Abstract
Objectives
To determine CO and gastric mucosal perfusion in patients during elective major surgery; to seek a relationship with subsequent outcome.
Design
Prospective descriptive study.
Setting
University hospital.
Patients
51 patients undergoing elective major surgery of an anticipated duration of greater than 2 h who were at risk of developing gut mucosal hypoperfusion and postoperative organ failure.
Measurements and results
CO was determined by oesophageal Doppler measurement of aortic blood flow. Gastric mucosal perfusion was determined by tonometric assessmment of gastric mucosal pH (pHi). Blood pressure and urine flow were measured. At the end of surgery no patients were oliguric or hypotensive. Post-operatively morbidity, mortality, duration and cost of stay in the ITU and hospital were assessed. There were 32 patients with evidence of gastric mucosal ischaemia at the end of surgery (pHi<7.32) despite maintenance of CO. This group of patients spent a mean of 4.7 (range 0–33) days in the ITU, 14 developed major complications (7 with multiple organ failure [MOF] and 6 died. In 19 patients gut mucosal perfusion was maintained during surgery (pHi≥7.32); these patients demonstrated an increase in CO of 48.4% (95% confidence interval 21.3–75.6) and spent a mean of 1.0 (range 0–4) days in the ITU. Only one developed a major complication and none died. The total cost of post-operative care for the 51 patients was estimated at £ 356650. Mean cost per patient in the low pHi group was significantly greater at £ 8 845 (range £600–£42 700) compared to £ 3 874 (range £2 600–£9 600) in the normal pHi group. The total·cost of post-operative care for the 7 patients who developed MOF was £ 171 450 i.e. 48% of the total cost.
Conclusion
A low gastric pHi measured during the intraoperative period in a group of patients undergoing major (mainly cardiovascular) surgery is associated with increased post-operative complications and cost.
Article PDF
Similar content being viewed by others
Avoid common mistakes on your manuscript.
References
Shoemaker WC, Czer LS (1979) Evaluation of the biologic importance of various hemodynamic and oxygen transport variables; which variables should be monitored in post-operative shock? Crit Care Med 7:424–430
Dahn MS, Lange MP, Jacobs LA (1988) Central, mixed and splanchnic venous oxygen saturation monitoring. Intensive Care Med 14:373–378
Montgomery A, Hartmann M, Jonsson K, Haglund U (1989) Intramucosal pH measurement with tonometers for detecting gastrointestinal ischemia in porcine hemorrhagic shock. Circ Shock 29:319–327
Landow L, Phillips DA, Heard SO, Prevost D, Vandersalm TJ, Fink MP (1991) Gastric tomometry and venous oximetry in cardiac surgery patients. Crit Care Med 19:1226–1233
Fiddian-Green RG, Baker S (1987) Predictive value of stomach wall pH for complications after cardiac operations: comparison with other monitoring. Crit Care Med 15:153–156
Hartmann M, Montgomery A, Jonsson K, Haglund U (1991) Tissue oxygenation in hemorrhagic shock measured as transcutaneous oxygen tension, subcutaneous oxygen tension, and gastrointestinal intramucosal pH in pigs. Crit Care Med 19:205–210
Grum CM, Fiddian-Green RG, Pittenger GL, Grant BJB, Rothman D, Dantzker DR (1984) Adequacy of tissue oxygenation in intact dog intestine. J Appl Physiol 56:1065–1069
Fink MP, Cohn SM, Lee PC, Rothschild HR, Deniz YF, Wang H, Fiddian-Green RG (1989) Effect of lipopolysaccharide on intestinal intramucosal hydrogen ion concentration in pigs: evidence of gut ischaemia in a normodynamic model of septic shock. Crit Care Med 17:641–646
Singer M, Clarke J, Bennett ED (1989) Continuous hemodynamic monitoring by esophageal Doppler. Crit Care Med 17:447–452
Fiddian-Green RG, Amelin PM, Herrmann JB, Arous E, Cutler BS, Schiedler M, Wheeler B, Baker S (1986) Prediction of the development of sigmoid ischaemia on the day of aortic operations: indirect measurements of intramural pH in the colon. Arch Surg 121:654–660
Gys T, Hubens A, Neels H, Lauwers LF, Peters R (1988) Prognostic value of gastric intra-mural pH in surgical intensive care patients. Crit Care Med 16:1222–1224
