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Effects of nitroglycerin on sublingual microcirculatory blood flow in patients with severe sepsis/septic shock after a strict resuscitation protocol: A double-blind randomized placebo controlled trial

Boerma, E Christiaan MD, PhD; Koopmans, Matty RN; Konijn, Arjan MD; Kaiferova, Katerina MD; Bakker, Andries J. PhD; van Roon, Eric N. PhD; Buter, Hanneke MD, PhD; Bruins, Nienke MD; Egbers, Peter H. MD; Gerritsen, Rik T. MD; Koetsier, Peter M. MD; Kingma, W Peter MD; Kuiper, Michael A. MD, PhD, FCCP, FCCM; Ince, Can PhD

doi: 10.1097/CCM.0b013e3181b02fc1
Clinical Investigations

Objectives: Microcirculatory alterations have been associated with morbidity and mortality in human sepsis. Such alterations occur despite pressure-guided resuscitation. Earlier data suggested that impaired microcirculatory blood flow could be corrected with intravenous nitroglycerin in these patients. We tested this concept after fulfillment of preset systemic hemodynamic resuscitation end points in the early phase of sepsis.

Design: Prospective, single center, randomized, placebo-controlled, double-blind clinical trial.

Setting: Closed-format 22-bed mixed intensive care unit in a tertiary teaching hospital.

Patients: Patients ≥18 yrs with sepsis, according to international criteria, and at least one early sign of organ dysfunction, as the principal reason for intensive care unit admission, were eligible for enrollment.

Interventions: Patients were randomly assigned to receive nitroglycerin (n = 35) or placebo (n = 35) after fulfillment of protocol-driven resuscitation end points. This trial is registered with ClinicalTrials.gov as NCT00493415.

Measurements and Main Results: Primary outcome was sublingual microcirculatory blood flow of small vessels, as assessed by side-stream dark field imaging. After protocolized resuscitation, we observed recruitment of sublingual microcirculation in both groups, as indicated by a significant improvement in the microcirculatory flow index after 24 hrs, in comparison to baseline. However, no difference in the sublingual microvascular flow index was observed between groups. The median microvascular flow index in sublingual small-sized vessels was 2.71 (1.85-3) in the nitroglycerin group and 2.71 (1.27-3), p = .80, in the placebo group. In medium-sized vessels, the respective values were 3 (2.75-3) vs. 2.86 (2.19-3), p = .21, and in large-sized vessels, 3 (3-3) vs. 3 (2.89-3), p = .06. In-hospital mortality, as a secondary outcome, was 34.3% in the nitroglycerin group and 14.2% in the placebo group, p = .09.

Conclusions: In the context of a strict resuscitation protocol, based upon fulfillment of systemic hemodynamic end points in patients with early-phase severe sepsis or septic shock, we conclude that intravenous nitroglycerin does not promote sublingual microcirculatory blood flow.

From the Department of Translational Physiology (ECB, CI), Academic Medical Centre, Amsterdam, The Netherlands; Departments of Intensive Care (ECB, MK, AK, KK, HB, NB, PHE, RTG, PMK, PK, MAK) and Clinical Pharmacy and Clinical Pharmacology (ENvR), Medical Centre Leeuwarden, The Netherlands; Department of Clinical Chemistry (AJB), Stichting Klinisch Chemisch Laboratorium, Leeuwarden, The Netherlands.

Supported, in part, by an unrestricted grant from a local hospital scientific committee.

Dr. Ince is chief scientific officer of MicroVisionMedical, a university-based company that develops optical spectroscopic tools, such as the SDF imaging methodology used in the present study. He holds patents and shares of relevance to this role. The remaining authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: e.boerma@chello.nl

© 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins