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Guo Q, Lian H, Wang G, Zhang H, Wang X. Prospective Evaluation of the Peripheral Perfusion Index in Assessing the Organ Dysfunction and Prognosis of Adult Patients With Sepsis in the ICU. J Intensive Care Med 2024:8850666241252758. [PMID: 38748544 DOI: 10.1177/08850666241252758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Background: The peripheral perfusion index (PI) reflects microcirculatory blood flow perfusion and indicates the severity and prognosis of sepsis. Method: The cohort comprised 208 patients admitted to the intensive care unit (ICU) with infection, among which 117 had sepsis. Demographics, medication history, ICU variables, and laboratory indexes were collected. Primary endpoints were in-hospital mortality and 28-day mortality. Secondary endpoints included organ function variables (coagulation function, liver function, renal function, and myocardial injury), lactate concentration, mechanical ventilation time, and length of ICU stay. Univariate and multivariate analyses were conducted to assess the associations between the PI and clinical outcomes. Sensitivity analyses were performed to explore the associations between the PI and organ functions in the sepsis and nonsepsis groups. Result: The PI was negatively associated with in-hospital mortality (odds ratio [OR] 0.29, 95% confidence interval [CI] 0.15 to 0.55), but was not associated with 28-day mortality. The PI was negatively associated with the coagulation markers prothrombin time (PT) (β -0.36, 95% CI -0.59 to 0.13) and activated partial thromboplastin time (APTT) (β -1.08, 95% CI -1.86 to 0.31), and the myocardial injury marker cardiac troponin I (cTnI) (β -2085.48, 95% CI -3892.35 to 278.61) in univariate analysis, and with the PT (β -0.36, 95% CI -0.60 to 0.13) in multivariate analysis. The PI was negatively associated with the lactate concentration (β -0.57, 95% CI -0.95 to 0.19), mechanical ventilation time (β -23.11, 95% CI -36.54 to 9.69), and length of ICU stay (β -1.28, 95% CI -2.01 to 0.55). Sensitivity analyses showed that the PI was significantly associated with coagulation markers (PT and APTT) and a myocardial injury marker (cTnI) in patients with sepsis, suggesting that the associations between the PI and organ function were stronger in the sepsis group than the nonsepsis group. Conclusion: The PI provides new insights for assessing the disease severity, short-term prognosis, and organ function damage in ICU patients with sepsis, laying a theoretical foundation for future research.
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Affiliation(s)
- Qirui Guo
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Lian
- Department of Health Care, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guangjian Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongmin Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Veith SB, Nickl R, Rössel T, Lachmann B, Koch T, Richter T. Hemodynamics and cutaneous microcirculation during induction of general anesthesia with and without esketamine. Clin Hemorheol Microcirc 2023; 84:385-398. [PMID: 37334583 DOI: 10.3233/ch-231711] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
OBJECTIVE Currently, there are limited data on the effect of macrocirculatory hemodynamic changes on human microcirculation, especially during the induction of general anesthesia (GA). METHODS We performed a non-randomized observational trial on patients receiving GA for elective surgery. In the control group (CG), for GA induction sufentanil, propofol, and rocuronium was administered. Patients assigned to the esketamine group (EG) received additional esketamine for GA induction. Invasive blood pressure (IBP) and pulse contour cardiac output (CO) measurement were performed continuously. Microcirculation was assessed using cutaneous Laser Doppler Flowmetry (forehead and sternum LDF), peripheral and central Capillary Refill Time (pCRT, cCRT), as well as brachial temperature gradient (Tskin-diff) at baseline, 5, 10 and 15 minutes after induction of GA. RESULTS 42 patients were included in the analysis (CG n = 22, EG n = 20). pCRT, cCRT, Tskin-diff, forehead and sternum LDF decreased following GA induction in both groups. IBP and CO were significantly more stable in esketamine group. However, the changes in the microcirculatory parameters were not significantly different between the groups. CONCLUSIONS The addition of esketamine for GA induction warranted better hemodynamic stability for the first five minutes, but had no significant effect on any of the cutaneous microcirculatory parameters measured.
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Affiliation(s)
- Sarah Berger Veith
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Rosa Nickl
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Thomas Rössel
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Björn Lachmann
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Thea Koch
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Torsten Richter
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
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Ortuno S, Geri G, Bouguoin W, Cariou A, Aissaoui N. Myocardial dysfunction after cardiac arrest: tips and pitfalls. Eur J Emerg Med 2022; 29:188-194. [PMID: 35135980 DOI: 10.1097/mej.0000000000000904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Postcardiac arrest shock (PCAS) is defined by hemodynamic instability occurring in the first hours after cardiac arrest (CA) and is a major cause of mortality among patients hospitalized after CA. It includes vasoplegia and myocardial dysfunction. This postcardiac arrest myocardial dysfunction is supposed to recover within the 3 days. However, there are many unknowns regarding its definition, its prognosis value and its management. In this review dedicated to emergency physicians, we choose to address tips and pitfalls they should know regarding this prevalent syndrome.
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Affiliation(s)
- Sofia Ortuno
- Assistance Publique des Hôpitaux de Paris (APHP) Cochin, Intensive Care Medicine
- Université de Paris, Paris
| | - Guillaume Geri
- Department of Cardiology and Critical Care, Clinique Ambroise Paré, Neuilly-sur-Seine
- After-ROSC Network, Paris
| | - Wulfran Bouguoin
- After-ROSC Network, Paris
- Service de Médecine Intensive Réanimation, Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy
- INSERM U970
- Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital
- Paris Sudden-Death-Expertise-Centre, Paris, France
| | - Alain Cariou
- Assistance Publique des Hôpitaux de Paris (APHP) Cochin, Intensive Care Medicine
- Université de Paris, Paris
- After-ROSC Network, Paris
- INSERM U970
- Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital
- Paris Sudden-Death-Expertise-Centre, Paris, France
| | - Nadia Aissaoui
- Assistance Publique des Hôpitaux de Paris (APHP) Cochin, Intensive Care Medicine
- Université de Paris, Paris
- After-ROSC Network, Paris
- INSERM U970
- Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital
- Paris Sudden-Death-Expertise-Centre, Paris, France
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Lavillegrand JR, Raia L, Urbina T, Hariri G, Gabarre P, Bonny V, Bigé N, Baudel JL, Bruneel A, Dupre T, Guidet B, Maury E, Ait-Oufella H. Vitamin C improves microvascular reactivity and peripheral tissue perfusion in septic shock patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2022; 26:25. [PMID: 35062987 PMCID: PMC8781452 DOI: 10.1186/s13054-022-03891-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/08/2022] [Indexed: 12/29/2022]
Abstract
Background Vitamin C has potential protective effects through antioxidant and anti-inflammatory properties. However, the effect of vitamin C supplementation on microvascular function and peripheral tissue perfusion in human sepsis remains unknown. We aimed to determine vitamin C effect on microvascular endothelial dysfunction and peripheral tissue perfusion in septic shock patients. Methods Patients with septic shock were prospectively included after initial resuscitation. Bedside peripheral tissue perfusion and skin microvascular reactivity in response to acetylcholine iontophoresis in the forearm area were measured before and 1 h after intravenous vitamin C supplementation (40 mg/kg). Norepinephrine dose was not modified during the studied period. Results We included 30 patients with septic shock. SOFA score was 11 [8–14], SAPS II was 66 [54–79], and in-hospital mortality was 33%. Half of these patients had vitamin C deficiency at inclusion. Vitamin C supplementation strongly improved microvascular reactivity (AUC 2263 [430–4246] vs 5362 [1744–10585] UI, p = 0.0004). In addition, vitamin C supplementation improved mottling score (p = 0.06), finger-tip (p = 0.0003) and knee capillary refill time (3.7 [2.6–5.5] vs 2.9 [1.9–4.7] s, p < 0.0001), as well as and central-to-periphery temperature gradient (6.1 [4.9–7.4] vs 4.6 [3.4–7.0] °C, p < 0.0001). The beneficial effects of vitamin C were observed both in patients with or without vitamin C deficiency. Conclusion In septic shock patients being resuscitated, vitamin C supplementation improved peripheral tissue perfusion and microvascular reactivity whatever plasma levels of vitamin C. ClinicalTrials.gov Identifier: NCT04778605 registered 26 January 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03891-8.
