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Effect of Increasing Blood Pressure With Noradrenaline on the Microcirculation of Patients With Septic Shock and Previous Arterial Hypertension

Fiorese Coimbra, Karla Tuanny MD; de Freitas, Flávio Geraldo Rezende MD, PhD; Bafi, Antônio Tonete MD; Pinheiro, Tuanny Teixeira MSc; Nunes, Nathaly Fonseca MD, MSc; de Azevedo, Luciano César Pontes MD, PhD; Machado, Flávia Ribeiro MD, PhD

doi: 10.1097/CCM.0000000000003795
Clinical Investigations

Objectives: To assess whether an increase in mean arterial pressure in patients with septic shock and previous systemic arterial hypertension changes microcirculatory and systemic hemodynamic variables compared with patients without arterial hypertension (control).

Design: Prospective, nonblinded, interventional study.

Setting: Three ICUs in two teaching hospitals.

Patients: After informed consent, we included patients older than 18 years with septic shock for at least 6 hours, sedated, and under mechanical ventilation. We paired patients with and without arterial hypertension by age.

Interventions: After obtaining systemic and microcirculation baseline hemodynamic variables (time 0), we increased noradrenaline dose to elevate mean arterial pressure up to 85–90 mm Hg before collecting a new set of measurements (time 1).

Measurements and Main Results: We included 40 patients (20 in each group). There was no significant difference in age between the groups. After the rise in mean arterial pressure, there was a significant increase in cardiac index and a slight but significant reduction in lactate in both groups. We observed a significant improvement in the proportion of perfused vessels (control: 57.2 ± 14% to 66 ± 14.8%; arterial hypertension: 61.4 ± 12.3% to 70.8 ± 7.1%; groups: p = 0.29; T0 and T1: p < 0.001; group and time interaction: p = 0.85); perfused vessels density (control: 15.6 ± 4 mm/mm2 to 18.6 ± 4.5 mm/mm2; arterial hypertension: 16.4 ± 3.5 mm/mm2 to 19.1 ± 3 mm/mm2; groups: p = 0.51; T0 and T1: p < 0.001; group and time interaction: p = 0.70), and microcirculatory flow index (control: 2.1 ± 0.6 to 2.4 ± 0.6; arterial hypertension: 2.1 ± 0.5 to 2.6 ± 0.2; groups: p = 0.71; T0 and T1: p = 0.002; group and time interaction: p = 0.45) in both groups.

Conclusions: Increasing mean arterial pressure with noradrenaline in septic shock patients improves density and flow in small vessels of sublingual microcirculation. However, this improvement occurs both in patients with previous arterial hypertension and in those without arterial hypertension.

All authors: Anesthesiology, Pain and Intensive Care Department, Universidade Federal de São Paulo, São Paulo, Brazil.

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Supported, in part, by grant from Fundação de Pesquisa do Estado de São Paulo—Grant 2012/19051-1.

Drs. Fiorese Coimbra’s, de Freitas’s, Bafi’s, Pinheiro’s, Nunes’s, and Machado’s institution received funding from Fundação de Amparo à Pesquisa do Estado de São Paulo—FAPESP, a government grant agency from State of São Paulo. Dr. de Azevedo disclosed that he does not have any potential conflicts of interest.

Trial registration: NCT02519699.

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