OXYGEN-TRANSPORT MEASUREMENTS TO EVALUATE TISSUE PERFUSION AND TITRATE THERAPY - DOBUTAMINE AND DOPAMINE EFFECTS

Background: Increased cardiac index, oxygen delivery (Do2), and oxygen consumption (Vo2) patterns were shown to characterize the physiologic status of surviving high-risk surgical patients, and indicate increased metabolic needs; relatively normal Do2 and Vo2 values were found to characterize the sequential pattern of nonsurvivors who developed an early oxygen debt followed by lethal organ failure. The cardiac index, Do2, and Vo2 values empirically determined from survivors' patterns were shown to improve outcome in prospective randomized trials. The present study considers these criteria to evaluat the tissue perfusion status as well as the effects of therapy on tissue perfusion and oxygenation. Objective: To summarize new information on the temporal patterns of Do2, Vo2, and oxygen debt on outcome and the effects of fluids and inotropes on these patterns in a wide range of clinical, temporal, and physiologic conditions. Design: Descriptive analysis based on data gathered prospectively using a specified protocol. Patients: High-risk patients with accidental or elective surgical trauma, and patients with or without sepsis or septic shock and organ failure. Setting: University-run county hospital with a large trauma service. Interventions: Fluids, dobutamine, and dopamine at various times and at various doses throughout critical illness of postoperative, posttraumatic, septic, and hypovolemic patients with and without lethal and nonlethal organ failure. Measurements and Main Results: The pattern of Do2 plotted against the corresponding Vo2 values in 437 consecutive critically ill surgical patients showed a wide variability and poor correlation probably because complex clinical conditions may obscure the supply-dependent and supply-independent Vo2 relationships observed in normal dogs bled or given bacterial infusions. However, the use of specific therapy by well-defined protocols was shown to provide objective evidence of efficacy. Significant increases in Do2 and Vo2 were previously shown after whole blood, packed red cells, and colloid administration, but not after crystalloid administration. Dobutamine administration in 715 circumstances in postoperative, traumatic, septic patients and patients with adult respiratory distress syndrome, renal failure, and multiple organ failure significantly improved Do2 and Vo2. Dopamine under comparable conditions produced less improvement in Do2 and Vo2 than that of dobutamine; most of the Vo2 changes were not significant. Conclusions: The monitored patterns of cardiac index, Do2, and Vo2 may be used to evaluate the adequacy of tissue perfusion as well as the relative effectiveness of alternative therapies. Second, these physiologic criteria may be used to titrate therapy in order to achieve optimal outcome. Third, after colloids optimally expand the plasma volume, dobutamine may be used to enhance flow and the distribution of flow in order to improve tissue oxygenation. Vasodilators may be used when hypertensive episodes occur or there is an inadequate response to inotropic agents. Vasopressors are used as a last resort, usually in the terminal or preterminal state.