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A Manifestation of a Common Metabolic Defect?

John H. Siegel, MD; Ivo Giovannini, MD; Bill Coleman; Frank B. Cerra, MD; Angelo Nespoli, MD

Arch Surg. 1982;117(2):225-238.

Abstract
• Multivariable physiologic studies of cardiovascular, respiratory, and metabolic functions were performed in 341 patients (884 studies). Eighty patients had cirrhotic liver disease, 64 had sepsis, 87 had nonseptic cardiogenic syndromes, and 110 had nonseptic general surgical or traumatic injury. The group with cirrhosis had the highest cardiac index and ejection fraction. When compared with the group with nonseptic surgery or trauma, vascular tone was reduced in the patients with cirrhosis or sepsis and was lowest in patients with both conditions. Ventricular function was good in the groups with cirrhosis or sepsis, due to the additive effect in reducing vascular tone that allowed ejection fraction to increase, but caused the ratio of alveolar ventilation to perfusion (V_A/Q_T) to fall, resulting in a greater perfusion of a decreased pulmonary vascular bed. The falls in vascular tone and V_A/Q_T in patients with cirrhosis or sepsis result from the reduced oxygen consumption that occurs due to a metabolic imbalance (B state). This B state seems to reflect a hepatic inability to metabolize aromatic amino acids, so that levels of tyrosine, phenylalanine, and the false neurotransmitter octopamine increase. These mechanisms are pathologically synergistic when sepsis and cirrhosis occur together.

(Arch Surg 1982;117:225-238)

Author Affiliations
From the Department of Surgery, State University of New York and the Buffalo General Hospital, Buffalo (Drs Siegel and Cerra and Mr Coleman), the Centro per lo Studio della Fisiopatologia dello Shock of the Consiglio Nazionale delle Richerche, Rome, and the Universita Cattolica del Sacro Cuore, Roma, Italy (Dr Giovannini), and the V Clinica Chirurgica Universita degli Studi di Milano, Ospedale Policlinico, Milan, Italy (Dr Nespoli).

Footnotes
Accepted for publication Oct 6, 1981.

Read at the first annual meeting of the Surgical Infection Society, Chicago, April 25, 1981.

Reprint requests to the Maryland Institute for Emergency Medical Services Systems, University of Maryland, 22 S Greene St, Baltimore, MD 21201 (Dr Siegel).

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