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Farina J, Erriquez A, Campo G, Biscaglia S, Zuin M, Casella G, Capecchi A, Nobile G, Pappalardo F. Combined use of intra-aortic balloon pump and impella in cardiogenic shock: A systematic review. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00448-2. [PMID: 38697884 DOI: 10.1016/j.carrev.2024.04.296] [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: 03/13/2024] [Revised: 04/07/2024] [Accepted: 04/23/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Use of Intra-Aortic Balloon Pump (IABP) in combination with Impella has been described as an alternative strategy for mechanical circulatory support (MCS) in patients with cardiogenic shock (CS). We provide a systematic review aimed to explore the effectiveness of this paired MCS approach. METHODS We conducted a comprehensive systematic search in MEDLINE, Scopus, and Cochrane databases to identify all studies that investigated dual MCS with IABP and Impella. RESULTS Our search strategy identified 12 articles, including 1 randomized controlled trial, 1 retrospective study, 1 case series, 7 case report and 2 animal studies. Rationale for this combined MCS strategy stems from an observed reduction in myocardial oxygen demand/supply ratio compared to the use of each device alone, without determining significant variations in left ventricular work. Nonetheless, this combined approach also leads to a 30-40 % decline in Impella flow, increasing the risk of bleeding, Impella displacement, as well as triggering positioning and pressure alarms. Additionally, hemolytic risk data yielded inconclusive results. Importantly, there were no notable disparities in mortality rates when comparing the combined strategy to the use of each device individually. CONCLUSION At the current state-of-the-art, there are no conclusive data demonstrating net clinical benefits of combining Impella with IABP. Considering the substantial risks of morbidity associated, we recommend against its use in clinical practice.
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Affiliation(s)
- Jacopo Farina
- Cardiology Unit, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy.
| | - Andrea Erriquez
- Cardiology Unit, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy
| | - Simone Biscaglia
- Cardiology Unit, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy
| | - Marco Zuin
- Cardiology Unit, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy
| | | | | | | | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care, AOU SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy and AOU Maggiore della Carità, Novara, Italy
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2
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Bogatu L, Turco S, Mischi M, Schmitt L, Woerlee P, Bezemer R, Bouwman AR, Korsten EHHM, Muehlsteff J. New Hemodynamic Parameters in Peri-Operative and Critical Care-Challenges in Translation. SENSORS (BASEL, SWITZERLAND) 2023; 23:2226. [PMID: 36850819 PMCID: PMC9961222 DOI: 10.3390/s23042226] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/03/2023] [Accepted: 02/06/2023] [Indexed: 06/18/2023]
Abstract
Hemodynamic monitoring technologies are evolving continuously-a large number of bedside monitoring options are becoming available in the clinic. Methods such as echocardiography, electrical bioimpedance, and calibrated/uncalibrated analysis of pulse contours are becoming increasingly common. This is leading to a decline in the use of highly invasive monitoring and allowing for safer, more accurate, and continuous measurements. The new devices mainly aim to monitor the well-known hemodynamic variables (e.g., novel pulse contour, bioreactance methods are aimed at measuring widely-used variables such as blood pressure, cardiac output). Even though hemodynamic monitoring is now safer and more accurate, a number of issues remain due to the limited amount of information available for diagnosis and treatment. Extensive work is being carried out in order to allow for more hemodynamic parameters to be measured in the clinic. In this review, we identify and discuss the main sensing strategies aimed at obtaining a more complete picture of the hemodynamic status of a patient, namely: (i) measurement of the circulatory system response to a defined stimulus; (ii) measurement of the microcirculation; (iii) technologies for assessing dynamic vascular mechanisms; and (iv) machine learning methods. By analyzing these four main research strategies, we aim to convey the key aspects, challenges, and clinical value of measuring novel hemodynamic parameters in critical care.
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Affiliation(s)
- Laura Bogatu
- Biomedical Diagnostics Lab (BM/d), Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands
- Patient Care and Measurements, Philips Research, 5656 AE Eindhoven, The Netherlands
| | - Simona Turco
- Biomedical Diagnostics Lab (BM/d), Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands
| | - Massimo Mischi
- Biomedical Diagnostics Lab (BM/d), Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands
| | - Lars Schmitt
- Patient Care and Measurements, Philips Research, 5656 AE Eindhoven, The Netherlands
| | - Pierre Woerlee
- Biomedical Diagnostics Lab (BM/d), Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands
| | - Rick Bezemer
- Patient Care and Measurements, Philips Research, 5656 AE Eindhoven, The Netherlands
| | - Arthur R. Bouwman
- Department of Anesthesiology, Intensive Care and Pain Medicine, Catharina Ziekenhuis, 5623 EJ Eindhoven, The Netherlands
| | - Erik H. H. M. Korsten
- Department of Anesthesiology, Intensive Care and Pain Medicine, Catharina Ziekenhuis, 5623 EJ Eindhoven, The Netherlands
| | - Jens Muehlsteff
- Patient Care and Measurements, Philips Research, 5656 AE Eindhoven, The Netherlands
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3
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Nam K, Jeon Y. Microcirculation during surgery. Anesth Pain Med (Seoul) 2022; 17:24-34. [PMID: 35139609 PMCID: PMC8841265 DOI: 10.17085/apm.22127] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 01/13/2022] [Indexed: 11/17/2022] Open
Abstract
Throughout the long history of surgery, there has been great advancement in the hemodynamic management of surgical patients. Traditionally, hemodynamic management has focused on macrocirculatory monitoring and intervention to maintain appropriate oxygen delivery. However, even after optimization of macro-hemodynamic parameters, microcirculatory dysfunction, which is related to higher postoperative complications, occurs in some patients. Although the clinical significance of microcirculatory dysfunction has been well reported, little is known about interventions to recover microcirculation and prevent microcirculatory dysfunction. This may be at least partly caused by the fact that the feasibility of monitoring tools to evaluate microcirculation is still insufficient for use in routine clinical practice. However, considering recent advancements in these research fields, with more popular use of microcirculation monitoring and more clinical trials, clinicians may better understand and manage microcirculation in surgical patients in the future. In this review, we describe currently available methods for microcirculatory evaluation. The current knowledge on the clinical relevance of microcirculatory alterations has been summarized based on previous studies in various clinical settings. In the latter part, pharmacological and clinical interventions to improve or restore microcirculation are also presented.
