Top

Intensive Care Medicine

Published in:

01-04-2009 | Original

Microvascular flow and tissue oxygenation after major abdominal surgery: association with post-operative complications

Authors: Shaman Jhanji, Clement Lee, David Watson, Charles Hinds, Rupert M. Pearse

Published in: Intensive Care Medicine | Issue 4/2009

Abstract

Objective

To evaluate the relationship between global oxygen delivery (DO₂I), microvascular flow and tissue oxygenation in patients who did and did not develop complications following major abdominal surgery.

Design

Prospective observational study.

Setting

Post-operative critical care unit.

Participants

Twenty-five patients receiving standard peri-operative care following major abdominal surgery.

Measurements and main results

Data were collected before, and for 8 h after surgery. DO₂I was measured by lithium dilution and arterial waveform analysis. Cutaneous PtO₂ was measured at two sites on the abdominal wall using a Clark electrode. The sublingual microcirculation was visualised using sidestream darkfield imaging. Cutaneous red cell flux was measured using laser Doppler flowmetry. Fourteen patients (56%) developed complications with two deaths. Small vessel (<20 μm) microvascular flow index in those patients who developed complications was lower before (P < 0.05) and after surgery (P < 0.0001) compared to patients who did not develop complications. Both the proportion and density of perfused small vessels were also lower in patients who developed complications after surgery (P < 0.01) but not before surgery. DO₂I was low in all patients but did not differ between patients who did and did not develop complications. Similarly, there were no associated differences in cutaneous red cell flux or PtO₂.

Conclusion

In a group of patients with low DO₂I following major abdominal surgery, microvascular flow abnormalities were more frequent in patients who developed complications. However, there were no differences in DO₂I, cutaneous PtO₂ or red cell flux between the two groups. Impaired microvascular flow may be associated with the development of post-operative complications.

Available only for authorised users

Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, Gawande AA (2008) An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 372:139–144PubMedCrossRef

Campling EA, Devlin HB, Lunn JN (1990) Report of the National Confidential Enquiry into Peri-Operative Deaths. In: Book report of the national confidential enquiry into peri-operative deaths. NCEPOD

Cullinane M, Gray AJ, Hargraves CM, Lansdown M, Martin IC, Schubert M (2003) The 2003 report of the national confidential enquiry into peri-operative deaths. In: Book The 2003 Report of the National Confidential Enquiry into Peri-Operative Deaths. NCEPOD

Pearse RM, Harrison DA, James P, Watson D, Hinds C, Rhodes A, Grounds RM, Bennett ED (2006) Identification and characterisation of the high-risk surgical population in the United Kingdom. Crit Care 10:R81PubMedCrossRef

Jhanji S, Thomas B, Ely A, Watson D, Hinds CJ, Pearse RM (2008) Mortality and utilisation of critical care resources amongst high-risk surgical patients in a large NHS trust. Anaesthesia 63:695–700PubMedCrossRef

Khuri SF, Henderson WG, DePalma RG, Mosca C, Healey NA, Kumbhani DJ (2005) Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg 242:326–341 discussion 341–323PubMed

Juul AB, Wetterslev J, Gluud C, Kofoed-Enevoldsen A, Jensen G, Callesen T, Norgaard P, Fruergaard K, Bestle M, Vedelsdal R, Miran A, Jacobsen J, Roed J, Mortensen MB, Jorgensen L, Jorgensen J, Rovsing ML, Petersen PL, Pott F, Haas M, Albret R, Nielsen LL, Johansson G, Stjernholm P, Molgaard Y, Foss NB, Elkjaer J, Dehlie B, Boysen K, Zaric D, Munksgaard A, Madsen JB, Oberg B, Khanykin B, Blemmer T, Yndgaard S, Perko G, Wang LP, Winkel P, Hilden J, Jensen P, Salas N (2006) Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial. BMJ 332:1482PubMedCrossRef

Clowes GH Jr, Del Guercio LR, Barwinsky J (1960) The cardiac output in response to surgical trauma. A comparison between patients who survived and those who died. Arch Surg 81:212–222PubMed

Shoemaker WC (1972) Cardiorespiratory patterns of surviving and nonsurviving postoperative patients. Surg Gynecol Obstet 134:810–814PubMed

10.

Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED (2005) Changes in central venous saturation after major surgery, and association with outcome. Crit Care 9:R694–R699PubMedCrossRef

11.

Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED (2005) Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial [ISRCTN38797445]. Crit Care 9:R687–R693PubMedCrossRef

12.

Boyd O, Grounds RM, Bennett ED (1993) A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients. JAMA 270:2699–2707PubMedCrossRef

13.

Wilson J, Woods I, Fawcett J, Whall R, Dibb W, Morris C, McManus E (1999) Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery. BMJ 318:1099–1103PubMed

14.

Pearse RM, Belsey JD, Cole JN, Bennett ED (2008) Effect of dopexamine infusion on mortality following major surgery: individual patient data meta-regression analysis of published clinical trials. Crit Care Med 36:1323–1329PubMedCrossRef

15.

Hopf HW, Hunt TK, West JM, Blomquist P, Goodson WH 3rd, Jensen JA, Jonsson K, Paty PB, Rabkin JM, Upton RA, von Smitten K, Whitney JD (1997) Wound tissue oxygen tension predicts the risk of wound infection in surgical patients. Arch Surg 132:997–1004 discussion 1005PubMed

16.

Greif R, Akca O, Horn EP, Kurz A, Sessler DI (2000) Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection. Outcomes Research Group. N Engl J Med 342:161–167PubMedCrossRef

17.

Belda FJ, Aguilera L, Garcia de la Asuncion J, Alberti J, Vicente R, Ferrandiz L, Rodriguez R, Company R, Sessler DI, Aguilar G, Botello SG, Orti R (2005) Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial. JAMA 294:2035–2042PubMedCrossRef

18.

