesiology and Intensive Care, University Hospital of Muenster, Albert-Schweitzer-Strasse 33, Muenster D-48149, Germany
| | - Sebastian Rehberg
- Department of Anesthesiology and Intensive Care, University Hospital of Muenster, Albert-Schweitzer-Strasse 33, Muenster D-48149, Germany
| | - Tim Kampmeier
- Department of Anesthesiology and Intensive Care, University Hospital of Muenster, Albert-Schweitzer-Strasse 33, Muenster D-48149, Germany
| | - Alessandra Orecchioni
- Department of Anesthesiology and Intensive Care, University of Rome, "La Sapienza," Viale del Policlinico 155, Rome I-00161, Italy
| | - Alessandro Di Russo
- Department of Anesthesiology and Intensive Care, University of Rome, "La Sapienza," Viale del Policlinico 155, Rome I-00161, Italy
| | - Annalia D'Egidio
- Department of Anesthesiology and Intensive Care, University of Rome, "La Sapienza," Viale del Policlinico 155, Rome I-00161, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, Università Vita-Salute San Raffaele, Via Olgettina 60, Milan I-20132, Italy
| | - Maria Rita Lombrano
- Department of Neuroscience-Anesthesia and Intensive Care Unit, Università Politecnica delle Marche, Via Tronto 10, Torrette di Ancona I-60020, Italy
| | - Laura Botticelli
- Department of Neuroscience-Anesthesia and Intensive Care Unit, Università Politecnica delle Marche, Via Tronto 10, Torrette di Ancona I-60020, Italy
| | - Agnese Valentini
- Department of Neuroscience-Anesthesia and Intensive Care Unit, Università Politecnica delle Marche, Via Tronto 10, Torrette di Ancona I-60020, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, Università Vita-Salute San Raffaele, Via Olgettina 60, Milan I-20132, Italy
| | - Paolo Pietropaoli
- Department of Anesthesiology and Intensive Care, University of Rome, "La Sapienza," Viale del Policlinico 155, Rome I-00161, Italy
| | - Martin Westphal
- Department of Anesthesiology and Intensive Care, University Hospital of Muenster, Albert-Schweitzer-Strasse 33, Muenster D-48149, Germany
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