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Affiliation(s)
| | - Yunseok Jeon
- Corresponding author: Yunseok Jeon, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: 82-2-2072-3108, Fax: 82-2-747-8363 E-mail:
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4
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Current methods for the assessment of skin microcirculation: Part 2. Postepy Dermatol Alergol 2019; 36:377-381. [PMID: 31616209 PMCID: PMC6791164 DOI: 10.5114/ada.2019.83657] [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] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 02/22/2018] [Indexed: 11/17/2022] Open
Abstract
Microcirculation accounts for about 99% of blood vessels in adults and mediates between the arterial and venous parts of the cardiovascular system, both structurally and functionally. Skin microcirculation consists of two vascular plexuses: superficial and deep. Microcirculation includes vessels with a diameter of less than 150 μm, i.e. arteries, small veins, lymphatic vessels and arteriovenous anastomoses, which build the microcirculation unit. Skin microcirculation may be affected both in systemic pathologies and specific skin disorders. Several non-invasive techniques are available to assess the skin microcirculation. Methods used in clinical practice were presented previously in Advances in Dermatology and Allergology. The current article describes methods that may be used in clinical research.
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Kazune S, Caica A, Luksevics E, Volceka K, Grabovskis A. Impact of increased mean arterial pressure on skin microcirculatory oxygenation in vasopressor-requiring septic patients: an interventional study. Ann Intensive Care 2019; 9:97. [PMID: 31468202 PMCID: PMC6715757 DOI: 10.1186/s13613-019-0572-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 08/20/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Heterogeneity of microvascular blood flow leading to tissue hypoxia is a common finding in patients with septic shock. It may be related to suboptimal systemic perfusion pressure and lead to organ failure. Mapping of skin microcirculatory oxygen saturation and relative hemoglobin concentration using hyperspectral imaging allows to identify heterogeneity of perfusion and perform targeted measurement of oxygenation. We hypothesized that increasing mean arterial pressure would result in improved oxygenation in areas of the skin with most microvascular blood pooling. METHODS We included adult patients admitted to the intensive care unit within the previous 24 h with sepsis and receiving a noradrenaline infusion. Skin oxygen saturation was measured using hyperspectral imaging-based method at baseline and after the increase in mean arterial pressure by 20 mm Hg by titration of noradrenaline doses. The primary outcome was an increase in skin oxygen saturation depending upon disease severity. RESULTS We studied 30 patients with septic shock. Median skin oxygen saturation changed from 26.0 (24.5-27.0) % at baseline to 30.0 (29.0-31.0) % after increase in mean arterial pressure (p = 0.04). After adjustment for baseline saturation, patients with higher SOFA scores achieved higher oxygen saturation after the intervention (r2 = 0.21; p = 0.02). Skin oxygen saturation measured at higher pressure was found to be marginally predictive of mortality (OR: 1.10; 95% CI 1.00-1.23; p = 0.053). CONCLUSIONS Improvement of microcirculatory oxygenation can be achieved with an increase in mean arterial pressure in most patients. Response to study intervention is proportional to disease severity.
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Affiliation(s)
- Sigita Kazune
- Department of Anesthesiology, Hospital of Traumatology and Orthopedics, 22 Duntes Street, Riga, 1013, Latvia. .,Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, 1004, Latvia.
| | - Anastasija Caica
- Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, 1004, Latvia.,Department of Human and Animal Physiology, Faculty of Biology, University of Latvia, 1 Jelgavas Street, Riga, 1004, Latvia
| | - Einars Luksevics
- Clinic of Toxicology and Sepsis, Riga East University Hospital, 2 Hipokrata Street, Riga, 1038, Latvia
| | - Karina Volceka
- Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, 1004, Latvia.,Department of Human and Animal Physiology, Faculty of Biology, University of Latvia, 1 Jelgavas Street, Riga, 1004, Latvia
| | - Andris Grabovskis
- Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, 1004, Latvia
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6
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Treml B, Kleinsasser A, Stadlbauer KH, Steiner I, Pajk W, Pilch M, Burtscher M, Knotzer H. Cutaneous Microvascular Blood Flow and Reactivity in Hypoxia. Front Physiol 2018; 9:160. [PMID: 29559919 PMCID: PMC5845666 DOI: 10.3389/fphys.2018.00160] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 02/19/2018] [Indexed: 01/04/2023] Open
Abstract
As is known, hypoxia leads to an increase in microcirculatory blood flow of the skin in healthy volunteers. In this pilot study, we investigated microcirculatory blood flow and reactive hyperemia of the skin in healthy subjects in normobaric hypoxia. Furthermore, we examined differences in microcirculation between hypoxic subjects with and without short-term acclimatization, whether or not skin microvasculature can acclimatize. Fourty-six healthy persons were randomly allocated to either short-term acclimatization using intermittent hypoxia for 1 h over 7 days at an FiO2 0.126 (treatment, n = 23) or sham short-term acclimatization for 1 h over 7 days at an FiO2 0.209 (control, n = 23). Measurements were taken in normoxia and at 360 and 720 min during hypoxia (FiO2 0.126). Microcirculatory cutaneous blood flow was assessed with a laser Doppler flowmeter on the forearm. Reactive hyperemia was induced by an ischemic stimulus. Measurements included furthermore hemodynamics, blood gas analyses and blood lactate. Microcirculatory blood flow increased progressively during hypoxia (12.3 ± 7.1–19.0 ± 8.1 perfusion units; p = 0.0002) in all subjects. The magnitude of the reactive hyperemia was diminished during hypoxia (58.2 ± 14.5–40.3 ± 27.4 perfusion units; p = 0.0003). Short-term acclimatization had no effect on microcirculatory blood flow. When testing for a hyperemic response of the skin's microcirculation we found a diminished signal in hypoxia, indicative for a compromised auto-regulative circulatory capacity. Furthermore, hypoxic short-term acclimatization did not affect cutaneous microcirculatory blood flow. Seemingly, circulation of the skin was unable to acclimatize using a week-long short-term acclimatization protocol. A potential limitation of our study may be the 7 days between acclimatization and the experimental test run. However, there is evidence that the hypoxic ventilatory response, an indicator of acclimatization, is increased for 1 week after short-term acclimatization. Then again, 1 week is what one needs to get from home to a location at significant altitude.
