1
|
De Lorenzo A, Fernandes M, Tibirica E. From bench to bedside: A review of the application and potential of microcirculatory assessment by hand-held videomicroscopy. IJC HEART & VASCULATURE 2024; 53:101451. [PMID: 39050555 PMCID: PMC11266521 DOI: 10.1016/j.ijcha.2024.101451] [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: 04/29/2024] [Revised: 06/02/2024] [Accepted: 06/19/2024] [Indexed: 07/27/2024]
Abstract
In clinical practice, there is vast knowledge regarding the evaluation of macrocirculatory parameters, such as systemic blood pressure and cardiac output, for the hemodynamic monitoring of patients. However, assessment of the microcirculation has not yet been incorporated into the bedside armamentarium. Hand-held intravital video microscopy enables the direct, noninvasive, evaluation of the sublingual microcirculation at the bedside, offering insights into the status of the systemic microcirculation. It is easily performed and may be employed in several clinical settings, providing immediate results that may help guide patient management. Therefore, the incorporation of hand-held intravital video microscopy into clinical practice may lead to tremendous improvements in the quality of care of critical, unstable patients or offer new data in the evaluation of patients with chronic diseases, especially those with microcirculatory involvement, such as occurs in diabetes.
Collapse
|
2
|
Kua KL, Rhoads E, Slaven JE, Edwards S, Haas DM, Ren CL, Tiller C, Bjerregaard J, Haneline LS, Tepper RS. Decreased vascular reactivity associated with increased IL-8 in 6-month-old infants of mothers with pre-eclampsia. Pediatr Res 2024:10.1038/s41390-024-03132-4. [PMID: 38509229 DOI: 10.1038/s41390-024-03132-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/22/2024] [Accepted: 02/15/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Offspring born to mothers with pre-eclampsia (Pre-E) suffer higher risks of adult cardiovascular diseases, suggesting that exposure to an antiangiogenic environment in-utero has a lasting impact on the development of endothelial function. The goal of this study is to test the hypothesis that in-utero exposure to Pre-E results in alterations of angiogenic factors/cytokines that negatively impact vascular development during infancy. METHODS Infants born from mothers with and without Pre-E were recruited and followed up at 6 months. Plasma cytokines, blood pressure, microvessel density, and vascular reactivity were assessed. RESULTS 6-month-old infants born to mothers with Pre-E had unchanged blood pressure (p = 0.86) and microvessel density (p = 0.57). Vascular reactivity was decreased in infants born to mothers with Pre-E compared to infants born to healthy mothers (p = 0.0345). Interleukin 8 (IL-8) (p = 0.03) and Angiopoeitin-2 (Ang-2) (p = 0.04) were increased in infants born to mothers with Pre-E. We observed that higher IL-8 was associated with lower vascular reactivity (rho = -0.14, p < 0.0001). CONCLUSION At 6 months of age, infants born to mothers with Pre-E had impaired vascular reactivity and higher IL-8 and Ang-2, but similar blood pressure and microvessel density compared to infants born to non-Pre-E mothers. IMPACT STATEMENT Changes in cord blood antiangiogenic factors are documented in infants of mothers with pre-eclampsia and may contribute to offspring risks of adult cardiovascular disease. How these factors evolve during early infancy and their correlation with offspring vascular development have not been studied. This study found that 6-month-old infants born to mothers with pre-eclampsia had decreased vascular reactivity, which was correlated with higher IL-8. These findings underscore the lasting impact of maternal pre-eclampsia on offspring vascular development and highlight the need for long-term follow-up in children born to mothers with pre-eclampsia.
Collapse
Affiliation(s)
- Kok Lim Kua
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eli Rhoads
- Department of Pediatrics, Division of Pediatric Pulmonology, University of Nebraska Medical Center, Omaha, NE, USA
| | - James E Slaven
- Department of Biostatistics and Health Data Sciences, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Shanique Edwards
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - David M Haas
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Clement L Ren
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Christina Tiller
- Department of Pediatrics, Division of Pulmonary, Allergy, and Sleep Medicine, Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jeffrey Bjerregaard
- Department of Pediatrics, Division of Pulmonary, Allergy, and Sleep Medicine, Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Laura S Haneline
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Robert S Tepper
- Department of Pediatrics, Division of Pulmonary, Allergy, and Sleep Medicine, Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA.
| |
Collapse
|
3
|
Erdem Ö, de Graaff JC, Hilty MP, Kraemer US, de Liefde II, van Rosmalen J, Ince C, Tibboel D, Kuiper JW. Microcirculatory Monitoring in Children with Congenital Heart Disease Before and After Cardiac Surgery. J Cardiovasc Transl Res 2023; 16:1333-1342. [PMID: 37450208 PMCID: PMC10721654 DOI: 10.1007/s12265-023-10407-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023]
Abstract
In this prospective observational study, we investigated whether congenital heart disease (CHD) affects the microcirculation and whether the microcirculation is altered following cardiac surgery with cardiopulmonary bypass (CPB). Thirty-eight children with CHD undergoing cardiac surgery with CPB and 35 children undergoing elective, non-cardiac surgery were included. Repeated non-invasive sublingual microcirculatory measurements were performed with handheld vital microscopy. Before surgery, children with CHD showed similar perfused vessel densities and red blood cell velocities (RBCv) but less perfused vessels (p < 0.001), lower perfusion quality (p < 0.001), and higher small vessel densities (p = 0.039) than children without CHD. After cardiac surgery, perfused vessel densities and perfusion quality of small vessels declined (p = 0.025 and p = 0.032), while RBCv increased (p = 0.032). We demonstrated that CHD was associated with decreased microcirculatory perfusion and increased capillary recruitment. The microcirculation was further impaired after cardiac surgery. Decreased microcirculatory perfusion could be a warning sign for altered tissue oxygenation and requires further exploration.
Collapse
Affiliation(s)
- Özge Erdem
- Intensive Care and department of Pediatric Surgery, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Jurgen C de Graaff
- Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Matthias P Hilty
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Ulrike S Kraemer
- Intensive Care and department of Pediatric Surgery, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Inge I de Liefde
- Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Dick Tibboel
- Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jan Willem Kuiper
- Intensive Care and department of Pediatric Surgery, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| |
Collapse
|
4
|
Liu B, He H, Feng X, Yuan S, Long Y, Akin Ş, Ince C. Sublingual microcirculation: comparison between the 415 nm blue light and 520 nm green light of sidestream dark field videomicroscopes. J Clin Monit Comput 2023; 37:297-302. [PMID: 35838871 DOI: 10.1007/s10877-022-00891-5] [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: 01/10/2022] [Accepted: 06/28/2022] [Indexed: 01/24/2023]
Abstract
Green light with a wavelength of 520 nm is commonly used in sidestream dark field (SDF) video microscopes for sublingual microcirculation assessment in clinical practice. However, blue light could obtain a clearer microcirculatory image due to a higher light absorption coefficient of hemoglobin. The aim of this study was to compare the sublingual microcirculatory image quality acquisition and related microcirculatory parameters between 520 nm green light and 415 nm blue light probes in the SDF device named MicroSee V100. Sublingual microcirculation films from twenty-one healthy volunteers were prospectively collected by blue light and green light probes, and only one video of each wavelength was recorded and analyzed in each volunteer. Moreover, 200 sublingual microcirculation films (100 by blue light probe and 100 by green light probe) of ICU patients were retrospectively scored for microcirculation image quality. Compared to green light, an increase in the perfused vessel density (paired t test, increased by 4.6 ± 4.7 mm/mm2, P < 0.0001) and total vessel density (paired t test, increased by 5.1 ± 4.6 mm/mm2, P < 0.0001) was observed by blue light in the healthy volunteers. The blue light probe had a significantly lower rate of unacceptable films than the green light probe in the 200 films of ICU patients (10/100 vs. 39/100, P < 0.0001). Blue light provides a higher microcirculatory vessel density and image quality than the existing SDF probe using green light.
Collapse
Affiliation(s)
- Bo Liu
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
- Department of Critical Care Medicine, affiliated hospital of Ji Ning Medical University, Jining, China
| | - Huaiwu He
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China.
- Department of Intensive Care, Erasmus MC University Hospital Rotterdam, Rotterdam, Netherlands.
| | - Xiaokai Feng
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
- ICU, Hebi People's Hospital of Henan Province, Zhengzhou, China
| | - Siyi Yuan
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Şakir Akin
- Department of Intensive Care, Erasmus MC University Hospital Rotterdam, Rotterdam, Netherlands
- Department of Intensive Care, Haga Teaching Hospital, The Hague, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus MC University Hospital Rotterdam, Rotterdam, Netherlands
| |
Collapse
|
5
|
Bottino DA, Bouskela E. Non-invasive techniques to access in vivo the skin microcirculation in patients. Front Med (Lausanne) 2023; 9:1099107. [PMID: 36687444 PMCID: PMC9849756 DOI: 10.3389/fmed.2022.1099107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/12/2022] [Indexed: 01/06/2023] Open
Abstract
The microcirculation is composed of blood vessels with mean internal diameter smaller than 100 μm. This structure is responsible for survival of cells and in the last 50 years its study has become increasingly interesting because it often participates in the pathophysiology of several diseases or can determine better or worse prognosis for them. Due to the growing importance of knowing more about the microcirculation, several techniques have been developed and now it is possible to study its structure or function. In the last 25 years, the cutaneous microcirculation has emerged as an accessible and representative portion of generalized vascular bed allowing the examination of mechanisms of microcirculatory function and dysfunction. This mini review presents several techniques used for non-invasive access to skin microcirculation, such as Nailfold Videocapillaroscopy, Orthogonal Polarization Spectral Imaging, Sidestream Dark Field Imaging, Incident Dark field Illumination, Laser Doppler Flowmetry, and Laser Speckle Contrast Imaging applied. The techniques presented will describe which types of variables (structural or functional) can be evaluated, their limitations and potential uses.
Collapse
|
6
|
Effects of Fluids on the Sublingual Microcirculation in Sepsis. J Clin Med 2022; 11:jcm11247277. [PMID: 36555895 PMCID: PMC9786137 DOI: 10.3390/jcm11247277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/02/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
Sepsis is one of the most common and deadly syndromes faced in Intensive Care settings globally. Recent advances in bedside imaging have defined the changes in the microcirculation in sepsis. One of the most advocated interventions for sepsis is fluid therapy. Whether or not fluid bolus affects the microcirculation in sepsis has not been fully addressed in the literature. This systematic review of the evidence aims to collate studies examining the microcirculatory outcomes after a fluid bolus in patients with sepsis. We will assimilate the evidence for using handheld intra vital microscopes to guide fluid resuscitation and the effect of fluid bolus on the sublingual microcirculation in patients with sepsis and septic shock. We conducted a systematic search of Embase, CENTRAL and Medline (PubMed) using combinations of the terms "microcirculation" AND "fluid" OR "fluid resuscitation" OR "fluid bolus" AND "sepsis" OR "septic shock". We found 3376 potentially relevant studies. Fifteen studies published between 2007 and 2021 fulfilled eligibility criteria to be included in analysis. The total number of participants was 813; we included six randomized controlled trials and nine non-randomized, prospective observational studies. Ninety percent used Sidestream Dark Field microscopy to examine the microcirculation and 50% used Hydroxyethyl Starch as their resuscitation fluid. There were no clear effects of fluid on the microcirculation parameters. There was too much heterogeneity between studies and methodology to perform meta-analysis. Studies identified heterogeneity of affect in the sepsis population, which could mean that current clinical classifications were not able to identify different microcirculation characteristics. Use of microcirculation as a clinical endpoint in sepsis could help to define sepsis phenotypes. More research into the effects of different resuscitation fluids on the microcirculation is needed.
