Scandinavian Journal of Thoracic and Cardiovascular Surgery
ISSN: 0036-5580 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/icdv19
Tissue Gas Tensions in the Calf Muscles of Patients with Lower Limb Arterial Ischaemia Erkki Jussila, Juha Niinikoski & M. V. Inberg To cite this article: Erkki Jussila, Juha Niinikoski & M. V. Inberg (1979) Tissue Gas Tensions in the Calf Muscles of Patients with Lower Limb Arterial Ischaemia, Scandinavian Journal of Thoracic and Cardiovascular Surgery, 13:1, 77-82, DOI: 10.3109/14017437909101791 To link to this article: http://dx.doi.org/10.3109/14017437909101791
Published online: 12 Jul 2009.
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Date: 17 March 2016, At: 03:43
Scand J Thor Cardiovasc Surg 13: 77-82, 1979
TISSUE GAS TENSIONS IN T H E C A L F MUSCLES OF PATIENTS WITH LOWER LIMB ARTERIAL ISCHAEMIA Erkki Jussila, Juha Niinikoski and M. V. Inberg From /he Depcirrtnmr ufSitrgery, University of
Tiirkit,
Tttrhrt, Finland
(submitted for publication March 15, 1978)
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Ahs/rrit./. 0, and CO, tensions were measured in the
gastrocnemius muscles of patients submitted for reconstructive arterial surgery due to obstructive arteriosclerosis (37) or abdominal aortic aneurysm ( 5 ) . Four patients without signs of arterial ischaemia served as controls. Measurements were carried out by means of implanted silastic tonometers during breathing of air and 100% 0, and immediately after walking on a treadmill. Peripheral blood pressures in the ankles were recorded with a Doppler apparatus. Baseline tissue gas tensions showed no essential differences between the various groups of patients: intermittent claudication, pain at rest, praegangrene, abdominal aortic aneurysm and controls. In contrast, baseline ankle pressures correlated well with the severity of the disease. During breathing of oxygen, the smallest increases of muscle PO, were observed in extremities with pain at rest or praegangrene and the highest responses were recorded in controls and aneurysm patients. Muscle PCO, values showed no alterations during oxygen breathing. In physical exercise, muscle PO, and PCOp levels as well as ankle blood pressures remained unchanged in controls and patients with aneurysm but no claudication. However, in all groups with arterial ischaemia, the exercise test resulted in a profound fall of muscle PO, and ankle blood pressure and an increase of muscle PCO,.
Clinical examination and arteriography are the principle means of assessing the circulatory status of ischaemic limbs. Peripheral blood flow measurements by means of ultrasound flowmetry, plethysmography or radioactive clearance techniques may also be utilised to help to evaluate limb circulation. Although these measurements and observations are valuable in the management of arterial ischaemia, they are at best indirect measurements of tissue nutrition in the ischaemic area. Recently, several investigations have demonstrated that measurements of oxygen and carbon dioxide tensions in the skeletal muscle provide an excellent index of peripheral tissue nutrition and perfusion (Furuse, Brawley, Struve & Gott, 1973; Brantigan, Ziegler, Hynes, Miyazawa & Smith, 1974;
Wakabayashi, Nakamura, Woolley, Mullin, Watanabe, Ino & Connolly, 1975). The development of tissue oxygen tonometry with implanted silastic tubes (Niinikoski. Heughan & Hunt, 1972; Niinikoski & Hunt, 1972) and its further refinement (Kivisaari & Niinikoski, 1973) have provided a new means of investigating tissue gas tensions. In the present work, this technique was employed to assess tissue gas tensions in the calf muscles of patients suffering from occlusive arterial disease.
MATERIAL A N D METHODS Oxygen and carbon dioxide tensions were measured in the medial belly of the gastrocnemius muscle of patients submitted into the hospital for reconstructive arterial surgery due to obstructive arteriosclerosis (37 patients) or abdominal aortic aneurysm ( 5 patients). Four volunteer patients showing no signs of lower limb arterial ischaemia or occlusive arteriosclerosis served as controls. The clinical characteristics of the patient material are depicted in Table I . Determinations of muscle PO, and PCO, were carried out by means of implanted silastic tubes 16 cm long, with an external diameter of 1.4 mm and an internal diameter of 1.0 mm (Fig. I ; Kivisaari & Niinikoski, 1973). Control patients received only one tonometer, whereas the other patients received two tonometers, one for each leg. Implantations were carried out by means of a wide-bore needle under local anaesthesia. The tube ends were left outside the skin and were fixed to the dermis with polypropylene sutures which did not occlude the tonometer lumen. The length of the tube remaining inside the gastrocnemius muscle was 14 cm. The measurements were carried out 5-7 days after implantations when the acute implantation trauma around the tonometer had subsided. The silastic tubes were filled with hypoxic saline solution (PO, 3-8 mmHg), the PO, and PCO, of which equilibrated with the corresponding tensions of the surrounding muscle within 2 min. The equilibrated fluid was then collected in an Astrup-type glass capillary tube (Fig. I), which was sealed with wax and stored on crushed ice for the analysis of PO, or PCO,.