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Affiliation(s)
- Benedikt Treml
- Department of General and Surgical Intensive Care, Medical University Innsbruck, Innsbruck, Austria
| | - Axel Kleinsasser
- Department of Anesthesiology and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Karl-Heinz Stadlbauer
- Department of Anesthesiology and Critical Care Medicine, Klinikum Vöcklabruck, Vöcklabruck, Austria
| | - Iris Steiner
- Department of Anesthesiology and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Werner Pajk
- Department of Anesthesiology and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Michael Pilch
- Department of Pediatrics, County Hospital Kufstein, Kufstein, Austria
| | - Martin Burtscher
- Department of Sport Science, Medical Section, University Innsbruck, Innsbruck, Austria
| | - Hans Knotzer
- Department of Anesthesiology and Critical Care Medicine II, Klinikum Wels-Grieskirchen, Wels, Austria
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7
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Vollmer C, Weber APM, Wallenfang M, Hoffmann T, Mettler-Altmann T, Truse R, Bauer I, Picker O, Mathes AM. Melatonin pretreatment improves gastric mucosal blood flow and maintains intestinal barrier function during hemorrhagic shock in dogs. Microcirculation 2018; 24. [PMID: 28316127 DOI: 10.1111/micc.12345] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 12/12/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Melatonin improves hepatic perfusion after hemorrhagic shock and may reduce stress-induced gastric lesions. This study was designed to investigate whether pretreatment with melatonin may influence gastric mucosal microcirculatory perfusion (μflow), oxygenation (μHbO2 ), or intestinal barrier function during physiological and hemorrhagic conditions in dogs. METHODS In a randomized crossover study, five anesthetized foxhounds received melatonin 100 μg kg-1 or vehicle (ethanol 5%) intravenously in the absence or presence of hemorrhagic shock (60 minutes, -20% blood volume). Systemic hemodynamic variables, gastric mucosal perfusion, and oxygenation were recorded continuously; intestinal barrier function was assessed intermittently via xylose absorption. RESULTS During hemorrhagic shock, melatonin significantly attenuated the decrease in μflow, compared with vehicle (-19±9 vs -43±10 aU, P<.05), without influence on μHbO2 . A significant increase in xylose absorption was detected during hemorrhage in vehicle-treated dogs, compared with sham-operated animals (13±2 vs 8±1 relative amounts, P<.05); this was absent in melatonin-treated animals (6±1 relative amounts). Melatonin did not influence macrocirculation. CONCLUSIONS Melatonin improves regional blood flow suggesting improved oxygen delivery in gastric mucosa during hemorrhagic shock. This could provide a mechanism for the observed protection of intestinal barrier function in dogs.
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Affiliation(s)
- Christian Vollmer
- Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Andreas P M Weber
- Institute of Plant Biochemistry, Cluster of Excellence on Plant Sciences (CEPLAS), Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Martin Wallenfang
- Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Till Hoffmann
- Department of Hemostaseology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Tabea Mettler-Altmann
- Plant Metabolism and Metabolomics Laboratory, Cluster of Excellence on Plant Sciences (CEPLAS), Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Richard Truse
- Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Inge Bauer
- Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Olaf Picker
- Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Alexander M Mathes
- Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany.,Department of Anesthesiology and Intensive Care Medicine, University Hospital Cologne, Cologne, Germany
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8
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Kollisch-Singule MC, Jain SV, Andrews PL, Satalin J, Gatto LA, Villar J, De Backer D, Gattinoni L, Nieman GF, Habashi NM. Looking beyond macroventilatory parameters and rethinking ventilator-induced lung injury. J Appl Physiol (1985) 2017; 124:1214-1218. [PMID: 29146685 DOI: 10.1152/japplphysiol.00412.2017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
| | - Sumeet V Jain
- Department of Surgery, SUNY Upstate Medical University , Syracuse, New York
| | - Penny L Andrews
- Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine , Baltimore, Maryland
| | - Joshua Satalin
- Department of Surgery, SUNY Upstate Medical University , Syracuse, New York
| | - Louis A Gatto
- Department of Surgery, SUNY Upstate Medical University , Syracuse, New York.,Department of Biological Sciences, SUNY Cortland, Cortland, New York
| | - Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III , Madrid , Spain.,Research Unit, Hospital Universitario Dr. Negrin , Las Palmas de Gran Canaria , Spain
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles , Brussels , Belgium
| | - Luciano Gattinoni
- Department of Anesthesia and Intensive Care, Georg-August-Universität, Göttingen , Germany
| | - Gary F Nieman
- Department of Surgery, SUNY Upstate Medical University , Syracuse, New York
| | - Nader M Habashi
- Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine , Baltimore, Maryland
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9
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Johnson A, Ahrens T. Stroke volume optimization: the new hemodynamic algorithm. Crit Care Nurse 2016; 35:11-27. [PMID: 25639574 DOI: 10.4037/ccn2015427] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Critical care practices have evolved to rely more on physical assessments for monitoring cardiac output and evaluating fluid volume status because these assessments are less invasive and more convenient to use than is a pulmonary artery catheter. Despite this trend, level of consciousness, central venous pressure, urine output, heart rate, and blood pressure remain assessments that are slow to be changed, potentially misleading, and often manifested as late indications of decreased cardiac output. The hemodynamic optimization strategy called stroke volume optimization might provide a proactive guide for clinicians to optimize a patient's status before late indications of a worsening condition occur. The evidence supporting use of the stroke volume optimization algorithm to treat hypovolemia is increasing. Many of the cardiac output monitor technologies today measure stroke volume, as well as the parameters that comprise stroke volume: preload, afterload, and contractility.
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Affiliation(s)
- Alexander Johnson
- Alexander Johnson is a clinical nurse specialist, Central DuPage Hospital, Cadence Health System-Northwestern Medicine, Winfield, Illinois.Thomas Ahrens is a research scientist, Barnes-Jewish Hospital, St Louis, Missouri.
| | - Thomas Ahrens
- Alexander Johnson is a clinical nurse specialist, Central DuPage Hospital, Cadence Health System-Northwestern Medicine, Winfield, Illinois.Thomas Ahrens is a research scientist, Barnes-Jewish Hospital, St Louis, Missouri
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10
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Nadort A, Kalkman K, van Leeuwen TG, Faber DJ. Quantitative blood flow velocity imaging using laser speckle flowmetry. Sci Rep 2016; 6:25258. [PMID: 27126250 PMCID: PMC4850477 DOI: 10.1038/srep25258] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 04/13/2016] [Indexed: 11/16/2022] Open
Abstract
Laser speckle flowmetry suffers from a debated quantification of the inverse relation between decorrelation time (τc) and blood flow velocity (V), i.e. 1/τc = αV. Using a modified microcirculation imager (integrated sidestream dark field - laser speckle contrast imaging [SDF-LSCI]), we experimentally investigate on the influence of the optical properties of scatterers on α in vitro and in vivo. We found a good agreement to theoretical predictions within certain limits for scatterer size and multiple scattering. We present a practical model-based scaling factor to correct for multiple scattering in microcirculatory vessels. Our results show that SDF-LSCI offers a quantitative measure of flow velocity in addition to vessel morphology, enabling the quantification of the clinically relevant blood flow, velocity and tissue perfusion.