Collapse
|
7
|
Cusack R, Leone M, Rodriguez AH, Martin-Loeches I. Endothelial Damage and the Microcirculation in Critical Illness. Biomedicines 2022; 10:biomedicines10123150. [PMID: 36551905 PMCID: PMC9776078 DOI: 10.3390/biomedicines10123150] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 11/22/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022] Open
Abstract
Endothelial integrity maintains microcirculatory flow and tissue oxygen delivery. The endothelial glycocalyx is involved in cell signalling, coagulation and inflammation. Our ability to treat critically ill and septic patients effectively is determined by understanding the underpinning biological mechanisms. Many mechanisms govern the development of sepsis and many large trials for new treatments have failed to show a benefit. Endothelial dysfunction is possibly one of these biological mechanisms. Glycocalyx damage is measured biochemically. Novel microscopy techniques now mean the glycocalyx can be indirectly visualised, using sidestream dark field imaging. How the clinical visualisation of microcirculation changes relate to biochemical laboratory measurements of glycocalyx damage is not clear. This article reviews the evidence for a relationship between clinically evaluable microcirculation and biological signal of glycocalyx disruption in various diseases in ICU. Microcirculation changes relate to biochemical evidence of glycocalyx damage in some disease states, but results are highly variable. Better understanding and larger studies of this relationship could improve phenotyping and personalised medicine in the future. Damage to the glycocalyx could underpin many critical illness pathologies and having real-time information on the glycocalyx and microcirculation in the future could improve patient stratification, diagnosis and treatment.
Collapse
Affiliation(s)
- Rachael Cusack
- Department of Intensive Care Medicine, St. James’s Hospital, James’s Street, D08 NHY1 Dublin, Ireland
- School of Medicine, Trinity College Dublin, College Green, D02 R590 Dublin, Ireland
| | - Marc Leone
- Department of Anaesthesiology and Intensive Care Unit, Hospital Nord, Assistance Publique Hôpitaux de Marseille, Aix Marseille University, 13015 Marseille, France
| | - Alejandro H. Rodriguez
- Intensive Care Unit, Hospital Universitario Joan XXIII, 43005 Tarragona, Spain
- Institut d’Investigació Sanitària Pere Virgil, 43007 Tarragona, Spain
- Departament Medicina I Cirurgia, Universitat Rovira i Virgili, 43003 Tarragona, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, St. James’s Hospital, James’s Street, D08 NHY1 Dublin, Ireland
- School of Medicine, Trinity College Dublin, College Green, D02 R590 Dublin, Ireland
- Correspondence:
| |
Collapse
|
8
|
Raia L, Zafrani L. Endothelial Activation and Microcirculatory Disorders in Sepsis. Front Med (Lausanne) 2022; 9:907992. [PMID: 35721048 PMCID: PMC9204048 DOI: 10.3389/fmed.2022.907992] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/16/2022] [Indexed: 11/19/2022] Open
Abstract
The vascular endothelium is crucial for the maintenance of vascular homeostasis. Moreover, in sepsis, endothelial cells can acquire new properties and actively participate in the host's response. If endothelial activation is mostly necessary and efficient in eliminating a pathogen, an exaggerated and maladaptive reaction leads to severe microcirculatory damage. The microcirculatory disorders in sepsis are well known to be associated with poor outcome. Better recognition of microcirculatory alteration is therefore essential to identify patients with the worse outcomes and to guide therapeutic interventions. In this review, we will discuss the main features of endothelial activation and dysfunction in sepsis, its assessment at the bedside, and the main advances in microcirculatory resuscitation.
Collapse
Affiliation(s)
- Lisa Raia
- Medical Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Lara Zafrani
- Medical Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique des Hôpitaux de Paris, Paris, France
- INSERM UMR 976, University of Paris Cité, Paris, France
- *Correspondence: Lara Zafrani
| |
Collapse
|
9
|
Güven G, Uz Z, Hilty MP, Bilecenoğlu B, Akin Ș, Ince Y, Ince C. Morphologic Mapping of the Sublingual Microcirculation in Healthy Volunteers. J Vasc Res 2022; 59:199-208. [PMID: 35313312 DOI: 10.1159/000522394] [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: 08/23/2021] [Accepted: 01/19/2022] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Monitoring the sublingual and oral microcirculation (SM-OM) using hand-held vital microscopes (HVMs) has provided valuable insight into the (patho)physiology of diseases. However, the microvascular anatomy in a healthy population has not been adequately described yet. METHODS Incident dark field-based HVM imaging was used to visualize the SM-OM. First, the SM was divided into four different fields; Field-a (between incisors-lingua), Field-b (between the canine-first premolar-lingua), Field-c (between the first-second premolar-lingua), Field-d (between the second molar-wisdom teeth-lingua). Second, we investigated the buccal area, lower and upper lip. Total/functional vessel density (TVD/FCD), focus depth (FD), small vessel mean diameters (SVMDs), and capillary tortuosity score (CTS) were compared between the areas. RESULTS Fifteen volunteers with a mean age of 29 ± 6 years were enrolled. No statistical difference was found between the sublingual fields in terms of TVD (p = 0.30), FCD (p = 0.38), and FD (p = 0.09). SVMD was similar in Field-a, Field-b, and Field-c (p = 0.20-0.30), and larger in Field-d (p < 0.01, p = 0.015). The CTS of the buccal area was higher than in the lips. CONCLUSION The sublingual area has a homogenous distribution in TVD, FCD, FD, and SVMD. This study can be a description of the normal microvascular anatomy for future researches regarding microcirculatory assessment.
Collapse
Affiliation(s)
- Göksel Güven
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Translational Physiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Department of Intensive Care, Hacettepe University, Ankara, Turkey
| | - Zühre Uz
- Department of Translational Physiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Matthias P Hilty
- Institute of Intensive Care, University Hospital of Zurich, Zurich, Switzerland
| | | | - Șakir Akin
- Department of Intensive Care, Hagaziekenhuis Teaching Hospital of The Hague, The Hague, The Netherlands
| | - Yasin Ince
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Translational Physiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
10
|
Urbán D, Cserni T, Boros M, Juhász Á, Érces D, Varga G. Bladder augmentation from an insider's perspective: a review of the literature on microcirculatory studies. Int Urol Nephrol 2021; 53:2221-2230. [PMID: 34435307 DOI: 10.1007/s11255-021-02971-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/03/2021] [Indexed: 02/07/2023]
Abstract
Augmentation cystoplasty is an exemplary multiorgan intervention in urology which is particularly associated with microvascular damage. Our aim was to review the available intravital imaging techniques and data obtained from clinical and experimental microcirculatory studies involving the most important donor organs applied in bladder augmentation. Although numerous direct or indirect methods are available to assess the condition of microvessels the implementation of microcirculatory diagnostic methods in humans is still challenging and the assessment of organ microcirculation in the operating theatre has limitations. Nevertheless, preclinical studies generally report good internal validity and although prospective human protocols with reduced variability are needed, a possible positive impact of microcirculatory diagnostics on the clinical outcomes of urologic surgery can be anticipated.
Collapse
Affiliation(s)
- Dániel Urbán
- Institute of Surgical Research, University of Szeged, Pulz u. 1., Szeged, 6724, Hungary.,Department of General and Thoracic Surgery, Hetényi Géza County Hospital, Tószegi u. 21., Szolnok, 5000, Hungary
| | - Tamás Cserni
- Institute of Surgical Research, University of Szeged, Pulz u. 1., Szeged, 6724, Hungary.,Department of Paediatric Urology, The Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Mihály Boros
- Institute of Surgical Research, University of Szeged, Pulz u. 1., Szeged, 6724, Hungary
| | - Árpád Juhász
- Department of General and Thoracic Surgery, Hetényi Géza County Hospital, Tószegi u. 21., Szolnok, 5000, Hungary
| | - Dániel Érces
- Institute of Surgical Research, University of Szeged, Pulz u. 1., Szeged, 6724, Hungary
| | - Gabriella Varga
- Institute of Surgical Research, University of Szeged, Pulz u. 1., Szeged, 6724, Hungary.
| |
Collapse
|
11
|
Bush MA, Florence SM, Yeo TW, Kalingonji AR, Chen Y, Granger DL, Rubach MP, Anstey NM, Mwaikambo ED, Weinberg JB. Degradation of endothelial glycocalyx in Tanzanian children with falciparum malaria. FASEB J 2021; 35:e21805. [PMID: 34403544 DOI: 10.1096/fj.202100277rr] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 06/25/2021] [Accepted: 07/01/2021] [Indexed: 01/20/2023]
Abstract
A layer of glycocalyx covers the vascular endothelium serving important protective and homeostatic functions. The objective of this study was to determine if breakdown of the endothelial glycocalyx (eGC) occurs during malaria infection in children. Measures of eGC integrity, endothelial activation, and microvascular reactivity were prospectively evaluated in 146 children: 44 with moderately severe malaria (MSM), 42 with severe malaria (SM), and 60 healthy controls (HC). Biochemical measures of eGC integrity included plasma syndecan-1 and total urinary glycosaminoglycans (GAG). Side-stream dark field imaging was used to quantitatively assess integrity of eGC. Plasma angiopoietin-2 (Ang-2) was measured as a marker of endothelial activation and also as a possible mediator of eGC breakdown. Our results show that urinary GAG, syndecan-1, and Ang-2 were elevated in patients with MSM and SM compared with HC. Syndecan-1 and GAG levels correlated significantly with each other and with plasma Ang-2. The eGC breakdown products also inversely correlated significantly with hemoglobin and platelet count. In the MSM group, imaging results provided further evidence for eGC degradation. Although not correlated with markers of eGC degradation, vascular function (assessed by non-invasive near infrared spectroscopy [NIRS]) demonstrated reduced microvascular reactivity, particularly affecting the SM group. Our findings provide further evidence for breakdown of eGC in falciparum malaria that may contribute to endothelial activation and adhesion of parasitized red blood cells, with reduced nitric oxide formation, and vascular dysfunction.
Collapse
Affiliation(s)
- Margaret A Bush
- School of Medicine, Duke University and Durham VA Medical Centers, Durham, NC, USA
| | | | - Tsin W Yeo
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia.,Lee Kong Chian School of Medicine, Nanyang Technological University, Republic of Singapore.,National Centre for Infectious Diseases, Tan Tock Seng Hospital, Republic of Singapore
| | | | - Youwei Chen
- School of Medicine, Duke University and Durham VA Medical Centers, Durham, NC, USA
| | - Donald L Granger
- University of Utah and VA Medical Centers, Salt Lake City, UT, USA
| | - Matthew P Rubach
- School of Medicine, Duke University and Durham VA Medical Centers, Durham, NC, USA
| | - Nicholas M Anstey
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | | | - Joe Brice Weinberg
- School of Medicine, Duke University and Durham VA Medical Centers, Durham, NC, USA
| |
Collapse
|
12
|
Katunaric B, Cohen KE, Beyer AM, Gutterman DD, Freed JK. Sweat the small stuff: The human microvasculature and heart disease. Microcirculation 2021; 28:e12658. [PMID: 32939881 PMCID: PMC7960576 DOI: 10.1111/micc.12658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/13/2020] [Accepted: 09/07/2020] [Indexed: 01/09/2023]
Abstract
Traditionally thought of primarily as the predominant regulator of myocardial perfusion, it is becoming more accepted that the human coronary microvasculature also exerts a more direct influence on the surrounding myocardium. Coronary microvascular dysfunction (CMD) not only precedes large artery atherosclerosis, but is associated with other cardiovascular diseases such as heart failure with preserved ejection fraction and hypertrophic cardiomyopathy. It is also highly predictive of cardiovascular events in patients with or without atherosclerotic cardiovascular disease. This review focuses on this recent paradigm shift and delves into the clinical consequences of CMD. Concepts of how resistance arterioles contribute to disease will be discussed, highlighting how the microvasculature may serve as a potential target for novel therapies and interventions. Finally, both invasive and non-invasive methods with which to assess the coronary microvasculature both for diagnostic and risk stratification purposes will be reviewed.
