1
|
Bidart JPM, Rosa RG, Bessel M, Pedrotti LG, Goldani LZ. Mortality predictors in patients with suspected sepsis in the emergency department of a tertiary care hospital: a retrospective cohort study. Int J Emerg Med 2024; 17:74. [PMID: 38880894 PMCID: PMC11181565 DOI: 10.1186/s12245-024-00655-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 06/09/2024] [Indexed: 06/18/2024] Open
Abstract
BACKGROUND Sepsis remains a worldwide major cause of hospitalization, mortality, and morbidity. To enhance the identification of patients with suspected sepsis at high risk of mortality and adverse outcomes in the emergency department (ED), the use of mortality predictors is relevant. This study aims to establish whether quick sofa (qSOFA) and the severity criteria applied in patients with suspicion of sepsis in a monitored ED are in fact predictors of mortality. METHODS We performed a retrospective cohort study among adult patients with suspicion of sepsis at the ED of a tertiary care hospital in Brazil between January 1st, 2019 and December 31, 2020. All adult patients (ages 18 and over) with suspected sepsis that scored two or more points on qSOFA score or at least one point on the severity criteria score were included in the study. RESULTS The total of patients included in the study was 665 and the average age of the sample was 73 ± 19 years. The ratio of men to women was similar. Most patients exhibited qSOFA ≥ 2 (58.80%) and 356 patients (53.61%) scored one point in the severity criteria at admission. The overall mortality rate was 19.7% (131 patients) with 98 patients (14.74%) having positive blood cultures, mainly showing Escherichia coli as the most isolated bacteria. Neither scores of qSOFA nor the severity criteria were associated with mortality rates, but scoring any point on qSOFA was considered as an independent factor for intensive care unit (ICU) admission (qSOFA = 1 point, p = 0.02; qSOFA = 2 points, p = 0.03, and qSOFA = 3 points, p = 0.04). Positive blood cultures (RR, 1.63;95% CI, 1.10 to 2.41) and general administration of vasopressors at the ED (RR, 2.14;95% CI, 1.44 to 3.17) were associated with 30-day mortality. The administration of vasopressors at the ED (RR, 2.25; CI 95%, 1.58 to 3.21) was found to be a predictor of overall mortality. CONCLUSIONS Even though an association was found between qSOFA and ICU admission, there was no association of qSOFA or the severity criteria with mortality. Therefore, patients with a tendency toward greater severity could be identified and treated more quickly and effectively in the emergency department. Further studies are necessary to assess novel scores or biomarkers to predict mortality in sepsis patients admitted to the ED's initial care.
Collapse
Affiliation(s)
- João P M Bidart
- Emergency Department, Moinhos de Vento Hospital, 910, Ramiro Barcelos Street, Porto Alegre, Zip code, 90035-001, Brazil.
| | - Regis G Rosa
- Internal Medicine Department, Moinhos de Vento Hospital, Ramiro Barcelos, 630, Porto Alegre, 90035- 001, Brazil
| | - Marina Bessel
- Proadi Social Responsability, Moinhos de Vento Hospital, Ramiro Barcelos, 910, Porto Alegre, 90035- 000, Brazil
| | - Luana G Pedrotti
- Proadi Social Responsability, Moinhos de Vento Hospital, Ramiro Barcelos, 910, Porto Alegre, 90035- 000, Brazil
| | - Luciano Z Goldani
- ⁵Section of Infectious Diseases, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2400, Porto Alegre, 90035-003, Brazil
| |
Collapse
|
2
|
Sugiya R, Arizono S, Higashimoto Y, Kimoto Y, Shiraishi M, Mizusawa H, Tawara Y, Shigeoka H, Bakker J, Shinozaki K. Association of tissue oxygen saturation levels with skeletal muscle injury in the critically ill. Sci Rep 2024; 14:4811. [PMID: 38413660 PMCID: PMC10899231 DOI: 10.1038/s41598-024-55118-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 02/20/2024] [Indexed: 02/29/2024] Open
Abstract
This study aimed to investigate the association between the level of tissue oxygen saturation (StO2) and quadriceps/skeletal muscle dysfunction, measured using the Medical Research Council (MRC) scale and ultrasonography, in critically ill patients. Thirty-four patients hospitalized at the Critical Care Medicine Center of Kindai University Hospital, between January 2022 and March 2023, were enrolled in this study. The StO2 of the quadriceps muscle was measured via near-infrared spectroscopy. Muscle atrophy was measured by the thickness, cross-sectional area (CSA), and echo intensity of the rectus femoris (RF). These values were evaluated every alternate day until 13 days after admission or until discharge, whichever occurred first. Muscle weakness was assessed using the sum score of the MRC scale (MRC-SS), with the patient sitting at bedside. The mean age of the patients was 67.3 ± 15.3 years, and 20 (59%) were men. Seven patients (21%) were admitted for trauma, and 27 (79%) were admitted for medical emergencies or others. The mean score for the MRC-SS was 51.0 ± 7.9 points. RF thickness and CSA significantly decreased after day 7 (p < 0.05). There were no significant changes in StO2 levels during hospitalization. However, there were positive correlations between the nadir StO2 during hospitalization and MRC-SS, and changes in RF thickness and CSA at discharge (r = 0.41, p = 0.03; r = 0.37, p = 0.03; and r = 0.35, p = 0.05, respectively). StO2 in the quadriceps muscle may be useful for predicting muscle atrophy and dysfunction in patients with critical illnesses.
Collapse
Affiliation(s)
- Ryuji Sugiya
- Department of Rehabilitation Medicine, Faculty of Medicine, Kindai University, Osaka, Japan
- School of Rehabilitation Science, Seirei Christopher University, Shizuoka, Japan
| | - Shinichi Arizono
- School of Rehabilitation Science, Seirei Christopher University, Shizuoka, Japan
| | - Yuji Higashimoto
- Department of Rehabilitation Medicine, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Yuta Kimoto
- Department of Rehabilitation Medicine, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Masashi Shiraishi
- Department of Rehabilitation Medicine, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Hiroki Mizusawa
- Department of Rehabilitation Medicine, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Yuichi Tawara
- School of Rehabilitation Science, Seirei Christopher University, Shizuoka, Japan
| | - Hironori Shigeoka
- Department of Emergency Medicine, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osakasayama, Osaka, 589-8511, Japan
| | - Jan Bakker
- Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Pulmonology and Critical Care, Columbia University Medical Center, New York, USA
- NYU School of Medicine Langone, New York, USA
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Koichiro Shinozaki
- Department of Emergency Medicine, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osakasayama, Osaka, 589-8511, Japan.
- Feinstein Institutes for Medical Research, Manhasset, NY, USA.
| |
Collapse
|
3
|
Gutiérrez-Zárate D, Rosas-Sánchez K, Zaragoza JJ. Clinical evaluation of peripheral tissue perfusion as a predictor of mortality in sepsis and septic shock in the intensive care unit: Systematic review and meta-analysis. Med Intensiva 2023; 47:697-707. [PMID: 37419840 DOI: 10.1016/j.medine.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/11/2023] [Accepted: 05/09/2023] [Indexed: 07/09/2023]
Abstract
OBJECTIVE To determine the diagnostic performance of the clinical evaluation of peripheral tissue perfusion in the prediction of mortality. DESIGN Systematic review and meta-analysis. SETTING Intensive care unit. PATIENTS AND PARTICIPANTS Patients with sepsis and septic shock. INTERVENTIONS Studies of patients with sepsis and/or septic shock that associated clinical monitoring of tissue perfusion with mortality were included. A systematic review was performed by searching the PubMed/MEDLINE, Cochrane Library, SCOPUS, and OVID databases. MAIN VARIABLES OF INTEREST The risk of bias was assessed with the QUADAS-2 tool. Sensitivity and specificity were calculated to evaluate the predictive accuracy for mortality. Review Manager software version 5.4 was used to draw the forest plot graphs, and Stata version 15.1 was used to build the hierarchical summary receiver operating characteristic model. RESULTS Thirteen studies were included, with a total of 1667 patients and 17 analyses. Two articles evaluated the temperature gradient, four evaluated the capillary refill time, and seven evaluated the mottling in the skin. In most studies, the outcome was mortality at 14 or 28 days. The pooled sensitivity of the included studies was 70%, specificity 75.9% (95% CI, 61.6%-86.2%), diagnostic odds ratio 7.41 (95% CI, 3.91-14.04), and positive and negative likelihood ratios 2.91 (95% CI, 1.80-4.72) and 0.39 (95% CI, 0.30-0.51), respectively. CONCLUSIONS Clinical evaluation of tissue perfusion at the bedside is a useful tool, with moderate sensitivity and specificity, to identify patients with a higher risk of death among those with sepsis and septic shock. REGISTRATION PROSPERO CRD42019134351.
Collapse
Affiliation(s)
| | - Karina Rosas-Sánchez
- Department of Intensive Care Medicine, Hospital Ángeles Centro Sur, Querétaro, Mexico
| | - Jose J Zaragoza
- Department of Intensive Care Medicine, Hospital H+ Querétaro, Querétaro, Mexico
| |
Collapse
|
4
|
Zhao K, Zhang Z, Liang Y, Wang Y, Cai Y. Effect of antimicrobial de-escalation strategy on 14-day mortality among intensive care unit patients: a retrospective propensity score-matched cohort study with inverse probability-of-treatment weighting. BMC Infect Dis 2023; 23:508. [PMID: 37537526 PMCID: PMC10401733 DOI: 10.1186/s12879-023-08491-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/28/2023] [Indexed: 08/05/2023] Open
Abstract
PURPOSE This study aimed to investigate the prevalence of antimicrobial de-escalation (ADE) strategy and assess its effect on 14-day mortality among intensive care unit patients. METHODS A single-center retrospective cohort study was conducted on patients admitted to the intensive care unit (ICU) with infectious diseases between January 2018 and December 2020. Patients were stratified into three groups based on the initial treatment regimen within 5 days of antimicrobial administration: ADE, No Change, and Other Change. Confounders between groups were screened using one-way ANOVA and Chi-square analysis. Univariate and multivariate analyses were performed to identify risk factors for 14-day mortality. Potential confounders were balanced using propensity score inverse probability of treatment weighting (IPTW), followed by multivariate logistic regression analysis to evaluate the effect of ADE strategy on 14-day mortality. RESULTS A total of 473 patients met the inclusion criteria, with 53 (11.2%) in the ADE group, 173 (36.6%) in the No Change group, and 247 (52.2%) in the Other Change group. The 14-day mortality rates in the three groups were 9.4%, 11.6%, and 21.9%, respectively. After IPTW, the adjusted odds ratio for 14-day mortality comparing No Change with ADE was 1.557 (95% CI 1.078-2.247, P = 0.0181) while comparing Other Change with ADE was 1.282(95% CI 0.884-1.873, P = 0.1874). CONCLUSION The prevalence of ADE strategy was low among intensive care unit patients. The ADE strategy demonstrated a protective effect or no adverse effect on 14-day mortality compared to the No Change or Other Change strategies, respectively. These findings provide evidence supporting the implementation of the ADE strategy in ICU patients.
Collapse
Affiliation(s)
- Kai Zhao
- Department of Pharmacy, the Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, China
- Department of Pharmacy, Northwest Women's and Children's Hospital, Shaanxi, 710061, Xi'an, China
| | - Zhengliang Zhang
- Emergency Department, the Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, China
| | - Ying Liang
- Department of Medical Statistics, Air Force Medical University, Shaanxi, 710032, Xi'an, China
| | - Yan Wang
- Department of Pharmacy, the Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, China
| | - Yan Cai
- Department of Pharmacy, the Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, China.
| |
Collapse
|
5
|
Chen Y, Peng JM, Hu XY, Li S, Wan XX, Liu RT, Wang CY, Jiang W, Dong R, Su LX, He HW, Long Y, Weng L, Du B. Tissue oxygen saturation is predictive of lactate clearance in patients with circulatory shock. BMC Anesthesiol 2023; 23:179. [PMID: 37231341 DOI: 10.1186/s12871-023-02139-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/14/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Tissue oxygen saturation (StO2) decrease could appear earlier than lactate alteration. However, the correlation between StO2 and lactate clearance was unknown. METHODS This was a prospective observational study. All consecutive patients with circulatory shock and lactate over 3 mmol/L were included. Based on the rule of nines, a BSA (body surface area) weighted StO2 was calculated from four sites of StO2 (masseter, deltoid, thenar and knee). The formulation was as follows: masseter StO2 × 9% + (deltoid StO2 + thenar StO2) × (18% + 27%)/ 2 + knee StO2 × 46%. Vital signs, blood lactate, arterial and central venous blood gas were measured simultaneously within 48 h of ICU admission. The predictive value of BSA-weighted StO2 on 6-hour lactate clearance > 10% since StO2 initially monitored was assessed. RESULTS A total of 34 patients were included, of whom 19 (55.9%) had a lactate clearance higher than 10%. The mean SOFA score was lower in cLac ≥ 10% group compared with cLac < 10% group (11 ± 3 vs. 15 ± 4, p = 0.007). Other baseline characteristics were comparable between groups. Compared to non-clearance group, StO2 in deltoid, thenar and knee were significantly higher in clearance group. The area under the receiver operating curves (AUROC) of BSA-weighted StO2 for prediction of lactate clearance (0.92, 95% CI [Confidence Interval] 0.82-1.00) was significantly higher than StO2 of masseter (0.65, 95% CI 0.45-0.84; p < 0.01), deltoid (0.77, 95% CI 0.60-0.94; p = 0.04), thenar (0.72, 95% CI 0.55-0.90; p = 0.01), and similar to knee (0.87, 0.73-1.00; p = 0.40), mean StO2 (0.85, 0.73-0.98; p = 0.09). Additionally, BSA-weighted StO2 model had continuous net reclassification improvement (NRI) over the knee StO2 and mean StO2 model (continuous NRI 48.1% and 90.2%, respectively). The AUROC of BSA-weighted StO2 was 0.91(95% CI 0.75-1.0) adjusted by mean arterial pressure and norepinephrine dose. CONCLUSIONS Our results suggested that BSA-weighted StO2 was a strong predictor of 6-hour lactate clearance in patients with shock.
