Efeitos hemodinâmicos da arginina vasopressina em baixas doses no choque séptico
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Data
2013-08-28
Autores
Nascente, Ana Paula Metran [UNIFESP]
Orientadores
Machado, Flávia Ribeiro [UNIFESP]
Tipo
Tese de doutorado
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A vasopressina é um dos vasopressores utilizados em pacientes com choque séptico. No entanto, os seus efeitos hemodinâmicos sistêmicos e microcirculatórios não são completamente conhecidos e compreendidos. Este estudo teve como objetivo avaliar os efeitos da vasopressina exógena na microcirculação sublingual, utilizando a técnica de sidestream dark field, e correlacionar estes potenciais achados com os efeitos sistêmicos da mesma. Neste estudo prospectivo com intervenção, foram incluídos pacientes com choque séptico, nas primeiras 48 horas de uso de catecolaminas vasopressoras, internados nas unidades de terapia intensiva da Disciplina de Anestesiologia, Dor e Terapia Intensiva da Universidade Federal de São Paulo. A vasopressina foi administrada a 0,04 U/min por uma hora. Foram obtidas medidas hemodinâmicas sistêmicas, imediatamente antes e 1 hora após o início da vasopressina. Além disso, imagens de microcirculação sublingual foram coletadas por meio da tecnologia de sidestream dark field, para posterior análise com software específico. Após inclusão de 18 pacientes, observou-se redução significativa da dose de catecolaminas após a vasopressina (0,41 μg/kg/min (0,23 - 0,90) versus
0,31 μg/kg/min (0,09 - 0,76), p = 0,001). Verificou-se redução da frequência cardíaca, índice sistólico, índice cardíaco, bem como da saturação venosa mista e alargamento do gradiente venoso-arterial de pCO2 (p = 0,009, 0,022, 0,002, 0,044 e 0,039, respectivamente). No entanto, houve redução dos níveis de lactato (30,3 ± 17,3 mg/dL versus 27,6 ± 15,8 mg/dL, p = 0,037) e não ocorreu alteração significativa na densidade vascular total, densidade de vasos perfundidos, proporção de vasos perfundidos, índice de fluxo microcirculatório e índice de heterogeneidade (p > 0,05 para todos). Encontrou-se correlação negativa entre a variação de três dos parâmetros da microcirculação e seu respectivo valor basal: densidade vascular total (r = - 0,670; p = 0,002), densidade vascular perfundida (r= - 0,71; p = 0,001) e proporção de vasos perfundidos (r = - 0,531; p = 0,023). Porém, não houve correlação entre estas variações e o índice cardíaco basal (r=- 0,100; p = 0,692 para densidade vascular total; r = - 0,204; p = 0,418 para densidade vascular perfundida; r = - 0,369; p = 0,132 para proporção de vasos perfundidos; r = 0,200; p = 0,425 para índice de fluxo microcirculatório e r = 0,106; p = 0,675 para índice de heterogeneidade). Desta forma, o presente estudo sugere que, embora a vasopressina esteja relacionada a efeitos potencialmente prejudiciais à macrocirculação, sua associação a catecolaminas vasopressoras proporciona redução da dose dos mesmos, sem impacto significativo na rede microcirculatória. Por outro lado, houve melhora dos parâmetros da microcirculação nos pacientes que os apresentaram comprometidos antes do início da infusão de vasopressina.