Collapse
Affiliation(s)
- Boran Katunaric
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Katie E. Cohen
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Medicine-Division of Cardiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Andreas M. Beyer
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Medicine-Division of Cardiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David D. Gutterman
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Medicine-Division of Cardiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Julie K. Freed
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, USA
| |
Collapse
|
13
|
Latul YP, Kastelein AW, Beemster PWT, van Trommel NE, Ince C, Roovers JPWR. Noninvasive, in vivo assessment of the cervical microcirculation using incident dark field imaging. Microvasc Res 2021; 135:104145. [PMID: 33571547 DOI: 10.1016/j.mvr.2021.104145] [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: 01/15/2021] [Revised: 02/03/2021] [Accepted: 02/04/2021] [Indexed: 11/17/2022]
Abstract
AIM This study evaluates the feasibility of handheld vital microscopy for noninvasive, objective assessment of the microcirculation of the human uterine cervix. We qualitatively and quantitatively describe the microcirculation in healthy subjects in order to provide a basis for its application in cervical pathology. METHODS Incident dark field imaging was used to image the microcirculation in four quadrants of the uterine ectocervix in ten healthy participants. If the squamocolumnar junction was visible, measurements were repeated on the endocervical columnar epithelium as well. Image acquisition time was recorded and participants scored the experienced level of discomfort. Angioarchitecture was classified according to Weber's classification. Quantitative parameters included capillary density (CD), total and perfused vessel density (TVD, PVD), proportion of perfused vessels (PPV) and microvascular flow index (MFI). RESULTS Image acquisition was easy, fast and well tolerated. Angioarchitecture was characterized by two distinctive and organized patterns; capillary loops underneath the squamous epithelium of the ectocervix and vascular networks underneath the columnar epithelium. In the image sequences containing capillary loops, mean CD was 33.2 cpll/mm2 (95% CI 28.2-38.2 cpll/mm2). In the image sequences with vascular networks, mean TVD was 12.5 mm/mm2 (95% CI 11.2-13.77 mm/mm2), mean PVD was 12.2 (95% CI 11.0-13.5 mm/mm2), MFI was 3 and PPV was 100%. CONCLUSIONS Incident dark field imaging allows for noninvasive, real time visualization and objective evaluation and quantification of the microcirculation of the uterine cervix. The organized vascular patterns and optimal perfusion observed in healthy subjects allow for comparison with cervical pathology, for example in patients with cervical dysplasia or cervical cancer.
Collapse
Affiliation(s)
- Yani P Latul
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
| | - Arnoud W Kastelein
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Patricia W T Beemster
- Bergman Clinics, Department of Gynaecology, Bergman Vrouwenzorg, Nijenburg 152, 1081 GG Amsterdam, the Netherlands
| | - Nienke E van Trommel
- Center for Gynecologic Oncology Amsterdam, Location Antoni van Leeuwenhoek Hospital/The Netherlands Cancer Institute, Plesmanlaan 121, 1066CX Amsterdam, the Netherlands
| | - Can Ince
- Erasmus Medical Center, Department of Intensive Care, Laboratory of Translational Intensive Care, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Jan-Paul W R Roovers
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Bergman Clinics, Department of Gynaecology, Bergman Vrouwenzorg, Nijenburg 152, 1081 GG Amsterdam, the Netherlands
| |
Collapse
|
14
|
Bruno RR, Schemmelmann M, Wollborn J, Kelm M, Jung C. Evaluation of a shorter algorithm in an automated analysis of sublingual microcirculation. Clin Hemorheol Microcirc 2020; 76:287-297. [PMID: 32925005 DOI: 10.3233/ch-209201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Diagnostic and risk stratification in intensive and emergency medicine must be fast, accurate, and reliable. The assessment of sublingual microcirculation is a promising tool for this purpose. However, its value is limited because the measurement is time-consuming in unstable patients. This proof-of-concept validation study examines the non-inferiority of a reduced frame rate in image acquisition regarding quality, measurement results, and time. METHODS This prospective observational study included healthy volunteers. Sublingual measurement of microcirculation was performed using a sidestream dark field camera (SDF, MicroVision Medical®). Video-quality was evaluated with a modified MIQS (microcirculation image quality score). AVA 4.3C software calculated microcirculatory parameters. RESULTS Thirty-one volunteers were included. There was no impact of the frame rate on the time needed by the software algorithm to measure one video (4.5 ± 0.5 minutes) for AVA 4.3C. 86 frames per video provided non inferior video quality (MIQS 1.8 ± 0.7 for 86 frames versus MIQS 2.2 ± 0.6 for 215 frames, p < 0.05), equal results for all microcirculatory parameters, but did not result in an advantage in terms of speed. No complications occurred. CONCLUSION Video captures with 86 frames offer equal video quality and results for consensus parameters compared to 215 frames. However, there was no advantage regarding the time needed for the overall measurement procedure.
Collapse
Affiliation(s)
- Raphael Romano Bruno
- Department of Cardiology, Pulmonary Diseases, and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Mara Schemmelmann
- Department of Cardiology, Pulmonary Diseases, and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Jakob Wollborn
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Malte Kelm
- Department of Cardiology, Pulmonary Diseases, and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf (CARID), Düsseldorf, Germany
| | - Christian Jung
- Department of Cardiology, Pulmonary Diseases, and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| |
Collapse
|
15
|
McBride A, Chanh HQ, Fraser JF, Yacoub S, Obonyo NG. Microvascular dysfunction in septic and dengue shock: Pathophysiology and implications for clinical management. Glob Cardiol Sci Pract 2020; 2020:e202029. [PMID: 33447608 PMCID: PMC7773436 DOI: 10.21542/gcsp.2020.29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The microcirculation comprising of arterioles, capillaries and post-capillary venules is the terminal vascular network of the systemic circulation. Microvascular homeostasis, comprising of a balance between vasoconstriction, vasodilation and endothelial permeability in healthy states, regulates tissue perfusion. In severe infections, systemic inflammation occurs irrespective of the infecting microorganism(s), resulting in microcirculatory dysregulation and dysfunction, which impairs tissue perfusion and often precedes end-organ failure. The common hallmarks of microvascular dysfunction in both septic shock and dengue shock, are endothelial cell activation, glycocalyx degradation and plasma leak through a disrupted endothelial barrier. Microvascular tone is also impaired by a reduced bioavailability of nitric oxide. In vitro and in vivo studies have however demonstrated that the nature and extent of microvascular dysfunction as well as responses to volume expansion resuscitation differ in these two clinical syndromes. This review compares and contrasts the pathophysiology of microcirculatory dysfunction in septic versus dengue shock and the attendant effects of fluid administration during resuscitation.
Collapse
Affiliation(s)
- Angela McBride
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam.,Brighton and Sussex Medical School, United Kingdom
| | - Ho Q Chanh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - John F Fraser
- Critical Care Research Group, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - Sophie Yacoub
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam.,Centre for Tropical Medicine and Global Health, University of Oxford, United Kingdom
| | - Nchafatso G Obonyo
- Critical Care Research Group, Brisbane, Australia.,KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Initiative to Develop African Research Leaders, Kilifi, Kenya
| |
Collapse
|
16
|
Liu W, He H, Ince C, Long Y. The effect of blood transfusion on sublingual microcirculation in critically ill patients: A scoping review. Microcirculation 2020; 28:e12666. [PMID: 33091957 DOI: 10.1111/micc.12666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 10/10/2020] [Accepted: 10/14/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE To investigate the effects of red blood cell (RBC) transfusion on sublingual microcirculation in critically ill patients. METHODS Systematic strategy was conducted to search studies that measured sublingual microcirculation before and after transfusion in critically ill patients. This review was reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses Scoping Review Extension. RESULTS The literature search yielded 114 articles. A total of 11 studies met the inclusion criteria. Observational evidence showed diffusive capacity of the microcirculation significantly improved in intraoperative and anemic hematologic patients after transfusion, while the convective parameters significantly improved in traumatic patients. RBC transfusion improved both diffusive and convective microcirculatory parameters in hypovolemic hemorrhagic shock patients. Most of the studies enrolled septic patients showed no microcirculatory improvements after transfusion. The positive effects of the leukoreduction were insufficiently supported. The effects of the storage time of the RBCs were not conclusive. The majority of the evidence supported a negative correlation between baseline proportion of perfused vessels (PPV) and changes in PPV. CONCLUSIONS This scoping review has catalogued evidence that RBC transfusion differently improves sublingual microcirculation in different populations. The existing evidence is not sufficient to conclude the effects of the leukoreduction and storage time of RBCs.
Collapse
Affiliation(s)
- Wanglin Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Huaiwu He
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Can Ince
- Department of Intensive Care, Laboratory of Translational Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| |
Collapse
|
17
|
Berhouma M, Picart T, Dumot C, Pelissou-Guyotat I, Meyronet D, Ducray F, Honnorat J, Eker O, Guyotat J, Lukaszewicz AC, Cotton F. Alterations of cerebral microcirculation in peritumoral edema: feasibility of in vivo sidestream dark-field imaging in intracranial meningiomas. Neurooncol Adv 2020; 2:vdaa108. [PMID: 33063011 PMCID: PMC7542984 DOI: 10.1093/noajnl/vdaa108] [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: 11/25/2022] Open
Abstract
Background Intracranial meningiomas display a variable amount of peritumoral brain edema (PTBE), which can significantly impact perioperative morbidity. The role of microcirculatory disturbances in the pathogenesis of PTBE is still debated. The aim of this study was to microscopically demonstrate and intraoperatively quantify, for the first time, the alterations to microcirculation in PTBE using sidestream dark-field (SDF) imaging. Methods Adult patients with WHO grade I meningiomas were recruited over a 9-month period and divided into 2 groups depending on the absence (NE group) or the presence (E group) of PTBE. In vivo intraoperative microcirculation imaging was performed in the peritumoral area before and after microsurgical resection. Results Six patients were included in the NE group and 6 in the E group. At the baseline in the NE group, there was a minor decrease in microcirculatory parameters compared to normal reference values, which was probably due to the mass effect. In contrast, microcirculatory parameters in the E group were significantly altered, affecting both vessel density and blood flow values, with a drop of approximately 50% of normal values. Surgical resection resulted in a quasi-normalization of microcirculation parameters in the NE group, whereas in the E group, even if all parameters statistically significantly improved, post-resection values remained considerably inferior to those of the normal reference pattern. Conclusion Our study confirmed significant alterations of microcirculatory parameters in PTBE in meningiomas. Further in vivo SDF imaging studies may explore the possible correlation between the severity of these microcirculatory alterations and the postoperative neurological outcome.
Collapse
Affiliation(s)
- Moncef Berhouma
- Department of Neurosurgical Oncology and Vascular Neurosurgery, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon, Lyon, France.,Creatis Lab, CNRS UMR 5220, INSERM U1206, Lyon 1 University, INSA Lyon, Lyon, France
| | - Thiebaud Picart
- Department of Neurosurgical Oncology and Vascular Neurosurgery, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon, Lyon, France
| | - Chloe Dumot
- Department of Neurosurgical Oncology and Vascular Neurosurgery, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon, Lyon, France
| | - Isabelle Pelissou-Guyotat
- Department of Neurosurgical Oncology and Vascular Neurosurgery, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon, Lyon, France
| | - David Meyronet
- Department of Pathology, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon, Lyon, France.,Centre de Recherche en Cancérologie de Lyon INSERM U1052 CNRS 5286, Lyon 1 University, Lyon, France
| | - François Ducray
- Department of Neurooncology, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon, Lyon, France
| | - Jerome Honnorat
- Department of Neurooncology, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon, Lyon, France
| | - Omer Eker
- Creatis Lab, CNRS UMR 5220, INSERM U1206, Lyon 1 University, INSA Lyon, Lyon, France.,Department of Neuroradiology, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon, Lyon, France
| | - Jacques Guyotat
- Department of Neurosurgical Oncology and Vascular Neurosurgery, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon, Lyon, France
| | - Anne-Claire Lukaszewicz
- Department of Neuroanesthesia and Neurocritical Care, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon, Lyon, France
| | - François Cotton
- Creatis Lab, CNRS UMR 5220, INSERM U1206, Lyon 1 University, INSA Lyon, Lyon, France.,Department of Neuroimaging, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| |
Collapse
|
18
|
Magnin M, Foulon É, Lurier T, Allaouchiche B, Bonnet-Garin JM, Junot S. Evaluation of microcirculation by Sidestream Dark Field imaging: Impact of hemodynamic status on the occurrence of pressure artifacts - A pilot study. Microvasc Res 2020; 131:104025. [PMID: 32497537 DOI: 10.1016/j.mvr.2020.104025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aims of the study were to evaluate the influence of hemodynamic status on pressure artifacts and the impact of pressure artifacts on microcirculatory flow. METHODS Sublingual microcirculation was assessed using a Sidestream Dark Field handheld imaging device in 7 anesthetized piglets, submitted to pharmacologically-induced blood pressure variations. For each video, a pressure score of 0, 1, or 10 was assigned for the category "pressure artifacts" of the "microcirculation image quality score". Videos with a pressure score of 0 and 1 were considered as "passing videos". The videos with a score of 10 were considered as "failing videos". Multivariate logistic regression models and multivariate linear mixed models with individual random effects were used. RESULTS As blood pressure decreased, the probability of obtaining a "failing video" increased (P = 0.0008). Pressure scores of 10 influenced significantly the perfused De Backer score (small and all vessels), the proportion of perfused vessels (small and all vessels), the microvascular flow index and the heterogeneity index. Pressure scores of 1 influenced significantly the parameters above-mentioned, except the perfused De Backer score for all vessels. CONCLUSION The probability of obtaining pressure artifacts during recording of microcirculation videos was higher when the arterial pressure was low. The presence of acceptable pressure artifacts also influenced microcirculation analysis.