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Späth M, Rohde M, Ni D, Knieling F, Stelzle F, Schmidt M, Klämpfl F, Hohmann M. The influence of the optical properties on the determination of capillary diameters. Sci Rep 2022; 12:270. [PMID: 34997168 PMCID: PMC8742127 DOI: 10.1038/s41598-021-04359-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/21/2021] [Indexed: 11/09/2022] Open
Abstract
Various clinically applicable scores and indices are available to help identify the state of a microcirculatory disorder in a patient. Several of these methods, however, leave room for interpretation and only provide clues for diagnosis. Thus, a measurement method that allows a reliable detection of impending or manifest circulatory malfunctions would be of great value. In this context, the optical and non-invasive method of shifted position-diffuse reflectance imaging (SP-DRI) was developed. It allows to determine the capillary diameter and thus to assess the state of the microcirculation. The aim of the present study is to investigate how the quantification of capillary diameters by SP-DRI behaves in different individuals, i.e. for a wide range of optical properties. For this, within Monte-Carlo simulations all optical properties (seven skin layers, hemoglobin) were randomly varied following a Gaussian distribution. An important finding from the present investigation is that SP-DRI works when the optical properties are chosen randomly. Furthermore, it is shown that appropriate data analysis allows calibration-free absolute quantification of the capillary diameter across individuals using SP-DRI. This underpins the potential of SP-DRI to serve as an early alert system for the onset of microcirculatory associated diseases.
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Affiliation(s)
- Moritz Späth
- Institute of Photonic Technologies, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91052, Erlangen, Germany. .,Erlangen Graduate School in Advanced Optical Technologies, 91052, Erlangen, Germany.
| | - Maximilian Rohde
- grid.411668.c0000 0000 9935 6525Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, 91054 Erlangen, Germany ,grid.5330.50000 0001 2107 3311Erlangen Graduate School in Advanced Optical Technologies, 91052 Erlangen, Germany
| | - Dongqin Ni
- grid.5330.50000 0001 2107 3311Institute of Photonic Technologies, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91052 Erlangen, Germany ,grid.5330.50000 0001 2107 3311Erlangen Graduate School in Advanced Optical Technologies, 91052 Erlangen, Germany
| | - Ferdinand Knieling
- grid.411668.c0000 0000 9935 6525Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, 91054 Erlangen, Germany
| | - Florian Stelzle
- grid.5330.50000 0001 2107 3311Institute of Photonic Technologies, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91052 Erlangen, Germany ,grid.411668.c0000 0000 9935 6525Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, 91054 Erlangen, Germany ,grid.5330.50000 0001 2107 3311Erlangen Graduate School in Advanced Optical Technologies, 91052 Erlangen, Germany
| | - Michael Schmidt
- grid.5330.50000 0001 2107 3311Institute of Photonic Technologies, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91052 Erlangen, Germany ,grid.5330.50000 0001 2107 3311Erlangen Graduate School in Advanced Optical Technologies, 91052 Erlangen, Germany
| | - Florian Klämpfl
- grid.5330.50000 0001 2107 3311Institute of Photonic Technologies, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91052 Erlangen, Germany ,grid.5330.50000 0001 2107 3311Erlangen Graduate School in Advanced Optical Technologies, 91052 Erlangen, Germany
| | - Martin Hohmann
- grid.5330.50000 0001 2107 3311Institute of Photonic Technologies, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91052 Erlangen, Germany ,grid.5330.50000 0001 2107 3311Erlangen Graduate School in Advanced Optical Technologies, 91052 Erlangen, Germany
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Liu X, Nie J, Pan J, Fu F. Value of peripheral perfusion index to predict acute limb ischaemia in newborns after peripheral artery cannulation. J Clin Nurs 2021; 31:2860-2866. [PMID: 34729836 DOI: 10.1111/jocn.16111] [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: 07/15/2021] [Revised: 10/02/2021] [Accepted: 10/11/2021] [Indexed: 11/26/2022]
Abstract
AIMS AND OBJECTIVES To investigate the feasibility of using peripheral perfusion index (PPI) to monitor acute limb ischaemia (ALI) in newborns after catheterisations. BACKGROUND ALI is common complication of neonatal peripheral artery cannulation. It is important to address as soon as the early signs of ALI. PPI could aid in noninvasive evaluation of distal extremity perfusion in an effort to notify risk of potential ischaemic injury from catheterisations. DESIGN A nested case-control study. METHODS Clinical information of newborns who had been admitted to the Neonatal Intensive Care Unit of Jiangxi Provincial Children's Hospital and had received peripheral artery cannulation from January 2018 to January 2020 was prospectively collected. Transcutaneous blood oxygen saturation (TcSO2 ), PPI and delta-PPI (ΔPPI1; the difference in PPI values of the two arms. ΔPPI2; difference in the PPI values before and after cannulation) were recorded. We used STROBE checklist as an EQUATOR in this study. RESULTS A total of 25 newborns with ALI were included in the study. These were then paired with 100 newborns without ALI. The PPI and TcSO2 of the cannulated limb were significantly lower in the ALI group than in the non-ALI (NALI) group (p < .05). The area under the receiver-operating characteristic curve was significant for ΔPPI1. The ΔPPI1 had a sensitivity and specificity of 92% and 87%, respectively, for diagnosing ALI. ΔPPI1 greater than 0.315 suggested that the infant was at risk of ALI. CONCLUSIONS Monitoring the change in the PPI in newborns after catheterisations helped in the early assessment of ALI. RELEVANCE TO CLINICAL PRACTICE Drops in the PPI and TcSO2 of the cannulated limbs might, to some extent, reflect the possibility of ALI in newborns. ΔPPI1 (the difference in PPI values of the two arms) proved to be a simple, objective parameter to predict the presence of ALI.
