Efeito da elevação da pressão arterial com noradrenalina sobre a microcirculação de pacientes com choque séptico e hipertensão arterial prévia

• Ano de defesa: 2018
• Autor(a) principal: Coimbra, Karla Tuanny Fiorese [UNIFESP]
• Tipo de documento: Tese
• Tipo de acesso: Acesso aberto
• Idioma: por
• Instituição de defesa: Universidade Federal de São Paulo (UNIFESP)
• Palavras-chave em Português: Sepsis; Hypertension; Microcirculation; Intensive therapy; Sepse; Hipertensão; Microcirculação; Terapia intensiva
• Link de acesso: https://sucupira.capes.gov.br/sucupira/public/consultas/coleta/trabalhoConclusao/viewTrabalhoConclusao.jsf?popup=true&id_trabalho=6392917; https://repositorio.unifesp.br/handle/11600/52550

Objective: To assess whether a rise in mean arterial pressure (MAP) in patients with septic shock and previous systemic arterial hypertension changes microcirculatory and systemic hemodynamic variables, as compared with patients without previous systemic arterial hypertension. Method: This is a bicentric study in patients older than 18 years, with septic shock for at least 6 hours, under mechanical ventilation and sedated, after consent. Patients with previous diagnosis of hypertension (hypertensive group) were paired by age with patients without this diagnosis (control group). The main exclusion criteria were shock duration greater than 72 hours, noradrenaline dose greater than 1 or less than 0.1mcg/kg/min. After inclusion, the noradrenaline dose was adjusted to maintain an initial MAP between 65 - 70mmHg. At this time, systemic and microcirculation baseline hemodynamic variables were obtained (Time 0). Then, the noradrenaline dose was adjusted to obtain a MAP of 85 - 90mmHg, and a new set of systemic and microcirculation hemodynamic measures was obtained (Time 1). We obtained sublingual microcirculation image using videomicroscopy Sidestream Dark Field (SDF, Microscan®; MicroVision Medical, Amsterdam, Holanda). We used ANOVA models fitted for generalized least square measures. In all tests, we used a significance levels of p < 0.05. Results: We included Forty patients. There was no significant difference in age (control: 57.2 ± 12.7 years and hypertensive: 62.5 ± 14.9 years, p = 0.234). We observed a significant improvement in the proportion of perfused vessels (control: 57.2 ± 14.0 to 66.0 ± 14.8; hypertensive: 61.4 ± 12.3 to 70.8 ± 7.1; groups: p = 0.291; T0 and T1: p < 0.001; group and time interaction: p = 0.846); perfused vessels density (control: 15.6±4 to 18.6±4.5; hypertensive: 16.4±3.5 to 19.1±3; groups: p = 0.506, T0 and T1: p < 0.001, group and time interaction: p = 0.699), and microcirculatory flow index (control: 2.1 ± 0.6 to 2.4 ± 0.6; hypertensive: 2.1 ± 0.5 to 2.6 ± 0.2 - groups: p = 0.713, T0 and T1: p = 0.002, group and time interaction: p = 0.452) in both groups. There was an increase in the cardiac index (CI) (control: 3.2 ± 1.2 to 3.5 ± 1.3; hypertensive: 2.7 ± 0.9 to 3.1 ± 1.0; groups: p = 0.166, T0 and T1: p < 0.001, group and time interaction: p = 0.594) as well as a reduction in serum lactate levels (control: 29.9 ± 40.8 mg/dL to 28.8 ± 40.6 mg/dL; hypertensive: 32.5 ± 38 mg/dL to 31.0 ± 38 mg/dL; groups: p = 0.830, T0 and T1: p= 0.037, group and time interaction: p = 0.745). Conclusion: In patients with septic shock, an increase in MAP improves density and flow in small vessels of the sublingual microcirculation similarly in patients with and without prior arterial hypertension. Likewise, there is an increase in CI and a reduction in lactate levels in both groups.