Collapse
Affiliation(s)
- Mathieu Magnin
- Université de Lyon, VetAgro Sup, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, Vetagro Sup, Unité de Physiologie, Pharmacodynamie et Thérapeutique, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France.
| | - Élisa Foulon
- Université de Lyon, VetAgro Sup, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, Vetagro Sup, Unité de Physiologie, Pharmacodynamie et Thérapeutique, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France.
| | - Thibaut Lurier
- Université Clermont Auvergne, INRAE, VetAgro Sup, UMR EPIA, Theix, F-63122 Saint-Genès-Champanelle, France; Université de Lyon, INRAE, VetAgro Sup, UMR EPIA, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, INRAE, VetAgro Sup, Usc 1233 UR RS2GP, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France.
| | - Bernard Allaouchiche
- Université de Lyon, VetAgro Sup, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Réanimation Médicale, 165 Chemin du Grand Revoyet, F-69310 Pierre-Bénite, France.
| | - Jeanne-Marie Bonnet-Garin
- Université de Lyon, VetAgro Sup, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, Vetagro Sup, Unité de Physiologie, Pharmacodynamie et Thérapeutique, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France.
| | - Stéphane Junot
- Université de Lyon, VetAgro Sup, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, VetAgro Sup, Service d'Anesthésie-Analgésie, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France.
| |
Collapse
|
19
|
Wernly B, Pernow J, Kelm M, Jung C. The role of arginase in the microcirculation in cardiovascular disease. Clin Hemorheol Microcirc 2020; 74:79-92. [PMID: 31743994 DOI: 10.3233/ch-199237] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In the microcirculation, the exchange of nutrients, water, gas, hormones, and waste takes place, and it is divided into the three main sections arterioles, capillaries, and venules. Disturbances in the microcirculation can be measured using surrogate parameters or be visualized either indirectly or directly.Arginase is a manganese metalloenzyme hydrolyzing L-arginine to urea and L-ornithine. It is located in different cell types, including vascular cells, but also in circulating cells such as red blood cells. A variety of pro-inflammatory factors, as well as interleukins, stimulate increased arginase expression. An increase in arginase activity consequently leads to a consumption of L-arginine needed for nitric oxide (NO) production by endothelial NO synthase. A vast body of evidence convincingly showed that increased arginase activity is associated with endothelial dysfunction in larger vessels of the vascular tree. Of note, arginase also influences the microcirculation. Arginase inhibition leads to an increase in the bioavailability of NO and reduces superoxide levels, resulting in improved endothelial function. Arginase inhibition might, therefore, be a potent treatment strategy in cardiovascular medicine. Recently, red blood cells emerged as an influential player in the development from increased arginase activity to endothelial dysfunction. As red blood cells directly interact with the microcirculation in gas exchange, this could constitute a potential link between arginase activity, endothelial dysfunction and microcirculatory disturbances.The aim of this review is to summarize recent findings revealing the role of arginase in regulating vascular function with particular emphasis on the microcirculation.
Collapse
Affiliation(s)
- Bernhard Wernly
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - John Pernow
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Malte Kelm
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - Christian Jung
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| |
Collapse
|
20
|
Dilken O, Ergin B, Ince C. Assessment of sublingual microcirculation in critically ill patients: consensus and debate. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:793. [PMID: 32647718 PMCID: PMC7333125 DOI: 10.21037/atm.2020.03.222] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The main concern in shock and resuscitation is whether the microcirculation can carry adequate oxygen to the tissues and remove waste. Identification of an intact coherence between macro- and microcirculation during states of shock and resuscitation shows a functioning regulatory mechanism. However, loss of hemodynamic coherence between the macro and microcirculation can be encountered frequently in sepsis, cardiogenic shock, or any hemodynamically compromised patient. This loss of hemodynamic coherence results in an improvement in macrohemodynamic parameters following resuscitation without a parallel improvement in microcirculation resulting in tissue hypoxia and tissue compromise. Hand-held vital microscopes (HVMs) can visualize the microcirculation and help to diagnose the nature of microcirculatory shock. Although treatment with the sole aim of recruiting the microcirculation is as yet not realized, interventions can be tailored to the needs of the patient while monitoring sublingual microcirculation. With the help of the newly introduced software, called MicroTools, we believe sublingual microcirculation monitoring and diagnosis will be an essential point-of-care tool in managing shock patients.
Collapse
Affiliation(s)
- Olcay Dilken
- Department of Intensive Care Med, Laboratory of Translational Intensive Care Med, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Intensive Care, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Bulent Ergin
- Department of Intensive Care Med, Laboratory of Translational Intensive Care Med, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care Med, Laboratory of Translational Intensive Care Med, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
21
|
Abstract
PURPOSE OF REVIEW Adequate tissue perfusion is of utmost importance to avoid organ failure in patients with cardiogenic shock. Within the recent years, the microcirculation, defined as the perfusion of the smallest vessels, has been identified to play a crucial role. Microcirculatory changes may include capillary flow disturbances as well as changes in the density of perfused vessels. Due to the availability of new technologies to assess the microcirculation, interesting new data came up and it is the purpose of this review to summarize recent studies in the field. RECENT FINDINGS Nowadays, an increasing number of studies confirm parameters of the microcirculation, derived by intravital microscopy, to represent strong outcome predictors in cardiogenic shock. In addition, microcirculation as read-out parameter in innovative clinical studies has meanwhile been accepted as serious endpoint. Treatment strategies such as mechanical assist devices, blood pressure regulating agents or fluids use tissue perfusion and microcirculatory network density as targets in addition to clinical perfusion evaluation and decreasing serum lactate levels. SUMMARY The parameter most frequently used to detect tissue malperfusion is serum lactate. Novel, noninvasive methods to quantify microvascular perfusion have the potential to guide treatment in terms of optimizing organ perfusion and oxygenation probably paving the way for an individualized therapy.
Collapse
|
22
|
Hessler M, Lehmann F, Arnemann PH, Eter N, Ertmer C, Alnawaiseh M. [Optical coherence tomography angiography in intensive care medicine : A new field of application?]. Ophthalmologe 2019; 116:728-734. [PMID: 31139886 DOI: 10.1007/s00347-019-0893-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Many critically ill patients show a disturbance of the microcirculation, which is not yet regularly examined in the clinical routine; however, for treatment decisions and estimation of the prognosis it would be important to obtain detailed information about the microcirculation in critically ill patients. Optical coherence tomography angiography (OCTA) is a non-invasive, contact-free technique, which enables visualization of the blood flow in the retinal microcirculation within a few seconds. Therefore, it may have the potential to diagnose microcirculation disorders in critically ill patients. OBJECTIVE The aims of the study were to assess the importance of the microcirculation in intensive care medicine, a comparison of the methods of video microscopy and OCTA and analysis of preclinical and clinical data on the use of OCTA in intensive care medicine. MATERIAL AND METHODS A selective literature review and data analysis were carried out. RESULTS A direct visualization of the microcirculation has been possible for many years with the technique of video microscopy but this has not become established in the clinical routine due to the susceptibility to interferences and a time-consuming manual analysis. The OCTA is a non-invasive and contact-free method for the visualization of retinal blood flow. First preclinical data in septic and hemorrhagic shock show good results of OCTA for analysis of the microcirculation. CONCLUSION The non-invasive technique of OCTA is a promising measurement method to enable bedside analysis of the microcirculation in critically ill paients in the future; however, some technical limitations must still be overcome.
Collapse
Affiliation(s)
- Michael Hessler
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland.
| | - Florian Lehmann
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| | - Philip-Helge Arnemann
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| | - Nicole Eter
- Klinik für Augenheilkunde, Universitätsklinikum Münster, 48149, Münster, Deutschland
| | - Christian Ertmer
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| | - Maged Alnawaiseh
- Klinik für Augenheilkunde, Universitätsklinikum Münster, 48149, Münster, Deutschland
| |
Collapse
|
23
|
George RB, Boyd C, McKeen D, Abdo IS, Lehmann C. Possible Impact of Spinal Anesthesia and Phenylephrine on Sublingual Microcirculation of Cesarean Delivery Patients. J Clin Med Res 2019; 11:543-549. [PMID: 31413765 PMCID: PMC6681856 DOI: 10.14740/jocmr3778] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 05/13/2019] [Indexed: 12/31/2022] Open
Abstract
Background This study was a proof of concept of a novel means to evaluate microcirculatory changes during spinal anesthesia for cesarean delivery. It sought to examine the distributive circulatory effects of spinal anesthesia and evaluate the impact of phenylephrine administration on the microcirculation of these women. Methods After Research Ethics Board approval, healthy, non-laboring pregnant women with singleton, term pregnancies scheduled for elective cesarean delivery were recruited. Participants were randomly assigned to receive either phenylephrine infusion or phenylephrine bolus. Spinal anesthesia was standardized. A sidestream dark-field (SDF) MicroScan® video microscope was applied to the sublingual mucosa to obtain microcirculation videos in five different visual fields. Videos were made before and after spinal anesthesia. The resultant videos were analyzed randomly and blindly. The mean microvascular flow index (MFI) values were compared before and after spinal anesthesia. The difference in MFI following spinal anesthesia was compared between phenylephrine infusion and bolus groups. Results Thirty-two patients were recruited for the study; 22 patients had complete video sets for analysis. Baseline characteristics were similar between the two groups, including preoperative hemodynamics. There were no significant differences between pre- and post-spinal MFI. The post-spinal MFI within the infusion group (mean ± standard deviation: 2.74 ± 0.21) was not significantly different from the bolus group (2.56 ± 0.42, P = 0.22). Conclusion Despite theoretical physiological implications of spinal anesthesia and phenylephrine on the microcirculation, significant alteration of the MFI was not observed between pre- and post-spinal anesthesia (within group). Additionally, despite an eight-fold larger phenylephrine dose for continuous infusion prophylaxis used in this group of women, this did not result in a significant alteration of the microcirculation compared to those who received phenylephrine treatment for hypotension (between groups).
Collapse
Affiliation(s)
- Ronald B George
- Department of Women's and Obstetric Anesthesia, IWK Health Centre, Halifax, NS, Canada.,Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| | - Colin Boyd
- Department of Women's and Obstetric Anesthesia, IWK Health Centre, Halifax, NS, Canada
| | - Dolores McKeen
- Department of Women's and Obstetric Anesthesia, IWK Health Centre, Halifax, NS, Canada.,Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| | - Islam Saleh Abdo
- Department of Anesthesia, Intensive care and Perioperative Medicine, Masaryk Hospital, Usti nad Labem, Czech Republic
| | - Christian Lehmann
- Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| |
Collapse
|
24
|
Liu M, Drexler W. Optical coherence tomography angiography and photoacoustic imaging in dermatology. Photochem Photobiol Sci 2019; 18:945-962. [PMID: 30735220 DOI: 10.1039/c8pp00471d] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Optical coherence tomography angiography (OCTA) is a relatively novel functional extension of the widely accepted ophthalmic imaging tool named optical coherence tomography (OCT). Since OCTA's debut in ophthalmology, researchers have also been trying to expand its translational application in dermatology. The ability of OCTA to resolve microvasculature has shown promising results in imaging skin diseases. Meanwhile, photoacoustic imaging (PAI), which uses laser pulse induced ultrasound waves as the signal, has been studied to differentiate human skin layers and to help in skin disease diagnosis. This perspective article gives a short review of OCTA and PAI in the field of photodermatology. After an introduction to the principles of OCTA and PAI, we describe the most updated results of skin disease imaging using these two optical imaging modalities. We also place emphasis on dual modality imaging combining OCTA and photoacoustic tomography (PAT) for dermatological applications. In the end, the challenges and prospects of these two imaging modalities in dermatology are discussed.