Doglio GR, Pusajo JF, Egurrola MA, Bonfigli GC, Parra C, Vetere L, Hernandez MS, Fernandez S, Fernando P, Gutierrez G (1991) Gastric mucosal pH as a prognostic index of mortality in critically ill patients. Crit Care Med 19:1037–1040
Gutierrez G, Palizas F, Doglio G, Wainstein N, Gallesio A, Pacin J, Dubin A, Schiavi E, Jorge M, Pusajo J, Klein F, San Roman E, Dorfman B, Shottlender J, Giniger R (1992) Gastric intramucosal pH as a therapeutic index of tissue oxygenation in critically ill patients. Lancet 339:197–199
Price HL, Deutsch S, Marshall BE, Stephen GW, Behar MG, Neufeld GR (1966) Haemodynamic and metabolic effects of haemorrhage in man with particular reference to the splanchnic circulation. Circ Res 18:469–474
Gilmour DG, Aitkenhead AR, Hothersall AP, Ledingham IMcA (1980) The effect of hypovolaemia on colon blood flow in the dog. Br J Surg 67:82–84
Deitch EA (1990) The role of intestinal barrier failure and bacterial translocation in the development of systemic infection and multiorgan failure. Arch Surg 125:403–405
Rush BF, Sori AJ, Murphy TJ, Smith S, Flanagan JJ, Machiedo GW (1988) Endotoxemia and bacteremia during hemorrhagic shock: the link between trauma and sepsis? Ann Surg 207:549–554
Koziol JM, Rush BF, Smith SM, Machiedo GW (1988) Occurrence of bacteremia during and after hemorrhagic shock. J Trauma 28:10–16
Machiedo GW, LoVerme PJ, McGovern PJ, Blackwood JM (1981) Patterns of mortality in a surgical intensive care unit. Surg Gynecol Obstet 152:757–759
Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) Prognosis in acute organ-system failure. Ann Surg 202:685–693
Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee T (1988) Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest 94:1176–1186
Heard SO, Helmsmoortel CM, Kent JC, Shahnarian A, Fink MP (1990) Gastric tonometry in healthy volunteers: effect of ranitidine on calculated intramural pH. Crit Care Med 19:271–274
Antonsson JB, Boyle CC, Kruithoff KL, Wang HL, Sacristan E, Rothschild HR, Fink MP (1990) Validity of tonometric measures of gut intramural pH during endotoxemia and mesenteric occlusion in pigs. Am J Physiol 259:G519–523
Benjamin E, Polokoff E, Oropello JM, Leibowitz AB, Iberti TJ (1992) Sodium bicarbonate administration affects the diagnostic accuracy of gastrointestinal tonometry in mesenteric ischemia. Crit Care Med 20:1181–1183
Webb AR, Newman LA, Taylor M, Keogh JB (1989) Hand grip dynamometry as a predictor of post operative complications. Reappraisal using age standardised grip strengths. JPEN 13:30–34
Shoemaker W (1992) Tissue oxygen debt. Clin Intensive Care 2 [Suppl 1]:46–58
Bland RD, Shoemaker WC, Abraham E, Cobo JC (1985) Hemodynamic and oxygen transport patterns in surviving and nonsurviving post-operative patients. Crit Care Med 13:85–95
Krauss XH, Verdauw PD, Hugenholtz PG, Nauta J (1975) On line monitoring of mixed venous oxygen saturation after cardiothoracic surgery. Thorax 30:636–643
Guttierrez G, Bismar H, Dantzer D, Silva N (1992) Comparison of gastric intramucosal pH with measures of oxygen transport and consumption in critically ill patients. Crit Care Med 20:451–457
Association of Anaesthetists of Great Britain and Ireland (1988) Survey of Anaesthetic Practice.
Weil MH, Shubin H, Rosoff L (1965) Fluid repletion in circulatory shock — Central venous pressure and other practical guides. JAMA 192:668–674
Baek S, Makabali GG, Byron-Brown CW, Kusek JM, Shoemaker WC (1975) Plasma expansion in surgical patients with high central venous pressure; the relationship of blood volume to hematocrit, CVP, pulmonary wedge pressure, and cardiorespiratory changes. Surgery 78:304–315
Peel ALG, Taylor EW (1991) Proposed definitions for the audit of post-operative infection: a discussion paper. Ann Surg 73:385–388
Author information
Authors and Affiliations
Additional information
This work was supported by the Sir Jules Thorn Charitable Trusts
Rights and permissions
About this article
Cite this article
Mythen, M.G., Webb, A.R. Intra-operative gut mucosal hypoperfusion is associated with increased post-operative complications and cost. Intensive Care Med 20, 99–104 (1994). https://doi.org/10.1007/BF01707662
Received:
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/BF01707662