Ingo Schwartges

Endocrine and psychological stress responses in a simulated emergency situation

BACKGROUND Several studies have assessed the effects of training using patient simulation systems on medical skills. However, endocrine and psychological stress responses in a patient simulation situation and the relationship between stress reactivity and medical performance have been studied rarely, so far. METHODS Medical students (18 males and 16 females) who had completed at least two months anaesthesiology training participated in the study. In a counterbalanced cross-over design they were subjected to three conditions: rest, laboratory stress (LS; public speaking), and simulated emergency situation (SIM; myocardial ischemia and ventricular fibrillation). Salivary cortisol and psychological responses (visual analogue scales, VAS) were assessed every 15 min from 15 min prior to until 60 min after intervention. Differences between stress and rest conditions were analysed. Medical performance was assessed according to the European Resuscitation Councils Guidelines for Resuscitation. RESULTS As compared to rest, cortisol increased significantly in both stress conditions with different time courses in LS and SIM. Psychological responses in SIM exceeded those in LS. Cortisol increase in LS (r(s)=.486; p=.019) but not in SIM (r(s)=.106; p=.631) correlated significantly with medical performance. DISCUSSION A simulated emergency situation is a profound stressor. The positive relationship between endocrine stress responsiveness in a standard laboratory situation and medical performance in a simulated emergency situation indicates that high stress responsiveness might be a predictor of good performance. At the same time the high stress response might counteract educational efforts associated with training using high-fidelity patient simulation.

Hypercapnic Acidosis Preserves Gastric Mucosal Microvascular Oxygen Saturation in a Canine Model of Hemorrhage.

The authors aimed to clarify the effects of hypercapnic acidosis and its timing on gastric mucosal oxygenation in a canine model of hemorrhage. This was designed as a prospective, controlled, randomized animal study set in a university research laboratory. Five chronically instrumented dogs were used. Dogs were repeatedly anesthetized (sevoflurane 1.5 MAC), mechanically ventilated, and randomized to each of the following protocols. In a control series (CON), animals underwent hemorrhage during normoventilation (etCO2, 35 mmHg). In a second series, hypercapnia (etCO2, 70 mmHg) was applied before onset of hemorrhage (prophylactic hypercapnia), whereas in the third series, hypercapnia was applied after hemorrhage (therapeutic hypercapnia, THE). Microvascular oxygenation (&mgr;HbO2) of the gastric mucosa was continuously assessed by tissue reflectance spectrophotometry. Cardiac output was continuously measured, and oxygen delivery (DO2) was intermittently calculated. In CON, hemorrhage decreased DO2 (from 11 ± 3 mL·kg−1·min−1 to 8 ± 2 mL·kg−1·min−1 and 8 ± 2 mL·kg−1·min−1 after 30 and 75 min, respectively) and &mgr;HbO2 (from 57% ± 4% to 43% ± 11% and 50% ± 11%). Prophylactic hypercapnia attenuated the effects of hemorrhage on DO2 (12 ± 2 mL·kg−1·min−1 to 10 ± 2 mL·kg−1·min−1 and 11 ± 2 mL·kg−1·min−1) and preserved &mgr;HbO2 (52% ± 3% to 47% ± 5% and 57% ± 3%). Initial effects of hemorrhage in THE were comparable to CON (DO2 from 11 ± 2 mL·kg−1·min−1 to 8 ± 1 mL·kg−1·min−1; &mgr;HbO2 from 56% ± 7% to 43% ± 9%), but after application of hypercapnic acidosis, baseline levels were restored (DO2 10 ± 3 mL·kg−1·min−1; &mgr;HbO2 52% ± 14%). Hypercapnic acidosis applied before or after hemorrhage (THE) preserves microvascular mucosal oxygenation. If these experimental findings may be transferred to the clinical setting, deliberate hypercapnic acidosis could serve to augment oxygenation of the splanchnic region in states of compromised circulation, e.g., hemorrhage.