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Affiliation(s)
- Annemarie Nadort
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands.,ARC Centre of Excellence for Nanoscale BioPhotonics, Macquarie University, Sydney 2109, NSW Australia
| | - Koen Kalkman
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands
| | - Ton G van Leeuwen
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands
| | - Dirk J Faber
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands
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11
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Knotzer H, Filipovic M, Siegemund M, Kleinsasser A. The physiologic perspective in fluid management in vascular anesthesiology. J Cardiothorac Vasc Anesth 2014; 28:1604-8. [PMID: 25240288 DOI: 10.1053/j.jvca.2014.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Indexed: 01/22/2023]
Abstract
Vascular surgery patients frequently suffer from atherosclerosis and peripheral arterial occlusive disease generating endothelial dysfunction. Furthermore, ischemia and reperfusion during surgery damage endothelial cells and, especially, the endothelial glycocalix. The damage of the glycocalix promotes an increase in permeability. Not only crystalloids, which freely diffuse between the intravascular and the interstitial compartment, but also colloidal fluids cross from the intravascular space in the interstitial space with the consequence of edema formation. Possible tissue edema may result in an impairment of tissue oxygenation, leading to wound healing disturbances and initiation of inflammatory responses up to tissue apoptosis. Particularly in vascular anesthesia, this possibly means that colloids only should be administered in acute volume resuscitation immediately after unclamping a big vessel for immediate volume restoration. Which colloidal fluid should be administered is still under intense discussion. From a theoretical physiologic point of view, iso-osmolar albumin is the best choice regarding volume effect, antioxidative properties, and protection against destruction of the glycocalix. Nonetheless, albumin experimentally has not lived up to its promise in the clinical setting. Thus, further well-conducted large randomized clinical trials are necessary to ascertain the optimal fluid therapy in vascular surgery patients.
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Affiliation(s)
- Hans Knotzer
- Institute for Anesthesiology and Critical Care Medicine, II, Klinikum Wels, Austria.
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12
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The right target at the right time: the microcirculation in circulatory shock. Crit Care Med 2014; 42:482-3. [PMID: 24434462 DOI: 10.1097/ccm.0000000000000004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Hypothermia improves oral and gastric mucosal microvascular oxygenation during hemorrhagic shock in dogs. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2013; 2013:589606. [PMID: 24327826 PMCID: PMC3845851 DOI: 10.1155/2013/589606] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 09/03/2013] [Accepted: 10/01/2013] [Indexed: 11/30/2022]
Abstract
Hypothermia is known to improve tissue function in different organs during physiological and pathological conditions. The aim of this study was to evaluate the effects of hypothermia on oral and gastric mucosal microvascular oxygenation (μHbO2) and perfusion (μflow) under physiological and hemorrhagic conditions. Five dogs were repeatedly anesthetized. All animals underwent each experimental protocol (randomized cross-over design): hypothermia (34°C), hypothermia during hemorrhage, normothermia, and normothermia during hemorrhage. Microcirculatory and hemodynamic variables were recorded. Systemic (DO2) and oral mucosal (μDO2) oxygen delivery were calculated. Hypothermia increased oral μHbO2 with no effect on gastric μHbO2. Hemorrhage reduced oral and gastric μHbO2 during normothermia (−36 ± 4% and −27 ± 7%); however, this effect was attenuated during additional hypothermia (−15 ± 5% and −11 ± 5%). The improved μHbO2 might be based on an attenuated reduction in μflow during hemorrhage and additional hypothermia (−51 ± 21 aU) compared to hemorrhage and normothermia (−106 ± 19 aU). μDO2 was accordingly attenuated under hypothermia during hemorrhage whereas DO2 did not change. Thus, in this study hypothermia alone improves oral μHbO2 and attenuates the effects of hemorrhage on oral and gastric μHbO2. This effect seems to be mediated by an increased μDO2 on the basis of increased μflow.
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14
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Dünser MW, Takala J, Brunauer A, Bakker J. Re-thinking resuscitation: leaving blood pressure cosmetics behind and moving forward to permissive hypotension and a tissue perfusion-based approach. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:326. [PMID: 24103466 PMCID: PMC4056569 DOI: 10.1186/cc12727] [Citation(s) in RCA: 113] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Definitions of shock and resuscitation endpoints traditionally focus on blood pressures and cardiac output. This carries a high risk of overemphasizing systemic hemodynamics at the cost of tissue perfusion. In line with novel shock definitions and evidence of the lack of a correlation between macro- and microcirculation in shock, we recommend that macrocirculatory resuscitation endpoints, particularly arterial and central venous pressure as well as cardiac output, be reconsidered. In this viewpoint article, we propose a three-step approach of resuscitation endpoints in shock of all origins. This approach targets only a minimum individual and context-sensitive mean arterial blood pressure (for example, 45 to 50 mm Hg) to preserve heart and brain perfusion. Further resuscitation is exclusively guided by endpoints of tissue perfusion irrespectively of the presence of arterial hypotension ('permissive hypotension'). Finally, optimization of individual tissue (for example, renal) perfusion is targeted. Prospective clinical studies are necessary to confirm the postulated benefits of targeting these resuscitation endpoints.