Collapse
Affiliation(s)
- Yan Chen
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Jin-Min Peng
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xiao-Yun Hu
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Shan Li
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xi-Xi Wan
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Rui-Ting Liu
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Chun-Yao Wang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Wei Jiang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Run Dong
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Long-Xiang Su
- Department of Critical Care Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Huai-Wu He
- Department of Critical Care Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Li Weng
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China.
| | - Bin Du
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China.
| |
Collapse
|
6
|
Harford M, Villarroel M, Jorge J, Redfern O, Finnegan E, Davidson S, Young JD, Tarassenko L, Watkinson P. Contactless skin perfusion monitoring with video cameras: tracking pharmacological vasoconstriction and vasodilation using photoplethysmographic changes. Physiol Meas 2022; 43. [PMID: 36270506 DOI: 10.1088/1361-6579/ac9c82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/21/2022] [Indexed: 02/07/2023]
Abstract
Objectives.Clinical assessment of skin perfusion informs prognosis in critically ill patients. Video camera monitoring could provide an objective, continuous method to monitor skin perfusion. In this prospective, interventional study of healthy volunteers, we tested whether video camera-derived photoplethysmography imaging and colour measurements could detect drug-induced skin perfusion changes.Approach.We monitored the lower limbs of 30 volunteers using video cameras while administering phenylephrine (a vasoconstrictor) and glyceryl trinitrate (a vasodilator). We report relative pixel intensity changes from baseline, as absolute values are sensitive to environmental factors. The primary outcome was the pre- to peak- infusion green channel amplitude change in the pulsatile PPGi waveform component. Secondary outcomes were pre-to-peak changes in the photoplethysmographic imaging waveform baseline, skin colour hue and skin colour saturation.Main results.The 30 participants had a median age of 29 years (IQR 25-34), sixteen (53%) were male. A 34.7% (p= 0.0001) mean decrease in the amplitude of the pulsatile photoplethysmographic imaging waveform occurred following phenylephrine infusion. A 30.7% (p= 0.000004) mean increase occurred following glyceryl trinitrate infusion. The photoplethysmographic imaging baseline decreased with phenylephrine by 2.1% (p= 0.000 02) and increased with glyceryl trinitrate by 0.5% (p= 0.026). Skin colour hue changed in opposite direction with phenylephrine (-0.0013,p= 0.0002) and glyceryl trinitrate (+0.0006,p= 0.019). Skin colour saturation decreased with phenylephrine by 0.0022 (p= 0.0002), with no significant change observed with glyceryl trinitrate (+0.0005,p= 0.21).Significance.Drug-induced vasoconstriction and vasodilation are associated with detectable changes in photoplethysmographic imaging waveform parameters and skin hue. Our findings suggest video cameras have great potential for continuous, contactless skin perfusion monitoring.
Collapse
Affiliation(s)
- M Harford
- Critical Care Research Group, Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom.,Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, United Kingdom.,Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - M Villarroel
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, United Kingdom
| | - J Jorge
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, United Kingdom
| | - O Redfern
- Critical Care Research Group, Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - E Finnegan
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, United Kingdom
| | - S Davidson
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, United Kingdom
| | - J D Young
- Critical Care Research Group, Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - L Tarassenko
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, United Kingdom
| | - P Watkinson
- Critical Care Research Group, Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom.,Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| |
Collapse
|
7
|
Luo JC, Zhang JD, Zhao QY, Wang H, Tu GW, Luo MH, Huang DL, Zhang JY, Lu W, Gao F, Luo Z. INFRARED THERMOGRAPHY-BASED BODY-SURFACE THERMAL INHOMOGENEITY MONITORING TO ASSESS THE SEVERITY OF HYPOPERFUSION IN CRITICALLY ILL PATIENTS. Shock 2022; 58:366-373. [PMID: 36155398 DOI: 10.1097/shk.0000000000001998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
ABSTRACT Background: Uneven body-surface thermal distribution is a manifestation of hypoperfusion and can be quantified by infrared thermography. Our aim was to investigate whether body-surface thermal inhomogeneity could accurately evaluate the severity of patients at risk of hypoperfusion. Methods: This was a prospective cohort study in which infrared thermography images were taken from unilateral legs of critically ill patients at high risk of hypoperfusion in a cardiac surgical intensive care unit. For each patient, five body-surface thermal inhomogeneity parameters, including standard deviation (SD), kurtosis, skewness, entropy, and low-temperature area rate (LTAR), were calculated. Demographic, clinical, and thermal characteristics of deceased and living patients were compared. The risk of mortality and capillary refill time (CRT) were chosen as the primary outcome and benchmarking parameter for hypoperfusion, respectively. The area under the receiver operating characteristic curve (AUROC) was used to evaluate predictive accuracy. Results: Three hundred seventy-three patients were included, and 55 (14.7%) died during hospital stay. Of inhomogeneity parameters, SD (0.738) and LTAR (0.768) had similar AUROC to CRT (0.757) for assessing mortality risk. Besides, there was a tendency for LTAR (1%-3%-7%) and SD (0.81°C-0.88°C-0.94°C) to increase in normotensive, hypotensive, and shock patients. These thermal parameters are associated with CRT, lactate, and blood pressure. The AUROC of a combined prediction incorporating three thermal inhomogeneity parameters (SD, kurtosis, and entropy) was considerably higher at 0.866. Conclusions: Body-surface thermal inhomogeneity provided a noninvasive and accurate assessment of the severity of critically ill patients at high risk of hypoperfusion.
Collapse
Affiliation(s)
- Jing-Chao Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jia-Dong Zhang
- Hybrid Imaging System Laboratory, Shanghai Engineering Research Center of Intelligent Vision and Imaging, School of Information Science and Technology, ShanghaiTech University, Shanghai, China
| | - Qin-Yu Zhao
- College of Engineering and Computer Science, Australian National University, Canberra, ACT, Australia
| | - Huan Wang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ming-Hao Luo
- Shanghai Medical College, Fudan University, Shanghai, China
| | - Dan-Lei Huang
- Shanghai Medical College, Fudan University, Shanghai, China
| | - Ji-Yang Zhang
- Department of Information and Intelligence Development, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wei Lu
- School of Physical Science and Technology, ShanghaiTech University, Shanghai, China
| | - Fei Gao
- Hybrid Imaging System Laboratory, Shanghai Engineering Research Center of Intelligent Vision and Imaging, School of Information Science and Technology, ShanghaiTech University, Shanghai, China
| | | |
Collapse
|
8
|
Lombardi S, Partanen P, Francia P, Calamai I, Deodati R, Luchini M, Spina R, Bocchi L. Classifying sepsis from photoplethysmography. Health Inf Sci Syst 2022; 10:30. [PMID: 36330224 PMCID: PMC9622958 DOI: 10.1007/s13755-022-00199-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 10/09/2022] [Indexed: 11/05/2022] Open
Abstract
Sepsis is a life-threatening organ dysfunction. It is caused by a dysregulated immune response to an infection and is one of the leading causes of death in the intensive care unit (ICU). Early detection and treatment of sepsis can increase the survival rate of patients. The use of devices such as the photoplethysmograph could allow the early evaluation in addition to continuous monitoring of septic patients. The aim of this study was to verify the possibility of detecting sepsis in patients from whom the photoplethysmographic signal was acquired via a pulse oximeter. In this work, we developed a deep learning-based model for sepsis identification. The model takes a single input, the photoplethysmographic signal acquired by pulse oximeter, and performs a binary classification between septic and nonseptic samples. To develop the method, we used MIMIC-III database, which contains data from ICU patients. Specifically, the selected dataset includes 85 septic subjects and 101 control subjects. The PPG signals acquired from these patients were segmented, processed and used as input for the developed model with the aim of identifying sepsis. The proposed method achieved an accuracy of 76.37% with a sensitivity of 70.95% and a specificity of 81.04% on the test set. As regards the ROC curve, the Area Under Curve reached a value of 0.842. The results of this study indicate how the plethysmographic signal can be used as a warning sign for the early detection of sepsis with the aim of reducing the time for diagnosis and therapeutic intervention. Furthermore, the proposed method is suitable for integration in continuous patient monitoring.
Collapse
Affiliation(s)
- Sara Lombardi
- Department of Information Engineering, University of Florence, Via S. Marta, 3, 50139 Florence, Italy
| | - Petri Partanen
- Faculty of Information Technology and Electrical Engineering, University of Oulu, Pentti Kaiteran katu 1, 90570 Oulu, Finland
| | - Piergiorgio Francia
- Department of Information Engineering, University of Florence, Via S. Marta, 3, 50139 Florence, Italy
| | - Italo Calamai
- S.O.C. Anestesia e Rianimazione, Ospedale S. Giuseppe, viale Giovanni Boccaccio, 16, 50053 Empoli, Italy
| | - Rossella Deodati
- S.O.C. Anestesia e Rianimazione, Ospedale S. Giuseppe, viale Giovanni Boccaccio, 16, 50053 Empoli, Italy
| | - Marco Luchini
- S.O.C. Anestesia e Rianimazione, Ospedale S. Giuseppe, viale Giovanni Boccaccio, 16, 50053 Empoli, Italy
| | - Rosario Spina
- S.O.C. Anestesia e Rianimazione, Ospedale S. Giuseppe, viale Giovanni Boccaccio, 16, 50053 Empoli, Italy
| | - Leonardo Bocchi
- Department of Information Engineering, University of Florence, Via S. Marta, 3, 50139 Florence, Italy
| |
Collapse
|
9
|
Catecholaminergic Vasopressors Reduce Toll-Like Receptor Agonist-Induced Microvascular Endothelial Cell Permeability But Not Cytokine Production. Crit Care Med 2021; 49:e315-e326. [PMID: 33481407 PMCID: PMC7892263 DOI: 10.1097/ccm.0000000000004854] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Supplemental Digital Content is available in the text. OBJECTIVES: Catecholaminergic vasopressors are the cornerstone of circulatory shock management. Nevertheless, catecholamines have problematic side effects, arousing a growing interest in noncatecholaminergic agents such as vasopressin or angiotensin-II. However, their respective effects on sepsis-associated microvascular endothelial dysfunction such as permeability or inflammation remain elusive. We investigated the role of catecholamines and other vasopressors on Toll-like receptor agonists-induced microvascular endothelial permeability and inflammation. SETTING: University research laboratory/cell research. SUBJECTS: Human pulmonary microvascular endothelial cells from multiple donors. INTERVENTION: Confluent monolayers of human pulmonary microvascular endothelial cells were treated with Toll-like receptor agonists (lipopolysaccharide, Poly[I:C], or tripalmitoyl-S-glyceryl cysteine) in the presence or absence of epinephrine, norepinephrine, vasopressin, and angiotensin-II. Permeability was inferred from transendothelial resistance, measured using electrical cell impedance sensing, where decreased transendothelial resistance is consistent with increased permeability. Cell-cell junction molecule expression was assessed via immunofluorescence microscopy and flow cytometry. We quantified cytokines in supernatants of Toll-like receptor agonist-treated human pulmonary microvascular endothelial cells. MEASUREMENTS AND MAIN RESULTS: Epinephrine and norepinephrine both ameliorate lipopolysaccharide, polyinosinic:polycytidylic acid, or tripalmitoyl-S-glyceryl cysteine–induced reductions in transendothelial resistance, a surrogate for endothelial permeability. In contrast, the noncatecholaminergic agents, vasopressin, and angiotensin-II did not affect Toll-like receptor agonists-induced reductions in transendothelial resistance. β1- and β2-adrenergic receptor antagonists reduced the effects of the catecholamines on transendothelial resistance, whereas α-adrenergic receptor antagonists did not. We observed that epinephrine and norepinephrine induced actin cytoskeletal rearrangement and normalized the membrane expression of proteins involved with adherens-junctions (vascular endothelial-cadherin) and tight-junctions (zona occludens-1). Despite having a substantial effect on endothelial permeability, epinephrine and norepinephrine did not affect human pulmonary microvascular endothelial cell survival or production of interleukin-8, interleukin-6, or monocyte chemoattractant protein-1 (CCL-2) induced by Toll-like receptor agonists, suggesting that these functions are regulated separately from permeability. CONCLUSIONS: Our findings demonstrate that treatment with epinephrine or norepinephrine strongly reduces endothelial permeability induced by agonists of multiple Toll-like receptors (Toll-like receptor-2, Toll-like receptor-3, Toll-like receptor-4) in vitro. Our studies suggest that both β1- and β2-adrenergic receptors mediate the stabilizing effects of epinephrine and norepinephrine on the endothelial barrier.
