Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, Paris, France.
Sorbonne Université, Paris, France.
Crit Care Med. 2021 Apr 1;49(4):e404-e411. doi: 10.1097/CCM.0000000000004846.
Cirrhosis is associated with hemodynamic and vascular disorders. However, microvascular reactivity of cirrhotic patients in the context of sepsis has poorly been investigated.
Prospective observational study.
Medical ICU in a tertiary teaching hospital.
We prospectively included adult patients admitted in the ICU for septic shock with and without cirrhosis. After initial resuscitation, global hemodynamic parameters were recorded and skin microvascular reactivity to local acetylcholine iontophoresis was measured.
None.
Thirty patients with septic shock were included (60% male), 10 with cirrhosis and 20 without, with a median age of 61 years (54-74 yr). Cirrhotic patients were mainly classed as Child-Pugh C (80%) and all of them had ascites. Sequential Organ Failure Assessment score and ICU mortality of cirrhotic patients were higher than the noncirrhotic patients, respectively (6.5 [5.0-8.3] vs 11.5 [9.0-14.0]; p < 0.01; 15% vs 70%; p < 0.01). Peripheral tissue perfusion and global hemodynamic parameters were not different between the cirrhotic and noncirrhotic patients but arterial lactate level was three times higher in patients with cirrhosis (6.0 mmol/L [3.9-8.0 mmol/L] vs 2.0 mmol/L [0.9-3.5 mmol/L]; p < 0.01). Basal skin microvascular blood flow was not statistically different between the groups (4.94 perfusion units [3.45-8.73 perfusion units] vs 6.95 perfusion units [5.24-8.38 perfusion units]; p = 0.29). After acetylcholine simulation, skin microvascular blood flow increased more in cirrhotic patients than in noncirrhotic patients (644% [217-966%] vs 169% [73-505%], p = 0.03). Global microvascular reactivity was seven times higher in cirrhotic patients (area under the curve, 16,412 perfusion units [13,898-19,041 perfusion units] vs 2,664 perfusion units [969-4,604 perfusion units]; p < 0.001).
We identified an exaggerated vasodilating microvascular response in cirrhotic patients with septic shock. Such a result may explain vasopressor resistance and paves the way for future therapeutic trials, targeting nitric oxide pathway specifically in this population.
肝硬化与血流动力学和血管紊乱有关。然而，在脓毒症背景下肝硬化患者的微血管反应仍研究甚少。
前瞻性观察性研究。
一家三级教学医院的重症监护病房（ICU）。
我们前瞻性纳入 ICU 因感染性休克而住院的成年患者，包括合并和不合并肝硬化的患者。初始复苏后，记录整体血流动力学参数，并测量皮肤对局部乙酰胆碱电渗的微血管反应。
无。
共纳入 30 例感染性休克患者（60%为男性），其中 10 例合并肝硬化，20 例不合并，中位年龄为 61 岁（54-74 岁）。肝硬化患者主要为 Child-Pugh C 级（80%），且均有腹水。序贯器官衰竭评估（SOFA）评分和 ICU 死亡率在肝硬化患者中均高于非肝硬化患者，分别为（6.5[5.0-8.3]比 11.5[9.0-14.0]；p＜0.01；15%比 70%；p＜0.01）。肝硬化和非肝硬化患者的外周组织灌注和整体血流动力学参数无差异，但肝硬化患者的动脉血乳酸水平高 3 倍（6.0mmol/L[3.9-8.0mmol/L]比 2.0mmol/L[0.9-3.5mmol/L]；p＜0.01）。两组间基础皮肤微血管血流无统计学差异（4.94 灌注单位[3.45-8.73 灌注单位]比 6.95 灌注单位[5.24-8.38 灌注单位]；p=0.29）。乙酰胆碱刺激后，肝硬化患者皮肤微血管血流增加较非肝硬化患者多（644%[217-966%]比 169%[73-505%]；p=0.03）。肝硬化患者的整体微血管反应性高 7 倍（曲线下面积 16412 灌注单位[13898-19041 灌注单位]比 2664 灌注单位[969-4604 灌注单位]；p＜0.001）。
我们发现感染性休克合并肝硬化患者存在血管扩张性微血管反应过度。这一结果可能解释了血管加压素抵抗，并为未来针对该人群中一氧化氮通路的治疗试验铺平了道路。