Sevoflurane and propofol anaesthesia differentially modulate the effects of epinephrine and norepinephrine on microcirculatory gastric mucosal oxygenation

BACKGROUND Adequate gastrointestinal mucosal oxygenation is regarded to be crucial in the prevention and therapy of critical illness. Epinephrine and norepinephrine are used for perioperative haemodynamic support. However, their per se effects on gastromucosal haemoglobin oxygenation (μHbO(2)) remain unclear. Moreover, respective effects of epinephrine and norepinephrine may be affected by the type of underlying anaesthesia. Thus, we studied the effects of epinephrine and norepinephrine during anaesthesia with sevoflurane or propofol on regional gastromucosal μHbO(2) and systemic O(2)-derived variables. METHODS In a double-randomized cross-over study, chronically instrumented dogs (n=6 per group) were anaesthetized randomly with sevoflurane or propofol, ventilated, and then randomly received either epinephrine or norepinephrine (0, 0.05, 0.1, and 0.2 µg kg(-1) min(-1)). We measured gastromucosal μHbO(2), systemic haemodynamics, and O(2)-derived variables. RESULTS During sevoflurane anaesthesia, norepinephrine markedly increased μHbO(2) (P<0.0001) and systemic oxygen transport (DO(2)) (P=0.0006). In contrast, epinephrine failed to increase μHbO(2), despite doubling DO(2) (P=0.0002). During propofol anaesthesia, in contrast to sevoflurane, neither epinephrine nor norepinephrine affected μHbO(2), although epinephrine, but not norepinephrine, again resulted in markedly increased DO(2) (P<0.0001). CONCLUSIONS The effects of epinephrine and norepinephrine depended on the type of anaesthesia. In addition, regional effects (i.e. μHbO(2)) were not predictable from systemic effects (i.e. DO(2)).

Vasopressin V1A receptors mediate the increase in gastric mucosal oxygenation during hypercapnia

Hypercapnia (HC) improves systemic oxygen delivery (DO₂) and microvascular hemoglobin oxygenation of the mucosa (μHbO₂). Simultaneously, HC increases plasma levels of vasopressin. Although vasopressin is generally regarded a potent vasoconstrictor particularly in the splanchnic region, its effects on splanchnic microcirculation during HC is unclear. The aim of this study was to evaluate the role of endogenous vasopressin on gastric mucosal oxygenation and hemodynamic variables during physiological (normocapnia) and hypercapnic conditions. Five dogs were repeatedly anesthetized to study the effect of vasopressin V(1A) receptor blockade ([Pmp¹,Tyr(Me)²]-Arg⁸-Vasopressin, 35  μg/kg) on hemodynamic variables and μHbO₂ during normocapnia or HC (end-tidal CO₂ 70  mmHg). In a control group, animals were subjected to HC alone. μHbO₂ was measured by reflectance spectrophotometry, systemic DO₂ was calculated from intermittent blood gas analysis, and cardiac output was measured by transpulmonary thermodilution. Data are presented as mean±s.e.m. for n=5 animals. During HC alone, DO₂ increased from 12±1 to 16±1 ml/kg per min and μHbO₂ from 70±4 to 80±2%. By contrast, additional vasopressin V(1A) receptor blockade abolished the increase in μHbO₂ (80±2 vs. 69±2%) without altering the increase in DO₂ (16±1 vs. 19±2  ml/kg per min). Vasopressin V1A receptor blockade (VB) during normocapnia neither affected DO₂ (13±1 vs. 14±1  ml/kg per min) nor μHbO₂ (75±3 vs. 71±5%). Vasopressin V(1A) receptor blockade abolished the increase in μHbO₂ during HC independent of DO₂. Thus, in contrast to its generally vasoconstrictive properties, the vasopressin V1A receptors seem to mediate the increase in gastric microcirculatory mucosal oxygenation induced by acute HC.

Neither inhalative nor intravenous application of carbon monoxide modifies gastric mucosal oxygenation.