Collapse
|
10
|
Castro R, Kattan E, Ferri G, Pairumani R, Valenzuela ED, Alegría L, Oviedo V, Pavez N, Soto D, Vera M, Santis C, Astudillo B, Cid MA, Bravo S, Ospina-Tascón G, Bakker J, Hernández G. Effects of capillary refill time-vs. lactate-targeted fluid resuscitation on regional, microcirculatory and hypoxia-related perfusion parameters in septic shock: a randomized controlled trial. Ann Intensive Care 2020; 10:150. [PMID: 33140173 PMCID: PMC7606372 DOI: 10.1186/s13613-020-00767-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 10/17/2020] [Indexed: 02/08/2023] Open
Abstract
Background Persistent hyperlactatemia has been considered as a signal of tissue hypoperfusion in septic shock patients, but multiple non-hypoperfusion-related pathogenic mechanisms could be involved. Therefore, pursuing lactate normalization may lead to the risk of fluid overload. Peripheral perfusion, assessed by the capillary refill time (CRT), could be an effective alternative resuscitation target as recently demonstrated by the ANDROMEDA-SHOCK trial. We designed the present randomized controlled trial to address the impact of a CRT-targeted (CRT-T) vs. a lactate-targeted (LAC-T) fluid resuscitation strategy on fluid balances within 24 h of septic shock diagnosis. In addition, we compared the effects of both strategies on organ dysfunction, regional and microcirculatory flow, and tissue hypoxia surrogates. Results Forty-two fluid-responsive septic shock patients were randomized into CRT-T or LAC-T groups. Fluids were administered until target achievement during the 6 h intervention period, or until safety criteria were met. CRT-T was aimed at CRT normalization (≤ 3 s), whereas in LAC-T the goal was lactate normalization (≤ 2 mmol/L) or a 20% decrease every 2 h. Multimodal perfusion monitoring included sublingual microcirculatory assessment; plasma-disappearance rate of indocyanine green; muscle oxygen saturation; central venous-arterial pCO2 gradient/ arterial-venous O2 content difference ratio; and lactate/pyruvate ratio. There was no difference between CRT-T vs. LAC-T in 6 h-fluid boluses (875 [375–2625] vs. 1500 [1000–2000], p = 0.3), or balances (982[249–2833] vs. 15,800 [740–6587, p = 0.2]). CRT-T was associated with a higher achievement of the predefined perfusion target (62 vs. 24, p = 0.03). No significant differences in perfusion-related variables or hypoxia surrogates were observed. Conclusions CRT-targeted fluid resuscitation was not superior to a lactate-targeted one on fluid administration or balances. However, it was associated with comparable effects on regional and microcirculatory flow parameters and hypoxia surrogates, and a faster achievement of the predefined resuscitation target. Our data suggest that stopping fluids in patients with CRT ≤ 3 s appears as safe in terms of tissue perfusion. Clinical Trials: ClinicalTrials.gov Identifier: NCT03762005 (Retrospectively registered on December 3rd 2018)
Collapse
Affiliation(s)
- Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - Giorgio Ferri
- Unidad de Cuidados Intensivos, Hospital Barros Luco-Trudeau, Santiago, Chile
| | - Ronald Pairumani
- Unidad de Cuidados Intensivos, Hospital Barros Luco-Trudeau, Santiago, Chile
| | - Emilio Daniel Valenzuela
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - Leyla Alegría
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - Vanessa Oviedo
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - Nicolás Pavez
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de Concepción, Concepción, Chile
| | - Dagoberto Soto
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - Magdalena Vera
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - César Santis
- Unidad de Cuidados Intensivos, Hospital Barros Luco-Trudeau, Santiago, Chile
| | - Brusela Astudillo
- Unidad de Cuidados Intensivos, Hospital Barros Luco-Trudeau, Santiago, Chile
| | - María Alicia Cid
- Unidad de Cuidados Intensivos, Hospital Barros Luco-Trudeau, Santiago, Chile
| | - Sebastian Bravo
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - Gustavo Ospina-Tascón
- Department of Intensive Care Medicine, Fundación Valle del Lili, Universidad ICES, Cali, Colombia
| | - Jan Bakker
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile.,Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, USA.,Department Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, CA, The Netherlands.,Division of Pulmonary, and Critical Care Medicine, New York University-Langone, New York, USA
| | - Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile.
| |
Collapse
|
11
|
Remote Photoplethysmographic Assessment of the Peripheral Circulation in Critical Care Patients Recovering From Cardiac Surgery. Shock 2020; 52:174-182. [PMID: 30113390 DOI: 10.1097/shk.0000000000001249] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE Camera-based photoplethysmography (cbPPG) remotely detects the volume pulse of cardiac ejection in the peripheral circulation. The cbPPG signal is sourced from the cutaneous microcirculation, yields a 2-dimensional intensity map, and is therefore an interesting monitoring technique. In this study, we investigated whether cbPPG is in general sufficiently sensitive to discern hemodynamic conditions. METHODS cbPPG recordings of 70 patients recovering from cardiac surgery were analyzed. Photoplethysmograms were processed offline and the optical pulse power (OPP) of cardiac ejection was calculated. Hemodynamic data, image intensity, and patient movements were recorded synchronously. The effects of hemodynamic parameters and measurement conditions on the patient's individual OPP variability and their actual OPP values were calculated in mixed-effects regression models. RESULTS Mean arterial pressure (MAP), pulse pressure (PP), heart rate (HR), and central venous pressure (CVP) significantly explained the individual OPP variability. PP had the highest explanatory power (19.9%). Averaged OPP significantly increased with PP and MAP (P < 0.001, respectively) and decreased with higher HR (P = 0.024). CVP had a 2-directional, nonsignificant effect on averaged OPP. Image intensity and patient movements did significantly affect OPP. After adjustment for hemodynamic covariables and measurement conditions, the effect of PP and HR remained unchanged, whereas that of MAP vanished. CONCLUSION cbPPG is sensitive to hemodynamic parameters in critical care patients. It is a potential application for monitoring the peripheral circulation. Its value in a clinical setting has to be determined.
Collapse
|
12
|
Mongkolpun W, Orbegozo D, Cordeiro CPR, Franco CJCS, Vincent JL, Creteur J. Alterations in Skin Blood Flow at the Fingertip Are Related to Mortality in Patients With Circulatory Shock. Crit Care Med 2020; 48:443-450. [PMID: 32205589 DOI: 10.1097/ccm.0000000000004177] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Skin blood flow is rapidly altered during circulatory shock and may remain altered despite apparent systemic hemodynamic stabilization. We evaluated whether changes in skin blood flow during circulatory shock were related to survival. DESIGN Prospective study. SETTING Thirty-five-bed medical-surgical university hospital department of intensive care. SUBJECTS Twenty healthy volunteers and 70 patients with circulatory shock (< 12 hr duration), defined as the need for vasopressors to maintain mean arterial pressure greater than or equal to 65 mm Hg and signs of altered tissue perfusion. INTERVENTIONS We assessed skin blood flow using skin laser Doppler on the fingertip for 3 minutes at basal temperature (SBFBT) and at 37°C (SBF37) (thermal challenge test) once in volunteers and at the time of inclusion and after 6, 24, 48, 72, and 96 hours in patients with shock. Capillary refill time and peripheral perfusion index were measured at the same time points on the contralateral hand. MEASUREMENTS AND MAIN RESULTS The thermal challenge response (ΔSBF/ΔT) was calculated using the following formula: (SBF37-SBFBT)/(37-basal temperature). Area under the receiver operating characteristic curves were calculated to evaluate variables predictive of ICU mortality. At inclusion, skin blood flow and ΔSBF/ΔT were lower in patients than in volunteers. Baseline skin blood flow (31 [17-113] vs 16 [9-32] arbitrary perfusion units; p = 0.01) and ΔSBF/ΔT (4.3 [1.7-10.9] vs 0.9 [0.4-2.9] arbitrary perfusion unit/s) were greater in survivors than in nonsurvivors. Capillary refill time was shorter in survivors than in nonsurvivors; peripheral perfusion index was similar in the two groups. ΔSBF/ΔT (area under the receiver operating characteristic curve 0.94 [0.88-0.99]) and SBFBT (area under the receiver operating characteristic curve 0.83 [0.73-0.93]) had the best predictive value for ICU mortality with cutoff values less than or equal to 1.25 arbitrary perfusion unit/°C (sensitivity 88%, specificity 89%) and less than or equal to 21 arbitrary perfusion unit (sensitivity 84%, specificity 81%), respectively. CONCLUSIONS Alterations in fingertip skin blood flow can be evaluated using a laser Doppler thermal challenge technique in patients with circulatory shock and are directly related to outcome. These novel monitoring techniques could potentially be used to guide resuscitation.
Collapse
Affiliation(s)
- Wasineenart Mongkolpun
- All authors: Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | | | | | | | | | | |
Collapse
|
13
|
Varis E, Pettilä V, Wilkman E. Near-Infrared Spectroscopy in Adult Circulatory Shock: A Systematic Review. J Intensive Care Med 2020; 35:943-962. [PMID: 32077780 DOI: 10.1177/0885066620907307] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Circulatory shock affects every third patient in intensive care units and is associated with high mortality. Near-infrared spectroscopy (NIRS) could serve as a means for monitoring tissue perfusion in circulatory shock. PURPOSE To assess the evidence of NIRS monitoring in circulatory shock, we conducted a systematic review of the literature. METHODS The study protocol was registered in International Prospective Register of Systematic Reviews (PROSPERO). We searched PubMed, Ovid MEDLINE, Scopus, and EBM Reviews databases. The reference lists of included articles, last volumes of key journals, and NIRS monitor manufacturers' webpages were searched manually. Two reviewers independently selected included studies. The quality of studies was assessed. The qualitative synthesis was guided by 3 questions: First, does NIRS monitoring improve patient-centered outcomes in adult circulatory shock patient? Second, do NIRS-derived parameters predict patient-centered outcomes, such as mortality and organ dysfunction, and third, does NIRS monitoring give additional information to guide treatment decisions? MAIN RESULTS Eighteen observational studies with 927 patients were included. Because of considerable clinical heterogeneity of the data, we were not able to perform a meta-analysis. Also, due to lack of randomized controlled trials, the first review question could not be answered. Based on the current review, baseline tissue oxygen saturation (StO2) however seems to predict mortality and identify patients with most severe forms of circulatory shock. CONCLUSIONS Near-infrared spectroscopy-derived StO2 can predict mortality in circulatory shock, but high-quality data on the impact of NIRS monitoring are lacking. Furthermore, the marked heterogeneity of the studies makes combining the results of individual studies difficult. Standardization of methodology and clinical randomized trials are needed before wider clinical use.
