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David W. Riddington, FRCA; B. Venkatesh, FRCA; Christopher M. Boivin, MSc, MPhil; Robert S. Bonser, FRCS, MRCP; Thomas S. J. Elliott, PhD, MRCPath; Timothy Marshall, MSc, CStat; Peter J. Mountford, PhD; Julian F. Bion, MRCP, FRCA, MD

JAMA. 1996;275(13):1007-1012.

Abstract
Objective.
—To examine the relationship between gastric intramucosal pH, intestinal permeability, endotoxemia, and oxygen delivery in patients undergoing cardiopulmonary bypass (CPB).

Design.
—Prospective, observational study.

Setting.
—Tertiary care center.

Patients.
—Fifty patients undergoing elective cardiac surgery and 10 patients awaiting elective cardiac surgery.

Interventions.
—Patients received chromium 51—labeled ethylenediaminetetraacetic acid (⁵¹Cr-EDTA) as a marker of intestinal permeability; insertion of a nasogastric tonometer to measure intramucosal pH (pHi); insertion of a pulmonary artery catheter to measure systemic oxygen delivery and consumption variables; arterial blood sampling for plasma endotoxin by the Limulus amebocyte lysate assay; and blood and urine sampling for measurement of⁵¹Cr-EDTA.

Main Outcome Measures.
—Systemic oxygen delivery, duration of gastric mucosal acidosis, absorption of⁵¹Cr-EDTA, appearance of systemic endotoxemia, renal dysfunction, and duration of hospital stay.

Results.
—Median (range) 24-hour urinary recovery of⁵¹ Cr-EDTA in patients was 10.6% (2.1% to 40.2%) while that in controls was 1.2% (0.7% to 2.0%, P<.001). Intestinal permeability increased during CPB. The median (range) for the lowest pHi after bypass was 6.98 (6.74 to 7.17). The pHi did not decline until CPB was discontinued and the heart took over the load of the circulation. Endotoxin was detectable (>0.2 endotoxin unit per milliliter) in the plasma of 21 patients (42%) during the study, most of whom were endotoxemic by the end of CPB. There was no evident relationship between the degree of gut permeability, endotoxemia, gut ischemia, or systemic oxygen dynamics.

Conclusions.
—Cardiopulmonary bypass is associated with increases in gut permeability, which precede gut mucosal ischemia. In cardiac surgical patients, a low pHi is not necessarily indicative of an adverse clinical outcome. Endotoxemia as measured by the Limulus amebocyte lysate assay is common. The increased intestinal absorption of⁵¹Cr-EDTA and gastric mucosal acidosis occur as independent phenomena and are not related in severity or time of onset.

(JAMA. 1996;275:1007-1012)

Author Affiliations
From the Department of Anaesthesia and Intensive Care Medicine (Drs Riddington, Venkatesh, and Bion) and Public Health and Epidemiology (Mr Marshall), University of Birmingham (United Kingdom), and Departments of Nuclear Medicine (Dr Mountford and Mr Boivin) and Medical Microbiology (Dr Elliott), and the Cardiothoracic Surgical Unit (Mr Bonser), Queen Elizabeth Hospital, Birmingham.

Footnotes
Corresponding author: Julian F. Bion, MRCP, FRCA, MD, University Department of Anaesthesia and Intensive Care Medicine, North 5 Wing, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom B15 2TH.

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