title: Conventional hemodynamic resuscitation may fail to optimize tissue perfusion: an observational study on the effects of dobutamine, enoximone, and norepinephrine in patients with acute myocardial infarction complicated by cardiogenic shock.
abstract: OBJECTIVE
  To investigate the effects of inotropic agents on parameters of tissue perfusion in patients with cardiogenic shock.
  
  
  RESULTS
  Thirty patients with cardiogenic shock were included. Patients received dobutamine, enoximone, or norepinephrine. We performed hemodynamic measurements at baseline and after titration of the inotropic agent until cardiac index (CI) ≥ 2.5 L.min-1.m(-2) or mixed-venous oxygen saturation (SvO2) ≥ 70% (dobutamine or enoximone), and mean arterial pressure (MAP) ≥ 70 mmHg (norepinephrine). As parameters of tissue perfusion, we measured central-peripheral temperature gradient (delta-T) and sublingual perfused capillary density (PCD). All patients reached predefined therapeutic targets. The inotropes did not significantly change delta-T. Dobutamine did not change PCD. Enoximone increased PCD (9.1 [8.9-10.2] vs. 11.4 [8.4-13.9] mm.mm(-2); p<0.05), and norepinephrine tended to decrease PCD (9.8 [8.5-11.9] vs. 8.8 [8.2-9.6] mm.mm-2, p = 0.08). Fifteen patients (50%) died within 30 days after admission. Patients who had low final PCD (≤ 10.3 mm.mm-2; 64%) were more likely to die than patients who had preserved PCD (>10.3 mm.mm(-2); mortality 72% vs. 17%, p = 0.003).
  
  
  CONCLUSIONS
  This study demonstrates the effects of commonly used inotropic agents on parameters of tissue perfusion in patients with cardiogenic shock. Despite hemodynamic optimization, tissue perfusion was not sufficiently restored in most patients. In these patients, mortality was high. Interventions directed at improving microcirculation may eventually help bridging the gap between improved hemodynamics and dismal patient outcome in cardiogenic shock.
authors.affiliation: Thoraxcenter, Erasmus Medical Center, Departments of Cardiology and Intensive Care Medicine, Rotterdam, the Netherlands.
authors.forename: Corstiaan A
authors.initials: CA
authors.lastname: den Uil
authors.affiliation: Academic Medical Center, Department of Intensive Care Medicine, Amsterdam, the Netherlands.
authors.forename: Wim K
authors.initials: WK
authors.lastname: Lagrand
authors.affiliation: Maasstad Hospital, Department of Cardiology, Rotterdam, the Netherlands.
authors.forename: Martin
authors.initials: M
authors.lastname: van der Ent
authors.affiliation: Thoraxcenter, Erasmus Medical Center, Departments of Cardiology and Intensive Care Medicine, Rotterdam, the Netherlands.
authors.forename: Koen
authors.initials: K
authors.lastname: Nieman
authors.affiliation: Thoraxcenter, Erasmus Medical Center, Departments of Cardiology and Intensive Care Medicine, Rotterdam, the Netherlands.
authors.forename: Ard
authors.initials: A
authors.lastname: Struijs
authors.affiliation: Thoraxcenter, Erasmus Medical Center, Departments of Cardiology and Intensive Care Medicine, Rotterdam, the Netherlands.
authors.forename: Lucia S D
authors.initials: LS
authors.lastname: Jewbali
authors.affiliation: Thoraxcenter, Erasmus Medical Center, Departments of Cardiology and Intensive Care Medicine, Rotterdam, the Netherlands.
authors.forename: Alina A
authors.initials: AA
authors.lastname: Constantinescu
authors.affiliation: Gelre Hospitals, Department of Intensive Care Medicine, Apeldoorn, the Netherlands.
authors.forename: Peter E
authors.initials: PE
authors.lastname: Spronk
authors.affiliation: Thoraxcenter, Erasmus Medical Center, Departments of Cardiology and Intensive Care Medicine, Rotterdam, the Netherlands.
authors.forename: Maarten L
authors.initials: ML
authors.lastname: Simoons
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002196:Capillaries / Q000187:drug effects / Q000503:physiopathology; D004280:Dobutamine / Q000008:administration & dosage / Q000494:pharmacology*; D017335:Enoximone / Q000008:administration & dosage / Q000494:pharmacology*; D005260:Female; D006439:Hemodynamics / Q000187:drug effects*; D006801:Humans; D008297:Male; D008833:Microcirculation / Q000187:drug effects*; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications* / Q000401:mortality / Q000503:physiopathology; D009638:Norepinephrine / Q000008:administration & dosage / Q000494:pharmacology*; D010477:Perfusion; D011652:Pulmonary Circulation / Q000187:drug effects; D012151:Resuscitation; D012770:Shock, Cardiogenic / Q000150:complications* / Q000401:mortality / Q000503:physiopathology; D016896:Treatment Outcome
chemical_list: D004280:Dobutamine; D017335:Enoximone; D009638:Norepinephrine
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