Collapse
Affiliation(s)
- Elina Varis
- Department of Anesthesiology, 89593Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville Pettilä
- Department of Anesthesiology, 89593Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Erika Wilkman
- Department of Anesthesiology, 89593Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
14
|
Ferraris A, Bouisse C, Thiollière F, Piriou V, Allaouchiche B. Mottling Incidence and Mottling Score According to Arterial Lactate Level in Septic Shock Patients. Indian J Crit Care Med 2020; 24:672-676. [PMID: 33024373 PMCID: PMC7519602 DOI: 10.5005/jp-journals-10071-23531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Objectives Mottling score is estimated from 0-5 according to mottling over the knee and described as clinical evaluation of tissue perfusion. This score was developed with ancient definitions of sepsis without lactate level, a major prognostic parameter when superior to 2 mmol/L. This study describes mottling incidence and mottling score in septic shock patients according to lactate level. Materials and methods We reanalyzed our prospective study in a French tertiary hospital in the intensive care unit (ICU) which studied mottling score and thermography correlation. Patients admitted to septic shock diagnosis and requiring vasoactive drugs were included. We recorded hemodynamic variables, mottling score, and lactate. Data collection was realized at ICU admission (H0) and after six hours (H6). Results Forty-three patients were included. Mean age was 67 (±4), mean sequential organ failure assessment (SOFA) score was 11 (8-12), and SAPS II 58 ±20. Mortality rate at day 28 was 30%. Among patients with lactate ≥2 mmol/L, mottling was more prevalent in 82.6% vs 47.4% (p value = 0.016), and at H6 mottling score was higher (p value = 0.009). Although, mottling incidence was not different between dead (85%) and survivors (81%; p value = 0.795). Conclusion A new sepsis definition implies a new epidemiology in mottling according to lactate threshold. Patients with lactate ≥2 mmol/L presented a higher incidence and score of mottling. However, mortality was not influenced by mottling in this study. Clinical significance Arterial lactate is a major prognostic parameter when superior to 2 mmol/L.A new definition of sepsis was published in 2016 with a new paradigm and epidemiology of septic shockPatients with lactate ≥2 mmol/L presented a higher incidence and score of mottling.Mottling score is a clinical sign of microcirculatory alteration, related to lactate level in septic shock. How to cite this article Ferraris A, Bouisse C, Thiollière F, Piriou V, Allaouchiche B. Mottling Incidence and Mottling Score According to Arterial Lactate Level in Septic Shock Patients. Indian J Crit Care Med 2020;24(8):672-676.
Collapse
Affiliation(s)
- Arnaud Ferraris
- Department of Service d'anesthésie Reanimation, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Camille Bouisse
- Department of Service d'anesthésie Reanimation, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Fabrice Thiollière
- Department of Service d'anesthésie Reanimation, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Vincent Piriou
- Department of Service d'anesthésie Reanimation, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Bernard Allaouchiche
- Department of Service d'anesthésie Reanimation, Hospices Civils de Lyon, Pierre-Bénite, France
| |
Collapse
|
15
|
[Association between peripheral perfusion, microcirculation and mortality in sepsis: a systematic review]. Rev Bras Anestesiol 2019; 69:605-621. [PMID: 31826803 DOI: 10.1016/j.bjan.2019.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 07/17/2019] [Accepted: 09/07/2019] [Indexed: 11/24/2022] Open
Abstract
Although increasing evidence supports the monitoring of peripheral perfusion in septic patients, no systematic review has been undertaken to explore the strength of association between poor perfusion assessed in microcirculation of peripheral tissues and mortality. A search of the most important databases was carried out to find articles published until February 2018 that met the criteria of this study using different keywords: sepsis, mortality, prognosis, microcirculation and peripheral perfusion. The inclusion criteria were studies that assessed association between peripheral perfusion/microcirculation and mortality in sepsis. The exclusion criteria adopted were: review articles, animal/pre-clinical studies, meta-analyzes, abstracts, annals of congress, editorials, letters, case-reports, duplicate and articles that did not present abstracts and/or had no text. In the 26 articles were chosen in which 2465 patients with sepsis were evaluated using at least one recognized method for monitoring peripheral perfusion. The review demonstrated a heterogeneous critically ill group with a mortality-rate between 3% and 71% (median=37% [28%-43%]). The most commonly used methods for measurement were Near-Infrared Spectroscopy (NIRS) (7 articles) and Sidestream Dark-Field (SDF) imaging (5 articles). The vascular bed most studied was the sublingual/buccal microcirculation (8 articles), followed by fingertip (4 articles). The majority of the studies (23 articles) demonstrated a clear relationship between poor peripheral perfusion and mortality. In conclusion, the diagnosis of hypoperfusion/microcirculatory abnormalities in peripheral non-vital organs was associated with increased mortality. However, additional studies must be undertaken to verify if this association can be considered a marker of the gravity or a trigger factor for organ failure in sepsis.
Collapse
|
16
|
Horak J, Martinkova V, Radej J, Matejovič M. Back to Basics: Recognition of Sepsis with New Definition. J Clin Med 2019; 8:jcm8111838. [PMID: 31683991 PMCID: PMC6912498 DOI: 10.3390/jcm8111838] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/23/2019] [Accepted: 10/24/2019] [Indexed: 12/12/2022] Open
Abstract
Patients with serious infections at risk of deterioration represent highly challenging clinical situations, and in particular for junior doctors. A comprehensive clinical examination that integrates the assessment of vital signs, hemodynamics, and peripheral perfusion into clinical decision making is key to responding promptly and effectively to evolving acute medical illnesses, such as sepsis or septic shock. Against this background, the new concept of sepsis definition may provide a useful link between junior doctors and consultant decision making. The purpose of this article is to introduce the updated definition of sepsis and suggest its practical implications, with particular emphasis on integrative clinical assessment, allowing for the rapid identification of patients who are at risk of further deterioration.
Collapse
Affiliation(s)
- Jan Horak
- Department of Internal Medicine, Faculty of Medicine in Pilsen, Pilsen University Hospital, Charles University Prague, Alej Svobody 80, 323 00 Pilsen, Czech Republic.
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University Prague, Alej Svobody 80, 323 00 Pilsen, Czech Republic.
| | - Vendula Martinkova
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University Prague, Alej Svobody 80, 323 00 Pilsen, Czech Republic.
- Third Department of Surgery, University Hospital Motol and First Medical School, Charles University, V Uvalu 84, 150 06 Prague, Czech Republic.
| | - Jaroslav Radej
- Department of Internal Medicine, Faculty of Medicine in Pilsen, Pilsen University Hospital, Charles University Prague, Alej Svobody 80, 323 00 Pilsen, Czech Republic.
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University Prague, Alej Svobody 80, 323 00 Pilsen, Czech Republic.
| | - Martin Matejovič
- Department of Internal Medicine, Faculty of Medicine in Pilsen, Pilsen University Hospital, Charles University Prague, Alej Svobody 80, 323 00 Pilsen, Czech Republic.
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University Prague, Alej Svobody 80, 323 00 Pilsen, Czech Republic.
| |
Collapse
|
17
|
Santos DMD, Quintans JSS, Quintans-Junior LJ, Santana-Filho VJ, Cunha CLPD, Menezes IAC, Santos MRV. Association between peripheral perfusion, microcirculation and mortality in sepsis: a systematic review. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2019. [PMID: 31826803 PMCID: PMC9391865 DOI: 10.1016/j.bjane.2019.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
| | - Jullyana S S Quintans
- Universidade Federal de Sergipe, Departamento de Fisiologia, São Cristóvão, SE, Brasil
| | | | | | | | | | - Márcio R Viana Santos
- Universidade Federal de Sergipe, Departamento de Fisiologia, São Cristóvão, SE, Brasil
| |
Collapse
|
18
|
Kazune S, Caica A, Volceka K, Suba O, Rubins U, Grabovskis A. Relationship of mottling score, skin microcirculatory perfusion indices and biomarkers of endothelial dysfunction in patients with septic shock: an observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:311. [PMID: 31511042 PMCID: PMC6739999 DOI: 10.1186/s13054-019-2589-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 08/29/2019] [Indexed: 11/17/2022]
Abstract
Background In patients with septic shock, the skin is often chosen for the evaluation of peripheral perfusion and oxygenation. Changes in skin microcirculatory vessel oxygen saturation and relative hemoglobin concentration can be described using a mottling score or captured with hyperspectral imaging. However, the effectiveness of the mottling score in assessing microcirculation remains to be shown. We hypothesize that the mottling score in patients with septic shock is related to skin microcirculatory perfusion indices quantified by hyperspectral imaging, biomarkers that reflect endothelium activation and damage, and clinical outcome. Methods Hyperspectral imaging of the knee area was performed in 95 intensive care patients with septic shock enrolled in a single-center observational study to obtain relative oxy/deoxyhemoglobin concentration values and construct anatomical maps of skin microcirculatory saturation. The blood was sampled to obtain concentrations of thrombomodulin, plasminogen activator inhibitor-1 (PAI-1), soluble intercellular adhesion molecule-1 (ICAM-1), soluble vascular cell adhesion molecule-1 (VCAM-1), angiopoietin-2, and syndecan-1. The spectrophotometrically obtained skin microvascular perfusion indices were compared to the mottling score and biomarker concentration. The association between mottling score, skin microcirculatory perfusion indices, and 28-day mortality was also analyzed. Results Microcirculatory oxygen saturation was significantly lower and total hemoglobin concentration was significantly higher in patients with a mottling score of 2 compared to those with a score of 0 (p = 0.02), with no difference between other scores. We found an association between microcirculatory oxygen saturation and PAI-1 levels (rho = − 0.3; p = 0.007). Increased mottling score and decreased microcirculatory oxygen saturation were predictive of 28-day mortality (mottling score 2 vs 0: OR 15.31, 95% CI 4.12–68.11; microcirculatory oxygen saturation: OR 0.90, 95% CI 0.85–0.95). Endothelial biomarkers did not increase the predictive value of skin microcirculatory perfusion indices. Conclusions Higher mottling scores are associated with lower microcirculatory oxygen saturation but with significant overlap between scores. Microcirculatory oxygen saturation is a quantitative measure of peripheral oxygenation and is more specific than the mottling score in predicting 28-day mortality. Electronic supplementary material The online version of this article (10.1186/s13054-019-2589-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Sigita Kazune
- Department of Anesthesiology, Hospital of Traumatology and Orthopedics, 22 Duntes Street, Riga, LV-1013, Latvia. .,Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, LV-1004, Latvia.
| | - Anastasija Caica
- Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, LV-1004, Latvia.,Department of Human and Animal Physiology, Faculty of Biology, University of Latvia, 1 Jelgavas Street, Riga, LV-1004, Latvia
| | - Karina Volceka
- Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, LV-1004, Latvia.,Department of Human and Animal Physiology, Faculty of Biology, University of Latvia, 1 Jelgavas Street, Riga, LV-1004, Latvia
| | - Olegs Suba
- Clinic of Toxicology and Sepsis, Riga East University Hospital, 2 Hipokrata Street, Riga, LV-1038, Latvia
| | - Uldis Rubins
- Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, LV-1004, Latvia
| | - Andris Grabovskis
- Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, LV-1004, Latvia
| |
Collapse
|
19
|
Kazune S, Caica A, Luksevics E, Volceka K, Grabovskis A. Impact of increased mean arterial pressure on skin microcirculatory oxygenation in vasopressor-requiring septic patients: an interventional study. Ann Intensive Care 2019; 9:97. [PMID: 31468202 PMCID: PMC6715757 DOI: 10.1186/s13613-019-0572-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 08/20/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Heterogeneity of microvascular blood flow leading to tissue hypoxia is a common finding in patients with septic shock. It may be related to suboptimal systemic perfusion pressure and lead to organ failure. Mapping of skin microcirculatory oxygen saturation and relative hemoglobin concentration using hyperspectral imaging allows to identify heterogeneity of perfusion and perform targeted measurement of oxygenation. We hypothesized that increasing mean arterial pressure would result in improved oxygenation in areas of the skin with most microvascular blood pooling. METHODS We included adult patients admitted to the intensive care unit within the previous 24 h with sepsis and receiving a noradrenaline infusion. Skin oxygen saturation was measured using hyperspectral imaging-based method at baseline and after the increase in mean arterial pressure by 20 mm Hg by titration of noradrenaline doses. The primary outcome was an increase in skin oxygen saturation depending upon disease severity. RESULTS We studied 30 patients with septic shock. Median skin oxygen saturation changed from 26.0 (24.5-27.0) % at baseline to 30.0 (29.0-31.0) % after increase in mean arterial pressure (p = 0.04). After adjustment for baseline saturation, patients with higher SOFA scores achieved higher oxygen saturation after the intervention (r2 = 0.21; p = 0.02). Skin oxygen saturation measured at higher pressure was found to be marginally predictive of mortality (OR: 1.10; 95% CI 1.00-1.23; p = 0.053). CONCLUSIONS Improvement of microcirculatory oxygenation can be achieved with an increase in mean arterial pressure in most patients. Response to study intervention is proportional to disease severity.