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Affiliation(s)
- Xiaoshu Liu
- Nursing Department, Jiangxi Provincial Children's Hospital, Nanchang, China
| | - Jiao Nie
- NICU, Jiangxi Provincial Children's Hospital, Nanchang, China
| | - Junhui Pan
- PICU, Jiangxi Provincial Children's Hospital, Nanchang, China
| | - Fang Fu
- NICU, Jiangxi Provincial Children's Hospital, Nanchang, China
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Boysen SR, Gommeren K. Assessment of Volume Status and Fluid Responsiveness in Small Animals. Front Vet Sci 2021; 8:630643. [PMID: 34124213 PMCID: PMC8193042 DOI: 10.3389/fvets.2021.630643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 04/29/2021] [Indexed: 12/30/2022] Open
Abstract
Intravenous fluids are an essential component of shock management in human and veterinary emergency and critical care to increase cardiac output and improve tissue perfusion. Unfortunately, there are very few evidence-based guidelines to help direct fluid therapy in the clinical setting. Giving insufficient fluids and/or administering fluids too slowly to hypotensive patients with hypovolemia can contribute to continued hypoperfusion and increased morbidity and mortality. Similarly, giving excessive fluids to a volume unresponsive patient can contribute to volume overload and can equally increase morbidity and mortality. Therefore, assessing a patient's volume status and fluid responsiveness, and monitoring patient's response to fluid administration is critical in maintaining the balance between meeting a patient's fluid needs vs. contributing to complications of volume overload. This article will focus on the physiology behind fluid responsiveness and the methodologies used to estimate volume status and fluid responsiveness in the clinical setting.
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Affiliation(s)
- Søren R Boysen
- Department of Veterinary Clinical and Diagnostic Sciences, Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada
| | - Kris Gommeren
- Department of Companion Animals, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
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Assessment of ocular blood flow in continuous-flow ventricular assist device by laser speckle flowgraphy. J Artif Organs 2021; 24:419-424. [PMID: 33825101 DOI: 10.1007/s10047-021-01265-5] [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: 08/24/2020] [Accepted: 03/25/2021] [Indexed: 12/16/2022]
Abstract
Although the influence of continuous-flow left ventricular assist device (CF-LVAD) support on peripheral circulation has been widely discussed, its monitoring modalities are limited. The aim of this study was to assess the peripheral circulation using the laser speckle flowgraph (LSFG) which can quantitatively measure the ocular blood flow. We implanted a centrifugal CF-LVAD (EVAHEART®; Sun Medical Technology Research Corporation, Nagano, Japan) in five adult goats (body weight 44.5 ± 2.9 kg) under general anesthesia. The waveform of the central retinal artery using the mean blur rate (MBR) for ocular blood velocity and fluctuations as a parameter of pulsatility were obtained before LVAD implantation and after LVAD full-bypass support. The MBR waveform and LSFG fluctuation data were compared with the waveform and pulsatility index of the external carotid artery using an ultrasonic flow meter to evaluate circulatory patterns at different levels. The MBR waveform pattern of the central retinal artery was pulsatile before LVAD implantation and less pulsatile under LVAD full bypass. The fluctuation was 14.7 ± 1.86 before LVAD implantation and 3.85 ± 0.61 under LVAD full bypass (p < 0.01), respectively. The fluctuations of LSFG showed a strong correlation with the pulsatility index of the external carotid artery meaning that similar changes in circulatory pattern were observed at two different levels. Measuring the ocular blood flow using LSFG has potential utility for the assessment of the status of the peripheral circulation and its pulsatility during CF-LVAD.
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Späth M, Hohmann M, Rohde M, Lengenfelder B, Stelzle F, Klämpfl F. Determination of the diameter of simulated human capillaries using shifted position-diffuse reflectance imaging. JOURNAL OF BIOPHOTONICS 2021; 14:e202000465. [PMID: 33432711 DOI: 10.1002/jbio.202000465] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/05/2021] [Accepted: 01/06/2021] [Indexed: 06/12/2023]
Abstract
Multiple diseases are associated with a wide spectrum of microvascular dysfunctions, microangiopathies and microcirculation disorders. Monitoring the microcirculation could thus be useful to diagnose many local and systemic circulatory disorders and to supervise critically ill patients. Many of the scores currently available to help identify the condition of a microcirculation disorder are invasive or leave scope for interpretation. Thus, the present study aims to investigate with Monte-Carlo simulations (as numerical solutions of the radiative transfer equation) whether shifted position-diffuse reflectance imaging (SP-DRI), a non-invasive diagnostic technique, reveals information on the capillary diameter to assess the state of the microcirculation. To quantify the SP-DRI signal, the modulation parameter K is introduced. It proves to correlate almost perfectly with the capillary diameter ( R¯2≈1 ), making it a valid parameter for reliably assessing microcirculation. SP-DRI is emerging as an important milestone on the way to early and conveniently diagnosing microcirculation associated diseases.
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Affiliation(s)
- Moritz Späth
- Institute of Photonic Technologies, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Erlangen Graduate School in Advanced Optical Technologies, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Martin Hohmann
- Institute of Photonic Technologies, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Erlangen Graduate School in Advanced Optical Technologies, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Maximilian Rohde
- Erlangen Graduate School in Advanced Optical Technologies, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Benjamin Lengenfelder
- Institute of Photonic Technologies, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Erlangen Graduate School in Advanced Optical Technologies, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Florian Stelzle
- Institute of Photonic Technologies, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Erlangen Graduate School in Advanced Optical Technologies, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Florian Klämpfl
- Institute of Photonic Technologies, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Erlangen Graduate School in Advanced Optical Technologies, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Morocho JP, Martínez AF, Cevallos MM, Vasconez-Gonzalez J, Ortiz-Prado E, Barreto-Grimaldos A, Vélez-Páez JL. Prolonged Capillary Refilling as a Predictor of Mortality in Patients With Septic Shock. J Intensive Care Med 2021; 37:423-429. [PMID: 33769108 DOI: 10.1177/08850666211003507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Microcirculatory alterations characterize septic shock; increased blood lactate level has been described as markers of microcirculation alteration in patients with septic shock. Although useful, this serological analysis is not always feasible in all settings worldwide. OBJECTIVE To determine if a prolonged capillary refilling is a predictor of mortality in patients with septic shock. METHODOLOGY A 10-months prospective cohort study was carried out on 175 patients admitted to the Intensive Care Unit (ICU) with the diagnosis of septic shock. The capillary refilling time (CRT) was evaluated Immediately upon admission and after 6 hours post-resuscitation. Traditional tissue perfusion markers were also used to compare and analyze their predictive value on mortality at 28 days. RESULTS The area under the ROC curve (AUC) to estimate mortality in patients with septic shock with CRT at admission was 0.666 (0.584-0.748), while at 6 hours was 0.819 (0.753-0.885), with a cut-off point of 4.5 seconds at admission (PPV 52.87% NPV 72.73%) and 3.5 sec at 6 hours (PPV 95.56% NPV 79.23%). In those with CRT > 3.5 seconds at 6 hours, they had a RR of 4.60, while a CRT > 4.5 seconds at admission had a RR of 1.94, with a non-survivor proportion of 95.56% for a CRT > 3.5 sec at 6 hours vs 20.77% for CRT ≤ 3.5 sec (P value < 0.001). The CRT at 6 hours showed significant differences in the survival curves with P-value < 0.001, where for values > 3.5 sec, survival at 28 days was 4.44% vs 79.20% for values ≤ 3.5 sec. CONCLUSION CRT is a strong predictor of mortality in patients with septic shock. Evaluating changes in CRT during resuscitation from septic shock might be used as an important clinical tool to predict mortality; especially in low-resources settings where using other biomarkers might be sometimes difficult.