Collapse
Affiliation(s)
- Mengyang Liu
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, 1090 Vienna, Austria.
| | | |
Collapse
|
25
|
González R, Urbano J, Solana MJ, Hervías M, Pita A, Pérez R, Álvarez R, Teigell E, Gil-Jaurena JM, Zamorano J, Sobrino A, López-Herce J. Microcirculatory Differences in Children With Congenital Heart Disease According to Cyanosis and Age. Front Pediatr 2019; 7:264. [PMID: 31312623 PMCID: PMC6613439 DOI: 10.3389/fped.2019.00264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 06/10/2019] [Indexed: 12/11/2022] Open
Abstract
Background: Congenital heart disease (CHD) is one of the main causes of morbidity and mortality in children. Microcirculatory changes in CHD patients have previously been investigated using a variety of techniques. Handheld videomicroscopy enables non-invasive direct visualization of the microcirculatory bed. The aim of our study was to determine if there are microcirculatory differences among CHD patients based on age and the presence of cyanosis. Methods: A prospective observational study was carried out. Patients with CHD undergoing corrective surgery were evaluated after anesthetic induction prior to surgery. Microcirculation was evaluated using sidestream dark field (SDF) imaging. Hemodynamics and respiratory, biochemical, and tissue perfusion parameters were analyzed. Results: A total of 30 patients were included, of whom 14 were classified as cyanotic and 16 as non-cyanotic. Cyanotic patients had a higher total vessel density (TVD) (p = 0.016), small vessel density (p = 0.004), and perfused small vessel density (p = 0.013), while their microvascular flow index (MFI) was lower (p = 0.013). After adjustment for age and PaO2, cyanotic patients showed increased TVD (p = 0.023), and small vessel density (p = 0.025) compared to non-cyanotic patients but there were no differences on the MFI. Age was directly correlated with total MFI (spearman's rho = 0.499, p = 0.005) and small vessel MFI (spearman's rho = 0.420, p = 0.021). After adjustment for the type of CHD (cyanotic vs. non-cyanotic) patients with MFI and small MFI vessels <3 were younger than those with values ≥3 (p = 0.033 and p = 0.037). Conclusions: SDF-based evaluation of microcirculation in CHD patients showed that patients with cyanotic defects had higher vascular density, as compared to patients with non-cyanotic defects. Younger patients were more likely to have a low MFI regardless of their type of CHD.
Collapse
Affiliation(s)
- Rafael González
- Service of Paediatric Intensive Care, Gregorio Marañón General University Hospital, Madrid, Spain.,Mother and Child Health and Development Network (REDSAMID), Madrid, Spain
| | - Javier Urbano
- Service of Paediatric Intensive Care, Gregorio Marañón General University Hospital, Madrid, Spain.,Mother and Child Health and Development Network (REDSAMID), Madrid, Spain.,Department of Paediatrics, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - María J Solana
- Service of Paediatric Intensive Care, Gregorio Marañón General University Hospital, Madrid, Spain.,Mother and Child Health and Development Network (REDSAMID), Madrid, Spain
| | - Mónica Hervías
- Paediatric Anaesthesia, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Ana Pita
- Paediatric Cardiac Surgery, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Rosario Pérez
- Paediatric Hemoperfusionist, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Reyes Álvarez
- Paediatric Cardiology, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Enrique Teigell
- Paediatric Anaesthesia, Gregorio Marañón General University Hospital, Madrid, Spain
| | | | - José Zamorano
- Paediatric Hemoperfusionist, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Adolfo Sobrino
- Paediatric Cardiology, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Jesús López-Herce
- Service of Paediatric Intensive Care, Gregorio Marañón General University Hospital, Madrid, Spain.,Mother and Child Health and Development Network (REDSAMID), Madrid, Spain.,Department of Paediatrics, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| |
Collapse
|
26
|
Erdem Ö, Ince C, Tibboel D, Kuiper JW. Assessing the Microcirculation With Handheld Vital Microscopy in Critically Ill Neonates and Children: Evolution of the Technique and Its Potential for Critical Care. Front Pediatr 2019; 7:273. [PMID: 31338353 PMCID: PMC6629784 DOI: 10.3389/fped.2019.00273] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 06/17/2019] [Indexed: 12/17/2022] Open
Abstract
Assuring adequate tissue oxygenation in the critically ill, but still developing child is challenging. Conventional hemodynamic monitoring techniques fall short in assessing tissue oxygenation as these are directed at the macrocirculation and indirect surrogates of tissue oxygenation. The introduction of handheld vital microscopy (HVM) has allowed for the direct visualization of the microcirculation and with this has offered insight into tissue oxygenation on a microcirculatory level. Since its introduction, technical improvements have been made to HVM, to both hardware and software, and guidelines have been developed through expert consensus on image assessment and analysis. Using HVM, the microcirculation of the skin, the buccal mucosa, and the sublingual mucosa of healthy and (critically) ill neonates and children have been visualized and investigated. Yet, integration of HVM in hemodynamic monitoring has been limited due to technical shortcomings. Only superficial microcirculatory beds can be visualized, inter-observer and intra-observer variabilities are not accounted for and image analysis happens offline and is semi-automated and time-consuming. More importantly, patients need to be cooperative or fully sedated to prevent pressure and movement artifacts, which is often not the case in children. Despite these shortcomings, observational research with HVM in neonates and children has revealed the following: (1) age-related developmental changes in the microcirculation, (2) loss of hemodynamic coherence, i.e., microcirculatory disturbances in the presence of a normal macrocirculation and, (3) microcirculatory disturbances which were independently associated with increased mortality risk. Although these observations underline the importance of microcirculatory monitoring, several steps have to be taken before integration in the decision process during critical care can happen. These steps include technological innovations to ease the use of HVM in the pediatric age group, measuring additional functional parameters of microvascular blood flow and integrated automated analysis software. As a next step, reference values for microcirculatory parameters need to be established, while also accounting for developmental changes. Finally, studies on microcirculatory guided therapies are necessary to assess whether the integration of microcirculatory monitoring will actually improve patient outcome. Nevertheless, HVM remains a promising, non-invasive tool to help physicians assure tissue oxygenation in the critically ill child.
Collapse
Affiliation(s)
- Özge Erdem
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Translational Physiology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Jan Willem Kuiper
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, Netherlands
| |
Collapse
|
27
|
Pietrasanta C, Pugni L, Ronchi A, Bottino I, Ghirardi B, Sanchez-Schmitz G, Borriello F, Mosca F, Levy O. Vascular Endothelium in Neonatal Sepsis: Basic Mechanisms and Translational Opportunities. Front Pediatr 2019; 7:340. [PMID: 31456998 PMCID: PMC6700367 DOI: 10.3389/fped.2019.00340] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 07/30/2019] [Indexed: 12/27/2022] Open
Abstract
Neonatal sepsis remains a major health issue worldwide, especially for low-birth weight and premature infants, with a high risk of death and devastating sequelae. Apart from antibiotics and supportive care, there is an unmet need for adjunctive treatments to improve the outcomes of neonatal sepsis. Strong and long-standing research on adult patients has shown that vascular endothelium is a key player in the pathophysiology of sepsis and sepsis-associated organ failure, through a direct interaction with pathogens, leukocytes, platelets, and the effect of soluble circulating mediators, in part produced by endothelial cells themselves. Despite abundant evidence that the neonatal immune response to sepsis is distinct from that of adults, comparable knowledge on neonatal vascular endothelium is much more limited. Neonatal endothelial cells express lower amounts of adhesion molecules compared to adult ones, and present a reduced capacity to neutralize reactive oxygen species. Conversely, available evidence on biomarkers of endothelial damage in neonates is not as robust as in adult patients, and endothelium-targeted therapeutic opportunities for neonatal sepsis are almost unexplored. Here, we summarize current knowledge on the structure of neonatal vascular endothelium, its interactions with neonatal immune system and possible endothelium-targeted diagnostic and therapeutic tools for neonatal sepsis. Furthermore, we outline areas of basic and translational research worthy of further study, to shed light on the role of vascular endothelium in the context of neonatal sepsis.
Collapse
Affiliation(s)
- Carlo Pietrasanta
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Precision Vaccines Program, Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, United States
| | - Lorenza Pugni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Andrea Ronchi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Ilaria Bottino
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Beatrice Ghirardi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Guzman Sanchez-Schmitz
- Precision Vaccines Program, Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Francesco Borriello
- Precision Vaccines Program, Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States.,Division of Immunology, Boston Children's Hospital, Boston, MA, United States.,Department of Translational Medical Sciences, Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,World Allergy Organisation Center of Excellence, Naples, Italy
| | - Fabio Mosca
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Ofer Levy
- Precision Vaccines Program, Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States.,Broad Institute of MIT and Harvard, Cambridge, MA, United States
| |
Collapse
|
28
|
Hessler M, Arnemann PH, Zamit F, Seidel L, Kampmeier TG, Kathöfer U, Morelli A, Ince C, Rehberg SW, Ertmer C. A new complimentary web-based tool for manual analysis of microcirculation videos: Validation of the Capillary Mapper against the current gold standard AVA 3.2. Microcirculation 2018; 25:e12505. [PMID: 30192423 DOI: 10.1111/micc.12505] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 08/17/2018] [Accepted: 09/04/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of the current study was to compare a newly developed web-based freely accessible software program for manual analysis of the microcirculation, the Capillary Mapper (CM), with AVA 3.2 software (AVA; MicroVision Medical B.V., Amsterdam, The Netherlands), which is the current gold standard for analysis of microcirculation videos. METHODS A web-based software program was developed, which enables manual analysis of videos of the microcirculation to be carried out according to recommendations of the 2018 consensus conference. A set of 50 high quality microcirculation videos was analyzed with AVA and CM with respect to total vessel density, perfused vessel density, proportion of perfused vessels, and the microvascular flow index. RESULTS Comparison of the mean values derived from manual analysis with CM and AVA revealed no significant differences in microcirculatory variables. Analysis according to Bland and Altman revealed an acceptable bias between manual analysis with the CM and AVA for all variables tested with sufficient limits of agreement. The analysis of intraclass correlation showed "excellent" agreement for all microcirculatory variables analyzed. CONCLUSIONS The newly developed CM was successfully validated for manual analyses of microcirculation videos against the current gold standard, the software AVA 3.2.