Collapse
Affiliation(s)
- Sigita Kazune
- Department of Anesthesiology, Hospital of Traumatology and Orthopedics, 22 Duntes Street, Riga, 1013, Latvia. .,Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, 1004, Latvia.
| | - Anastasija Caica
- Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, 1004, Latvia.,Department of Human and Animal Physiology, Faculty of Biology, University of Latvia, 1 Jelgavas Street, Riga, 1004, Latvia
| | - Einars Luksevics
- Clinic of Toxicology and Sepsis, Riga East University Hospital, 2 Hipokrata Street, Riga, 1038, Latvia
| | - Karina Volceka
- Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, 1004, Latvia.,Department of Human and Animal Physiology, Faculty of Biology, University of Latvia, 1 Jelgavas Street, Riga, 1004, Latvia
| | - Andris Grabovskis
- Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, 1004, Latvia
| |
Collapse
|
20
|
Dumas G, Lavillegrand JR, Joffre J, Bigé N, de-Moura EB, Baudel JL, Chevret S, Guidet B, Maury E, Amorim F, Ait-Oufella H. Mottling score is a strong predictor of 14-day mortality in septic patients whatever vasopressor doses and other tissue perfusion parameters. Crit Care 2019; 23:211. [PMID: 31182133 PMCID: PMC6558704 DOI: 10.1186/s13054-019-2496-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 05/28/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Mottling score, a tissue perfusion parameter, is correlated with outcome in septic shock patients. However, its predictive value on mortality according to prognostic covariates such as vasopressor dose and other tissue perfusion parameters remains unknown. METHODS Mottling score and tissue perfusion parameters were recorded at ICU admission (H0), H-6, H 12, and H-24 and used to assess the predictive value of mottling score on 14-day mortality in a development cohort. Results were then validated in an independent cohort of septic shock patients in Brazil. RESULTS Overall, 259 patients with sepsis or septic shock were included, 14-day mortality was 37%. Factors associated with death were mottling score (OR 2.26 [95% CI, 1.72-2.97]), arterial lactate level (OR 1.29 [1.11-1.5]), and urine output < 0.5 ml/Kg/h (OR 3.03 [1.37-6.69]). The C statistic for the model was 0.90 in the development cohort and 0.76 in the validation cohort. The predictive value of mottling score was not affected by vasopressor doses (p for interaction = 0.33): OR for mottling score ranged from 2.34 [1.10-3.15] in patients without vasopressor to 3.84 [1.98-7.43] in patients infused with high doses of vasopressor (> 0.8 μg/kg/min). There was no difference in the effect of mottling score on mortality according to mean arterial pressure, heart rate, cardiac index, and urine output, but we found a significant interaction between arterial lactate level and mottling score (p = 0.04). The predictive value of the mottling score remains significant when using the recent SEPSIS-3 definition of septic shock. Finally, a decrease of mottling score during resuscitation was significantly associated with better outcome after adjustment on SOFA score (p = 0.001). CONCLUSIONS Our results support the high prognostic value of mottling score for 14-day mortality in septic patients, whatever vasopressor dosage and other perfusion parameters. Mottling score variations during resuscitation are also predictive of mortality.
Collapse
Affiliation(s)
- Guillaume Dumas
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
- Sorbonne Université, Paris, France
- ECSTRA team, Biostatistics and clinical epidemiology, UMR 1153 (center of epidemiology and biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot University, Paris, France
| | - Jean-Rémi Lavillegrand
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
- Sorbonne Université, Paris, France
| | - Jérémie Joffre
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
| | - Naïke Bigé
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
| | | | - Jean-Luc Baudel
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
| | - Sylvie Chevret
- ECSTRA team, Biostatistics and clinical epidemiology, UMR 1153 (center of epidemiology and biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot University, Paris, France
| | - Bertrand Guidet
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
- Sorbonne Université, Paris, France
- Inserm U1136, F-75012 Paris, France
| | - Eric Maury
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
- Sorbonne Université, Paris, France
- Inserm U1136, F-75012 Paris, France
| | - Fabio Amorim
- Adult Intensive Care Unit, Hospital Santa Luzia, School of Medicine, Brasília, Brazil
| | - Hafid Ait-Oufella
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
- Sorbonne Université, Paris, France
- Université de Paris, Inserm U970, Centre de Recherche Cardiovasculaire de Paris (PARCC), Paris, France
| |
Collapse
|
21
|
Microvascular reactivity, assessed by near-infrared spectroscopy and a vascular occlusion test, is associated with patient outcomes following cardiac surgery: A prospective observational study. Eur J Anaesthesiol 2019; 35:356-364. [PMID: 29084009 DOI: 10.1097/eja.0000000000000731] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Microvascular dysfunction in patients admitted to the ICU following cardiac surgery may be related to perioperative complications and increased resource utilisation even in the presence of acceptable systemic haemodynamic variables. OBJECTIVES To assess the relationship between microvascular impairment using peripheral near-infrared spectroscopy at ICU admission and 6 h postadmission and the duration of mechanical ventilatory support, length of stay in ICU and in hospital. DESIGN Prospective, observational cohort study. SETTING Single-centre, tertiary-level cardiac ICU. PATIENTS Sixty-nine adult patients following elective cardiac surgery excluding patients with on-going extracorporeal support or in whom tissue haemoglobin oxygen saturation (StO2) measurements were not feasible. MAIN OUTCOME MEASURES Thenar and forearm StO2 in response to a vascular occlusion test to calculate desaturation and reperfusion slopes. A logistic regression model was used to ascertain the associations between StO2, desaturation and reperfusion slopes as well as cardiac index, mean arterial pressure, arterial lactate concentrations and prolonged (≥75th percentile) duration of mechanical ventilation, ICU length of stay and hospital length of stay. RESULTS A reduced reperfusion slope at ICU admission was associated independently with prolonged mechanical ventilation at thenar (OR 0.08; 95% CI [0.02 to 0.47], P = 0.003) and forearm [OR 0.2 (0.04 to 0.59), P = 0.006] sites. Similarly, a reduced Rres was associated with prolonged ICU LOS at both thenar [OR 0.3 (0.13 to 0.77), P = 0.007] and forearm [OR 0.2 (0.05 to 0.62), P = 0.007] sites at ICU0 h, as well as ICU6 h [OR 0.2 (0.05 to 0.66), P = 0.004 and OR 0.05 (0.008 to 0.34), P = 0.002]. An increased Rdes was associated with prolonged hospital LOS at the thenar eminence at ICU0 h [OR 1.9 (1.4 to 2.3), P = 0.004] and ICU6 h [OR 6.7 (2.0 to 23), P = 0.002] as well as the forearm at ICU0 h [OR 1.5 (1.3 to 1.9), P = 0.004] and ICU6 h [OR 1.6 (1.3 to 2.1), P = 0.004]. CONCLUSION In the early postoperative period following cardiac surgery, changes in thenar and forearm tissue oxygenation variables are associated with patient resource utilisation outcomes.
Collapse
|
22
|
Misango D, Pattnaik R, Baker T, Dünser MW, Dondorp AM, Schultz MJ. Haemodynamic assessment and support in sepsis and septic shock in resource-limited settings. Trans R Soc Trop Med Hyg 2019; 111:483-489. [PMID: 29438568 PMCID: PMC5914406 DOI: 10.1093/trstmh/try007] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 01/16/2018] [Indexed: 12/16/2022] Open
Abstract
Background Recommendations for haemodynamic assessment and support in sepsis and septic shock in resource-limited settings are largely lacking. Methods A task force of six international experts in critical care medicine, all of them members of the Global Intensive Care Working Group of the European Society of Intensive Care Medicine and with extensive bedside experience in resource-limited intensive care units, reviewed the literature and provided recommendations regarding haemodynamic assessment and support, keeping aspects of efficacy and effectiveness, availability and feasibility and affordability and safety in mind. Results We suggest using capillary refill time, skin mottling scores and skin temperature gradients; suggest a passive leg raise test to guide fluid resuscitation; recommend crystalloid solutions as the initial fluid of choice; recommend initial fluid resuscitation with 30 ml/kg in the first 3 h, but with extreme caution in settings where there is a lack of mechanical ventilation; recommend against an early start of vasopressors; suggest starting a vasopressor in patients with persistent hypotension after initial fluid resuscitation with at least 30 ml/kg, but earlier when there is lack of vasopressors and mechanical ventilation; recommend using norepinephrine (noradrenaline) as a first-line vasopressor; suggest starting an inotrope with persistence of plasma lactate >2 mmol/L or persistence of skin mottling or prolonged capillary refill time when plasma lactate cannot be measured, and only after initial fluid resuscitation; suggest the use of dobutamine as a first-line inotrope; recommend administering vasopressors through a central venous line and suggest administering vasopressors and inotropes via a central venous line using a syringe or infusion pump when available. Conclusion Recommendations for haemodynamic assessment and support in sepsis and septic shock in resource-limited settings have been developed by a task force of six international experts in critical care medicine with extensive practical experience in resource-limited settings.
Collapse
Affiliation(s)
- David Misango
- Department of Anaesthesiology and Critical Care Medicine, Aga Khan University Hospital, Nairobi, Kenya
| | - Rajyabardhan Pattnaik
- Department of Intensive Care Medicine, Ispat General Hospital, Rourkela, Sundargarh, Odisha, India
| | - Tim Baker
- Department of Anesthesia, Intensive Care and Surgical Services, Karolinska University Hospital, Stockholm, Sweden.,Department of Public Health Sciences, Karolinska Institutet
| | - Martin W Dünser
- Department of Critical Care, University College of London Hospital, London, UK
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok 10400, Thailand.,Oxford Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.,Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok 10400, Thailand.,Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | | | | |
Collapse
|
23
|
Hariri G, Joffre J, Dumas G, Lavillegrand JR, Bigé N, Baudel JL, Guidet B, Maury E, Ait-Oufella H. Exploration de la perfusion tissulaire microcirculatoire au cours du choc septique. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2018-0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Au cours des infections graves, les travaux chez l’animal et chez l’homme ont mis en évidence une altération de la perfusion microcirculatoire à l’origine des défaillances viscérales et potentiellement du décès. La sévérité des anomalies microcirculatoires ainsi que leur persistance sont des facteurs prédictifs de mortalité indépendamment du débit cardiaque ou de la pression artérielle. Il est donc indispensable de développer des outils permettant d’évaluer la perfusion microcirculatoire au lit du malade. De nombreux travaux au cours du sepsis suggèrent que l’analyse de la perfusion cutanée au travers de sa température (et/ou du gradient), du temps de recoloration cutané, de l’étendue des marbrures et de l’indice de perfusion périphérique constitue un outil simple qui permet au réanimateur une évaluation rapide des anomalies microcirculatoires.
Collapse
|
24
|
Ferraris A, Bouisse C, Mottard N, Thiollière F, Anselin S, Piriou V, Allaouchiche B. Mottling score and skin temperature in septic shock: Relation and impact on prognosis in ICU. PLoS One 2018; 13:e0202329. [PMID: 30114284 PMCID: PMC6095547 DOI: 10.1371/journal.pone.0202329] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 08/01/2018] [Indexed: 01/20/2023] Open
Abstract
Introduction Mottling score, defined by 5 areas over the knee is developed to evaluate tissue perfusion at bedside. Because of the subjective aspect of the score, we aimed to compare mottling score and skin temperature in septic shock with infrared thermography in ICU and the correlation to survival. Methods We conducted a prospective and observational study in a teaching hospital in France during 8 months in ICU. All patients with sepsis requiring vasoactive drugs were included. We recorded epidemiologic data, hemodynamic parameters, mottling score and skin temperature with a thermic camera of the 5 mottling areas around the knee (temperatures recorded with FLIR™ software) at bedside. Measures were performed at ICU admission (H0) and six hours after initial resuscitation (H6). Results 46 patients were included. Median age was 69 (60–78), SOFA score 11 (8–12) mean SAPS II was 57±20 and 28-day mortality rate was 30%. Patients with mottling (score≥1), had a skin temperature of the knee significantly lower (30.7 vs 33,2°C p = 0.01 at H6) than patients without mottling (score = 0). Skin temperatures of the knee in mottling groups 1 to 5 were similar at H0 and H6. Neither mottling score nor skin temperature of the knee were associated with prognostic regarding day-28 mortality. Conclusions Skin temperature measured with infrared thermography technology around the knee is lower when mottling sign is present and sign microcirculation alterations. This method, compared to standard mottling score is objective and allows data collections. However, this method failed to predict mortality in ICU patients.