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Affiliation(s)
| | | | | | | | - Esteban Ortiz-Prado
- One Health Global Researh Group, Universidad de las Américas, Quito, Ecuador
| | | | - Jorge Luis Vélez-Páez
- Intensive Care Unit, Hospital Pablo Arturo Suarez, Quito, Ecuador.,Intensive Care Program, Universidad Central del Ecuador, Quito, Ecuador
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Monteerarat Y, Limthongthang R, Laohaprasitiporn P, Vathana T. Reliability of capillary refill time for evaluation of tissue perfusion in simulated vascular occluded limbs. Eur J Trauma Emerg Surg 2021; 48:1231-1237. [PMID: 33475776 DOI: 10.1007/s00068-020-01594-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 12/27/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE No standardized execution or evidence demonstrates the area of the digit giving the most accurate capillary refill time (CRT). This study investigated the reliability and validity of CRT, and the relative merits of areas where the test could be performed. METHODS In all, 127 healthy volunteers were assessed for normal CRT at the fingernail, lateral paronychia, and proximal and distal pulps of the index finger. The predictive validity of the CRT for the diagnosis of compromised vascular perfusion was also investigated on 24 subjects, using an inflated tourniquet. Three raters assessed interobserver reliability. RESULTS The mean fingernail, lateral paronychia, proximal pulp, and distal pulp CRTs were 1.93, 1.78, 1.70, and 1.57 s, respectively. The tourniquet and non-tourniquet results demonstrated significant mean differences; however, the fingernail showed a subtle difference (1.22 s) compared with the proximal pulp (4.46 s). The CRT interobserver reliability was fair at the fingernail (intraclass correlation coefficient [ICC] = 0.51), but very poor in occluded limbs (ICC = 0.13). At the lateral paronychia and finger pulp, the interobserver reliability was reasonable (ICC = 0.75-0.81 [non-tourniquet] vs 0.62-0.68 [tourniquet]). In a receiver-operating characteristic curve analysis, the proximal pulp demonstrated better discrimination (area under the curve = 0.93, 95% CI 0.89-0.97, p < 0.0001); the best cutoff point was calculated to be 3 s at the proximal pulp. CONCLUSIONS CRT use at appropriate areas is reliable. The most dependable site is the finger pulp, and the proposed cutoff is 3 s.
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Affiliation(s)
- Yuwarat Monteerarat
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Roongsak Limthongthang
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Panai Laohaprasitiporn
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Torpon Vathana
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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Falotico JM, Shinozaki K, Saeki K, Becker LB. Advances in the Approaches Using Peripheral Perfusion for Monitoring Hemodynamic Status. Front Med (Lausanne) 2020; 7:614326. [PMID: 33365323 PMCID: PMC7750533 DOI: 10.3389/fmed.2020.614326] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/16/2020] [Indexed: 12/27/2022] Open
Abstract
Measures of peripheral perfusion can be used to assess the hemodynamic status of critically ill patients. By monitoring peripheral perfusion status, clinicians can promptly initiate life-saving therapy and reduce the likelihood of shock-associated death. Historically, abnormal perfusion has been indicated by the observation of pale, cold, and clammy skin with increased capillary refill time. The utility of these assessments has been debated given that clinicians may vary in their clinical interpretation of body temperature and refill time. Considering these constraints, current sepsis bundles suggest the need to revise resuscitation guidelines. New technologies have been developed to calculate capillary refill time in the hopes of identifying a new gold standard for clinical care. These devices measure either light reflected at the surface of the fingertip (reflected light), or light transmitted through the inside of the fingertip (transmitted light). These new technologies may enable clinicians to monitor peripheral perfusion status more accurately and may increase the potential for ubiquitous hemodynamic monitoring across different clinical settings. This review will summarize the different methods available for peripheral perfusion monitoring and will discuss the advantages and disadvantages of each approach.
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Affiliation(s)
- Julianne M Falotico
- Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, United States
| | - Koichiro Shinozaki
- Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, United States.,The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Kota Saeki
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States.,Nihon Kohden Innovation Center, Cambridge, MA, United States
| | - Lance B Becker
- Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, United States.,The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
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13
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Abstract
PURPOSE OF REVIEW Currently, the treatment of patients with shock is focused on the clinical symptoms of shock. In the early phase, this is usually limited to heart rate, blood pressure, lactate levels and urine output. However, as the ultimate goal of resuscitation is the improvement in microcirculatory perfusion the question is whether these currently used signs of shock and the improvement in these signs actually correspond to the changes in the microcirculation. RECENT FINDINGS Recent studies have shown that during the development of shock the deterioration in the macrocirculatory parameters are followed by the deterioration of microcirculatory perfusion. However, in many cases the restoration of adequate macrocirculatory parameters is frequently not associated with improvement in microcirculatory perfusion. This relates not only to the cause of shock, where there are some differences between different forms of shock, but also to the type of treatment. SUMMARY The improvement in macrohemodynamics during the resuscitation is not consistently followed by subsequent changes in the microcirculation. This may result in both over-resuscitation and under-resuscitation leading to increased morbidity and mortality. In this article the principles of coherence and the monitoring of the microcirculation are reviewed.
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14
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Transcutaneous oxygen pressure-related variables as noninvasive indicators of low lactate clearance in sepsis patients after resuscitation. J Clin Monit Comput 2020; 35:435-442. [PMID: 32965558 DOI: 10.1007/s10877-020-00594-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 09/18/2020] [Indexed: 12/30/2022]
Abstract
The transcutaneous oxygen challenge test (OCT) is associated with central venous oxygen saturation and cardiac output index, and has predictive value for prognosis. Whether the change of transcutaneous oxygen pressure (PtcO2)-related variables can reflect lactate clearance in sepsis patients is worth studying. We conducted a prospective observational study of 79 patients with sepsis or septic shock in the ICU. Immediately after enrollment, PtcO2 monitoring was continuously performed for 6 h. The OCT was performed at enrollment (T0) and the sixth hour (T6). The correlation between lactate clearance and PtcO2-related variables such as PtcO2 at T6, ΔPtcO2 (PtcO2 at T6 - PtcO2 at T0), ΔPtcO2 index (PtcO2/PaO2 at T6 - PtcO2/PaO2 at T0), 10 OCT [(PtcO2 after 10 min on FiO2 of 1.0) - (PtcO2 at baseline)], Δ10 OCT (10 OCT at T6 - 10 OCT at T0) was analyzed. The difference of PtcO2-related variables was compared between the high and low lactate clearance groups. PtcO2 at T6 (r = 0.477, p < 0.001), ΔPtcO2 (r = 0.592, p < 0.001), ΔPtcO2 index (r = 0.553, p < 0.001) and Δ10 OCT (r = 0.379, p = 0.001) were significantly correlated with the lactate clearance. To discriminate low lactate clearance, the area under the ROC curve was largest for ΔPtcO2, which was 0.804. PtcO2 at T6, PtcO2 index, ΔPtcO2, ΔPtcO2 index and Δ10 OCT were significantly different between the two different lactate clearance groups. Low lactate clearance in the initial 6 h of resuscitation of septic shock was associated to lower improvements in PtcO2-related variables.
