Intramucosal pH as a criterion for the organism emergency from hepatospanchnic ischemia, or centralization of blood flow

In critical conditions, despite the restoration of systemic hemodynamics and overall oxygen delivery, tissue hypoxia and reduced oxygen extraction remain. One of the important tasks of intensive care for critical conditions is the early diagnosis of tissue perfusion disorders. In clinical circumstances, signs of hypoperfusion are arterial hypotension, tachycardia, oliguria, encephalopathy, low body temperature, the disappearance of skin capillary pattern, metabolic lactate acidosis. However, blood pressure is an insensitive indicator of tissue hypoperfusion itself. Experimental clinical trials have repeatedly documented that local perfusion pressure in critical conditions does not directly depend on systemic blood pressure. Lactate is not a specific marker of anaerobic metabolism, but rather impaired microcirculation seems to be one of the possible mechanisms of hyperlactatemia. Reliable markers of tissue perfusion and the effectiveness of early targeted therapy are regional capnometry (gastric intramucosal pH, sublingual pCO2), a saturation of mixed venous blood, etc. Intramucosal pH is of particular practical importance as a marker of regional capnometry. The aim of the study is the analysis of literature sources devoted to the effectiveness and diagnostic significance of intramucosal pH as a marker of regional perfusion. The value of intramucosal pH was evaluated: 1) during abdominal operations and the development of postoperative complications in comparison against IL-6 and IL-8; 2) during and after surgical interventions in conditions of prolonged cardiopulmonary bypass to assess the adequacy of blood supply to the abdominal organs; 3) in experimental septic shock compared to the values of lactate and hypoxanthine concentration in the liver and arterial blood; 4) the correlation between intramucosal pH va-lues, indices of the pediatric mortality risk scale, forming of great (cardiac arrest, shock) and minor (hypotension, hypovolemia, arrhythmia) hemodynamic complications and duration of staying in intensive care unit and intensive therapy; 5) during laparoscopic cholecystectomy in apparently healthy patients with the simultaneous calculation of the difference between arterial and intramucosal pH. Intramuscular pH-controlled intensive therapy is a separate fragment: an intramucosal pH of less than 7.3 reflects splanchnic hypoperfusion and is an indicator of the unfavorable outcomes; intramucousal pH of more than 7.3 is a criterion for the emergency of the organism from hepatosplanchic ischemia, i.e. centralization of blood circulation. Therefore, the intramucosal pH is valuable in the clinical picture of critical conditions as a marker of regional perfusion measured by capnometry, which allows monitoring that reflects the perfusion of the intestinal wall. The lower threshold is 7.35 (the sensitivity of the method is 67 %, specificity is 74 %). An intramucosal pH of < 7.3 reflects splanchnic hypoperfusion and is an indicator of an adverse outcome. An alternative measurement of intramucosal pCO2, pCO2 in arterial blood and the difference [P (1-a) CO2] is a more reliable index of intestinal oxygenation than single intramucosal pH, but rather pH (1-a) makes it possible to adequately assess the acid-base state of arterial blood. The improvement and widespread use of capnometry and capnography for monitoring during general anaesthesia and intensive care, on the one hand, and modern knowledge of the pathophysiology of gas exchange, on the other hand, stimulate the wider use of less invasive and more affordable methods of regional capnometry and aerial tonometry.

Gastrointestinal Issues in the Cardiothoracic ICU

A thorough understanding of gastrointestinal issues in critical illness is necessary to optimize management of the cardiothoracic patient. Post-operatively, these patients are at increased risk of GI complications due a combination of underlying vascular disease, cardiopulmonary bypass, and low cardiac output, all of which lead to splanchnic hypoperfusion and subsequent damage to the gut mucosa. While GI complications are uncommon, they are associated with a disproportionately high rate of morbidity and mortality. Presence of unexplained fever, leukocytosis, bacteremia, hemodynamic compromise or abdominal pain or distention are concerning and require prompt assessment. Other GI management issues include delivery of adequate nutrition to counteract catabolism and promote wound healing and stress ulcer prophylaxis in patients with risk factors for upper gastrointestinal bleeding.