Collapse
Affiliation(s)
- Arnaud Ferraris
- Service d’Anesthésie-Réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
- * E-mail:
| | - Camille Bouisse
- Service d’Anesthésie-Réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Nicolas Mottard
- Service d’Anesthésie-Réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Fabrice Thiollière
- Service d’Anesthésie-Réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Sophie Anselin
- Service d’Anesthésie-Réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Vincent Piriou
- Service d’Anesthésie-Réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
- Université Lyon 1 Claude Bernard, Lyon, France
| | - Bernard Allaouchiche
- Service d’Anesthésie-Réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
- Université Lyon 1 Claude Bernard, Lyon, France
| |
Collapse
|
25
|
Abstract
PURPOSE OF REVIEW Monitoring of mental status and peripheral circulatory changes can be accomplished noninvasively in patients in the ICU. Emphasis on physical examination in conditions such as sepsis have gained increased attention as these evaluations can often serve as a surrogate marker for short-term treatment efficacy of therapeutic interventions. Sepsis associated encephalopathy and mental status changes correlate with worse prognosis in patients. Evaluation of peripheral circulation has been shown to be a convenient, easily accessible, and accurate marker for prognosis in patients with septic shock. The purpose of this article is to emphasize the main findings according to recent literature into the monitoring of physical examination changes in patients with sepsis. RECENT FINDINGS Several recent studies have expanded our knowledge about the pathophysiology of mental status changes and the clinical assessment of peripheral circulation in patients with sepsis. Sepsis-associated encephalopathy is associated with an increased rate of morbidity and mortality in an intensive care setting. Increased capillary refill time (CRT) and persistent skin mottling are strongly predictive of mortality, whereas temperature gradients can reveal vasoconstriction and more severe organ dysfunction. SUMMARY Monitoring of physical examination changes is a significant and critical intervention in patients with sepsis. Utilizing repeated neurologic evaluations, and assessing CRT, mottling score, and skin temperature gradients should be emphasized as important noninvasive diagnostic tools. The significance of these methods can be incorporated during the utilization of therapeutic strategies in resuscitation protocols in patients with sepsis.
Collapse
|
26
|
Alternatives to the Swan–Ganz catheter. Intensive Care Med 2018; 44:730-741. [DOI: 10.1007/s00134-018-5187-8] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 04/18/2018] [Indexed: 12/12/2022]
|
27
|
Abstract
: In 2015, the Surviving Sepsis Campaign six-hour bundle was updated. The revised version now recommends documenting the reassessment of volume status and tissue perfusion after initial fluid resuscitation through a repeated focused examination. This article addresses the practice and interpretation of two components of this examination in adults: capillary refill time and skin mottling score. It further discusses how to best integrate these noninvasive parameters into the care of patients undergoing resuscitation for septic shock.
Collapse
|
28
|
Bourcier S, Joffre J, Dubée V, Preda G, Baudel JL, Bigé N, Leblanc G, Levy BI, Guidet B, Maury E, Ait-Oufella H. Marked regional endothelial dysfunction in mottled skin area in patients with severe infections. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017. [PMID: 28641580 PMCID: PMC5481873 DOI: 10.1186/s13054-017-1742-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Mottling around the knee, reflecting a reduced skin blood flow, is predictive of mortality in patients with septic shock. However, the causative pathophysiology of mottling remains unknown. We hypothesized that the cutaneous hypoperfusion observed in the mottled area is related to regional endothelial dysfunction. Methods This was a prospective, observational study in a medical ICU in a tertiary teaching hospital. Consecutive adult patients with sepsis admitted to ICU were included. After resuscitation, endothelium-dependent vasodilation in the skin circulation was measured before and after iontophoresis of acetylcholine (Ach) in the forearm and the knee area. We analyzed the patterns of induced vasodilatation according to the presence or absence of mottling and vital status at 14 days. Results We evaluated 37 septic patients, including 11 without and 26 with septic shock. Overall 14-day mortality was 22%. Ten patients had mottling around the knee (10/37, 27%). In the knee area, the increased skin blood flow following iontophoresis of Ach was lower in patients with mottled skin as compared to patients without mottled skin (area under curve (AUC) 3280 (2643–6440) vs. 7980 (4233–19,707), both P < 0.05). In the forearm area, the increased skin blood flow following iontophoresis of Ach was similar in patients with and without mottled skin. Among patients with septic shock, the increased skin blood flow following iontophoresis of Ach in the knee area was significantly lower in non-survivors as compared to survivors at 14 days (AUC 3256 (2600–4426) vs. 7704 (4539–15,011), P < 0.01). In patients with septic shock, the increased skin blood flow in the forearm area following iontophoresis of Ach was similar in survivors and non-survivors at 14 days. Conclusion Mottling is associated with regional endothelial dysfunction in patients with septic shock. Endothelial dysfunction in the knee skin area was more pronounced in non-survivors than in survivors. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1742-x) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Simon Bourcier
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris, Cedex 12, France.,Université Pierre-et-Marie Curie, Paris 6, France.,Inserm U1136, Paris, F-75012, France
| | - Jérémie Joffre
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris, Cedex 12, France.,Université Pierre-et-Marie Curie, Paris 6, France.,Inserm U970, Centre de Recherche Cardiovasculaire de Paris (PARCC), Paris, France
| | - Vincent Dubée
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris, Cedex 12, France.,Université Pierre-et-Marie Curie, Paris 6, France
| | - Gabriel Preda
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris, Cedex 12, France
| | - Jean-Luc Baudel
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris, Cedex 12, France
| | - Naïke Bigé
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris, Cedex 12, France
| | - Guillaume Leblanc
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris, Cedex 12, France.,Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Bernard I Levy
- Inserm U970, Centre de Recherche Cardiovasculaire de Paris (PARCC), Paris, France
| | - Bertrand Guidet
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris, Cedex 12, France.,Université Pierre-et-Marie Curie, Paris 6, France.,Inserm U1136, Paris, F-75012, France
| | - Eric Maury
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris, Cedex 12, France.,Université Pierre-et-Marie Curie, Paris 6, France.,Inserm U1136, Paris, F-75012, France
| | - Hafid Ait-Oufella
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris, Cedex 12, France. .,Université Pierre-et-Marie Curie, Paris 6, France. .,Inserm U970, Centre de Recherche Cardiovasculaire de Paris (PARCC), Paris, France.
| |
Collapse
|
29
|
Charlton M, Sims M, Coats T, Thompson JP. The microcirculation and its measurement in sepsis. J Intensive Care Soc 2016; 18:221-227. [PMID: 29118834 DOI: 10.1177/1751143716678638] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
The microcirculation describes the smallest elements of the cardiovascular conducting system and is pivotal in the maintenance of homeostasis. Microcirculatory dysfunction is present early in the pathophysiology of sepsis, with the extent of microcirculatory derangement relating to disease severity and prognosis in ICU patients. However, at present microcirculatory function is not routinely monitored at the bedside. This article describes the pathophysiology of microcirculatory derangements in sepsis, methods of its measurement and evidence to support their clinical use.
Collapse
Affiliation(s)
- Matthew Charlton
- Anaesthetics and Critical Care, Diagnostic Development Unit, University of Leicester, Leicester, UK
| | - Mark Sims
- Astrobiology and Space Instrumentation, Diagnostic Development Unit, University of Leicester, Leicester, UK
| | - Tim Coats
- Emergency Medicine, Diagnostic Development Unit, University of Leicester, Leicester, UK
| | - Jonathan P Thompson
- Anaesthetics and Critical Care, Diagnostic Development Unit, University of Leicester, Leicester, UK
| |
Collapse
|
30
|
Willingham TB, Southern WM, McCully KK. Measuring reactive hyperemia in the lower limb using near-infrared spectroscopy. JOURNAL OF BIOMEDICAL OPTICS 2016; 21:091302. [PMID: 27050534 DOI: 10.1117/1.jbo.21.9.091302] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 01/14/2016] [Indexed: 05/24/2023]
Abstract
Near-infrared spectroscopy (NIRS) has been used to measure reactive hyperemia following a vascular occlusion. However, the procedures and methods of analysis used have varied. The purpose of the present study is to identify reproducible methods for measuring reactive hyperemia using HbO2 NIRS signals in the calf and foot. Healthy participants (10 male, 10 female) aged 19 to 28 years performed one of two tests: reproducibility trials or elevation protocol (30 and 60 cm limb elevation above the heart). The time to 50% reperfusion (T1/2) and the second (R2q) quartile rates of reperfusion were found to be the most reproducible parameters (coefficient of variation= 7.12 to 14.1%). The time to 95% reperfusion (T95) was 12.7% more reproducible on average than the previously reported parameter of time to peak hyperemia. Measures of reperfusion time and rate slowed with increasing limb elevation. Correlations were identified between the calf and foot in the measurements of R2q (R2 = 0.713, p = 0.021), T1/2 (R2 = 0.673, p = 0.033), and T95 (R2 = 0.792, p = 0.006). Half and 95% recovery times and second and third quartile rates expressed good reproducibility and sensitivity to change with reduced perfusion pressure. NIRS measures of reactive hyperemia have the potential to evaluate microvascular perfusion in clinical populations.
Collapse
|
31
|
Butler E, Chin M, Aneman A. Peripheral Near-Infrared Spectroscopy: Methodologic Aspects and a Systematic Review in Post-Cardiac Surgical Patients. J Cardiothorac Vasc Anesth 2016; 31:1407-1416. [PMID: 27876185 DOI: 10.1053/j.jvca.2016.07.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Ethan Butler
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Melissa Chin
- Intensive Care Unit, Liverpool Hospital, Sydney, Australia
| | - Anders Aneman
- Intensive Care Unit, Liverpool Hospital, Sydney, Australia; University of New South Wales, South Western Sydney Clinical School, Sydney, Australia; Ingham Institute for Applied Medical Research, Sydney, Australia.
| |
Collapse
|
32
|
Bourcier S, Pichereau C, Boelle PY, Nemlaghi S, Dubée V, Lejour G, Baudel JL, Galbois A, Lavillegrand JR, Bigé N, Tahiri J, Leblanc G, Maury E, Guidet B, Ait-Oufella H. Toe-to-room temperature gradient correlates with tissue perfusion and predicts outcome in selected critically ill patients with severe infections. Ann Intensive Care 2016; 6:63. [PMID: 27401441 PMCID: PMC4940318 DOI: 10.1186/s13613-016-0164-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 06/27/2016] [Indexed: 12/11/2022] Open
Abstract
Background Microcirculatory disorders leading to tissue hypoperfusion play a central role in the pathophysiology of organ failure in severe sepsis and septic shock. As microcirculatory disorders have been identified as strong predictive factors of unfavourable outcome, there is a need to develop accurate parameters at the bedside to evaluate tissue perfusion. We evaluated whether different body temperature gradients could relate to sepsis severity and could predict outcome in critically ill patients with severe sepsis and septic shock. Method We conducted a prospective observational study in a tertiary teaching hospital in France. During a 10-month period, all consecutive adult patients with severe sepsis or septic shock who required ICU admission were included. Six hours after initial resuscitation (H6), we recorded the hemodynamic parameters and four temperature gradients: central-to-toe, central-to-knee, toe-to-room and knee-to-room. Results We evaluated 40 patients with severe sepsis (40/103, 39 %) and 63 patients with septic shock (63/103, 61 %). In patients with septic shock, central-to-toe temperature gradient was significantly higher (12.5 [9.2; 13.8] vs 6.9 [3.4; 12.0] °C, P < 0.001) and toe-to-room temperature gradient significantly lower (1.2 [−0.3; 5.2] vs 6.0 [0.6; 9.5] °C, P < 0.001) than in patients with severe sepsis. Overall ICU mortality rate due to multiple organ failure (MOF) was 21 %. After initial resuscitation, toe-to-room temperature gradient was significantly lower in patients dead from MOF than in the survivors (−0.2 [−1.1; +1.3] °C vs +3.9 [+0.5; +7.2] °C, P < 0.001) and the difference in gradients increased during the first 24 h. Furthermore, toe-to-room temperature gradient was related to tissue perfusion parameters such as arterial lactate level (r = −0.54, P < 0.0001), urine output (r = 0.37, P = 0.0002), knee capillary refill time (r = −0.42, P < 0.0001) and mottling score (P = 0.001). Conclusions Toe-to-room temperature gradient reflects tissue perfusion at the bedside and is a strong prognosis factor in critically ill patients with severe infections. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0164-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Simon Bourcier
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Claire Pichereau
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Pierre-Yves Boelle
- Service de santé publique, AP-HP, Hôpital Saint-Antoine, 75571, Paris Cedex 12, France
| | - Safaa Nemlaghi
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Service de Réanimation polyvalente Quincy-sous-Sénart, Générale de Santé, Hôpital Privé Claude Galien, Quincy-Sous-Sénart, France
| | - Vincent Dubée
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Gabriel Lejour
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Jean-Luc Baudel
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Arnaud Galbois
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Service de Réanimation polyvalente Quincy-sous-Sénart, Générale de Santé, Hôpital Privé Claude Galien, Quincy-Sous-Sénart, France
| | - Jean-Rémi Lavillegrand
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Naïke Bigé
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Jalel Tahiri
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Guillaume Leblanc
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Eric Maury
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Université Pierre et Marie Curie-Paris 6, Paris, France.,Inserm U1136, 75012, Paris, France
| | - Bertrand Guidet
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Université Pierre et Marie Curie-Paris 6, Paris, France.,Inserm U1136, 75012, Paris, France
| | - Hafid Ait-Oufella
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France. .,Université Pierre et Marie Curie-Paris 6, Paris, France. .,Inserm U970, Centre de recherche cardiovasculaire de Paris (PARCC), Paris, France.