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Yadav N, Bhatia S, Ragheb J, Song Y, Romero A, Oh S, Lin WC. Evaluating and improving the quality of time-dependent, diffuse reflectance spectroscopic signals measured from in vivo brain during craniotomy. Med Eng Phys 2013; 35:1551-7. [PMID: 23665345 DOI: 10.1016/j.medengphy.2013.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 04/05/2013] [Accepted: 04/17/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Optical spectroscopy can be used to assess the pathophysiological characteristics of diseased and injured biological tissue in vivo in a non-destructive way. It is often used in conjunction with a contact optical probe for the purposes of operating and sensing in a sterile field. Since the probe is often held by the hand of an investigator during data acquisition, any hand instability can affect the quality of acquired data and, hence, degrade the accuracy of diagnosis. This study was designed to quantitatively characterize these artifacts, and then propose an effective engineering solution to remove them. METHODS Time-dependent diffuse reflectance spectra (Rd(λ,t)) were acquired from the normal cortex region of pediatric patients undergoing epilepsy surgery. They were acquired at a rate of 33 Hz, and their range was 400 and 900 nm. Two distinct ways of collecting data were tested: one with the fiber optical probe held by the surgeon's hand during data acquisition, and the other with the probe held by a specially designed probe holder. The probe holder was designed and constructed to minimize the variations in probe contact pressure and contact point for the full duration of any given investigation. Spectral data acquired using versus not using the probe holder were characterized and compared in the time, wavelength, and frequency domains, using both descriptive and inferential statistics. RESULTS Hand motion manifested as strong random variations in Rd(λ,t) which impacted temporal and frequency characteristics of Rd(λ,t). The percentage standard deviation %STD of Rd(λ,t) acquired without probe holder could be as high as 60%, and they are significantly higher than those with probe holder at all wavelengths. This difference is especially prominent between 400 and 600 nm. Rd(λ,t) acquired without the probe holder also processed a higher spectral power energy in the frequency domain than those with the probe holder. The correlation analysis revealed that the hand motions induced synchronistic variations in Rd(λ,t) between 600 and 800 nm, but this synchronicity is not obvious between 400 and 600 nm. CONCLUSION The results of this investigation demonstrate the nature and the magnitude of hand motion induced artifacts in in vivo diffuse reflectance spectra and propose one potential solution (i.e., a probe holder) to remove them. These findings allow us to improve the quality of time-dependent, diffuse reflectance signals acquired to study the dynamic characteristics of biological tissues, like brain, in vivo.
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Affiliation(s)
- Nitin Yadav
- Department of Biomedical Engineering, Florida International University, Miami, FL, USA.
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Muris DMJ, Houben AJHM, Schram MT, Stehouwer CDA. Microvascular dysfunction: an emerging pathway in the pathogenesis of obesity-related insulin resistance. Rev Endocr Metab Disord 2013; 14:29-38. [PMID: 23299657 DOI: 10.1007/s11154-012-9231-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The prevalence of type 2 diabetes mellitus (T2DM) and its major risk factor, obesity, has reached epidemic proportions in Western society. How obesity leads to insulin resistance and subsequent T2DM is incompletely understood. It has been established that insulin can redirect blood flow in skeletal muscle from non-nutritive to nutritive capillary networks, without increasing total blood flow. This results in a net increase of the overall number of perfused nutritive capillary networks and thereby increases insulin-mediated glucose uptake by skeletal muscle. This process, referred to as functional (nutritive) capillary recruitment, has been shown to be endothelium-dependent and to require activation of the phosphatidylinositol-kinase (PI3K) pathway in the endothelial cell. Several studies have demonstrated that these processes are impaired in states of microvascular dysfunction. In obesity, changes in several adipokines are likely candidates to influence insulin signaling pathways in endothelial cells, thereby causing microvascular dysfunction. Microvascular dysfunction, in turn, impairs the timely access of glucose and insulin to their target tissues, and may therefore be an additional cause of insulin resistance. Thus, microvascular dysfunction may be a key feature in the development of obesity-related insulin resistance. In the present review, we will discuss the evidence for this emerging role for the microcirculation as a possible link between obesity and insulin resistance.
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Affiliation(s)
- Dennis M J Muris
- Department of Internal Medicine, Maastricht University Medical Centre (MUMC+), P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands
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Muris DMJ, Houben AJHM, Schram MT, Stehouwer CDA. Microvascular dysfunction is associated with a higher incidence of type 2 diabetes mellitus: a systematic review and meta-analysis. Arterioscler Thromb Vasc Biol 2012; 32:3082-94. [PMID: 23042819 DOI: 10.1161/atvbaha.112.300291] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Recent data support the hypothesis that microvascular dysfunction may be a potential mechanism in the development of insulin resistance. We examined the association of microvascular dysfunction with incident type 2 diabetes mellitus (T2DM) and impaired glucose metabolism by reviewing the literature and conducting a meta-analysis of longitudinal studies on this topic. METHODS AND RESULTS We searched Medline and Embase for articles published up to October 2011. Prospective cohort studies that focused on microvascular measurements in participants free of T2DM at baseline were included. Pooled relative risks were calculated using random effects models. Thirteen studies met the inclusion criteria for this meta-analysis. These studies focused on T2DM or impaired fasting glucose, not on impaired glucose tolerance. The pooled relative risks for incident T2DM (3846 cases) was 1.25 (95% confidence interval, 1.15; 1.36) per 1 SD greater microvascular dysfunction when all estimates of microvascular dysfunction were combined. In analyses of single estimates of microvascular dysfunction, the pooled relative risks for incident T2DM was 1.49 (1.36; 1.64) per 1 SD higher plasma soluble E-selectin levels; 1.21(1.11; 1.31) per 1 SD higher plasma soluble intercellular adhesion molecule-1 levels; 1.48 (1.03; 2.12) per 1 SD lower response to acetylcholine-mediated peripheral vascular reactivity; 1.18 (1.08; 1.29) per 1 SD lower retinal arteriole-to-venule ratio; and 1.43 (1.33; 1.54) per 1 logarithmically transformed unit higher albumin-to-creatinine ratio. In addition, the pooled relative risks for incident impaired fasting glucose (409 cases) was 1.15 (1.01-1.31) per 1 SD greater retinal venular diameters. CONCLUSIONS These data indicate that various estimates of microvascular dysfunction were associated with incident T2DM and, possibly, impaired fasting glucose, suggesting a role for the microcirculation in the pathogenesis of T2DM.
