Perioperative Medicine  |   April 2019
Preload Dependence Is Associated with Reduced Sublingual Microcirculation during Major Abdominal Surgery
Author Notes
  • From the University Hospitals of Paris-Sud, Assistance Publique Des Hôpitaux De Paris, Critical Care and Anesthesia Department, Antoine Béclère Hospital, Clamart, France (K.B.); University Hospitals of Paris-Sud, Assistance Publique Des Hôpitaux De Paris, Medical Intensive Care Unit (J.-L.T.) and Critical Care and Anesthesia Department (L.V., J.D.), Bicêtre Hospital, Le Kremlin Bicêtre, France; and Clinical Research Unit, UMR 942, Lariboisiere University Hospital, Paris, France (E.V.).
  • Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • Submitted for publication February 27, 2018. Accepted for publication December 27, 2018.
    Submitted for publication February 27, 2018. Accepted for publication December 27, 2018.×
  • Address correspondence to Dr. Duranteau: jacques.duranteau@aphp.fr. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Perioperative Medicine / Clinical Science / Cardiovascular Anesthesia
Perioperative Medicine   |   April 2019
Preload Dependence Is Associated with Reduced Sublingual Microcirculation during Major Abdominal Surgery
Anesthesiology 4 2019, Vol.130, 541-549. doi:10.1097/ALN.0000000000002631
Anesthesiology 4 2019, Vol.130, 541-549. doi:10.1097/ALN.0000000000002631
Abstract

Editor’s Perspective:

What We Already Know about This Topic:

  • Whether sublingual microcirculation reflects systemic preload remains unknown

What This Article Tells Us That Is New:

  • Thirty-two preload dependent episodes were identified in 17 patients

  • Episodes were accompanied by reduced arterial pressure and stroke volume, along with reduced sublingual microcirculation

  • Fluid administration improved microcirculation and stroke volume, but not blood pressure

  • Sublingual microcirculation might be an indicator of vascular volume

Background: Dynamic indices, such as pulse pressure variation, detect preload dependence and are used to predict fluid responsiveness. The behavior of sublingual microcirculation during preload dependence is unknown during major abdominal surgery. The purpose of this study was to test the hypothesis that during abdominal surgery, microvascular perfusion is impaired during preload dependence and recovers after fluid administration.

Methods: This prospective observational study included patients having major abdominal surgery. Pulse pressure variation was used to identify preload dependence. A fluid challenge was performed when pulse pressure variation was greater than 13%. Macrocirculation variables (mean arterial pressure, heart rate, stroke volume index, and pulse pressure variation) and sublingual microcirculation variables (perfused vessel density, microvascular flow index, proportion of perfused vessels, and flow heterogeneity index) were recorded every 10 min.

Results: In 17 patients, who contributed 32 preload dependence episodes, the occurrence of preload dependence during major abdominal surgery was associated with a decrease in mean arterial pressure (72 ± 9 vs. 83 ± 15 mmHg [mean ± SD]; P = 0.016) and stroke volume index (36 ± 8 vs. 43 ± 8 ml/m2; P < 0.001) with a concomitant decrease in microvascular flow index (median [interquartile range], 2.33 [1.81, 2.75] vs. 2.84 [2.56, 2.88]; P = 0.009) and perfused vessel density (14.9 [12.0, 16.4] vs. 16.1 mm/mm2 [14.7, 21.4], P = 0.009), while heterogeneity index was increased from 0.2 (0.2, 0.4) to 0.5 (0.4, 0.7; P = 0.001). After fluid challenge, all microvascular parameters and the stroke volume index improved, while mean arterial pressure and heart rate remained unchanged.

Conclusions: Preload dependence was associated with reduced sublingual microcirculation during major abdominal surgery. Fluid administration successfully restored microvascular perfusion.