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15
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Schaefer JD, Reminga CL, Reineke EL, Drobatz KJ. Evaluation of the rectal-interdigital temperature gradient as a diagnostic marker of shock in dogs. J Vet Emerg Crit Care (San Antonio) 2020; 30:670-676. [PMID: 32965089 DOI: 10.1111/vec.12992] [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: 05/11/2018] [Revised: 12/23/2018] [Accepted: 01/28/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate the difference in the rectal-interdigital temperature gradient (RITG) between dogs that were presented to an emergency room with clinical signs of shock compared to those without signs of shock, and if this gradient can be used as a diagnostic marker for shock. DESIGN Prospective, single center, observational study conducted from 2014 to 2015. SETTING University veterinary teaching hospital. ANIMALS Twenty dogs with a clinical diagnosis of shock and 60 dogs without a clinical diagnosis of shock (controls). MEASUREMENTS AND MAIN RESULTS Upon presentation to the emergency room and prior to intervention, measurements of rectal temperature, interdigital temperature, ambient temperature, systemic markers of perfusion (capillary refill time [CRT], heart rate [HR], respiratory rate [RR], Doppler blood pressure [DBP], and venous plasma lactate concentration), and venous blood gas analytes were recorded. Dogs were initially determined to be in shock by the attending clinician, and post hoc inclusion criteria were applied. Shock was defined as abnormalities in ≥3 of the 6 following criteria: HR > 120/min, RR > 40/min, CRT > 2 seconds, rectal temperature <37.8°C (100.0°F), venous plasma lactate concentration >2.5 mmol/L, or DBP < 90 mm Hg. Animals with circulatory shock had a significantly increased RITG. An increased RITG was also correlated with individual perfusion parameters including prolonged CRT (ρ = .353, P = 0.0013), tachycardia (ρ = .3485, P = 0.0015), decreased DBP (ρ = -0.6162, P = 0.0003), and shock index (ρ = 0.6168, P = 0.0003). Receiver operator curve analysis indicated a RITG cutoff point of 11.6°F had 90% specificity for the diagnosis of shock (area under the curve = 0.7604). CONCLUSIONS The RITG in this study was associated with a diagnosis of shock and therefore may serve as a diagnostic marker of circulatory shock. Future studies with larger sample sizes to validate the use of temperature gradients and other peripheral perfusion abnormalities as diagnostic and monitoring tools are warranted.
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Affiliation(s)
- Jonathan D Schaefer
- School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christin L Reminga
- School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erica L Reineke
- School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kenneth J Drobatz
- School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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16
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Reversible Microvascular Hyporeactivity to Acetylcholine During Diabetic Ketoacidosis. Crit Care Med 2019; 46:e772-e778. [PMID: 29782357 DOI: 10.1097/ccm.0000000000003224] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Metabolic acidosis is commonly observed in critically ill patients. Experimental studies suggested that acidosis by itself could impair vascular function, but this has been poorly investigated in human. DESIGN Prospective observational study. SETTING Medical ICU in a tertiary teaching hospital. PATIENTS To assess the relationship between metabolic acidosis severity and microvascular reactivity, we included adult diabetic patients admitted in ICU for ketoacidosis. Microvascular response to acetylcholine iontophoresis was measured at admission (baseline) and after correction of metabolic acidosis (24 hr). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Thirty-nine patients with diabetic ketoacidosis were included (68% male), with a median age of 43 (31-57) years. At admission, microvascular reactivity negatively correlated with acidosis severity (R = -0.53; p < 0.001). Microvascular response was strongly depressed at pH less than 7.20 (area under the curve, 1,779 [740-3,079] vs 12,944 [4,874-21,596] at pH > 7.20; p < 0.0001). In addition, acidosis severity was significantly correlated with capillary refill time (R = 0.50; p = 0.02). At H24, after rehydration and insulin infusion, clinical and biological disorders were fully corrected. After acidosis correction, microvascular reactivity increased more in patients with severe baseline acidosis (pH < 7.20) than in those with mild baseline acidosis (area under the curve, +453% [213%-1,470%] vs +121% [79%-312%]; p < 0.01). CONCLUSIONS We identified an alteration of microvascular reactivity during metabolic acidosis in critically ill patients with diabetic ketoacidosis. Microvascular hyporeactivity recovered after acidosis correction.
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Kazune S, Caica A, Volceka K, Suba O, Rubins U, Grabovskis A. Relationship of mottling score, skin microcirculatory perfusion indices and biomarkers of endothelial dysfunction in patients with septic shock: an observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:311. [PMID: 31511042 PMCID: PMC6739999 DOI: 10.1186/s13054-019-2589-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 08/29/2019] [Indexed: 11/17/2022]
Abstract
Background In patients with septic shock, the skin is often chosen for the evaluation of peripheral perfusion and oxygenation. Changes in skin microcirculatory vessel oxygen saturation and relative hemoglobin concentration can be described using a mottling score or captured with hyperspectral imaging. However, the effectiveness of the mottling score in assessing microcirculation remains to be shown. We hypothesize that the mottling score in patients with septic shock is related to skin microcirculatory perfusion indices quantified by hyperspectral imaging, biomarkers that reflect endothelium activation and damage, and clinical outcome. Methods Hyperspectral imaging of the knee area was performed in 95 intensive care patients with septic shock enrolled in a single-center observational study to obtain relative oxy/deoxyhemoglobin concentration values and construct anatomical maps of skin microcirculatory saturation. The blood was sampled to obtain concentrations of thrombomodulin, plasminogen activator inhibitor-1 (PAI-1), soluble intercellular adhesion molecule-1 (ICAM-1), soluble vascular cell adhesion molecule-1 (VCAM-1), angiopoietin-2, and syndecan-1. The spectrophotometrically obtained skin microvascular perfusion indices were compared to the mottling score and biomarker concentration. The association between mottling score, skin microcirculatory perfusion indices, and 28-day mortality was also analyzed. Results Microcirculatory oxygen saturation was significantly lower and total hemoglobin concentration was significantly higher in patients with a mottling score of 2 compared to those with a score of 0 (p = 0.02), with no difference between other scores. We found an association between microcirculatory oxygen saturation and PAI-1 levels (rho = − 0.3; p = 0.007). Increased mottling score and decreased microcirculatory oxygen saturation were predictive of 28-day mortality (mottling score 2 vs 0: OR 15.31, 95% CI 4.12–68.11; microcirculatory oxygen saturation: OR 0.90, 95% CI 0.85–0.95). Endothelial biomarkers did not increase the predictive value of skin microcirculatory perfusion indices. Conclusions Higher mottling scores are associated with lower microcirculatory oxygen saturation but with significant overlap between scores. Microcirculatory oxygen saturation is a quantitative measure of peripheral oxygenation and is more specific than the mottling score in predicting 28-day mortality. Electronic supplementary material The online version of this article (10.1186/s13054-019-2589-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sigita Kazune
- Department of Anesthesiology, Hospital of Traumatology and Orthopedics, 22 Duntes Street, Riga, LV-1013, Latvia. .,Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, LV-1004, Latvia.