78
E . J ~ s s i l art ul.
Table I . Clinicul churacteristics c f t h r variorrs groups ofpurirnts Arteriography Major site of occlusive lesion
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Sex Group
Male
Female
Claudication Pain at rest Praegangrene Aortic aneurysm Controls
15 10 7
2 2
4
1 I
3
I
Age (mean? S.D.)
Abd. aorta
Common iliac
Ext. iliac
sup. fem.
51f 9 60? 6 68+ 6 63+ 3 5 7 f 10
I 2
3 3 I -
6 4 1
7 3 6
I
-
When all samples had been collected, the capillaries were inserted, one at a time, into a microsample injector and emptied into a thermostated cuvette containing either an 0, or CO, electrode (Radiometer, Copenhagen, Denmark). The electrodes were connected to a Radiometer gas monitor type PHM 71. Measurements of muscle gas tensions were carried out with the patient supine during breathing of air and 100% O2 and immediately before and after walking on a treadmill. At first, baseline PO, and PCO, values were recorded for a period of 15-20 min. Thereafter determinationa were carried out while the patient breathed pure oxygen for 20 min through a tightly fitting face mask. In the exercise test the patients walked at a constant rate, 1 m/sec, for 5 min or until the patient reported intolerable pain. The maximal claudication distance and the duration of the pain after the exercise were registered. During the exercise, the tonometer tubes were filled with saline solution and the tube ends were closed with glass plugs. After the patient had stopped walking the first saline sample could be collected within 30 sec. The exercise test was repeated once after a 20-min interval. Parallel with tissue gas tension measurements, ankle blood pressures were determined by means of a Doppler ultrasound flowmeter (Directional Doppler@, Model 806, Parks Electronics Lab., Beaverton, Oregon, USA). All data were tested for significance on a computer by Student's f-testing.
-
-
RESULTS As depicted in Table 11, baseline muscle PO, and
PCO, levels showed no essential differences between the various groups of patients: intermittent claudication, rest pain, praegangrene, abdominal aortic aneurysm and controls. Neither were there any changes in tissue gas tensions between the affected and contralateral extremities under normal conditions. On the other hand, baseline ankle blood pressures were clearly decreased in extremities with arterial ischaemia and correlated well with the severity of the disease. During breathing of pure oxygen the smallest increases of muscle PO, were observed in extremities with pain at rest or praegangrene, whereas the highest muscle PO, levels during systemic hyperoxia were recorded in controls and patients with abdominal aortic aneurysm but no claudication (Table 11, Fig. 2 ) . Overall, muscle PCO, values showed no marked alterations during oxygen breathing. In the exercise test, muscle POz and PCOBlevels as well as ankle blood pressures remained unchanged in the controls and patients with aortic
Fig. I . Measurement of tissue PO2 and PCO, in the medial belly of the gastrocnemius muscle by means of an implanted silastic tube and capillary sampling technique. Observe that the tip of the syringe needle and the glass capillary inside the tonometer must extend to the muscle to avoid contamination of samples with subcutaneous tissue gases.
Tissue gus tensions in arteriul ischuemiu
79
Table 11. Miiscle !issire goses ( m m H g ) utid unkle blood pressures (mmHg)in lower limb urferial ischaemiu Baseline conditions
O2breathing
Exercise
PO,
PCO,
PO,
44f2 3923
49*11*** 27+2*** 4 6 f l * * 38+3*** 41+2*** 163&12***
42f3 42f3
3013*** 4411 37+_2* 42+1
17?14*** 72+20**
29i3*** 49+4* 37+2** 40+3*
4k 4*** 104+31*** 20 154520 158514
Ankle
Ankle Group
Claudication
Extremity
PO2
PCO,
pressure
Claudication
42+1 42k1 40+1 41+2
4121 42fl 43il 41f1
80f O*** 147+11*** 49+17*** 90+17*
43+3 42+1 46 48k2 43+2
4011 37f2 41 38k2 40f2
34+11*** 104222**
Nosymptoms
Pain at rest
Praegangrene Aortic aneurysm
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Controls
Pain at rest Other side Praegangrene Other side ClatJdication No symptoms Nosymptoms
40 161 i13 141f15
87f 6 98f 9 68i16* 70t14
62+ 6** 4122 39f2 70f10 44 73 37?4 96i 9 101f 6 42f3
30 45+2 44+2
PCO,
46 39k3 41f3
pressure
Each value represents the mean k S.E.M.
**p