Secondary Logo

Journal Logo

Institutional members access full text with Ovid®

The β-Blocker Esmolol Restores the Vascular Waterfall Phenomenon After Acute Endotoxemia*

Du, Wei MD; Liu, Dawei MD; Long, Yun MD; Wang, Xiaoting MD

doi: 10.1097/CCM.0000000000002721
Online Laboratory Investigations
Editor's Choice

Background: A vascular waterfall occurs when the critical closing pressure is greater than the mean systemic filling pressure. Because the waterfall phenomenon likely exists in the microcirculation, β1-receptor blockers such as esmolol could have some effect on microcirculation and vascular waterfall.

Objectives: To determine whether a vascular waterfall exists during septic shock and to assess the effects of vasopressors and β-blockers on vascular waterfall.

Design: Sixteen mongrel dogs were mounted with ultrasonic flow probes to measure renal blood flow. The hemodynamic variables of 16 animals were measured at baseline, after induction of acute endotoxemia; then, they underwent volume expansion, and norepinephrine was used to achieve baseline. After achieving septic myocardial depression, the animals were randomly divided into two groups (esmolol vs control groups) after reaching septic myocardial depression.

Measurements and Main Results: There was a pressure gap of 41.9 ± 13.9 mm Hg between the arterial critical closing pressure and the mean systemic filling pressure, indicating that a vascular waterfall was present under baseline conditions. Endotoxemia caused a decrease in cardiac output, mean arterial pressure, and critical closing pressure. Endotoxemia also caused the vascular waterfall to disappear. Neither volume expansion nor norepinephrine had any effect on the vascular waterfall. Esmolol infusion restored the vascular waterfall effect following endotoxemia and resuscitation. The 24-hour survival was 75% in the esmolol group versus 12.5% in controls (p = 0.041).

Conclusions: Vascular pressure gradients in renal vasculature suggest the presence of a vascular waterfall at baseline. Although this phenomenon disappeared in endotoxemic dogs, it could be restored with β-blocker therapy (esmolol).

All authors: Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.

*See also p. 2115.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Dr. Du designed the study, participated in the conception and design of the study, acquired the data, performed statistical analysis, interpreted the data, and drafted the article. Dr. Liu conceived and designed the study, interpreted the data, helped draft the article, gave final approval of the version to be published, and agreed to be accountable for all aspects of the work, including its accuracy. Drs. Long and Wang participated in recruitment of the patients, data acquisition, and technical support and contributed to revising the article critically for important intellectual content. All of the authors read and approved the final article.

Supported, in part, by a grant from the National Natural Science Foundations of China (# 81501639).

The authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail:

Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.