| | - Anastasija Caica
- Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, LV-1004, Latvia.,Department of Human and Animal Physiology, Faculty of Biology, University of Latvia, 1 Jelgavas Street, Riga, LV-1004, Latvia
| | - Karina Volceka
- Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, LV-1004, Latvia.,Department of Human and Animal Physiology, Faculty of Biology, University of Latvia, 1 Jelgavas Street, Riga, LV-1004, Latvia
| | - Olegs Suba
- Clinic of Toxicology and Sepsis, Riga East University Hospital, 2 Hipokrata Street, Riga, LV-1038, Latvia
| | - Uldis Rubins
- Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, LV-1004, Latvia
| | - Andris Grabovskis
- Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, LV-1004, Latvia
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Constantinescu C, Bodolea C, Pasca S, Teodorescu P, Dima D, Rus I, Tat T, Achimas-Cadariu P, Tanase A, Tomuleasa C, Einsele H. Clinical Approach to the Patient in Critical State Following Immunotherapy and/or Stem Cell Transplantation: Guideline for the On-Call Physician. J Clin Med 2019; 8:jcm8060884. [PMID: 31226876 PMCID: PMC6616972 DOI: 10.3390/jcm8060884] [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] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/17/2019] [Accepted: 06/18/2019] [Indexed: 12/11/2022] Open
Abstract
The initial management of the hematology patient in a critical state is crucial and poses a great challenge both for the hematologist and the intensive care unit (ICU) physician. After years of clinical practice, there is still a delay in the proper recognition and treatment of critical situations, which leads to late admission to the ICU. There is a much-needed systematic ABC (Airway, Breathing, Circulation) approach for the patients being treated on the wards as well as in the high dependency units because the underlying hematological disorder, as well as disease-related complications, have an increasing frequency. Focusing on score-based decision-making on the wards (Modified Early Warning Score (MEWS), together with Quick Sofa score), active sepsis screening with inflammation markers (C-reactive protein, procalcitonin, and presepsin), and assessment of microcirculation, organ perfusion, and oxygen supply by using paraclinical parameters from the ICU setting (lactate, central venous oxygen saturation (ScVO2), and venous-to-arterial carbon dioxide difference), hematologists can manage the immediate critical patient and improve the overall outcome.
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Affiliation(s)
- Catalin Constantinescu
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, 400124 Cluj Napoca, Romania.
- Intensive Care Unit, Ion Chiricuta Clinical Cancer Center, 400005 Cluj Napoca, Romania.
| | - Constantin Bodolea
- Department of Anesthesia, Iuliu Hatieganu University of Medicine and Pharmacy, 400124 Cluj Napoca, Romania.
| | - Sergiu Pasca
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, 400124 Cluj Napoca, Romania.
| | - Patric Teodorescu
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, 400124 Cluj Napoca, Romania.
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, 400005 Cluj Napoca, Romania.
| | - Delia Dima
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, 400005 Cluj Napoca, Romania.
| | - Ioana Rus
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, 400005 Cluj Napoca, Romania.
| | - Tiberiu Tat
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, 400005 Cluj Napoca, Romania.
| | - Patriciu Achimas-Cadariu
- Department of Surgery, Iuliu Hatieganu University of Medicine and Pharmacy, 400124 Cluj Napoca, Romania.
| | - Alina Tanase
- Department of Stem Cell Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania.
| | - Ciprian Tomuleasa
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, 400124 Cluj Napoca, Romania.
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, 400005 Cluj Napoca, Romania.
- Research Center for Functional Genomics and Translational Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Victor Babes Street, 400124 Cluj Napoca, Romania.
| | - Hermann Einsele
- Department of Internal Medicine II, University Hospital Wuerzburg, 97070 Wuerzburg, Germany.
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19
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Dumas G, Lavillegrand JR, Joffre J, Bigé N, de-Moura EB, Baudel JL, Chevret S, Guidet B, Maury E, Amorim F, Ait-Oufella H. Mottling score is a strong predictor of 14-day mortality in septic patients whatever vasopressor doses and other tissue perfusion parameters. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:211. [PMID: 31182133 PMCID: PMC6558704 DOI: 10.1186/s13054-019-2496-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 05/28/2019] [Indexed: 01/01/2023]
Abstract
Background Mottling score, a tissue perfusion parameter, is correlated with outcome in septic shock patients. However, its predictive value on mortality according to prognostic covariates such as vasopressor dose and other tissue perfusion parameters remains unknown. Methods Mottling score and tissue perfusion parameters were recorded at ICU admission (H0), H-6, H 12, and H-24 and used to assess the predictive value of mottling score on 14-day mortality in a development cohort. Results were then validated in an independent cohort of septic shock patients in Brazil. Results Overall, 259 patients with sepsis or septic shock were included, 14-day mortality was 37%. Factors associated with death were mottling score (OR 2.26 [95% CI, 1.72–2.97]), arterial lactate level (OR 1.29 [1.11–1.5]), and urine output < 0.5 ml/Kg/h (OR 3.03 [1.37–6.69]). The C statistic for the model was 0.90 in the development cohort and 0.76 in the validation cohort. The predictive value of mottling score was not affected by vasopressor doses (p for interaction = 0.33): OR for mottling score ranged from 2.34 [1.10–3.15] in patients without vasopressor to 3.84 [1.98–7.43] in patients infused with high doses of vasopressor (> 0.8 μg/kg/min). There was no difference in the effect of mottling score on mortality according to mean arterial pressure, heart rate, cardiac index, and urine output, but we found a significant interaction between arterial lactate level and mottling score (p = 0.04). The predictive value of the mottling score remains significant when using the recent SEPSIS-3 definition of septic shock. Finally, a decrease of mottling score during resuscitation was significantly associated with better outcome after adjustment on SOFA score (p = 0.001). Conclusions Our results support the high prognostic value of mottling score for 14-day mortality in septic patients, whatever vasopressor dosage and other perfusion parameters. Mottling score variations during resuscitation are also predictive of mortality. Electronic supplementary material The online version of this article (10.1186/s13054-019-2496-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Guillaume Dumas
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris, cedex 12, France. .,Sorbonne Université, Paris, France. .,ECSTRA team, Biostatistics and clinical epidemiology, UMR 1153 (center of epidemiology and biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot University, Paris, France.