| |
Collapse
|
33
|
Hernández G, Teboul JL. Is the macrocirculation really dissociated from the microcirculation in septic shock? Intensive Care Med 2016; 42:1621-1624. [DOI: 10.1007/s00134-016-4416-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 06/01/2016] [Indexed: 10/21/2022]
|
34
|
Salcedo MC, Tart K, Hall K. A systematic review of human and veterinary applications of noninvasive tissue oxygen monitoring. J Vet Emerg Crit Care (San Antonio) 2016; 26:323-32. [PMID: 27062438 DOI: 10.1111/vec.12465] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 08/27/2014] [Accepted: 09/15/2014] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To describe the methodology for and utilization of tissue oxygen monitoring by near infrared spectroscopy, and to review the current literature on the use of this monitoring modality in human and veterinary settings. DATA SOURCES Scientific reviews and original research found using the PubMed and CAB Abstract search engines with the following keywords: "tissue oxygen monitoring," "near-infrared tissue spectroscopy," and "tissue oxygen saturation (StO2 )." HUMAN DATA SYNTHESIS Tissue oxygen monitors have been evaluated in a wide variety of human clinical applications including trauma and triage, surgery, sepsis, and septic shock, and early goal-directed therapy. StO2 more rapidly identifies occult shock in human patients compared to traditional methods, which can lead to earlier intervention in these patients. VETERINARY DATA SYNTHESIS Veterinary studies involving tissue oxygen monitoring are limited, but the technology may have utility for identification of hemorrhagic shock earlier than changes in base excess, blood lactate concentration, or other traditional perfusion parameters. CONCLUSION Tissue oxygen monitoring is most commonly performed utilizing a noninvasive, portable monitor, which provides real-time, continuous, repeatable StO2 measurements. A decline in StO2 is an early indicator of shock in both human and veterinary patients. Low StO2 values in human patients are associated with increased morbidity, mortality, and length of hospitalization, as well as the development of multiple organ system dysfunction and surgical site infections.
Collapse
Affiliation(s)
- Mallory C Salcedo
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St. Paul, MN, 55108
| | - Kelly Tart
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St. Paul, MN, 55108
| | - Kelly Hall
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St. Paul, MN, 55108
| |
Collapse
|
35
|
Abstract
PURPOSE OF REVIEW Despite the progress made over the past 20 years in the treatment of septic shock, mortality remains high. Microcirculatory disorders raise considerable interest aiming to improve the understanding of the physiopathology of septic shock and its management. RECENT FINDINGS Numerous experimental and clinical studies have gradually focused on the analysis of microcirculatory blood flow and identified alterations in small vessels. These microcirculatory abnormalities appear early, are heterogeneous, and are directly linked to organ failure, as well as the patient's prognosis. These anomalies vary from one patient to the other, and their evolution during resuscitation cannot be predicted by the isolated analysis of global hemodynamic parameters such as blood pressure or heart rate. SUMMARY Microcirculatory disorders appear at a central place of the physiopathology and are highly associated with the patient prognosis; it therefore seems important to develop and integrate parameters reflecting tissue perfusion in the management of septic shock.
Collapse
|
36
|
de Moura EB, Amorim FF, da Cruz Santana AN, Kanhouche G, de Souza Godoy LG, de Jesus Almeida L, Rodrigues TA, da Silveira CDG, de Oliveira Maia M. Skin mottling score as a predictor of 28-day mortality in patients with septic shock. Intensive Care Med 2015; 42:479-480. [PMID: 26687581 DOI: 10.1007/s00134-015-4184-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2015] [Indexed: 11/28/2022]
Affiliation(s)
| | - Fábio Ferreira Amorim
- Adult Intensive Care Unit, Hospital Santa Luzia, Brasília, Brazil. .,School of Medicine, Coordenação de Pós-Graduação e Extensão, Escola Superior de Ciências da Saúde (ESCS), SMHN Quadra 03, conjunto A, Bloco 1, Edifício FEPECS, Brasília, DF, CEP: 70710-907, Brazil.
| | - Alfredo Nicodemos da Cruz Santana
- School of Medicine, Coordenação de Pós-Graduação e Extensão, Escola Superior de Ciências da Saúde (ESCS), SMHN Quadra 03, conjunto A, Bloco 1, Edifício FEPECS, Brasília, DF, CEP: 70710-907, Brazil.,Thoracic Unit, Hospital Regional da Asa Norte, Brasília, Brazil
| | - Gabriel Kanhouche
- School of Medicine, Faculdades Integradas da União Educacional do Planalto Central (Faciplac), Brasília, Brazil
| | - Lucas Garcia de Souza Godoy
- School of Medicine, Coordenação de Pós-Graduação e Extensão, Escola Superior de Ciências da Saúde (ESCS), SMHN Quadra 03, conjunto A, Bloco 1, Edifício FEPECS, Brasília, DF, CEP: 70710-907, Brazil
| | - Lucila de Jesus Almeida
- School of Medicine, Coordenação de Pós-Graduação e Extensão, Escola Superior de Ciências da Saúde (ESCS), SMHN Quadra 03, conjunto A, Bloco 1, Edifício FEPECS, Brasília, DF, CEP: 70710-907, Brazil
| | - Thais Almeida Rodrigues
- School of Medicine, Coordenação de Pós-Graduação e Extensão, Escola Superior de Ciências da Saúde (ESCS), SMHN Quadra 03, conjunto A, Bloco 1, Edifício FEPECS, Brasília, DF, CEP: 70710-907, Brazil
| | - Carlos Darwin Gomes da Silveira
- Adult Intensive Care Unit, Hospital Santa Luzia, Brasília, Brazil.,School of Medicine, Coordenação de Pós-Graduação e Extensão, Escola Superior de Ciências da Saúde (ESCS), SMHN Quadra 03, conjunto A, Bloco 1, Edifício FEPECS, Brasília, DF, CEP: 70710-907, Brazil
| | | |
Collapse
|
37
|
Marín-Corral J, Claverias L, Bodí M, Pascual S, Dubin A, Gea J, Rodriguez A. Prognostic value of brachioradialis muscle oxygen saturation index and vascular occlusion test in septic shock patients. Med Intensiva 2015; 40:208-15. [PMID: 26394682 DOI: 10.1016/j.medin.2015.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 06/26/2015] [Accepted: 07/09/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To compare rSO2 (muscle oxygen saturation index) static and dynamic variables obtained by NIRS (Near Infrared Spectroscopy) in brachioradialis muscle of septic shock patients and its prognostic implications. DESIGN Prospective and observational study. SETTING Intensive care unit. SUBJECTS Septic shock patients and healthy volunteers. INTERVENTIONS The probe of a NIRS device (INVOS 5100) was placed on the brachioradialis muscle during a vascular occlusion test (VOT). VARIABLES Baseline, minimum and maximum rSO2 values, deoxygenation rate (DeOx), reoxygenation slope (ReOx) and delta value. RESULTS Septic shock patients (n=35) had lower baseline rSO2 (63.8±12.2 vs. 69.3±3.3%, p<0.05), slower DeOx (-0.54±0.31 vs. -0.91±0.35%/s, p=0.001), slower ReOx (2.67±2.17 vs. 9.46±3.5%/s, p<0.001) and lower delta (3.25±5.71 vs. 15.1±3.9%, p<0.001) when compared to healthy subjects (n=20). Among septic shock patients, non-survivors showed lower baseline rSO2 (57.0±9.6 vs. 69.8±11.3%, p=0.001), lower minimum rSO2 (36.0±12.8 vs. 51.3±14.8%, p<0.01) and lower maximum rSO2 values (60.6±10.6 vs. 73.3±11.2%, p<0.01). Baseline rSO2 was a good mortality predictor (AUC 0.79; 95%CI: 0.63-0.94, p<0.01). Dynamic parameters obtained with VOT did not improve the results. CONCLUSION Septic shock patients present an important alteration of microcirculation that can be evaluated by NIRS with prognostic implications. Monitoring microvascular reactivity in the brachioradialis muscle using VOT with our device does not seem to improve the prognostic value of baseline rSO2.
Collapse
Affiliation(s)
- J Marín-Corral
- Critical Care Department - University Joan XXIII Hospital - IISPV-URV, Tarragona, Spain.
| | - L Claverias
- Critical Care Department - University Joan XXIII Hospital - IISPV-URV, Tarragona, Spain
| | - M Bodí
- Critical Care Department - University Joan XXIII Hospital - IISPV-URV, Tarragona, Spain; CIBERES (CIBER Enfermedades Respiratorias), ISC III, Bunyola, Palma de Mallorca, Spain
| | - S Pascual
- Respiratory Department - Hospital del Mar - IMIM. Department CEXS, UPF, Barcelona, Spain; CIBERES (CIBER Enfermedades Respiratorias), ISC III, Bunyola, Palma de Mallorca, Spain
| | - A Dubin
- Sanatorio Otamendi y Miroli, Servicio de Terapia Intensiva, Buenos Aires, Argentina; Cátedra de Farmacología Aplicada, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, La Plata, Argentina
| | - J Gea
- Respiratory Department - Hospital del Mar - IMIM. Department CEXS, UPF, Barcelona, Spain; CIBERES (CIBER Enfermedades Respiratorias), ISC III, Bunyola, Palma de Mallorca, Spain
| | - A Rodriguez
- Critical Care Department - University Joan XXIII Hospital - IISPV-URV, Tarragona, Spain; CIBERES (CIBER Enfermedades Respiratorias), ISC III, Bunyola, Palma de Mallorca, Spain
| |
Collapse
|
38
|
|
39
|
Mesquida J. Evaluating tissue oxygenation at the bedside: global, regional, or both? J Clin Monit Comput 2015; 29:431-3. [PMID: 25855405 DOI: 10.1007/s10877-015-9690-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 03/23/2015] [Indexed: 01/20/2023]
Abstract
Early recognition of tissue hypoperfusion, and monitoring tissue response to resuscitation interventions, are key points in the management of critically ill patients. In the present issue of J Clin Monit Comput, Dr. Koch and coworkers present the results of a study evaluating regional and global markers of tissue perfusion in a population of septic shock patients. We propose an integrative approach to tissue perfusion assessment, where combining both, global and regional variables, might account for a better understanding of tissue oxygenation status, and might prove useful for septic shock patients' management.
Collapse
Affiliation(s)
- Jaume Mesquida
- Critical Care Center, Hospital de Sabadell, Corporació Sanitària Universitària Parc Taulí, Universitat Autònoma de Barcelona,, Parc Tauli, 1, 08208, Sabadell, Spain,
| |
Collapse
|
40
|
Timsit JF, Perner A, Bakker J, Bassetti M, Benoit D, Cecconi M, Curtis JR, Doig GS, Herridge M, Jaber S, Joannidis M, Papazian L, Peters MJ, Singer P, Smith M, Soares M, Torres A, Vieillard-Baron A, Citerio G, Azoulay E. Year in review in Intensive Care Medicine 2014: III. Severe infections, septic shock, healthcare-associated infections, highly resistant bacteria, invasive fungal infections, severe viral infections, Ebola virus disease and paediatrics. Intensive Care Med 2015; 41:575-88. [PMID: 25810214 PMCID: PMC4491096 DOI: 10.1007/s00134-015-3755-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 03/12/2015] [Indexed: 01/09/2023]
Affiliation(s)
- Jean-François Timsit
- APHP-Hopital Bichat-Medical and Infectious Diseases ICU, UMR 1137-IAME Team 5-DeSCID: Decision Sciences in Infectious Diseases, Control and Care Inserm/Univ Paris Diderot, Sorbonne Paris Cité, 75018, Paris, France,
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Galbois A, Bigé N, Pichereau C, Boëlle PY, Baudel JL, Bourcier S, Maury E, Guidet B, Ait-Oufella H. Exploration of skin perfusion in cirrhotic patients with septic shock. J Hepatol 2015; 62:549-55. [PMID: 25457199 DOI: 10.1016/j.jhep.2014.10.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 09/16/2014] [Accepted: 10/07/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Skin perfusion alterations are early and strong predictors of death in patients with septic shock. Cirrhosis is associated with systemic vasodilation and increases mortality from septic shock. We aimed at assessing whether the mottling score and tissue oxygen saturation (StO2) could be used as early predictors of death in cirrhotic patients with septic shock. METHODS This observational study included cirrhotic patients with septic shock. Each 6 h during the first 24 h, we collected data reflecting macrocirculation (mean arterial pressure, heart rate, central venous pressure, and cardiac output) and organ perfusion (arterial lactate, urinary output, ScvO2, mottling score, thenar, and knee StO2). Data of 75 non-cirrhotic patients with previously reported septic shock were used as control. RESULTS 42 cirrhotic patients were included. Mortality at day 14 was 71%. At H6, parameters reflecting macrocirculation were not associated with mortality, whereas higher arterial lactate and mottling score were associated with death. Mottling score was the strongest predictor of mortality (sensitivity=0.63, specificity=1, OR=42.4 (2.3-785.9)). At H6, knee StO2 decreased in non-survivors and predicted death (sensitivity=0.45, specificity=1). In comparison with control, mottling kinetic was different in cirrhotic patients (delayed mottling appearance in non-survivors, earlier mottling disappearance in survivors). Knee StO2 and skin perfusion, assessed by laser-Doppler, were higher in cirrhotic patients. CONCLUSIONS Mottling score and knee StO2 at H6 were very specific predictors of death in patients with cirrhosis and septic shock. Their sensitivity was lower in cirrhotic patients due to delayed mottling appearance and higher knee StO2 related to higher skin perfusion.