Collapse
Affiliation(s)
- Michael Hessler
- Department of Anesthesiology, Intensive Care and Pain Therapy, University of Muenster Medical Centre, Muenster, Germany
| | - Philip-Helge Arnemann
- Department of Anesthesiology, Intensive Care and Pain Therapy, University of Muenster Medical Centre, Muenster, Germany
| | - Frédéric Zamit
- IT-Center Research and Education, Medical Faculty of Muenster, University of Muenster, Muenster, Germany
| | - Laura Seidel
- Department of Anesthesiology, Intensive Care and Pain Therapy, University of Muenster Medical Centre, Muenster, Germany
| | - Tim-Gerald Kampmeier
- Department of Anesthesiology, Intensive Care and Pain Therapy, University of Muenster Medical Centre, Muenster, Germany
| | - Ulrich Kathöfer
- IT-Center Research and Education, Medical Faculty of Muenster, University of Muenster, Muenster, Germany
| | - Andrea Morelli
- Department of Anesthesiology and Intensive Care, University of Rome "La Sapienza", Rome, Italy
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Sebastian W Rehberg
- Department of Anesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine and Pain Therapy, Protestant Hospital of the Bethel Foundation, Bielefeld, Germany
| | - Christian Ertmer
- Department of Anesthesiology, Intensive Care and Pain Therapy, University of Muenster Medical Centre, Muenster, Germany
| |
Collapse
|
29
|
Uz Z, Ince C, Guerci P, Ince Y, P Araujo R, Ergin B, Hilty MP, van Gulik TM, de Mol BA. Recruitment of sublingual microcirculation using handheld incident dark field imaging as a routine measurement tool during the postoperative de-escalation phase-a pilot study in post ICU cardiac surgery patients. Perioper Med (Lond) 2018; 7:18. [PMID: 30116524 PMCID: PMC6083575 DOI: 10.1186/s13741-018-0091-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 04/30/2018] [Indexed: 02/07/2023] Open
Abstract
Background Management of tissue perfusion following cardiac surgery is a challenging task where common clinical parameters do not reflect microcirculatory dysfunction. Heterogeneity in blood flow perfusion and abnormalities in capillary density characterize microcirculatory dysfunction. The restoration of a normal microcirculation may become a novel target for therapy in the future in addition to macrocirculatory parameters. The aim of this study is to determine how the sublingual microcirculatory parameters vary at the bedside in post-cardiac surgery patients which underwent diuretic therapy to correct fluid overload. Methods In this prospective observational pilot study, video clips of sublingual microcirculation in post-cardiac surgery patients receiving furosemide and/or spironolactone to achieve normal fluid balance were recorded using Cytocam-IDF imaging. Data was obtained on the first (T0), second (T1), and third (T2) day after the patients left the intensive care unit (ICU). Measurements were analyzed off-line to obtain the following microcirculatory parameters: total vessel density (TVD), microcirculatory flow index (MFI), proportion of perfused vessel (PPV), and perfused vessel density (PVD). Macrocirculatory parameters and body weight were also collected at these time points. Results Ninety measurements were performed in ten post ICU cardiac surgery patients. Thirteen measurements were excluded due to quality reasons; these excluded measurements were spread across the patients and time points, and there was no loss of patients or time points. An increase in TVD was observed from T0 to T1 (20 ± 2.7 to 24 ± 3.2 mm/mm2; p = 0.0410) and from T0 to T2 (20 ± 2.7 to 26 ± 3.3 mm/mm2; p = 0.0005). An increase in PVD was present from T0 to T1 (19 ± 2.3 to 24 ± 3.5 mm/mm2; p = 0.0072) and from T0 to T2 (19 ± 2.3 to 26 ± 3.4 mm/mm2, p = 0.0008). Fluid overload was assessed through a positive cumulative fluid balance on the day of ICU discharge. Conclusions Cytocam-IDF imaging to monitor microcirculation as a daily parameter is feasible and could become a valuable tool to non-invasively assess the tissue oxygenation at the bedside. An increase in TVD and PVD (functional capillary density) indicated the recruitment of the sublingual microcirculation in patients with diuretic therapy. Future research is needed to prove the correlation between the recruitment of the sublingual microcirculation and the de-escalation phase of the fluid management.
Collapse
Affiliation(s)
- Zühre Uz
- 1Department of Experimental Surgery and Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Can Ince
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Philippe Guerci
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Yasin Ince
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Renata P Araujo
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Bulent Ergin
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Matthias P Hilty
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Thomas M van Gulik
- 1Department of Experimental Surgery and Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Bas A de Mol
- 3Department of Cardio-Thoracic Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| |
Collapse
|
30
|
Tafner PFDA, Chen FK, Rabello R, Corrêa TD, Chaves RCDF, Serpa A. Recent advances in bedside microcirculation assessment in critically ill patients. Rev Bras Ter Intensiva 2018; 29:238-247. [PMID: 28977264 PMCID: PMC5496759 DOI: 10.5935/0103-507x.20170033] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 09/18/2016] [Indexed: 12/22/2022] Open
Abstract
Parameters related to macrocirculation, such as the mean arterial pressure, central venous pressure, cardiac output, mixed venous saturation and central oxygen saturation, are commonly used in the hemodynamic assessment of critically ill patients. However, several studies have shown that there is a dissociation between these parameters and the state of microcirculation in this group of patients. Techniques that allow direct viewing of the microcirculation are not completely disseminated, nor are they incorporated into the clinical management of patients in shock. The numerous techniques developed for microcirculation assessment include clinical assessment (e.g., peripheral perfusion index and temperature gradient), laser Doppler flowmetry, tissue oxygen assessment electrodes, videomicroscopy (orthogonal polarization spectral imaging, sidestream dark field imaging or incident dark field illumination) and near infrared spectroscopy. In the near future, the monitoring and optimization of tissue perfusion by direct viewing and microcirculation assessment may become a goal to be achieved in the hemodynamic resuscitation of critically ill patients.
Collapse
Affiliation(s)
| | | | - Roberto Rabello
- Unidade de Terapia Intensiva Adulto, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Thiago Domingos Corrêa
- Unidade de Terapia Intensiva Adulto, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | | | - Ary Serpa
- Unidade de Terapia Intensiva Adulto, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| |
Collapse
|
31
|
Abstract
PURPOSE OF REVIEW Critical illness includes a wide range of conditions from sepsis to high-risk surgery. All these diseases are characterized by reduced tissue oxygenation. Macrohemodynamic parameters may be corrected by fluids and/or vasoactive compounds; however, the microcirculation and its tissues may be damaged and remain hypoperfused. An evaluation of microcirculation may enable more physiologically based approaches for understanding the pathogenesis, diagnosis, and treatment of critically ill patients. RECENT FINDINGS Microcirculation plays a pivotal role in delivering oxygen to the cells and maintains tissue perfusion. Negative results of several studies, based on conventional hemodynamic resuscitation procedures to achieve organ perfusion and decrease morbidity and mortality following conditions of septic shock and other cardiovascular compromise, have highlighted the need to monitor microcirculation. The loss of hemodynamic coherence between the macrocirculation and microcirculation, wherein improvement of hemodynamic variables of the systemic circulation does not cause a parallel improvement of microcirculatory perfusion and oxygenation of the essential organ systems, may explain why these studies have failed. SUMMARY Critical illness is usually accompanied by abnormalities in microcirculation and tissue hypoxia. Direct monitoring of sublingual microcirculation using hand-held microscopy may provide a more physiological approach. Evaluating the coherence between macrocirculation and microcirculation in response to therapy seems to be essential in evaluating the efficacy of therapeutic interventions.
Collapse
|
32
|
Abstract
PURPOSE OF REVIEW Tissue monitoring is one of the main strategies at the bedside to guide resuscitation of shock. Advances in tissue monitoring technologies have established noninvasive optical methods and transcutaneous oximetry as modalities of considerable value in the critical care setting for tissue monitoring in shock. The purpose of this article is to highlight the latest developments into the clinical applications of near-infrared spectroscopy, direct visualization of sublingual microcirculation, and transcutaneous oxygen measurements (PtcO2). RECENT FINDINGS Near-infrared spectroscopy has been successfully applied in patients with septic shock during vasopressor and blood transfusion therapy to identify patients at high risk for microcirculatory failure. A new generation incident dark field imaging-based handheld microscope has been introduced for quantification of microcirculatory alterations at bedside. Preliminary comparisons with previous versions have shown better quality and superiority of incident dark field in detecting more vessels. PtcO2 measurements have been applied mainly to detect a peripheral low-flow state in circulatory failure using the oxygen challenge test. Altered lung function might have an influence on PtcO2, and thus affect the oxygen challenge test. SUMMARY The latest developments of noninvasive optical monitoring and transcutaneous oximetry technologies have helped early identification of septic patients at high risk for microcirculatory failure and could allow more targeted interventions in shock.
Collapse
|
33
|
Pelland A, George RB, Lehmann C, Coolen J. Sidestream Dark Field Imaging of the Microcirculation to Assess Preeclampsia Microvascular Dysfunction. J Clin Med Res 2018; 10:391-395. [PMID: 29581801 PMCID: PMC5862086 DOI: 10.14740/jocmr3368w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 02/23/2018] [Indexed: 01/28/2023] Open
Abstract
Background Development of predictive models of preeclampsia has only yielded modest results. We hypothesized that impaired indices of microcirculatory function could be detected using sidestream dark field imaging. The objective of this study was to examine microvascular function in women at high risk for preeclampsia at mid-gestation. Methods Women between 16 and 22 weeks of gestation were screened for eligibility. Patients were recruited if they met eligibility criteria indicating high risk for preeclampsia. Investigators performed non-invasive sidestream dark field imaging of the sublingual microcirculation. Images were analyzed to determine microcirculatory parameters (microvascular flow index, perfused vessel density, total vessel density, and proportion of perfused vessels). After delivery, charts were reviewed to determine if they developed gestational hypertension, preeclampsia or severe preeclampsia. Results Twelve of 66 participants (18.2%) developed preeclampsia or severe preeclampsia during the course of their pregnancy. Microvascular flow index was not significantly different between participants with normal pregnancies and participants with preeclampsia or severe preeclampsia (2.75 ± 0.38 vs. 2.80 ± 0.34, respectively; P = 0.459). Similarly, there were no significant differences between groups in the remaining microcirculatory parameters. Conclusions Sidestream dark field imaging of the sublingual microcirculation may remain an appropriate tool to identify women at risk for preeclampsia, albeit later in pregnancy.
Collapse
Affiliation(s)
- Amelie Pelland
- Department of Anesthesiology, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| | - Ronald B George
- Department of Anesthesiology, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| | - Christian Lehmann
- Department of Anesthesiology, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada.,Department of Pharmacology, Dalhousie University, Halifax, NS, Canada.,Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada
| | - Jillian Coolen
- Department of Obstetrics and Gynecology, Dalhousie University, Halifax, NS, Canada
| |
Collapse
|
34
|
Uz Z, de Mol BA, van Gulik TM, Ince C. Sublingual microcirculation reveals fluid overload and leukocytosis in a post-cardiac surgery patient. BMJ Case Rep 2018; 2018:bcr-2017-223681. [PMID: 29472425 DOI: 10.1136/bcr-2017-223681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Zühre Uz
- Department of Surgery, AMC, Amsterdam, North Holland, The Netherlands
| | - Bastianus Ajm de Mol
- Department of Cardio-Thoracic Surgery, AMC, Amsterdam, North Holland, The Netherlands
| | | | - Can Ince
- Department of Translational Physiology, AMC, Amsterdam, North Holland, The Netherlands
| |
Collapse
|
35
|
van Elteren HA, de Jonge RCJ, van Rosmalen J, Ince C, Reiss IKM. Adaptation of the Cutaneous Microcirculation in Preterm Neonates. Microcirculation 2018; 23:468-74. [PMID: 27378187 DOI: 10.1111/micc.12295] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 06/28/2016] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Transition from fetal to neonatal circulation is characterized by multiple hemodynamic changes. The role of the microcirculation in this process is underexposed. Visualizing the cutaneous microcirculation can help us understand peripheral perfusion in a noninvasive manner. METHODS Cutaneous microcirculation of term and preterm infants born below 32 weeks of GA was measured in the first month of life using IDF imaging. Linear mixed modeling was used to identify clinical variables which influence the cutaneous microcirculation. RESULTS Sixty preterm and 33 term infants were included. TVD of preterm infants significantly decreased in the first month of life (31.7 mm/mm(2) day 1 vs 27.9 mm/mm(2) day 28), but remained significantly higher compared to TVD of term infants on day 1 (25.8 mm/mm(2) ). Besides postnatal age, no clinical variables were associated with TVD. Infants born SGA had significantly higher TVD values directly after birth than those born appropriate for GA (35.4 mm/mm(2) vs 31.6 mm/mm(2) ; p = 0.015). CONCLUSIONS TVD decreases in the first month after birth and is higher in preterm infants compared to those born term. Differences in antenatal oxygen exposure might explain the adaptation of the microcirculation.