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Affiliation(s)
- Dennis M J Muris
- Department of Internal Medicine, Maastricht University Medical Centre, and Cardiovascular Research Institute Maastricht Maastricht University, Maastricht, the Netherlands
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Krite Svanberg E, Wollmer P, Andersson-Engels S, Åkeson J. Physiological influence of basic perturbations assessed by non-invasive optical techniques in humans. Appl Physiol Nutr Metab 2011; 36:946-57. [DOI: 10.1139/h11-119] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
New non-invasive techniques enabling frequent or continuous assessments of various pathophysiological conditions might be used to improve in-hospital outcome by enabling earlier and more reliable bedside detection of medical deterioration. In this preclinical study, three modern non-invasive optical techniques, laser Doppler imaging (LDI), near-infrared spectroscopy (NIRS), and tissue viability imaging (TVI), were all evaluated with respect to the influence of basic physiological perturbations (including local changes in arm positioning, skin temperature, and regional blood flow conditions) on quasi simultaneously obtained values of skin perfusion, muscle tissue oxygenation (StO2), and skin blood volume, recorded in eighteen healthy volunteers. Skin perfusion measured by LDI responded prominently to changes in positioning of the arm, whereas muscle StO2 measured by NIRS did not change significantly. Total haemoglobin count (HbT) measured by NIRS and blood volume estimated by TVI both increased significantly on lowering of the limb. On local cooling, the perfusion and blood volume were both found to increase considerably, while StO2 and HbT did not change. Local heating induced a more than 10-fold increase in skin perfusion and a small increase in blood volume. On progressive venoarterial occlusion, the perfusion, StO2, HbT, and blood volume values decreased, after transient increases in HbT and blood volume before full arterial occlusion occurred, and all values approached the baseline level on release of the occlusion with a slight overshoot of the StO2. The results obtained have potential bearing on future utilization of these non-invasive techniques in the management of severely injured and (or) critically ill patients.
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Affiliation(s)
- Emilie Krite Svanberg
- Department of Anaesthesiology and Intensive Care Medicine, Lund University, Skåne University Hospital, entrance 42, 3rd floor, SE – 205 02 Malmö, Sweden
| | - Per Wollmer
- Clinical Physiology and Nuclear Medicine, Lund University, Skåne University Hospital, Malmö, Sweden
| | | | - Jonas Åkeson
- Department of Anaesthesiology and Intensive Care Medicine, Lund University, Skåne University Hospital, entrance 42, 3rd floor, SE – 205 02 Malmö, Sweden
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Chen P, Fernald B, Lin W. Estimation of regional hemoglobin concentration in biological tissues using diffuse reflectance spectroscopy with a novel spectral interpretation algorithm. Phys Med Biol 2011; 56:3985-4000. [DOI: 10.1088/0031-9155/56/13/015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Chen PC, Lin WC. Spectral-profile-based algorithm for hemoglobin oxygen saturation determination from diffuse reflectance spectra. BIOMEDICAL OPTICS EXPRESS 2011; 2:1082-96. [PMID: 21559121 PMCID: PMC3087566 DOI: 10.1364/boe.2.001082] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Revised: 03/29/2011] [Accepted: 04/01/2011] [Indexed: 05/26/2023]
Abstract
Variations of hemoglobin (Hb) oxygenation in tissue provide important indications concerning the physiological conditions of tissue, and the data related to these variations are of intense interest in medical research as well as in clinical care. In this study, we derived a new algorithm to estimate Hb oxygenation from diffuse reflectance spectra. The algorithm was developed based on the unique spectral profile differences between the extinction coefficient spectra of oxy-Hb and deoxy-Hb within the visible wavelength region. Using differential wavelet transformation, these differences were quantified using the locations of certain spectral features, and, then, they were related to the oxygenation saturation level of Hb. The applicability of the algorithm was evaluated using a set of diffuse reflectance spectra produced by a Monte Carlo simulation model of photon migration and by tissue phantoms experimentally. The algorithm was further applied to the diffuse reflectance spectra acquired from in vivo experiments to demonstrate its clinical utility. The validation and evaluation results concluded that the algorithm is applicable to various tissue types (i.e., scattering properties) and can be easily used in conjunction with a diverse range of probe geometries for real-time monitoring of Hb oxygenation.
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Affiliation(s)
- Po-Ching Chen
- Department of Biomedical Engineering, Florida International University, 10555 West Flagler Street, EAS 2673, Miami, Florida 33176, USA
| | - Wei-Chiang Lin
- Department of Biomedical Engineering, Florida International University, 10555 West Flagler Street, EAS 2673, Miami, Florida 33176, USA
- Brain Institute, Miami Children’s Hospital, 3100 SW 62 Ave, Miami, FL 33155, USA
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Hsiu H, Hsu CL, Jan MY. Relations Between Beat-to-Beat Microcirculatory Blood Flow and Variations Therein. Photomed Laser Surg 2010; 28:785-92. [DOI: 10.1089/pho.2009.2690] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Hsin Hsiu
- Graduate Institute of Biomedical Engineering National Taiwan University of Science and Technology, Taipei, Taiwan, ROC
| | - Chia-Liang Hsu
- Department of Electrical Engineering, Yuan Ze University, Taoyuan, Taiwan, ROC
| | - Ming-Yie Jan
- Biophysics Lab, Institute of Physics, Academia Sinica, Taipei, Taiwan, ROC
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Abstract
The microcirculation plays an essential role in health and disease. Microvascular perfusion can be assessed directly using laser Doppler flowmetry and various imaging techniques or indirectly using regional capnometry and measurement of indicators of mismatch between oxygen delivery and oxygen consumption or indices of disturbed cellular oxygen utilization. Assessment of microvascular oxygen availability implies measurement of oxygen pressure or measurement of hemoglobin oxygen saturation. Microvascular function is assessed using other methods, including venous plethysmography. In this paper, I review current knowledge concerning assessment of the microcirculation with special emphasis on methods that could be used at the bedside.
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Affiliation(s)
- Yasser Sakr
- Department of Anesthesiology and Intensive Care, Friedrich Schiller University Hospital, Erlanger Allee 101, Jena 07743, Germany.