| | - Jean-Rémi Lavillegrand
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris, cedex 12, France.,Sorbonne Université, Paris, France
| | - Jérémie Joffre
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris, cedex 12, France
| | - Naïke Bigé
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris, cedex 12, France
| | | | - Jean-Luc Baudel
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris, cedex 12, France
| | - Sylvie Chevret
- ECSTRA team, Biostatistics and clinical epidemiology, UMR 1153 (center of epidemiology and biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot University, Paris, France
| | - Bertrand Guidet
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris, cedex 12, France.,Sorbonne Université, Paris, France.,Inserm U1136, F-75012, Paris, France
| | - Eric Maury
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris, cedex 12, France.,Sorbonne Université, Paris, France.,Inserm U1136, F-75012, Paris, France
| | - Fabio Amorim
- Adult Intensive Care Unit, Hospital Santa Luzia, School of Medicine, Brasília, Brazil
| | - Hafid Ait-Oufella
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris, cedex 12, France.,Sorbonne Université, Paris, France.,Université de Paris, Inserm U970, Centre de Recherche Cardiovasculaire de Paris (PARCC), Paris, France
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20
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He HW, Long Y, Liu DW, Ince C. Resuscitation incoherence and dynamic circulation-perfusion coupling in circulatory shock. Chin Med J (Engl) 2019; 132:1218-1227. [PMID: 30896570 PMCID: PMC6511427 DOI: 10.1097/cm9.0000000000000221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Poor tissue perfusion/cellular hypoxia may persist despite restoration of the macrocirculation (Macro). This article reviewed the literatures of coherence between hemodynamics and tissue perfusion in circulatory shock. DATA SOURCES We retrieved information from the PubMed database up to January 2018 using various search terms or/and their combinations, including resuscitation, circulatory shock, septic shock, tissue perfusion, hemodynamic coherence, and microcirculation (Micro). STUDY SELECTION The data from peer-reviewed journals printed in English on the relationships of tissue perfusion, shock, and resuscitation were included. RESULTS A binary (coherence/incoherence, coupled/uncoupled, or associated/disassociated) mode is used to describe resuscitation coherence. The phenomenon of resuscitation incoherence (RI) has gained great attention. However, the RI concept requires a more practical, systematic, and comprehensive framework for use in clinical practice. Moreover, we introduce a conceptual framework of RI to evaluate the interrelationship of the Macro, Micro, and cell. The RI is divided into four types (Type 1: Macro-Micro incoherence + impaired cell; Type 2: Macro-Micro incoherence + normal cell; Type 3: Micro-Cell incoherence + normal Micro; and Type 4: both Macro-Micro and Micro-cell incoherence). Furthermore, we propose the concept of dynamic circulation-perfusion coupling to evaluate the relationship of circulation and tissue perfusion during circulatory shock. CONCLUSIONS The concept of RI and dynamic circulation-perfusion coupling should be considered in the management of circulatory shock. Moreover, these concepts require further studies in clinical practice.
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Affiliation(s)
- Huai-Wu He
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing 100730, China
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing 100730, China
| | - Da-Wei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing 100730, China
| | - Can Ince
- Department of Intensive Care, Erasmus MC University Hospital Rotterdam, Rotterdam 3015 CE, the Netherlands
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21
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Abstract
PURPOSE OF REVIEW Microcirculatory alterations play a major role in the pathogenesis of shock. Monitoring tissue perfusion might be a relevant goal for shock resuscitation. The goal of this review was to revise the evidence supporting the monitoring of peripheral perfusion and microcirculation as goals of resuscitation. For this purpose, we mainly focused on skin perfusion and sublingual microcirculation. RECENT FINDINGS Although there are controversies about the reproducibility of capillary refill time in monitoring peripheral perfusion, it is a sound physiological variable and suitable for the ICU settings. In addition, observational studies showed its strong ability to predict outcome. Moreover, a preliminary study suggested that it might be a valuable goal for resuscitation. These results should be confirmed by the ongoing ANDROMEDA-SHOCK randomized controlled trial. On the other hand, the monitoring of sublingual microcirculation might also provide relevant physiological and prognostic information. On the contrary, methodological drawbacks mainly related to video assessment hamper its clinical implementation at the present time. SUMMARY Measurements of peripheral perfusion might be useful as goal of resuscitation. The results of the ANDROMEDA-SHOCK will clarify the role of skin perfusion as a guide for the treatment of shock. In contrast, the assessment of sublingual microcirculation mainly remains as a research tool.
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22
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Hariri G, Joffre J, Leblanc G, Bonsey M, Lavillegrand JR, Urbina T, Guidet B, Maury E, Bakker J, Ait-Oufella H. Narrative review: clinical assessment of peripheral tissue perfusion in septic shock. Ann Intensive Care 2019; 9:37. [PMID: 30868286 PMCID: PMC6419794 DOI: 10.1186/s13613-019-0511-1] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 03/01/2019] [Indexed: 12/21/2022] Open
Abstract
Sepsis is one of the main reasons for intensive care unit admission and is responsible for high morbidity and mortality. The usual hemodynamic targets for resuscitation of patients with septic shock use macro-hemodynamic parameters (hearth rate, mean arterial pressure, central venous pressure). However, persistent alterations of microcirculatory blood flow despite restoration of macro-hemodynamic parameters can lead to organ failure. This dissociation between macro- and microcirculatory compartments brings a need to assess end organs tissue perfusion in patients with septic shock. Traditional markers of tissue perfusion may not be readily available (lactate) or may take time to assess (urine output). The skin, an easily accessible organ, allows clinicians to quickly evaluate the peripheral tissue perfusion with noninvasive bedside parameters such as the skin temperatures gradient, the capillary refill time, the extent of mottling and the peripheral perfusion index.
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Affiliation(s)
- Geoffroy Hariri
- Service de réanimation médicale, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Sorbonne Université, Université Pierre-et-Marie Curie-Paris 6, Paris, France
| | - Jérémie Joffre
- Service de réanimation médicale, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Sorbonne Université, Université Pierre-et-Marie Curie-Paris 6, Paris, France
| | - Guillaume Leblanc
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, QC, Canada.,Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Centre de recherche du CHU de Québec - Université Laval, Université Laval, Québec City, QC, Canada
| | - Michael Bonsey
- Service de réanimation médicale, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Jean-Remi Lavillegrand
- Service de réanimation médicale, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Sorbonne Université, Université Pierre-et-Marie Curie-Paris 6, Paris, France
| | - Tomas Urbina
- Service de réanimation médicale, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Bertrand Guidet
- Service de réanimation médicale, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Sorbonne Université, Université Pierre-et-Marie Curie-Paris 6, Paris, France.,Inserm U1136, Paris, 75012, France
| | - Eric Maury
- Service de réanimation médicale, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Sorbonne Université, Université Pierre-et-Marie Curie-Paris 6, Paris, France.,Inserm U1136, Paris, 75012, France
| | - Jan Bakker
- Department Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Pulmonology and Critical Care, Columbia University Medical Center, New York, USA.,Department of Pulmonology and Critical Care, New York University Medical Center - Bellevue Hospital, New York, USA.,Department of Intensive Care, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Hafid Ait-Oufella
- Service de réanimation médicale, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France. .,Sorbonne Université, Université Pierre-et-Marie Curie-Paris 6, Paris, France. .,Inserm U970, Centre de Recherche Cardiovasculaire de Paris (PARCC), Paris, France.
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Hariri G, Joffre J, Dumas G, Lavillegrand JR, Bigé N, Baudel JL, Guidet B, Maury E, Ait-Oufella H. Exploration de la perfusion tissulaire microcirculatoire au cours du choc septique. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2018-0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Au cours des infections graves, les travaux chez l’animal et chez l’homme ont mis en évidence une altération de la perfusion microcirculatoire à l’origine des défaillances viscérales et potentiellement du décès. La sévérité des anomalies microcirculatoires ainsi que leur persistance sont des facteurs prédictifs de mortalité indépendamment du débit cardiaque ou de la pression artérielle. Il est donc indispensable de développer des outils permettant d’évaluer la perfusion microcirculatoire au lit du malade. De nombreux travaux au cours du sepsis suggèrent que l’analyse de la perfusion cutanée au travers de sa température (et/ou du gradient), du temps de recoloration cutané, de l’étendue des marbrures et de l’indice de perfusion périphérique constitue un outil simple qui permet au réanimateur une évaluation rapide des anomalies microcirculatoires.