This study was designed to compare the effects of different ways of administering carbon monoxide (intravenous and inhalative) on gastric mucosal oxygenation in a canine model of hemorrhage. Six chronically instrumented dogs were repeatedly anesthetized and randomized to each of the following protocols: In a first series the animals were ventilated either with 100 ppm carbon monoxide (CO) or without followed by hemorrhage and re-transfusion. In a second series a saturated CO solution was infused, compared to normal saline, again followed by hemorrhage and re-transfusion. In a control series, animals received either CO-saline or saline without any further intervention. Microvascular oxygenation of the gastric mucosa (µHbO2) was assessed continuously by tissue reflectance spectrophotometry. Cardiac output was measured intermittently and oxygen delivery (DO2) was calculated. The application of CO, inhalative and intravenous, increased carboxyhemoglobin levels without effect on µHbO2. Hemorrhage reduced µHbO2 in all groups, paralleled by a reduction in DO2 without any differences between groups related to the application of CO. Neither intravenous nor inhalative application of CO alters µHbO2 during physiological conditions or during hemorrhage. Thus, independent of the application way, low dose CO does not seem to modulate regional mucosal oxygenation in cytoprotective concentrations.

Perioperative liver protection.

Purpose of reviewThis review presents important pathophysiological alterations associated with impaired liver function and discusses protective perioperative strategies and the various anaesthetic agents recommended. Recent findingsPerioperative liver impairment is a serious complication of anaesthesia and surgery. Unfortunately, clinicians are provided with only crude macrohaemodynamic monitoring devices to optimize their therapy. Technical improvements have revealed some complex mysteries of perioperative microcirculatory alterations and have disclosed a large heterogeneity between different vascular beds. The present review will critically discuss current clinical concepts of optimizing global haemodynamic variables and the often contrasting effects of vasoactive agents on the microcirculatory nutritional blood flow. Finally, promising protective experimental interventions of pharmacological or ischaemic preconditioning are presented and their often disillusioning transition into recent clinical trials is highlighted. SummaryTargeted perioperative liver protection still lacks adequate monitoring tools and is currently based on optimization of global haemodynamic variables. While there is currently no evidence suggesting a positive effect of ischaemic preconditioning, promising experimental results of pharmacological preconditioning and therapeutic hypothermia require further evaluation in larger randomized clinical trials.

Hypothermia Improves Oral and Gastric Mucosal Microvascular Oxygenation during Hemorrhagic Shock in Dogs

Hypothermia is known to improve tissue function in different organs during physiological and pathological conditions. The aim of this study was to evaluate the effects of hypothermia on oral and gastric mucosal microvascular oxygenation (μHbO2) and perfusion (μflow) under physiological and hemorrhagic conditions. Five dogs were repeatedly anesthetized. All animals underwent each experimental protocol (randomized cross-over design): hypothermia (34°C), hypothermia during hemorrhage, normothermia, and normothermia during hemorrhage. Microcirculatory and hemodynamic variables were recorded. Systemic (DO2) and oral mucosal (μDO2) oxygen delivery were calculated. Hypothermia increased oral μHbO2 with no effect on gastric μHbO2. Hemorrhage reduced oral and gastric μHbO2 during normothermia (−36 ± 4% and −27 ± 7%); however, this effect was attenuated during additional hypothermia (−15 ± 5% and −11 ± 5%). The improved μHbO2 might be based on an attenuated reduction in μflow during hemorrhage and additional hypothermia (−51 ± 21 aU) compared to hemorrhage and normothermia (−106 ± 19 aU). μDO2 was accordingly attenuated under hypothermia during hemorrhage whereas DO2 did not change. Thus, in this study hypothermia alone improves oral μHbO2 and attenuates the effects of hemorrhage on oral and gastric μHbO2. This effect seems to be mediated by an increased μDO2 on the basis of increased μflow.

Hypercapnia counteracts captopril-induced depression of gastric mucosal oxygenation