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Schreml S, Szeimies R, Prantl L, Karrer S, Landthaler M, Babilas P. Oxygen in acute and chronic wound healing. Br J Dermatol 2010; 163:257-68. [DOI: 10.1111/j.1365-2133.2010.09804.x] [Citation(s) in RCA: 395] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Jung C, Lauten A, Rödiger C, Krizanic F, Figulla HR, Ferrari M. Effect of intra-aortic balloon pump support on microcirculation during high-risk percutaneous intervention. Perfusion 2010; 24:417-21. [DOI: 10.1177/0267659109358208] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Intra-aortic balloon counter-pulsation (IABP) is recommended for hemodynamic support in cardiogenic shock. In addition, it can be applied during high-risk percutaneous interventions (PCI). While IABP support improves microflow in cardiogenic shock, its effect in hemodynamically stable patients is still unclear. We, therefore, sought to evaluate the effect of IABP treatment on microflow in hemodynamically stable patients undergoing elective high-risk PCI. Methods: In six patients with >" xbd="892" xhg="869" ybd="1310" yhg="1284"/>50% left main stenosis, microflow was evaluated according to current guidelines, using side-stream dark-field microscopy, visualizing microcirculatory vessels without using fluorescent dyes. Microflow was analyzed separately for each vessel category (diameter: 10-25µm and 26-50µm), using a semiquantitative system (0= no flow; 1= intermittent flow; 2= sluggish flow; 3= continuous flow) by a trained investigator. Steady state recordings and additional recordings twenty seconds after discontinuation of the electively implanted IABP were acquired. Results: Microflow in vessel categories 10-25µm and 26-50µm increased in this group of hemodynamically stable patients on use of IABP. Microflow decreased from 2.73±0.39 (p=0.052; 26-50µm: 2.88±0.20, p=0.008) to 2.22±0.23 (2.18±0.45) after stopping the IABP and increased to 2.90±0.14 (p=0.009; 2.85±0.28, p=0.009) after restart of the IABP. Conclusions: Circulatory support with IABP increases microcirculatory flow in the smallest vessels of the sublingual mucosa. Our data support the hypothesis that intra-aortic balloon counter-pulsation increases coronary and microvascular perfusion, thus, improving microcirculation even in hemodynamically stable patients. The use of IABP may increase safety of complex PCI and decrease the risk of deleterious complications.
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Affiliation(s)
- Christian Jung
- Friedrich-Schiller-University, Clinic of Internal Medicine I, Jena, Germany,
| | - Alexander Lauten
- Friedrich-Schiller-University, Clinic of Internal Medicine I, Jena, Germany
| | - Christoph Rödiger
- Friedrich-Schiller-University, Clinic of Internal Medicine I, Jena, Germany
| | - Florian Krizanic
- Friedrich-Schiller-University, Clinic of Internal Medicine I, Jena, Germany
| | - Hans R Figulla
- Friedrich-Schiller-University, Clinic of Internal Medicine I, Jena, Germany
| | - Markus Ferrari
- Friedrich-Schiller-University, Clinic of Internal Medicine I, Jena, Germany
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High Frequency of Organ Failures During Extracorporeal Membrane Oxygenation: Is the Microcirculation the Answer? Ann Thorac Surg 2010; 89:345-6; author reply 346. [DOI: 10.1016/j.athoracsur.2009.08.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Revised: 06/09/2009] [Accepted: 08/11/2009] [Indexed: 11/19/2022]
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Maier S, Hasibeder W, Pajk W, Hengl C, Ulmer H, Hausdorfer H, Wurzinger B, Knotzer H. Arginine-vasopressin attenuates beneficial norepinephrine effect on jejunal mucosal tissue oxygenation during endotoxinaemia. Br J Anaesth 2009; 103:691-700. [DOI: 10.1093/bja/aep239] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Jung C, Lauten A, Roediger C, Fritzenwanger M, Schumm J, Figulla HR, Ferrari M. In Vivo Evaluation of Tissue Microflow under Combined Therapy with Extracorporeal Life Support and Intra-aortic Balloon Counterpulsation. Anaesth Intensive Care 2009; 37:833-5. [DOI: 10.1177/0310057x0903700517] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Treatment with, percutaneous extracorporeal mechanical assist devices provides the ultimate therapeutic option to improve the macrocirculation in patients suffering from refractory cardiac arrest, severe cardiogenic shock or during high-risk interventions. However, the flow in the smallest vessels in these critical periods is poorly understood but prognostically of high importance. Using sidestream darkfield intravitalmicroscopy, we visualised the sublingual microflow in a patient suffering from severe cardiogenic shock supported by extracorporeal membrane oxygenation and intra-aortic balloon pump. Our results show that intra-aortic balloon counterpulsation applied in addition to extracorporeal membrane oxygenation further improves the microflow. This in vivo finding supports pilot studies favouring the application of devices supporting cardiac output (extracorporeal membrane oxygenation) together with devices aimed at pulsatility (intra-aortic balloon pump).
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Affiliation(s)
- C. Jung
- Division of Cardiology, Department of Internal Medicine I, Friedrich-Schiller-University, Jena, Germany
| | - A. Lauten
- Division of Cardiology, Department of Internal Medicine I, Friedrich-Schiller-University, Jena, Germany
| | - C. Roediger
- Division of Cardiology, Department of Internal Medicine I, Friedrich-Schiller-University, Jena, Germany
| | - M. Fritzenwanger
- Division of Cardiology, Department of Internal Medicine I, Friedrich-Schiller-University, Jena, Germany
| | - J. Schumm
- Division of Cardiology, Department of Internal Medicine I, Friedrich-Schiller-University, Jena, Germany
| | - H. R. Figulla
- Division of Cardiology, Department of Internal Medicine I, Friedrich-Schiller-University, Jena, Germany
| | - M. Ferrari
- Division of Cardiology, Department of Internal Medicine I, Friedrich-Schiller-University, Jena, Germany
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In search of the optimal perfusion pressure--does the microcirculation give us the answer? Crit Care Med 2009; 37:2120-1. [PMID: 19448465 DOI: 10.1097/ccm.0b013e3181a5c2b8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Elbers P, Atasever B. Quality and consistency in microvascular research. Br J Anaesth 2009; 102:886; author reply 886-7. [PMID: 19451158 DOI: 10.1093/bja/aep117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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[Long-term therapy with propofol has no impact on microcirculation in medical intensive care patients]. ACTA ACUST UNITED AC 2009; 104:336-42. [PMID: 19444413 DOI: 10.1007/s00063-009-1071-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2008] [Accepted: 03/03/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Microcirculation has become a major focus of research in critical care medicine due to its growing clinical relevance detecting changes in organ perfusion at an early stage. A negative impact of propofol infusion on microcirculation during short-term anesthesia was described recently. The influence of long-term sedation with propofol on microflow of critical care patients is still unclear. PATIENTS AND METHODS Microflow was analyzed using sidestream darkfield microscopy of sublingual mucosa in 28 patients of whom eleven received continuous infusion of propofol. According to current guidelines, microflow was recorded digitally. Quantitative analysis was performed offline in a semiquantitative way (0: no flow; 1: intermittent flow; 2: sluggish flow; 3: continuous flow). RESULTS Good microflow rates were detected in sublingual vessels (10-100 microm) in hemodynamically stable, medical intensive care patients. In the majority of cases, continuous flow profiles were recorded. There was no difference in flow rates between patients with and without propofol therapy. CONCLUSION In hemodynamically stable intensive care patients, long-term therapy with propofol did not affect sublingual microflow in this small cohort. However, intensive care physicians should keep such possible interactions in mind avoiding administration of these substances in patients with manifested shock. The effects of propofol in hemodynamically impaired patients should be evaluated in further studies.
