The role of vasoactive agents in the resuscitation of microvascular perfusion and tissue oxygenation in critically ill patients.
OBJECTIVE
The clinical use of vasoactive drugs is not only intended to improve systemic hemodynamic variables, but ultimately to attenuate derangements in organ perfusion and oxygenation during shock. This review aims (1) to discuss basic physiology with respect to manipulating vascular tone and its effect on the microcirculation, and (2) to provide an overview of available clinical data on the relation between vasoactive drugs and organ perfusion, with specific attention paid to recent developments that have enabled direct in vivo observation of the microcirculation and concepts that have originated from it.


METHODS
A MedLine search was conducted for clinical articles in the English language over the last 15 years pertainig to shock, sepsis, organ failure, or critically ill patients in combination with vasoactive drugs and specific variables of organ perfusion/oxygenation (e.g., tonometry, indocyanine clearance, laser Doppler, and sidestream dark field imaging).


RESULTS
Eighty original papers evaluating the specific relationship between organ perfusion/oxygenation and the use of vasoactive drugs were identified and are discussed in light of physiological theory of vasomotor tone.


CONCLUSIONS
Solid clinical data in support of the idea that increasing blood pressure in shock improves microcirculatory perfusion/oxygenation seem to be lacking, and such a concept might not be in line with physiological theory of microcirculation as a low-pressure vascular compartment. In septic shock no beneficial effect on microcirculatory perfusion above a mean arterial pressure of 65 mmHg has been reported, but a wide range in inter-individual effect seems to exist. Whether improvement of microcirculatory perfusion is associated with better patient outcome remains to be elucidated.
Boerma
E Christiaan
EC
Department of Translational Physiology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands. e.boerma@chello.nl
Ince
Can
C
D016638:Critical Illness; D006801:Humans; D008833:Microcirculation / Q000187:drug effects*; D010101:Oxygen Consumption / Q000187:drug effects*; D014662:Vasoconstrictor Agents / Q000494:pharmacology* / Q000627:therapeutic use*; D014665:Vasodilator Agents / Q000494:pharmacology* / Q000627:therapeutic use*
D014662:Vasoconstrictor Agents; D014665:Vasodilator Agents
Br J Anaesth. 2009 Apr;102(4):485-91
19244260
Circulation. 2003 May 13;107(18):2313-9
12732600
Br J Anaesth. 2008 Feb;100(2):240-4
18211997
Am J Physiol Regul Integr Comp Physiol. 2008 Sep;295(3):R891-8
18635446
Acta Anaesthesiol Scand. 2009 Sep;53(8):1052-9
19572935
Crit Care Med. 2007 Apr;35(4):1055-60
17334238
Science. 1997 Jun 27;276(5321):2034-7
9197264
Intensive Care Med. 2002 Sep;28(9):1208-17
12209267
Lancet. 2002 Nov 2;360(9343):1395-6
12423989
Anesth Analg. 2006 Jun;102(6):1617-22
16717297
Crit Care Med. 2008 Jun;36(6):1886-91
18496356
Am J Respir Crit Care Med. 1996 Dec;154(6 Pt 1):1684-8
8970355
Crit Care Med. 2005 Sep;33(9):1897-902
16148457
Anesth Analg. 2004 Feb;98(2):461-468
14742388
Acta Anaesthesiol Scand. 2005 Oct;49(9):1387-90
16146482
Intensive Care Med. 2009 Apr;35(4):671-7
18936911
Intensive Care Med. 2009 Jul;35(7):1225-33
19189077
Crit Care Med. 2005 Apr;33(4):780-6
15818105
Crit Care. 2006;10(5):R131
16970804
Am J Physiol. 1999 Dec;277(6 Pt 2):S203-10
10644247
Crit Care Med. 1999 May;27(5):893-900
10362410
Crit Care Med. 2004 Sep;32(9):1825-31
15343008
Intensive Care Med. 2004 Apr;30(4):597-604
14673520
Lancet. 2005 Mar 5-11;365(9462):871-5
15752531