Hypercapnia (HC) increases systemic oxygen delivery (DO2) and gastric mucosal oxygenation. However, it activates the renin-angiotensin-aldosterone system (RAAS), which conversely reduces mesenteric perfusion. The aims of this study were to evaluate the effect of RAAS inhibition during normocapnia and HC on oral and gastric mucosal oxygenation (μHbO2) and to assess the effect of blood pressure under these circumstances. Five dogs were repeatedly anesthetized to study the effects of ACE inhibition (ACE-I; 5 mg/kg captopril, followed by 0.25 mg/kg per h) on μHbO2 (reflectance spectrophotometry) and hemodynamic variables during normocapnia (end-tidal CO2=35 mmHg) and HC (end-expiratory carbon dioxide (etCO2)=70 mmHg). In the control group, the dogs were subjected to HC alone. To exclude the effects of reduced blood pressure, in one group, blood pressure was maintained at baseline values via titrated phenylephrine (PHE) infusion during HC and additional captopril infusion. ACE-I strongly reduced gastric μHbO2 from 72±2 to 65±2% and mean arterial pressure (MAP) from 64±2 to 48±4 mmHg, while DO2 remained unchanged. This effect was counteracted in the presence of HC, which increased gastric μHbO2 from 73±3 to 79±6% and DO2 from 15±2 to 22±4 ml/kg per min during ACE-I without differences during HC alone. However, MAP decreased similar to that observed during ACE-I alone from 66±3 to 47±5 mmHg, while left ventricular contractility (dPmax) increased from 492±63 to 758±119 mmHg/s. Titrated infusion of PHE had no additional effects on μHbO2. In summary, our data suggest that RAAS inhibition reduces gastric mucosal oxygenation in healthy dogs. HC not only abolishes this effect, but also increases μHbO2, DO2, and dPmax. The increase in μHbO2 during ACE-I under HC is in accordance with our results independent of blood pressure.

The differential effects of recombinant brain natriuretic peptide, nitroglycerine and dihydralazine on systemic oxygen delivery and gastric mucosal microvascular oxygenation in dogs*

Brain natriuretic peptide has vasodilatory properties and may thus increase splanchnic perfusion and oxygenation. We compared the effects of recombinant brain natriuretic peptide on gastric mucosal microvascular haemoglobin oxygenation (reflectance spectrophotometry) and systemic variables with those of equi‐hypotensive doses of two other vasodilators (nitroglycerine and dihydralazine). Chronically instrumented, healthy dogs were randomly allocated to receive on different days, one of the three drugs (nitroglycerine and dihydralazine doses titrated to reduce mean arterial pressure by ∼20%). Brain natriuretic peptide significantly increased gastric mucosal microvascular haemoglobin oxygenation selectively, i.e. without concomitant haemodynamic effects. In contrast, the other vasodilators either did not increase gastric mucosal microvascular haemoglobin oxygenation at all (nitroglycerine), or did so only with marked increases in other systemic haemodynamic variables (dihydralazine). Our data suggest a potential role of recombinant brain natriuretic peptide selectively for increasing microvascular mucosal oxygenation. Studies are required to extend these findings to the clinical setting.

Clonidine Elicits A Long-Term Depression in Mucosal Red Cell Flux

OBJECTIVE To evaluate the impact of clonidine on mucosal red cell flux during baseline sedation with propofol or sevoflurane, respectively. MATERIALS AND METHODS Six healthy, chronically instrumented dogs for the measurement of cardiac output (CO) were repeatedly studied. During baseline sedation with either propofol (15 mg x kg(-1) x h(-1)) or sevoflurane (1.5 MAC), local tissue cell flux was assessed using laser Doppler flowmetry at the enoral mucosa. After baseline measurements, a bolus of clonidine (2.0 microg/kg) was infused within 1 min. Data are presented as mean +/- SEM; STATISTICS ANOVA, Scheffés post hoc test, p < 0.05. RESULTS Clonidine significantly reduced CO from 75 +/- 4 and 75 +/- 6 ml x kg(-1) x min(-1) (sedation with propofol or sevoflurane, respectively) to 40 +/- 3 and 49 +/- 5 ml x kg(-1) x min(-1), however, with almost complete recovery to baseline after 30 min (70 +/- 4 and 71 +/- 6 ml x kg(-1) x min(-1), NS from baseline). Similarly, clonidine decreased mucosal red cell flux by 44 +/- 8% and 54 +/- 4%. However, mucosal perfusion did not return to baseline (-25 +/- 5% and -27 +/- 3%). CONCLUSIONS In spite of the rapid return to baseline in systemic perfusion, the mucosal red cell flux of the enoral mucosa remained markedly reduced after a single bolus of clonidine. Given the crucial role of preserved microcirculatory perfusion for an intact mucosal barrier function, our data suggest that clonidine might impair this important mechanism to prevent the translocation of bacteria and endotoxins into the systemic circulation.