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Jung C, Rödiger C, Fritzenwanger M, Schumm J, Lauten A, Figulla HR, Ferrari M. Acute microflow changes after stop and restart of intra-aortic balloon pump in cardiogenic shock. Clin Res Cardiol 2009; 98:469-75. [DOI: 10.1007/s00392-009-0018-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2008] [Accepted: 03/25/2009] [Indexed: 01/08/2023]
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Maier S, Hasibeder W, Hengl C, Pajk W, Schwarz B, Margreiter J, Ulmer H, Engl J, Knotzer H. Effects of phenylephrine on the sublingual microcirculation during cardiopulmonary bypass. Br J Anaesth 2009; 102:485-91. [DOI: 10.1093/bja/aep018] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Maier S, Pajk W, Ulmer H, Hausdorfer H, Torgersen C, Klocker J, Hasibeder W, Knotzer H. Epoprostenol improves mucosal tissue oxygen tension in an acute endotoxemic pig model. Shock 2009; 31:104-10. [PMID: 18520707 DOI: 10.1097/shk.0b013e31817c06ed] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The objective of the present study was to determine the effects of increasing dosages of continuously infused epoprostenol (PGI), a prostacyclin analog, on intestinal oxygen supply and jejunal mucosal tissue oxygen tension in an acute endotoxic pig model. Jejunal mucosal tissue PO2, oxygen saturation of jejunal microvascular hemoglobin, and gut microvascular blood flow were investigated. Systemic hemodynamic variables, mesenteric-venous and systemic acid base and blood gas variables, and lactate measurements were recorded. Measurements were performed at baseline, after Escherichia coli LPS administration, and at 20-min intervals during incremental PGI infusion (n = 8; 25, 50, 100, and 200microg x kg x h, respectively); or infusion of an equal amount of isotonic sodium chloride solution (n = 7). LPS infusion led to a significant decrease in mucosal tissue oxygen tension and microvascular hemoglobin oxygen saturation. Epoprostenol infusion led to a significant, dose-dependent increase in cardiac index and systemic oxygen delivery. Mucosal tissue oxygen tension and microvascular hemoglobin oxygen saturation increased after PGI administration and even returned to more-than-baseline values. Continuously infused PGI increased intestinal hemoglobin oxygen saturation and mucosal tissue oxygen tension in a dose-dependent manner mainly due to an increase in villus blood flow in this acute endotoxic pig model.
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Affiliation(s)
- Stephan Maier
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
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Knotzer H, Hasibeder W. [Microcirculation of intensive care patients. From the physiology to the bedside]. Anaesthesist 2008; 57:151-64. [PMID: 18273581 DOI: 10.1007/s00101-007-1300-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The microcirculation is unique in its anatomy and physiology and is a self-contained organ system within the human body. It is the site where gas exchange and nutrient supply takes place, but it is also the site which experiences pathological alterations during various shock states and therefore compromises the oxygen supply to tissues and organs. Systemic inflammation for example leads amongst others to increased heterogeneous blood flow, formation of interstitial edema, altered viscosity, leukocyte activation, disturbances in the coagulation system, and to a breakdown of the endothelial barrier function. These alterations inevitably lead to limitations of the oxygen supply to tissues. Without interruption of these pathomechanisms, the dysfunction of the microcirculation will consequently result in organ dysfunction. In this review article a short description of the microcirculatory physiology, the interaction between the macrocirculation and the microcirculation, as well as microcirculatory alterations generated by a systemic inflammatory response will be given. Finally, various therapy options will be described, which, experimentally, can lead to an improvement in microcirculatory dysfunction.
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Affiliation(s)
- H Knotzer
- Universitätsklinik für Anästhesiologie und Allgemeine Intensivmedizin, Medizinische Universität Innsbruck, Anichstrasse 35, 6020 Innsbruck, Osterreich.
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Jung C, Schlosser M, Figulla HR, Ferrari M. Providing macro- and microcirculatory support with the Lifebridge System during high-risk PCI in cardiogenic shock. Heart Lung Circ 2008; 18:296-8. [PMID: 18762457 DOI: 10.1016/j.hlc.2008.05.601] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2007] [Revised: 04/04/2008] [Accepted: 05/11/2008] [Indexed: 12/01/2022]
Abstract
High-risk percutaneous procedures are necessary in patients with contraindications to surgery in whom the inherent risk of the underlying disease is very high. Circulatory support may be provided with an intra-aortic balloon pump. If active cardiac support is required different devices have been successfully used. We report the case of a 75-year-old patient admitted in cardiogenic shock with a severe coronary three-vessel disease with distal left main stenosis. The ejection fraction was 23%. The high-risk PCI of the distal left main coronary artery and left circumflex artery PCI as the main supplying vessel was supported by Lifebridge (Lifebridge Medizintechnik GmbH, Ampfing, Germany), a new portable mechanical circulatory support system. During the procedure we evaluated the macro- and microcirculation. The complex procedure succeeded with a flow of 2-2.5l providing both adequate macro- and microcirculation.
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Affiliation(s)
- Christian Jung
- Division of Cardiology, Department of Internal Medicine I, Friedrich-Schiller-University, Jena, Germany.
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Jung C, Ferrari M, Rödiger C, Fritzenwanger M, Figulla HR. Combined Impella and intra-aortic ballon pump support to improve macro- and microcirculation: a clinical case. Clin Res Cardiol 2008; 97:849-50. [DOI: 10.1007/s00392-008-0693-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2008] [Accepted: 06/16/2008] [Indexed: 01/06/2023]
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