Collapse
Affiliation(s)
- Arnaud Galbois
- AP-HP, Hôpital Saint-Antoine, Service de Réanimation Médicale, F-75012 Paris, France; Université Pierre et Marie Curie (UPMC), Univ Paris 06, Sorbonne Universités, F-75005 Paris, France; INSERM, UMR_S 938, CdR Saint-Antoine, F-75012 Paris, France.
| | - Naïke Bigé
- AP-HP, Hôpital Saint-Antoine, Service de Réanimation Médicale, F-75012 Paris, France; Université Pierre et Marie Curie (UPMC), Univ Paris 06, Sorbonne Universités, F-75005 Paris, France
| | - Claire Pichereau
- AP-HP, Hôpital Saint-Antoine, Service de Réanimation Médicale, F-75012 Paris, France; Université Pierre et Marie Curie (UPMC), Univ Paris 06, Sorbonne Universités, F-75005 Paris, France
| | - Pierre-Yves Boëlle
- Université Pierre et Marie Curie (UPMC), Univ Paris 06, Sorbonne Universités, F-75005 Paris, France; AP-HP, Hôpital Saint-Antoine, Service de Santé Publique, F-75012 Paris, France; INSERM, UMR_S 707, F-75012 Paris, France
| | - Jean-Luc Baudel
- AP-HP, Hôpital Saint-Antoine, Service de Réanimation Médicale, F-75012 Paris, France
| | - Simon Bourcier
- AP-HP, Hôpital Saint-Antoine, Service de Réanimation Médicale, F-75012 Paris, France; Université Pierre et Marie Curie (UPMC), Univ Paris 06, Sorbonne Universités, F-75005 Paris, France
| | - Eric Maury
- AP-HP, Hôpital Saint-Antoine, Service de Réanimation Médicale, F-75012 Paris, France; Université Pierre et Marie Curie (UPMC), Univ Paris 06, Sorbonne Universités, F-75005 Paris, France; INSERM, UMR_S 707, F-75012 Paris, France
| | - Bertrand Guidet
- AP-HP, Hôpital Saint-Antoine, Service de Réanimation Médicale, F-75012 Paris, France; Université Pierre et Marie Curie (UPMC), Univ Paris 06, Sorbonne Universités, F-75005 Paris, France; INSERM, UMR_S 707, F-75012 Paris, France
| | - Hafid Ait-Oufella
- AP-HP, Hôpital Saint-Antoine, Service de Réanimation Médicale, F-75012 Paris, France; Université Pierre et Marie Curie (UPMC), Univ Paris 06, Sorbonne Universités, F-75005 Paris, France; Paris Research Cardiovascular Center, Inserm U970, Paris, France
| |
Collapse
|
42
|
Pourquoi ne fais-je pas de monitoring hémodynamique ? MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1043-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
43
|
Incidence and impact of skin mottling over the knee and its duration on outcome in critically ill patients. Intensive Care Med 2014; 41:452-9. [PMID: 25516087 DOI: 10.1007/s00134-014-3600-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 12/03/2014] [Indexed: 02/06/2023]
Abstract
PURPOSE Skin mottling is frequent and can be associated with an increased mortality rate in ICU patients with septic shock. Its overall incidence in ICU and its impact on outcome is unknown. We aimed to assess the incidence of skin mottling over the knee among all critically ill patients admitted in ICU and its role on their outcome. METHODS An observational study over a 1-year period in a 15-bed medical ICU of a teaching hospital. Skin mottling over the knee was prospectively and qualitatively assessed by trained nurses. RESULTS Incidence of skin mottling was 29% (230 of 791 patients) in overall, and 49% (32 of 65 patients) in the subset of patients admitted for septic shock. Skin mottling was present on the day on admission in 65% of patients and persisted more than 6 h in 59% of cases. In-ICU mortality was 8% in patients without mottling, 30% in patients with short skin mottling and 40% in patients with persistent skin mottling (p < 0.01 between all groups). In the overall population, skin mottling over the knee was associated with in-ICU mortality independently from SAPS II (aOR 3.29 [95% CI, 2.08-5.19], p < 0.0001). Among patients with skin mottling over the knee, persistence of skin mottling remained associated with increased in-ICU mortality independently of organ dysfunctions at the mottling onset (OR 2.77 [95% CI, 1.34-5.72], p = 0.004). CONCLUSIONS Skin mottling is frequent in the general population of patients admitted in ICU. Occurrence and persistence of skin mottling are independently associated with in-ICU mortality.
Collapse
|
44
|
Lima A, Takala J. Clinical significance of monitoring perfusion in non-vital organs. Intensive Care Med 2014; 40:1052-4. [PMID: 24871502 DOI: 10.1007/s00134-014-3345-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 05/15/2014] [Indexed: 01/09/2023]
Affiliation(s)
- Alexandre Lima
- Department of Intensive Care Adults, Erasmus MC University Medical Centre, P.O. Box 2040, Room H625, 3000 CA, Rotterdam, The Netherlands,
| | | |
Collapse
|
45
|
Capillary refill time exploration during septic shock. Intensive Care Med 2014; 40:958-64. [DOI: 10.1007/s00134-014-3326-4] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 04/28/2014] [Indexed: 11/26/2022]
|
46
|
Gruartmoner G, Mesquida J, Baigorri F. Saturación tisular de oxígeno en el paciente crítico. Med Intensiva 2014; 38:240-8. [DOI: 10.1016/j.medin.2013.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 07/06/2013] [Accepted: 07/12/2013] [Indexed: 01/01/2023]
|
47
|
|
48
|
Association between static and dynamic thenar near-infrared spectroscopy and mortality in patients with sepsis: a systematic review and meta-analysis. J Trauma Acute Care Surg 2014; 76:226-33. [PMID: 24368385 DOI: 10.1097/ta.0b013e3182a9221f] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Oxygen delivery and consumption disturbances are frequently seen with critically illness, potentially leading to pathologic changes in tissue oxygenation (StO2). Near-infrared spectroscopy (NIRS) is a potentially useful method to monitor StO2, but the role of NIRS in prognostication of septic patients is uncertain. The aim of this study was to systematically review the literature and evaluate static and dynamic NIRS in patients with sepsis. METHODS This is a systematic review and meta-analysis of publications between 1966 and 2013. The MEDLINE and EMBASE databases were searched for studies on StO2 in patients with severe sepsis or septic shock. Meta-analysis was limited to studies about static and dynamic variables derived from NIRS in patients with sepsis. The association between StO2, reperfusion slope (Rres), occlusion slope, and maximum StO2 minus basal StO2 (ΔStO2) and prognosis in septic patients was evaluated. RESULTS The search identified 20 articles (962 participants; 717 with severe sepsis or septic shock, and 245 healthy controls). Compared with healthy controls, septic patients had lower levels of StO2 (78.27% [4.91%] vs. 82.02% [3.57%], p = 0.012), Rres (2.75% [0.63%] vs. 5.19% [2.86%] per second, p = 0.003), and ΔStO2 (7.86% [0.11%] vs. 12.53% [2.65%], p = 0.011). Survivors from sepsis presents higher levels of StO2 (81.68% [4.68%] vs. 74.54% [5.31%], p = 0.02) and Rres (3.37% [0.44%] vs. 2.16% [0.51%] per second, p = 0.016). CONCLUSION Septic patients have lower levels of StO2, Rres and ΔStO2, and survivors from sepsis present higher levels of StO2 and Rres compared with nonsurvivors. LEVEL OF EVIDENCE Systematic review/meta-analysis, level III.
Collapse
|
49
|
Macdonald SPJ, Brown SGA. Near-infrared spectroscopy in the assessment of suspected sepsis in the emergency department. Emerg Med J 2013; 32:404-8. [PMID: 24154943 DOI: 10.1136/emermed-2013-202956] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 10/06/2013] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND AIMS The conventional approach to sepsis resuscitation involves early interventions targeting global oxygenation and macro-haemodynamic variables such as central venous and systemic arterial pressures. There is increasing recognition of the importance of microcirculatory changes in shock states, including sepsis, and the relationship of these to outcome. Near-infrared spectroscopy (NIRS) is a recently developed non-invasive technology that measures tissue oxygen saturations (StO2), which may be an indirect measure of the adequacy of the microcirculation. StO2 measurements, therefore, have the potential to identify patients who are at risk of progressing to organ dysfunction and could be used to guide resuscitation. This article reviews the current state of knowledge of NIRS in the setting of sepsis, examining its application, validity and prognostic value. METHODS A search of the relevant literature was performed using Medline, Embase and Cochrane databases, and a qualitative analysis was undertaken. RESULTS A limited number of observational studies, mostly conducted among patients with severe sepsis, have shown that NIRS may correlate with severity of illness but demonstrate a variable relationship between StO2 and outcome. CONCLUSIONS Outstanding questions still remain as to whether NIRS can help to risk-stratify patients with suspected sepsis in the emergency department and the utility of StO2 as a resuscitation target.
Collapse
Affiliation(s)
- Stephen P J Macdonald
- Discipline of Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia Centre for Clinical Research in Emergency Medicine, Western Australian Institute for Medical Research, Perth, Western Australia, Australia Department of Emergency Medicine, Armadale Health Service, Armadale, Western Australia, Australia
| | - Simon G A Brown
- Discipline of Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia Centre for Clinical Research in Emergency Medicine, Western Australian Institute for Medical Research, Perth, Western Australia, Australia Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| |
Collapse
|
50
|
Ait-Oufella H, Bourcier S, Alves M, Galbois A, Baudel JL, Margetis D, Bige N, Offenstadt G, Maury E, Guidet B. Alteration of skin perfusion in mottling area during septic shock. Ann Intensive Care 2013; 3:31. [PMID: 24040941 PMCID: PMC3848827 DOI: 10.1186/2110-5820-3-31] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 08/21/2013] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Mottling score has been reported to be a strong predictive factor during septic shock. However, the pathophysiology of mottling remains unclear. METHODS In patients admitted in ICU for septic shock, we measured on the same area the mean skin perfusion by laser Doppler, the mottling score, and variations of both indices between T1 (6 hours after vasopressors were started) and T2 (24 hours later). RESULTS Fourteen patients were included, SAPS II was 56 [37-71] and SOFA score at T1 was 10 [7-12]. The mean skin surface area analyzed was 4108 ± 740 mm2; 1184 ± 141 measurements were performed over each defined skin surface area. Skin perfusion was significantly different according to mottling score and decreased from 37 [31-42] perfusion units (PUs) for a mottling score of [0-1] to 22 [20-32] PUs for a mottling score of [2-3] and 23 [16-28] for a score of [4-5] (Kruskal-Wallis test, P = 0.05). We analyzed skin perfusion changes during resuscitation in each patient and together with mottling score variations between T1 and T2 using a Wilcoxon signed-rank test. Among the 14 patients included, mottling score increased (worsened) in 5 patients, decreased (improved) in 5 patients, and remained stable in 4 patients. Baseline skin perfusion at T1 was arbitrarily scored 100%. Mean skin perfusion significantly decreased in all the patients whose mottling score worsened from 100% baseline to 63.2 ± 10.7% (P = 0.001), mean skin perfusion significantly increased in all patients whose mottling score improved from 100% baseline to 172.6 ± 46.8% (P = 0.001), and remained stable in patients whose mottling score did not change (100.5 ± 6.8%, P = 0.95). CONCLUSIONS We have shown that mottling score variations and skin perfusion changes during septic shock resuscitation were correlated, providing additional evidence that mottling reflects skin hypoperfusion.
Collapse
Affiliation(s)
- Hafid Ait-Oufella
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 184 rue du Faubourg Saint-Antoine, Cedex 12, Paris 75571, France.
| | | | | | | | | | | | | | | | | | | |
Collapse
|