Abstract
BackgroundIn vascular surgery with aortic cross-clamping, ischemia/reperfusion injury induces systemic haemodynamic and microcirculatory disturbances. Different anaesthetic regimens may have a varying impact on tissue perfusion. The aim of this study was to explore changes in microvascular perfusion in patients undergoing elective open abdominal aortic aneurysm repair under balanced or total intravenous anaesthesia.MethodsProspective observational study. Patients undergoing elective open infrarenal abdominal aortic aneurysm repair received balanced (desflurane + remifentanil, n = 20) or total intravenous anaesthesia (TIVA, propofol + remifentanil using target-controlled infusion, n = 20) according to the clinician’s decision. A goal-directed haemodynamic management was applied in all patients. Measurements were obtained before anaesthesia induction (baseline) and at end-surgery and included haemodynamics, arterial/venous blood gases, sublingual microvascular flow and density (incident dark field illumination imaging), peripheral muscle tissue oxygenation and microcirculatory reactivity (thenar near infrared spectroscopy with a vascular occlusion test).ResultsThe two groups did not differ for baseline characteristics, mean aortic-clamping time and requirement of vasoactive agents during surgery. Changes in mean arterial pressure, systemic vascular resistance index, haemoglobin and blood lactate levels were similar between the two groups, while the cardiac index increased at end-surgery in patients undergoing balanced anaesthesia. The sublingual microcirculation was globally unaltered in the TIVA group at end-surgery, while patients undergoing balanced anaesthesia showed an increase in the total and perfused small vessel densities (from 16.6 ± 4.2 to 19.1 ± 5.4 mm/mm2, p < 0.05). Changes in microvascular density were negatively correlated with changes in the systemic vascular resistance index. The area of reactive hyperaemia during the VOT increased in the balanced anaesthesia group (from 14.8 ± 8.1 to 25.6 ± 14.8%*min, p < 0.05). At end-surgery, the tissue haemoglobin index in the TIVA group was lower than that in the balanced anaesthesia group.ConclusionsIn patients undergoing elective open abdominal aortic aneurysm repair with a goal-directed hemodynamic management, indices of sublingual or peripheral microvascular perfusion/oxygenation were globally preserved with both balanced anaesthesia and TIVA. Patients undergoing balanced anaesthesia showed microvascular recruitment at end-surgery.Trial registrationNCT03510793, https://www.clinicaltrials.gov, date of registration April 27th 2018, retrospectively registered.
Highlights
In vascular surgery with aortic cross-clamping, ischemia/reperfusion injury induces systemic haemodynamic and microcirculatory disturbances
The cardiac index (CI) increased in patients undergoing balanced anaesthesia, while it remained substantially stable in the total intravenous anaesthesia (TIVA) group
The tissue haemoglobin index (THI) tended to decrease and was significantly lower at end-surgery in the TIVA group, while it remained stable in the balanced anaesthesia group (Fig. 4). In this prospective observational study on 40 patients undergoing elective open abdominal aortic aneurysm repair with an intraoperative goal-directed haemodynamic optimization, we aimed to explore whether different anaesthetic regimens could have a varying impact on microvascular perfusion in a condition of potential I/R
Summary
In vascular surgery with aortic cross-clamping, ischemia/reperfusion injury induces systemic haemodynamic and microcirculatory disturbances. Ischemia/reperfusion (I/R) injury is common in patients undergoing aortic clamping for vascular surgery and leads to systemic inflammation and organ dysfunction [1,2,3]. The production of pro-inflammatory molecules and oxidative stress increase especially in the reperfusion phase and are responsible for microvascular alterations similar to those observed during sepsis [4,5,6]. These include an impairment in blood flow, capillary shunting with reduction in microcirculatory density and increased perfusion heterogeneity, resulting in a mismatch between oxygen delivery and consumption [4, 5]. After cardiac surgery a rise in MAP by norepinephrine infusion induced an increase in splanchnic oxygen extraction without altering the intestinal mucosal perfusion, possibly because of autoregulation phenomenon [13,14,15]
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