Collapse
Affiliation(s)
- Hugo A van Elteren
- Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands
| | - Rogier C J de Jonge
- Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
36
|
Vrancken SL, van Heijst AF, de Boode WP. Neonatal Hemodynamics: From Developmental Physiology to Comprehensive Monitoring. Front Pediatr 2018; 6:87. [PMID: 29675404 PMCID: PMC5895966 DOI: 10.3389/fped.2018.00087] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/19/2018] [Indexed: 12/16/2022] Open
Abstract
Maintenance of neonatal circulatory homeostasis is a real challenge, due to the complex physiology during postnatal transition and the inherent immaturity of the cardiovascular system and other relevant organs. It is known that abnormal cardiovascular function during the neonatal period is associated with increased risk of severe morbidity and mortality. Understanding the functional and structural characteristics of the neonatal circulation is, therefore, essential, as therapeutic hemodynamic interventions should be based on the assumed underlying (patho)physiology. The clinical assessment of systemic blood flow (SBF) by indirect parameters, such as blood pressure, capillary refill time, heart rate, urine output, and central-peripheral temperature difference is inaccurate. As blood pressure is no surrogate for SBF, information on cardiac output and systemic vascular resistance should be obtained in combination with an evaluation of end organ perfusion. Accurate and reliable hemodynamic monitoring systems are required to detect inadequate tissue perfusion and oxygenation at an early stage before this result in irreversible damage. Also, the hemodynamic response to the initiated treatment should be re-evaluated regularly as changes in cardiovascular function can occur quickly. New insights in the understanding of neonatal cardiovascular physiology are reviewed and several methods for current and future neonatal hemodynamic monitoring are discussed.
Collapse
Affiliation(s)
- Sabine L Vrancken
- Department of Perinatology (Neonatology), Amalia Children's Hospital, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Arno F van Heijst
- Department of Perinatology (Neonatology), Amalia Children's Hospital, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Willem P de Boode
- Department of Perinatology (Neonatology), Amalia Children's Hospital, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| |
Collapse
|
37
|
Akin S, Dos Reis Miranda D, Caliskan K, Soliman OI, Guven G, Struijs A, van Thiel RJ, Jewbali LS, Lima A, Gommers D, Zijlstra F, Ince C. Functional evaluation of sublingual microcirculation indicates successful weaning from VA-ECMO in cardiogenic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:265. [PMID: 29073930 PMCID: PMC5658964 DOI: 10.1186/s13054-017-1855-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 10/05/2017] [Indexed: 12/23/2022]
Abstract
Background Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly adopted for the treatment of cardiogenic shock (CS). However, a marker of successful weaning remains largely unknown. Our hypothesis was that successful weaning is associated with sustained microcirculatory function during ECMO flow reduction. Therefore, we sought to test the usefulness of microcirculatory imaging in the same sublingual spot, using incident dark field (IDF) imaging in assessing successful weaning from VA-ECMO and compare IDF imaging with echocardiographic parameters. Methods Weaning was performed by decreasing the VA-ECMO flow to 50% (F50) from the baseline. The endpoint of the study was successful VA-ECMO explantation within 48 hours after weaning. The response of sublingual microcirculation to a weaning attempt (WA) was evaluated. Microcirculation was measured in one sublingual area (single spot (ss)) using CytoCam IDF imaging during WA. Total vessel density (TVDss) and perfused vessel density (PVDss) of the sublingual area were evaluated before and during 50% flow reduction (TVDssF50, PVDssF50) after a WA and compared to conventional echocardiographic parameters as indicators of the success or failure of the WA. Results Patients (n = 13) aged 49 ± 18 years, who received VA-ECMO for the treatment of refractory CS due to pulmonary embolism (n = 5), post cardiotomy (n = 3), acute coronary syndrome (n = 2), myocarditis (n = 2) and drug intoxication (n = 1), were included. TVDssF50 (21.9 vs 12.9 mm/mm2, p = 0.001), PVDssF50 (19.7 vs 12.4 mm/mm2, p = 0.01) and aortic velocity–time integral (VTI) at 50% flow reduction (VTIF50) were higher in patients successfully weaned vs not successfully weaned. The area under the curve (AUC) was 0.99 vs 0.93 vs 0.85 for TVDssF50 (small vessels) >12.2 mm/mm2, left ventricular ejection fraction (LVEF) >15% and aortic VTI >11 cm. Likewise, the AUC was 0.91 vs 0.93 vs 0.85 for the PVDssF50 (all vessels) >14.8 mm/mm2, LVEF >15% and aortic VTI >11 cm. Conclusion This study identified sublingual microcirculation as a novel potential marker for identifying successful weaning from VA-ECMO. Sustained values of TVDssF50 and PVDssF50 were found to be specific and sensitive indicators of successful weaning from VA-ECMO as compared to echocardiographic parameters. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1855-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Sakir Akin
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. .,Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.
| | - Dinis Dos Reis Miranda
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Kadir Caliskan
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Osama I Soliman
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Goksel Guven
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.,Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Ard Struijs
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Robert J van Thiel
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Lucia S Jewbali
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.,Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Alexandre Lima
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| |
Collapse
|
38
|
Abstract
Transfusion decision making (TDM) in the critically ill requires consideration of: (1) anemia tolerance, which is linked to active pathology and to physiologic reserve, (2) differences in donor RBC physiology from that of native RBCs, and (3) relative risk from anemia-attributable oxygen delivery failure vs hazards of transfusion, itself. Current approaches to TDM (e.g. hemoglobin thresholds) do not: (1) differentiate between patients with similar anemia, but dissimilar pathology/physiology, and (2) guide transfusion timing and amount to efficacy-based goals (other than resolution of hemoglobin thresholds). Here, we explore approaches to TDM that address the above gaps.
Collapse
Affiliation(s)
- Chris Markham
- Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, McDonnell Pediatric Research Building, Campus Box 8208, 660 South Euclid Avenue, St Louis, MO 63110-1093, USA
| | - Sara Small
- Social Systems Design Laboratory, Brown School of Social Work, Washington University, Campus Box 1196, 1 Brookings Drive, St Louis, MO 63130, USA
| | - Peter Hovmand
- Social Systems Design Laboratory, Brown School of Social Work, Washington University, Campus Box 1196, 1 Brookings Drive, St Louis, MO 63130, USA
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, McDonnell Pediatric Research Building, Campus Box 8208, 660 South Euclid Avenue, St Louis, MO 63110-1093, USA.
| |
Collapse
|
39
|
Erdem Ö, Kuiper JW, Ince C, Tibboel D. Videomicroscopic investigation of the microcirculation requires uniform definitions. Physiol Rep 2017; 5:5/11/e13303. [PMID: 28603142 PMCID: PMC5471442 DOI: 10.14814/phy2.13303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 03/21/2017] [Indexed: 11/24/2022] Open
Affiliation(s)
- Özge Erdem
- Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Jan Willem Kuiper
- Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Can Ince
- Department of Translational Physiology, Academic Medical Center, Amsterdam, the Netherlands.,Department of Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, the Netherlands
| |
Collapse
|
40
|
Hilty MP, Pichler J, Ergin B, Hefti U, Merz TM, Ince C, Maggiorini M. Assessment of endothelial cell function and physiological microcirculatory reserve by video microscopy using a topical acetylcholine and nitroglycerin challenge. Intensive Care Med Exp 2017; 5:26. [PMID: 28523563 PMCID: PMC5436993 DOI: 10.1186/s40635-017-0139-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 05/09/2017] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Assessment of the microcirculation is a promising target for the hemodynamic management of critically ill patients. However, just as the sole reliance on macrocirculatory parameters, single static parameters of the microcirculation may not represent a sufficient guide. Our hypothesis was that by serial topical application of acetylcholine (ACH) and nitroglycerin (NG), the sublingual microcirculation can be challenged to determine its endothelial cell-dependent and smooth muscle-dependent physiological reserve capacity. METHODS In 41 healthy subjects, sublingual capillary microscopy was performed before and after topical application of ACH and NG. Total vessel density (TVD) was assessed in parallel using manual computer-assisted image analysis as well as a fully automated analysis pathway utilizing a newly developed computer algorithm. Flow velocity was assessed using space-time diagrams of the venules as well as the algorithm-based calculation of an average perfused speed indicator (APSI). RESULTS No change in all measured parameters was detected after sublingual topical application of ACH. Sublingual topical application of NG however led to an increase in TVD, space-time diagram-derived venular flow velocity and APSI. No difference was detected in heart rate, blood pressure, and cardiac output as measured by echocardiography, as well as in plasma nitric oxide metabolite content before and after the topical application of ACH and NG. CONCLUSIONS In healthy subjects, the sublingual microcirculatory physiological reserve can be assessed non-invasively by topical application of nitroglycerin without affecting systemic circulation.
Collapse
Affiliation(s)
- Matthias Peter Hilty
- Medical Intensive Care Unit, University Hospital of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Jacqueline Pichler
- Department of Pulmonary Medicine, Inselspital, Bern University Hospital, Bern, Switzerland.,Department of Intensive Care Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Bulent Ergin
- Department of Translational Physiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Urs Hefti
- Swiss Sportclinic, Bern, Switzerland
| | - Tobias Michael Merz
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Can Ince
- Department of Translational Physiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Marco Maggiorini
- Medical Intensive Care Unit, University Hospital of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| |
Collapse
|
41
|
Haemodynamic coherence in perioperative setting. Best Pract Res Clin Anaesthesiol 2016; 30:445-452. [PMID: 27931648 DOI: 10.1016/j.bpa.2016.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 10/21/2016] [Accepted: 10/27/2016] [Indexed: 11/23/2022]
Abstract
Over the last decade, there has been an increased interest in the use of goal-directed therapy (GDT) in patients undergoing high-risk surgery, and various haemodynamic monitoring tools have been developed to guide perioperative care. Both the complexity of the patient and surgical procedure need to be considered when deciding whether GDT will be beneficial. Ensuring optimum tissue perfusion is paramount in the perioperative period and relies on the coherence between both macrovascular and microvascular circulations. Although global haemodynamic parameters may be optimised with the use of GDT, microvascular impairment can still persist. This review will provide an overview of both haemodynamic optimisation and microvascular assessment in the perioperative period.
Collapse
|
42
|
Ocak I, Kara A, Ince C. Monitoring microcirculation. Best Pract Res Clin Anaesthesiol 2016; 30:407-418. [DOI: 10.1016/j.bpa.2016.10.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 10/27/2016] [Indexed: 12/20/2022]
|
43
|
Arnemann PH, Hessler M, Kampmeier T, Morelli A, Van Aken HK, Westphal M, Rehberg S, Ertmer C. Comparison of an automatic analysis and a manual analysis of conjunctival microcirculation in a sheep model of haemorrhagic shock. Intensive Care Med Exp 2016; 4:37. [PMID: 27864774 PMCID: PMC5116019 DOI: 10.1186/s40635-016-0110-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 11/07/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Life-threatening diseases of critically ill patients are known to derange microcirculation. Automatic analysis of microcirculation would provide a bedside diagnostic tool for microcirculatory disorders and allow immediate therapeutic decisions based upon microcirculation analysis. METHODS After induction of general anaesthesia and instrumentation for haemodynamic monitoring, haemorrhagic shock was induced in ten female sheep by stepwise blood withdrawal of 3 × 10 mL per kilogram body weight. Before and after the induction of haemorrhagic shock, haemodynamic variables, samples for blood gas analysis, and videos of conjunctival microcirculation were obtained by incident dark field illumination microscopy. Microcirculatory videos were analysed (1) manually with AVA software version 3.2 by an experienced user and (2) automatically by AVA software version 4.2 for total vessel density (TVD), perfused vessel density (PVD) and proportion of perfused vessels (PPV). Correlation between the two analysis methods was examined by intraclass correlation coefficient and Bland-Altman analysis. RESULTS The induction of haemorrhagic shock decreased the mean arterial pressure (from 87 ± 11 to 40 ± 7 mmHg; p < 0.001); stroke volume index (from 38 ± 14 to 20 ± 5 ml·m-2; p = 0.001) and cardiac index (from 2.9 ± 0.9 to 1.8 ± 0.5 L·min-1·m-2; p < 0.001) and increased the heart rate (from 72 ± 9 to 87 ± 11 bpm; p < 0.001) and lactate concentration (from 0.9 ± 0.3 to 2.0 ± 0.6 mmol·L-1; p = 0.001). Manual analysis showed no change in TVD (17.8 ± 4.2 to 17.8 ± 3.8 mm*mm-2; p = 0.993), whereas PVD (from 15.6 ± 4.6 to 11.5 ± 6.5 mm*mm-2; p = 0.041) and PPV (from 85.9 ± 11.8 to 62.7 ± 29.6%; p = 0.017) decreased significantly. Automatic analysis was not able to identify these changes. Correlation analysis showed a poor correlation between the analysis methods and a wide spread of values in Bland-Altman analysis. CONCLUSIONS As characteristic changes in microcirculation during ovine haemorrhagic shock were not detected by automatic analysis and correlation between automatic and manual analyses (current gold standard) was poor, the use of the investigated software for automatic analysis of microcirculation cannot be recommended in its current version at least in the investigated model. Further improvements in automatic vessel detection are needed before its routine use.
