Maureen S. Thorniley

Near infra-red spectroscopy: a non-invasive monitor of perfusion and oxygenation within the microcirculation of limbs and flaps

Reliable early detection of adverse circulatory changes within a flap following free tissue transfer and early re-exploration are vital to minimise flap failure. Most surgeons rely on clinical assessment to monitor these changes but techniques such as plethysmography and laser Doppler have their advocates. These methods are limited however to measuring changes close to the surface. Near infra-red spectroscopy (NIRS) is a relatively new, non-invasive technique which allows continuous monitoring of concentration changes in oxy-, deoxy- and total haemoglobin (HbO2, Hb and HbT), as well as oxidised cytochrome aa3, through tissue up to 10 cm in depth. Information is provided on tissue oxygen supply, cellular oxygen utilisation, blood volume and perfusion status. A study has been performed in 10 rabbit hind limbs to assess the ability of NIRS to detect and distinguish between venous, arterial and total vascular occlusion. Clear patterns of change have been identified which allow rapid detection of vascular occlusion with accurate prediction of site. Arterial occlusions were characterised by an increase in Hb with a corresponding decrease in HbO2 and HbT. Venous occlusions resulted in an increase in HbT with relatively minor fluctuations in Hb and HbO2. Simultaneous occlusion of both artery and vein produced similar changes to those of arterial occlusion except that HbT decreased only minimally. These findings suggest that NIRS has a potentially useful role in the monitoring of free flaps, with the great advantage that perfusion can be measured to a considerable depth and information provided on the oxygenation profiles both accurately and non-invasively.

Plasma free radical activity and antioxidant vitamin levels in dyspeptic patients: correlation with smoking and helicobacter pylori infection

Background The pathological processes by which Helicobacter pylori infection leads to the development of gastroduodenal disease are still incompletely understood. Oxygen-derived free radicals are important mediators of inflammation and potential carcinogens. Furthermore, dietary studies have suggested that antioxidant vitamins may protect against gastric cancer. Objective To determine plasma free radical activity and antioxidant vitamin levels in dyspeptic patients and to correlate the results with H. pylori infection and tobacco smoking. Subjects Forty-three patients undergoing routine endoscopy for investigation of dyspepsia. Methods Plasma free radical activity was determined by measurement of thiobarbituric acid-reactive substances (TBARS). Plasma samples were also assayed for the antioxidant vitamins A, C and E. Gastroduodenal biopsies were obtained from all patients for histological examination. Results Plasma TBARS levels were significantly higher in H. pylori positive versus negative subjects (P<0.03), smokers versus non-smokers (P<0.04) and males versus females (P<0.01). Multiple regression analysis revealed that after correcting for male sex and smoking there was no significant association between plasma free radical activity and H. pylori infection. Smokers had significantly lower levels of plasma vitamin C than non-smokers (P<0.05); no differences were seen in vitamin A and E levels. Gender and H. pylori infection did not significantly affect plasma antioxidant vitamin levels. Gastroduodenal disease was present in all of the smokers compared with 67% of the non-smokers (P<0.05); 69% of the smokers were H. pylori positive versus 53% of the non-smokers. Conclusions Tobacco smoking and male sex, both recognized risk factors for gastroduodenal disease, appear to be the major determinants of increased plasma free radical activity in dyspeptic subjects, rather than H. pylori infection. The reason for the higher prevalence of H. pylori infection and gastroduodenal disease in dyspeptic smokers is unclear but may relate to weakened antioxidant defences.

Monitoring of Mitochondrial Nadh Levels by Surface Fluorimetry as an Indication of Ischaemia During Hepatic and Renal Transplantation

One of the major causes of dysfunction in transplanted organs is ischaemia-reperfusion (IR) injury. Impairment of mitochondrial function is likely to be central to many of the known consequences of ischaemia; these include loss of cellular homeostasis involving a fall in intracellular pH (Fuller et al., 1988), mitochondrial calcium loading and cellular swelling (Caiman et al., 1973), accumulation of reduced pyridine nucleotides, inhibition of mitochondrial electron transfer, and a fall in ATP levels (Hardy et al., 1991). In irreversibly damaged cells, respiratory control is lost and is accompanied by oxidation of cytochromes a and a3 and NADH (Taegtmeyer et al., 1985). The latter was attributed originally to substrate deficiency (Chance and Williams, 1955) but more recent studies indicate that an enzymological defect develops resulting in an inability to metabolise NADH-linked substrates (Taegtmeyer et al., 1985 and Hardy et al., 1991). In vitro studies of the respiratory chain (RC) complexes have been made in several tissues including cardiac and renal tissue, subjected to ischaemia-reperfusion injury and it was found that complexes I and IV are major defective sites (Hardy et al., 1991 and Veitch et al., 1992). Return of function may, therefore, relate to preservation of inner mitochondrial membrane integrity, and the structure and activities of the RC complexes. The integrity of oxidative metabolic pathways and capacity to resynthesise ATP rather than the immediate post-ischaemic ATP levels appears to determine the return of function (Taegtmeyer et al., 1985).

APPLICATIONS OF NIRS FOR MEASUREMENTS OF TISSUE OXYGENATION AND HAEMODYNAMICS DURING SURGERY

Since 1977 when Jobsis described the first use of near infra-red spectroscopy (NIRS) for non-invasive monitoring of changes in cerebral oxyhaemoglobin (O2Hb), deoxyhaemoglobin (HHb) and Caa3 the field has undergone major transformations1,2.

Measurement of cerebral oxygenation and haemodynamics during haemorrhage/fluid replacement

Many major surgical procedures are accompanied by haemorrhage necessitating replacement with either fluid or blood. Despite apparently adequate replacement, tissue oxygen delivery may still be poor, resulting in cellular hypoxia and consequent metabolic dysfunction, which can ultimately lead to multi-organ failure. The overall aim of these investigations was to determine whether near infra-red spectroscopy (NIRS) can be used to measure changes in cerebral oxygenation and haemodynamics in response to controlled blood loss, with and without fluid replacement using a rat model of haemorrhage1-6.

Reoxygenation following hypoxia stimulates lipid peroxidation and phosphatidylinositol breakdown in kidney cortical slices

Reoxygenation of hypoxic (120 min at 37 degrees) rabbit kidney cortical slices in vitro resulted in a rapid increase in lipid peroxidation and phosphatidylinositol hydrolysis. No changes in phosphatidylinositol breakdown occurred during hypoxia or upon reoxygenation in the absence of calcium. Incubation of renal slices with carbon tetrachloride resulted in increased lipid peroxidation but had no effect on phosphatidylinositol breakdown. It is concluded that altered intracellular calcium homeostasis during reoxygenation is involved in mediating increased phosphatidylinositol hydrolysis through activation of a specific phospholipase C, but that oxidative stress per se does not have a significant effect on the inositol phosphate secondary messenger response in this model system.