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Objective To observe the effect of early goal directed therapy (EGDT) on tissue perfusion,microcirculation and tissue oxygenation in patients with septic shock.Methods A prospective observational study was carried out in 20 patients with early septic shock admitted to ICU within 24 hours after onset.Patients with one of following conditions,including stroke,brain injury,other types of shock,severe heart failure,acute myocardium infarction,ages below 18,pregnancy,terminal stage of disease,cardiac arrest,extensive bums,mouth bleeding,oromandiblular dyetonia (difficult to open the mouth),and the time elapsed over 24 hours after onset of septic shock,were excluded.The eligible patients were treated with the standard procedure of EGDT.The partial pressure of transcutaneous oxygen and carbon dioxide (PtcO2,PtcCO2) was monitored and hemodynamic data were recorded.Sidestream dark field imaging device was applied to detect the sublingual microcirculation.Hemodynamics,tissue oxygen,and sublingual microcirculation were compared before treatment and after EGDT.When the variables met the normal distribution,t test was applied.Otherwise,Wilcoxon test was used.Correlation between variables was analyzed with Pearson Correlation Analysis.Results Of 20 patients,19 met all 4 elements in criteria of EGDT after treatment and were eligible for study.PtcO2 and PtcCO2 were monitored in 19 patients.Sublingual microcirculation was obtained in four of them.(1) After the criteria of EGDT were entirely met,PtcO2 increased from (62.7 ± 24.0) mm Hg to (78.0 ± 30.9) mm Hg (P ＜ 0.05) ; tissue oxygenation index (PtcO2/FiO2) was (110.7 ± 60.4) mm Hg before treatment and (141.6 ± 78.2) mm Hg after EGDT (P ＜ 0.05).PtcCO2 and PaCO2 gap (difference between PtcCO2 and PaCO2) decreased significantly after EGDT (P ＜ 0.05).(2) Both proportion of small vessels with perfusion (PVP) and microcirculatory flow index of small vessels (MFI) showed a trend of increase after EGDT,but there were no significant differences between pre-and post-EGDT (P was 0.051 and 0.074 respectively).(3) PtcO2,PtcO2/FiO2,and PtcCO2 were not linearly related to central venous saturation,lactate,oxygen delivery,and oxygen consumption (All P ＞ 0.05).Conclusions Peripheral perfusion improved after EGDT in patients with septic shock but those hemodynamic variables might not exactly reflect the authenticity of global perfusion.
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@#BACKGROUND: This study aimed to observe the effect of early goal directed therapy (EGDT) on tissue perfusion, microcirculation and tissue oxygenation in patients with septic shock. METHODS: Patients with early septic shock (<24 hours) who had been admitted to the ICU of Zhongda Hospital Affiliated to Southeast University from September 2009 through May 2011 were enrolled (research time: 12 months), and they didn't meet the criteria of EGDT. Patients who had one of the following were excluded: stroke, brain injury, other types of shock, severe heart failure, acute myocardial infarction, age below 18 years, pregnancy, end-stage disease, cardiac arrest, extensive burns, oral bleeding, difficulty in opening the mouth, and the onset of septic shock beyond 24 hours. Patients treated with the standard protocol of EGDT were included. Transcutaneous pressure of oxygen and carbon dioxide (PtcO2, PtcCO2) were monitored and hemodynamic measurements were obtained. Side-stream dark field (SDF) imaging device was applied to obtain sublingual microcirculation. Hemodynamics, tissue oxygen, and sublingual microcirculation were compared before and after EGDT. If the variable meets the normal distribution, Student's t test was applied. Otherwise, Wilcoxon's rank-sum test was used. Correlation between variables was analyzed with Pearson's product-moment correlation coefficient method. RESULTS: Twenty patients were involved, but one patient wasn't analyzed because he didn't meet the EGDT criteria. PtcO2 and PtcCO2 were monitored in 19 patients, of whom sublingual microcirculation was obtained. After EGDT, PtcO2 increased from 62.7±24.0 mmHg to 78.0±30.9 mmHg (P<0.05) and tissue oxygenation index (PtcO2/FiO2) was 110.7±60.4 mmHg before EGDT and 141.6±78.2 mmHg after EGDT (P<0.05). The difference between PtcCO2 and PCO2 decreased significantly after EGDT (P<0.05). The density of perfused small vessels (PPV) and microcirculatory flow index of small vessels (MFI) tended to increase, but there were no significant differences between them (P>0.05). PtcO2, PtcO2/FiO2, and PtcCO2 were not linearly related to central venous saturation, lactate, oxygen delivery, and oxygen consumption (P>0.05). CONCLUSION: Peripheral perfusion was improved after EGDT in patients with septic shock, and it was not exactly reflected by the index of systemic perfusion.