Levosimendan for resuscitating the microcirculation in patients with septic shock: a randomized controlled study

Introduction: The purpose of the present study was to investigate microcirculatory blood flow in patients with septic shock treated with levosimendan as compared to an active comparator drug (i.e. dobutamine). The primary end point was a difference of >= 20% in the microvascular flow index of small vessels (MFIs) among groups. Methods: The study was designed as a prospective, randomized, double-blind clinical trial and performed in a multidisciplinary intensive care unit. After achieving normovolemia and a mean arterial pressure of at least 65 mmHg, 40 septic shock patients were randomized to receive either levosimendan 0.2 mu g.kg(-1).min(-1) (n = 20) or an active comparator (dobutamine 5 mu g.kg(-1).min(-1); control; n = 20) for 24 hours. Sublingual microcirculatory blood flow of small and medium vessels was assessed by sidestream dark-field imaging. Microcirculatory variables and data from right heart catheterization were obtained at baseline and 24 hours after randomization. Baseline and demographic data were compared by means of Mann-Whitney rank sum test or chi-square test, as appropriate. Microvascular and hemodynamic variables were analyzed using the Mann-Whitney rank sum test. Results: Microcirculatory flow indices of small and medium vessels increased over time and were significantly higher in the levosimendan group as compared to the control group (24 hrs: MFIm 3.0 (3.0; 3.0) vs. 2.9 (2.8; 3.0); P = .02; MFIs 2.9 (2.9; 3.0) vs. 2.7 (2.3; 2.8); P < .001). The relative increase of perfused vessel density vs. baseline was significantly higher in the levosimendan group than in the control group (dMFIm 10 (3; 23)% vs. 0 (-1; 9)%; P = .007; dMFIs 47 (26; 83)% vs. 10 (-3; 27); P <.001). In addition, the heterogeneity index decreased only in the levosimendan group (dHI - 93 (- 100; - 84)% vs. 0 (- 78; 57)%; P <.001). There was no statistically significant correlation between systemic and microcirculatory flow variables within each group (each P > .05). Conclusions: Compared to a standard dose of 5 mu g.kg(-1).min(-1) of dobutamine, levosimendan at 0.2 mu g.kg(-1).min(-1) improved sublingual microcirculatory blood flow in patients with septic shock, as reflected by changes in microcirculatory flow indices of small and medium vessels.