Collapse
Affiliation(s)
- Philip-Helge Arnemann
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Muenster University Hospital, Albert-Schweitzer-Campus 1, Building A1, 49149, Muenster, Germany.
| | - Michael Hessler
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Muenster University Hospital, Albert-Schweitzer-Campus 1, Building A1, 49149, Muenster, Germany
| | - Tim Kampmeier
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Muenster University Hospital, Albert-Schweitzer-Campus 1, Building A1, 49149, Muenster, Germany
| | - Andrea Morelli
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, University of Rome, "La Sapienza", Viale del Policlinico 155, 00161, Rome, Italy
| | - Hugo Karel Van Aken
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Muenster University Hospital, Albert-Schweitzer-Campus 1, Building A1, 49149, Muenster, Germany
| | - Martin Westphal
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Muenster University Hospital, Albert-Schweitzer-Campus 1, Building A1, 49149, Muenster, Germany
| | - Sebastian Rehberg
- Department of Anaesthesiology, Greifswald University Hospital, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
| | - Christian Ertmer
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Muenster University Hospital, Albert-Schweitzer-Campus 1, Building A1, 49149, Muenster, Germany
| |
Collapse
|
44
|
Kuiper JW, Tibboel D, Ince C. The vulnerable microcirculation in the critically ill pediatric patient. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:352. [PMID: 27794361 PMCID: PMC5086412 DOI: 10.1186/s13054-016-1496-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In neonates, cardiovascular system development does not stop after the transition from intra-uterine to extra-uterine life and is not limited to the macrocirculation. The microcirculation (MC), which is essential for oxygen, nutrient, and drug delivery to tissues and cells, also develops. Developmental changes in the microcirculatory structure continue to occur during the initial weeks of life in healthy neonates. The physiologic hallmarks of neonates and developing children make them particularly vulnerable during critical illness; however, the cardiovascular monitoring possibilities are limited compared with critically ill adult patients. Therefore, the development of non-invasive methods for monitoring the MC is necessary in pediatric critical care for early identification of impending deterioration and to enable the initiation and titration of therapy to ensure cell survival. To date, the MC may be non-invasively monitored at the bedside using hand-held videomicroscopy, which provides useful information regarding the microcirculation. There is an increasing number of studies on the MC in neonates and pediatric patients; however, additional steps are necessary to transition MC monitoring from bench to bedside. The recently introduced concept of hemodynamic coherence describes the relationship between changes in the MC and macrocirculation. The loss of hemodynamic coherence may result in a depressed MC despite an improvement in the macrocirculation, which represents a condition associated with adverse outcomes. In the pediatric intensive care unit, the concept of hemodynamic coherence may function as a framework to develop microcirculatory measurements towards implementation in daily clinical practice.
Collapse
Affiliation(s)
- J W Kuiper
- Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Postbox 2040, 3000 CA, Rotterdam, The Netherlands.
| | - D Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Postbox 2040, 3000 CA, Rotterdam, The Netherlands
| | - C Ince
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| |
Collapse
|
45
|
The response of the microcirculation to mechanical support of the heart in critical illness. Best Pract Res Clin Anaesthesiol 2016; 30:511-522. [PMID: 27931654 DOI: 10.1016/j.bpa.2016.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 10/20/2016] [Indexed: 12/25/2022]
Abstract
Critical illness associated with cardiac pump failure results in reduced tissue perfusion in all organs and occurs in various conditions such as sepsis, cardiogenic shock, and heart failure. Mechanical circulatory support (MCS) devices can be used to maintain organ perfusion in patients with cardiogenic shock and decompensated chronic heart failure. However, correction of global hemodynamic parameters by MCS does not always cause a parallel improvement in microcirculatory perfusion and oxygenation of the organ systems, a condition referred to as a loss of hemodynamic coherence between macro- and microcirculation (MC). In this paper, we review the literature describing hemodynamic coherence or loss occurring during MCS of the heart. By using Embase, Medline Cochrane, Web of Science, and Google Scholar, we analyzed the literature on the response of MC and macrocirculation to MCS of the heart in critical illness. The characteristics of patients, MCS devices, and micro- and macrocirculatory parameters were very heterogenic. Short-term MCS studies (78%) described the effects of intra-aortic balloon pumps (IABPs) on the MC and macrocirculation. Improvement in MC, observed by handheld microscopy (orthogonal polarization spectral (OPS), sidestream dark-field (SDF), and Cytocam IDF imaging) in line with restored macrocirculation was found in 44% and 40% of the studies of short- and long-term MCS, respectively. In only 6 of 14 studies, hemodynamic coherence was described. It is concluded that more studies using direct visualization of the MC in short- and long-term MCS by handheld microscopy are needed, preferably randomized controlled studies, to identify the presence and clinical significance of hemodynamic coherence. It is anticipated that these further studies can enable to better identify patients who will benefit from treatment by mechanical heart support to ensure adequate organ perfusion.
Collapse
|
46
|
Kara A, Akin S, Dos Reis Miranda D, Struijs A, Caliskan K, van Thiel RJ, Dubois EA, de Wilde W, Zijlstra F, Gommers D, Ince C. Microcirculatory assessment of patients under VA-ECMO. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:344. [PMID: 27776535 PMCID: PMC5078964 DOI: 10.1186/s13054-016-1519-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 09/30/2016] [Indexed: 12/03/2022]
Abstract
Background Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an effective technique for providing emergency mechanical circulatory support for patients with cardiogenic shock. VA-ECMO enables a rapid restoration of global systemic organ perfusion, but it has not been found to always show a parallel improvement in the microcirculation. We hypothesized in this study that the response of the microcirculation to the initiation of VA-ECMO might identify patients with increased chances of intensive care unit (ICU) survival. Methods Twenty-four patients were included in this study. Sublingual microcirculation measurements were performed using the CytoCam-IDF (incident dark field) imaging device. Microcirculatory measurements were performed at baseline, after VA-ECMO insertion (T1), 48–72 h after initiation of VA-ECMO (T2), 5–6 days after (T3), 9–10 days after (T4), and within 24 h of VA-ECMO removal. Results Of the 24 patients included in the study population, 15 survived and 9 died while on VA-ECMO. There was no significant difference between the systemic global hemodynamic variables at initiation of VA-ECMO between the survivors and non-survivors. There was, however, a significant difference in the microcirculatory parameters of both small and large vessels at all time points between the survivors and non-survivors. Perfused vessel density (PVD) at baseline (survivor versus non-survivor, 19.21 versus 13.78 mm/mm2, p = 0.001) was able to predict ICU survival on initiation of VA-ECMO; the area under the receiver operating characteristic curve (ROC) was 0.908 (95 % confidence interval 0.772–1.0). Conclusion PVD of the sublingual microcirculation at initiation of VA-ECMO can be used to predict ICU mortality in patients with cardiogenic shock. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1519-7) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Atila Kara
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. .,Department of Intensive Care, Hacettepe University Faculty of Medicine, Ankara, Turkey. .,Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.
| | - Sakir Akin
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.,Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Dinis Dos Reis Miranda
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Ard Struijs
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Kadir Caliskan
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Robert J van Thiel
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Eric A Dubois
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Wouter de Wilde
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| |
Collapse
|
47
|
Digging into the microcirculation: the rush for gold may excavate apples and oranges. J Clin Monit Comput 2016; 31:665-667. [PMID: 27730451 PMCID: PMC5500674 DOI: 10.1007/s10877-016-9935-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 09/15/2016] [Indexed: 11/20/2022]
|
48
|
Ability and efficiency of an automatic analysis software to measure microvascular parameters. J Clin Monit Comput 2016; 31:669-676. [DOI: 10.1007/s10877-016-9928-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 08/19/2016] [Indexed: 01/06/2023]
|
49
|
Gassmann NN, van Elteren HA, Goos TG, Morales CR, Rivera-Ch M, Martin DS, Cabala Peralta P, Passano Del Carpio A, Aranibar Machaca S, Huicho L, Reiss IKM, Gassmann M, de Jonge RCJ. Pregnancy at high altitude in the Andes leads to increased total vessel density in healthy newborns. J Appl Physiol (1985) 2016; 121:709-15. [PMID: 27445300 PMCID: PMC5142254 DOI: 10.1152/japplphysiol.00561.2016] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 07/19/2016] [Indexed: 01/17/2023] Open
Abstract
The developing human fetus is able to cope with the physiological reduction in oxygen supply occurring in utero. However, it is not known if microvascularization of the fetus is augmented when pregnancy occurs at high altitude. Fifty-three healthy term newborns in Puno, Peru (3,840 m) were compared with sea-level controls. Pre- and postductal arterial oxygen saturation (SpO2) was determined. Cerebral and calf muscle regional tissue oxygenation was measured using near infrared spectroscopy (NIRS). Skin microcirculation was noninvasively measured using incident dark field imaging. Pre- and postductal SpO2 in Peruvian babies was 88.1 and 88.4%, respectively, which was 10.4 and 9.7% lower than in newborns at sea level (P < 0.001). Cerebral and regional oxygen saturation was significantly lower in the Peruvian newborns (cerebral: 71.0 vs. 74.9%; regional: 68.5 vs. 76.0%, P < 0.001). Transcutaneously measured total vessel density in the Peruvian newborns was 14% higher than that in the newborns born at sea level (29.7 vs. 26.0 mm/mm(2); P ≤ 0.001). This study demonstrates that microvascular vessel density in neonates born to mothers living at high altitude is higher than that in neonates born at sea level.
Collapse
Affiliation(s)
- Norina N Gassmann
- Institute of Veterinary Physiology, Vetsuisse Faculty, and Zurich Center for Integrative Human Physiology (ZIHP), Medical Faculty, University of Zurich, Zurich, Switzerland; Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands
| | - Hugo A van Elteren
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands
| | - Tom G Goos
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands; Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - Claudia R Morales
- Laboratory of Adaptation to High Altitude, Universidad Peruana Cayetano Heredia (UPCH), Lima, Peru
| | - Maria Rivera-Ch
- Laboratory of Adaptation to High Altitude, Universidad Peruana Cayetano Heredia (UPCH), Lima, Peru; Center of Research for Integral and Sustainable Development (CIDIS), UPCH, Lima, Peru
| | - Daniel S Martin
- University College London Centre for Altitude Space and Extreme Environment Medicine, Univesity College London Hospital (UCLH) National Institute for Health Research (NIHR) Biomedical Research Centre, Institute of Sport and Exercise Health, London, United Kingdom
| | | | | | | | - Luis Huicho
- Center of Research for Integral and Sustainable Development (CIDIS), UPCH, Lima, Peru; School of Medicine, UPCH, Lima, Peru
| | - Irwin K M Reiss
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands
| | - Max Gassmann
- Institute of Veterinary Physiology, Vetsuisse Faculty, and Zurich Center for Integrative Human Physiology (ZIHP), Medical Faculty, University of Zurich, Zurich, Switzerland; School of Medicine, UPCH, Lima, Peru
| | - Rogier C J de Jonge
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
50
|
Focal depth measurements of the vaginal wall: a new method to noninvasively quantify vaginal wall thickness in the diagnosis and treatment of vaginal atrophy. Menopause 2016; 23:833-8. [DOI: 10.1097/gme.0000000000000634] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
|