Lymphatic drainage between thorax and abdomen: please take good care of this well-performing machinery...
BACKGROUND
Patients with sepsis often receive large amounts of fluids and the presence of capillary leak, trauma or bleeding results in ongoing fluid resuscitation. This increases interstitial and intestinal edema and finally leads to intra-abdominal hypertension (IAH), which in turn impedes lymphatic drainage. Patients with IAH often develop secondary respiratory failure needing mechanical ventilation with high intrathoracic pressure or PEEP that might further alter lymphatic drainage. This review will try to convince the reader of the importance of the lymphatics in septic patients with IAH.


METHODS
A Medline and PubMed literature search was performed using the terms "abdominal pressure", "lymphatic drainage" and "ascites formation". The references from these studies were searched for relevant articles that may have been missed in the primary search. These articles served as the basis for the recommendations below.


RESULTS
Induction of sepsis with lesion of the capillary alveolar barrier results in an increased water gradient between the capillaries and the interstitium in the lungs. The drainage flow to the thoracic duct is initially increased in order to protect the Lung and maintain the pulmonary interstitium as dry as possible, however this results in increased intrathoracic pressure. Sepsis also increases the permeability of the capillaries in the splanchnic beds. In analogy to the lungs the lymphatic flow in the splanchnic areas increases together with the pressure inside as a physiological response in order to limit the increase in IAP. At a critical IAP level (around 20 cmH2O) the lymph flow starts to decrease and the splanchnic water content progressively increases. The lymph flow from the abdomen to the thorax is progressively decreased resulting in increased splanchnic water content and ascites formation. The presence of mechanical ventilation with high PEEP reduces the lymph drainage further which together with the increase in IAP decreases the lymphatic pressure gradient in the splanchnic regions, with a further increase in water content and IAP triggering a vicious cycle.


CONCLUSIONS
Although often overlooked the role of lymphatic flow is complex but very important to determine not only the fluid balance in the lung but also in the peripheral organs. Different pathologies and treatments can markedly influence the pathophysiology of the lymphatics with dramatic effects on endorgan function.
Malbrain
M L N G
ML
ZiekenhuisNetwerk Antwerpen, Campus Stuivenberg, Intensive Care Unit, Antwerp, Belgium. manu.malbrain@skynet.be
Pelosi
P
P
De laet
I
I
Lattuada
M
M
Hedenstierna
G
G
D000005:Abdomen; D002199:Capillary Permeability; D004322:Drainage / Q000379:methods*; D005440:Fluid Therapy / Q000379:methods*; D006801:Humans; D008196:Lymph / Q000378:metabolism*; D008643:Mesentery / Q000378:metabolism; D011312:Pressure; D012131:Respiratory Insufficiency / Q000517:prevention & control; D018805:Sepsis / Q000378:metabolism* / Q000628:therapy*; D013909:Thorax