Vasopressin is one of the vasopressor used in patients with septic shock. However, its systemic hemodynamic effects and its microcirculation effects are not completely known. This study aimed to evaluate the effects of exogenous vasopressin on sublingual microcirculation using sidestream dark field technique and to correlate them with its systemic effects. We included in this prospective interventional study patients with septic shock admitted to the intensive care unit of the Departamento de Anestesiologia, Dor e Terapia Intensiva from Universidade Federal de São Paulo, during the first 48 hours of use of catecholamine vasopressors. Vasopressin was administered at 0.04 U/min for one hour. Systemic hemodynamic measurements were obtained immediately before and 1 hour after vasopressin. In addition, images of sublingual microcirculation were collected through sidestream dark field technology and analyzed with specific software. After the inclusion of 18 patients, we found a significant reduction in catecholamine’s dose after vasopressin (0.41 mg/kg/min (0.23 to 0.90) versus 0.31 ug/kg/min (0.09 to 0.76) p = 0.001). There were also a reduction in heart rate, stroke volume index, cardiac index, and mixed venous saturation and an increase in venous-arterial pCO2 gradient (p = 0.009, 0.022, 0.002, 0.044 and 0.039, respectively). However, lactate levels decreased (30.3 ± 17.3 mg/dL versus 27.6 ± 15.8 mg/dL, p = 0.037) and there was no significant change in the total vascular density, perfused vessel density, proportion of perfused vessels, microcirculatory flow index and heterogeneity index (p> 0.05 for all). We also found a significant negative correlation between the variation of three microcirculation parameters and their respective baseline values - total vascular density (r = - 0.670, p = 0.002), perfused vessel density (r = - 0.71, p = 0.001) and proportion of perfused vessels (r = - 0.531, p = 0.023). However, there was no correlation between these variation and the baseline cardiac index (r = - 0.100, p = 0.692 for total vascular density, r = - 0.204, p = 0.418 for perfused vascular density, r = - 0.369, p = 0.132 for proportion of perfused vessels, r = 0.200, p = 0.425 for microcirculatory flow index, r = 0.106, p = 0.675 for heterogeneity index). In conclusion, this study suggested that, although vasopressin was associated with potentially harmful effects on macrocirculation, its use in association with catecholamine vasopressors provides reduction in catecholamine’s dose without significant impact on the microcirculatory network. In addition, in patients with worst baseline microcirculatory parameters, there was an improvement in microcirculation after vasopressin infusion.
Vasopressin is one of the vasopressor used in patients with septic shock. However, its systemic hemodynamic effects and its microcirculation effects are not completely known. This study aimed to evaluate the effects of exogenous vasopressin on sublingual microcirculation using sidestream dark field technique and to correlate them with its systemic effects. We included in this prospective interventional study patients with septic shock admitted to the intensive care unit of the Departamento de Anestesiologia, Dor e Terapia Intensiva from Universidade Federal de São Paulo, during the first 48 hours of use of catecholamine vasopressors. Vasopressin was administered at 0.04 U/min for one hour. Systemic hemodynamic measurements were obtained immediately before and 1 hour after vasopressin. In addition, images of sublingual microcirculation were collected through sidestream dark field technology and analyzed with specific software. After the inclusion of 18 patients, we found a significant reduction in catecholamine’s dose after vasopressin (0.41 mg/kg/min (0.23 to 0.90) versus 0.31 ug/kg/min (0.09 to 0.76) p = 0.001). There were also a reduction in heart rate, stroke volume index, cardiac index, and mixed venous saturation and an increase in venous-arterial pCO2 gradient (p = 0.009, 0.022, 0.002, 0.044 and 0.039, respectively). However, lactate levels decreased (30.3 ± 17.3 mg/dL versus 27.6 ± 15.8 mg/dL, p = 0.037) and there was no significant change in the total vascular density, perfused vessel density, proportion of perfused vessels, microcirculatory flow index and heterogeneity index (p> 0.05 for all). We also found a significant negative correlation between the variation of three microcirculation parameters and their respective baseline values - total vascular density (r = - 0.670, p = 0.002), perfused vessel density (r = - 0.71, p = 0.001) and proportion of perfused vessels (r = - 0.531, p = 0.023). However, there was no correlation between these variation and the baseline cardiac index (r = - 0.100, p = 0.692 for total vascular density, r = - 0.204, p = 0.418 for perfused vascular density, r = - 0.369, p = 0.132 for proportion of perfused vessels, r = 0.200, p = 0.425 for microcirculatory flow index, r = 0.106, p = 0.675 for heterogeneity index). In conclusion, this study suggested that, although vasopressin was associated with potentially harmful effects on macrocirculation, its use in association with catecholamine vasopressors provides reduction in catecholamine’s dose without significant impact on the microcirculatory network. In addition, in patients with worst baseline microcirculatory parameters, there was an improvement in microcirculation after vasopressin infusion.
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Citação
NASCENTE, Ana Paula Metran. Efeitos hemodinâmicos da arginina vasopressina em baixas doses no choque séptico. São Paulo, 2013. 111 f. Tese (Doutorado em Medicina Translacional) – Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, 2013.