Am J Respir Crit Care Med. 1999 Dec;160(6):1983-6
10588617
J Cardiothorac Vasc Anesth. 2009 Feb;23(1):95-101
19058975
Intensive Care Med. 2008 Dec;34(12):2226-34
18654759
Adv Exp Med Biol. 1971 Oct;23(0):13-23
5164840
Crit Care Med. 2009 Mar;37(3):876-81
19237891
Acta Anaesthesiol Scand. 2008 Jul;52(6):785-92
18477074
N Engl J Med. 1987 Aug 13;317(7):397-403
3302704
Crit Care Med. 2006 Jun;34(6):1752-7
16625119
Intensive Care Med. 2007 Sep;33(9):1557-62
17486316
Intensive Care Med. 2006 Nov;32(11):1782-9
17019548
Crit Care Med. 2004 Jan;32(1):1-12
14707554
Ann Emerg Med. 2007 Jan;49(1):88-98, 98.e1-2
17095120
Crit Care Med. 1998 Aug;26(8):1458-60
9710110
Crit Care Med. 2006 Feb;34(2):403-8
16424721
Anesth Analg. 2005 Apr;100(4):1107-1111
15781529
Crit Care. 2007;11(1):R17
17298665
Br J Anaesth. 2003 Dec;91(6):878-85
14633761
J Am Coll Cardiol. 2007 Mar 27;49(12):1296-8
17394961
Crit Care. 2009;13(6):R181
19917106
Lancet. 2002 Apr 6;359(9313):1209-10
11955542
Crit Care Med. 2004 Jan;32(1):21-30
14707556
Curr Opin Crit Care. 2009 Oct;15(5):431-6
19617821
Nat Med. 1999 Oct;5(10):1209-12
10502828
Crit Care. 2008;12(6):R143
19017409
Ann Thorac Surg. 1997 Mar;63(3):728-35
9066392
Crit Care Med. 2009 Jun;37(6):1961-6
19384212
Shock. 2008 Apr;29(4):446-51
17885646
Crit Care. 2005;9 Suppl 4:S13-9
16168069
Eur J Heart Fail. 2009 Apr;11(4):386-90
19211570
Cardiovasc Res. 1996 Oct;32(4):654-67
8915184
Intensive Care Med. 1997 Jan;23(1):31-7
9037637
Chest. 2003 Dec;124(6):2256-60
14665508
Am Heart J. 2004 Jan;147(1):91-9
14691425
Intensive Care Med. 2001;27 Suppl 1:S80-92
11307372
Am J Physiol. 1993 Feb;264(2 Pt 2):H294-301
8447446
Circulation. 1996 Aug 1;94(3):490-7
8759094
Crit Care Med. 2000 Aug;28(8):2729-32
10966242
Cardiovasc Drugs Ther. 1990 Jan;4 Suppl 1:101-4
2285638
Anaesthesia. 2009 Jun;64(6):589-94
19453310
Crit Care Med. 1997 Mar;25(3):399-404
9118653
N Engl J Med. 2001 Aug 23;345(8):588-95
11529214
Crit Care Med. 2008 Apr;36(4):1323-9
18379261
Crit Care Med. 2000 Aug;28(8):2758-65
10966247
Acad Emerg Med. 2008 May;15(5):399-413
18439194
Lancet. 2007 Aug 25;370(9588):676-84
17720019
Acta Anaesthesiol Scand. 2009 May;53(5):581-8
19239407
Acta Anaesthesiol Scand. 1995 Jul;39(5):599-604
7572007
Intensive Care Med. 1995 May;21(5):414-21
7665751
Shock. 2004 Oct;22(4):314-9
15377885
Crit Care Med. 2010 Jan;38(1):93-100
19730258
Best Pract Res Clin Anaesthesiol. 2008 Jun;22(2):335-50
18683479
Crit Care. 2006 Feb;10(1):R32
16507156
Anesthesiology. 1997 Apr;86(4):818-24
9105226
J Physiol. 1921 Nov 18;55(5-6):412-22
16993526
Crit Care Med. 2003 Nov;31(11):2646-50
14605537
Am J Respir Crit Care Med. 1996 Dec;154(6 Pt 1):1664-70
8970352
Intensive Care Med. 2008 Jan;34(1):17-60
18058085
N Engl J Med. 2010 Mar 4;362(9):779-89
20200382
Intensive Care Med. 1997 Feb;23(2):146-58
9068999
Clin Res Cardiol. 2009 Aug;98(8):469-75
19367424
Intensive Care Med. 2003 Jun;29(6):1020-1023
12736775
Crit Care Med. 2008 Feb;36(2):535-42
18216603
Clin Res Cardiol. 2009 May;98(5):311-8
19280085
Dermatology. 2009;218(4):334-7
19155616
Br J Anaesth. 1995 Feb;74(2):149-54
7696062
N Engl J Med. 2008 Feb 28;358(9):877-87
18305265
JAMA. 1994 Nov 2;272(17):1354-7
7933396
Chest. 2004 Aug;126(2):534-9
15302741
Crit Care. 2009;13(3):R92
19534818
Am J Respir Crit Care Med. 1998 May;157(5 Pt 1):1586-92
9603142
Crit Care Med. 1994 May;22(5):789-95
8181287
Intensive Care Med. 1996 Sep;22(9):880-7
8905421
Best Pract Res Clin Anaesthesiol. 2008 Jun;22(2):351-8
18683480
Microcirculation. 2005 Jan-Feb;12(1):33-45
15804972
Crit Care Med. 2003 May;31(5):1394-8
12771608
Int J Cardiol. 2008 Jan 24;123(3):221-8
18037513
Intensive Care Med. 2005 May;31(5):638-44
15812624