Kurz A, Sessler DI, Lenhardt R (1996) Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med 334:1209–1215PubMedCrossRef

19.

Melling AC, Ali B, Scott EM, Leaper DJ (2001) Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomised controlled trial. Lancet 358:876–880PubMedCrossRef

20.

Pierie JP, De Graaf PW, Poen H, Van der Tweel I, Obertop H (1994) Impaired healing of cervical oesophagogastrostomies can be predicted by estimation of gastric serosal blood perfusion by laser Doppler flowmetry. Eur J Surg 160:599–603PubMed

21.

Miyazaki T, Kuwano H, Kato H, Yoshikawa M, Ojima H, Tsukada K (2002) Predictive value of blood flow in the gastric tube in anastomotic insufficiency after thoracic esophagectomy. World J Surg 26:1319–1323PubMedCrossRef

22.

Vignali A, Gianotti L, Braga M, Radaelli G, Malvezzi L, Di Carlo V (2000) Altered microperfusion at the rectal stump is predictive for rectal anastomotic leak. Dis Colon Rectum 43:76–82PubMedCrossRef

23.

Jhanji S, Dawson J, Pearse RM (2008) Cardiac output monitoring: basic science and clinical application. Anaesthesia 63:172–181PubMedCrossRef

24.

Ince C (2005) The microcirculation is the motor of sepsis. Crit Care 9(Suppl 4):S13–S19PubMedCrossRef

25.

De Backer D, Hollenberg S, Boerma C, Goedhart P, Buchele G, Ospina-Tascon G, Dobbe I, Ince C (2007) How to evaluate the microcirculation: report of a round table conference. Crit Care 11:R101PubMedCrossRef

26.

Cohen J (1960) A coefficient of agreement for nominal scales. Educ Psychol Meas 20:37–46CrossRef

27.

Buise MP, Ince C, Tilanus HW, Klein J, Gommers D, van Bommel J (2005) The effect of nitroglycerin on microvascular perfusion and oxygenation during gastric tube reconstruction. Anesth Analg 100:1107–1111PubMedCrossRef

28.

Buise M, van Bommel J, Jahn A, Tran K, Tilanus H, Gommers D (2006) Intravenous nitroglycerin does not preserve gastric microcirculation during gastric tube reconstruction: a randomized controlled trial. Crit Care 10:R131PubMedCrossRef

29.

Boerma EC, van der Voort PH, Spronk PE, Ince C (2007) Relationship between sublingual and intestinal microcirculatory perfusion in patients with abdominal sepsis. Crit Care Med 35:1055–1060PubMedCrossRef

30.

Kimberger O, Fleischmann E, Brandt S, Kugener A, Kabon B, Hiltebrand L, Krejci V, Kurz A (2007) Supplemental Oxygen, but Not Supplemental Crystalloid Fluid, Increases Tissue Oxygen Tension in Healthy and Anastomotic Colon in Pigs. Anesth Analg 105:773–779PubMedCrossRef

31.

Kabon B, Fleischmann E, Treschan T, Taguchi A, Kapral S, Kurz A (2003) Thoracic epidural anesthesia increases tissue oxygenation during major abdominal surgery. Anesth Analg 97:1812–1817PubMedCrossRef

32.

Treschan TA, Taguchi A, Ali SZ, Sharma N, Kabon B, Sessler DI, Kurz A (2003) The effects of epidural and general anesthesia on tissue oxygenation. Anesth Analg 96:1553–1557, table of contents

33.

Chang N, Goodson WH 3rd, Gottrup F, Hunt TK (1983) Direct measurement of wound and tissue oxygen tension in postoperative patients. Ann Surg 197:470–478PubMedCrossRef

34.

Ince C (2006) Go with the flow—recruit the microcirculation!. Intensive Care Med 32:488–489PubMedCrossRef

35.

Creteur J, De Backer D, Sakr Y, Koch M, Vincent JL (2006) Sublingual capnometry tracks microcirculatory changes in septic patients. Intensive Care Med 32:516–523PubMedCrossRef

36.

De Backer D, Creteur J, Dubois MJ, Sakr Y, Koch M, Verdant C, Vincent JL (2006) The effects of dobutamine on microcirculatory alterations in patients with septic shock are independent of its systemic effects. Crit Care Med 34:403–408PubMedCrossRef

37.

Spronk PE, Ince C, Gardien MJ, Mathura KR, Oudemans-van Straaten HM, Zandstra DF (2002) Nitroglycerin in septic shock after intravascular volume resuscitation. Lancet 360:1395–1396PubMedCrossRef

Title: Microvascular flow and tissue oxygenation after major abdominal surgery: association with post-operative complications
Authors: Shaman Jhanji
Clement Lee
David Watson
Charles Hinds
Rupert M. Pearse
Publication date: 01-04-2009
Publisher: Springer-Verlag
Published in: Intensive Care Medicine / Issue 4/2009
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-008-1325-z

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Microvascular flow and tissue oxygenation after major abdominal surgery: association with post-operative complications

Abstract

Objective

Design

Setting

Participants

Measurements and main results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Objective

Design

Setting

Participants

Measurements and main results

Conclusion

Please log in to get access to this content

Other articles of this Issue 4/2009

Protocols in expedited review: tackling the workload of ethics committees

Noninvasive ventilation for acute respiratory failure after lung resection: an observational study

A simple aspiration test to determine the accuracy of oesophageal placement of fine-bore feeding tubes

Austrian validation and customization of the SAPS 3 Admission Score

A comparison of methods to identify open-lung PEEP

Let automated weaning systems rise to the Summit. Response to the letter of Maldonado et al.