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Cecconi M, Hernandez G, Dunser M, Antonelli M, Baker T, Bakker J, Duranteau J, Einav S, Groeneveld ABJ, Harris T, Jog S, Machado FR, Mer M, Monge García MI, Myatra SN, Perner A, Teboul JL, Vincent JL, De Backer D. Fluid administration for acute circulatory dysfunction using basic monitoring: narrative review and expert panel recommendations from an ESICM task force. Intensive Care Med 2018; 45:21-32. [DOI: 10.1007/s00134-018-5415-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 10/11/2018] [Indexed: 12/21/2022]
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Hernández G, Cavalcanti AB, Ospina-Tascón G, Dubin A, Hurtado FJ, Damiani LP, Friedman G, Castro R, Alegría L, Cecconi M, Teboul JL, Bakker J. Statistical analysis plan for early goal-directed therapy using a physiological holistic view - the ANDROMEDA-SHOCK: a randomized controlled trial. Rev Bras Ter Intensiva 2018; 30:253-263. [PMID: 30066731 PMCID: PMC6180476 DOI: 10.5935/0103-507x.20180041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 05/11/2018] [Indexed: 01/13/2023] Open
Abstract
Background ANDROMEDA-SHOCK is an international, multicenter, randomized controlled trial
comparing peripheral perfusion-targeted resuscitation to lactate-targeted
resuscitation in patients with septic shock in order to test the hypothesis
that resuscitation targeting peripheral perfusion will be associated with
lower morbidity and mortality. Objective To report the statistical analysis plan for the ANDROMEDA-SHOCK trial. Methods We describe the trial design, primary and secondary objectives, patients,
methods of randomization, interventions, outcomes, and sample size. We
describe our planned statistical analysis for the primary, secondary and
tertiary outcomes. We also describe the subgroup and sensitivity analyses.
Finally, we provide details for presenting our results, including mock
tables showing baseline characteristics, the evolution of hemodynamic and
perfusion variables, and the effects of treatments on outcomes. Conclusion According to the best trial practice, we report our statistical analysis plan
and data management plan prior to locking the database and initiating the
analyses. We anticipate that this procedure will prevent analysis bias and
enhance the utility of the reported results.
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Affiliation(s)
- Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile - Santiago, Chile
| | | | - Gustavo Ospina-Tascón
- Departamento de Medicina Intensiva, Fundación Valle del Lili, Universidad ICESI - Cali, Colômbia
| | - Arnaldo Dubin
- Serviço de Terapia Intensiva, Sanatorio Otamendi y Miroli - Ciudad Autónoma de Buenos Aires, Argentina
| | - Francisco Javier Hurtado
- Centro de Terapia Intensiva, Hospital Español, Escuela de Medicina, Universidad de la República - Montevidéu, Uruguai
| | | | - Gilberto Friedman
- Departamento de Medicina Interna, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile - Santiago, Chile
| | - Leyla Alegría
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile - Santiago, Chile
| | - Maurizio Cecconi
- St George's University Hospitals NHS Foundation Trust - Londres, Reino Unido
| | - Jean-Louis Teboul
- Service de Réanimation Médicale, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris - Paris, França
| | - Jan Bakker
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile - Santiago, Chile.,Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center - Nova Iorque, Estados Unidos.,Erasmus MC University Medical Center, Department Intensive Care Adults - Rotterdam, CA, Holanda.,Division of Pulmonary, and Critical Care Medicine, New York University - Langone - Nova Iorque, Estados Unidos
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26
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Oi Y, Sato K, Nogaki A, Shinohara M, Matsumoto J, Abe T, Morimura N. Association between venous blood lactate levels and differences in quantitative capillary refill time. Acute Med Surg 2018; 5:321-328. [PMID: 30338077 PMCID: PMC6167399 DOI: 10.1002/ams2.348] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 04/27/2018] [Indexed: 01/01/2023] Open
Abstract
Aim Capillary refill time has been widely adopted for clinical assessment of the circulatory status of patients in emergency settings. We previously introduced quantitative capillary refill time and found a positive association between longer quantitative capillary refill time and higher lactate levels in the intensive care units, but not in the emergency department. In this study, we aimed to identify a quantitative and clinically applicable index of circulatory status (ΔA b) that can be measured with quantitative capillary refill time, then evaluated the linear association between this index and lactate levels in the emergency department. Methods We undertook a prospective single-center observational study at a university hospital from November 2015 to July 2016. We included 139 patients with endogenous diseases to test the association between quantitative capillary refill time, ΔA b (measured with a pulse oximeter), and lactate levels. Results ΔA b was independently and significantly associated with high lactate levels (odds ratio [95% confidence interval]: 0.16 [0.05-0.45]). Conclusions We introduced ΔA b, measured using quantitative capillary refill time, as a surrogate index of lactate levels to overcome the shortcomings of capillary refill time. We showed that ΔA b is a feasible, non-invasive, and rapid assessment of patients with high lactate levels in emergency primary care settings. Future multicenter studies with a longitudinal design should be undertaken to verify our findings.
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Affiliation(s)
- Yasufumi Oi
- Emergency Care Department Yokohama City University Hospital Yokohama Japan.,Department of Emergency medicine Yokohama City University School of Medicine Yokohama Japan
| | - Kosuke Sato
- Emergency Care Department Yokohama City University Hospital Yokohama Japan.,Department of Emergency medicine Yokohama City University School of Medicine Yokohama Japan
| | - Ayako Nogaki
- Emergency Care Department Yokohama City University Hospital Yokohama Japan.,Department of Emergency medicine Yokohama City University School of Medicine Yokohama Japan
| | - Mafumi Shinohara
- Emergency Care Department Yokohama City University Hospital Yokohama Japan.,Department of Emergency medicine Yokohama City University School of Medicine Yokohama Japan
| | - Jun Matsumoto
- Emergency Care Department Yokohama City University Hospital Yokohama Japan.,Department of Emergency medicine Yokohama City University School of Medicine Yokohama Japan
| | - Takeru Abe
- Department of Emergency medicine Yokohama City University School of Medicine Yokohama Japan.,Advanced Critical Care and Emergency Center Yokohama City University Medical Center Yokohama Japan
| | - Naoto Morimura
- Department of Emergency medicine Yokohama City University School of Medicine Yokohama Japan.,Department of Acute Medicine Graduate School of Medicine The University of Tokyo Tokyo Japan
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Hernández G, Cavalcanti AB, Ospina-Tascón G, Zampieri FG, Dubin A, Hurtado FJ, Friedman G, Castro R, Alegría L, Cecconi M, Teboul JL, Bakker J. Early goal-directed therapy using a physiological holistic view: the ANDROMEDA-SHOCK-a randomized controlled trial. Ann Intensive Care 2018; 8:52. [PMID: 29687277 PMCID: PMC5913056 DOI: 10.1186/s13613-018-0398-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 04/12/2018] [Indexed: 01/01/2023] Open
Abstract
Background Septic shock is a highly lethal condition. Early recognition of tissue hypoperfusion and its reversion are key factors for limiting progression to multiple organ dysfunction and death. Lactate-targeted resuscitation is the gold-standard under current guidelines, although it has several pitfalls including that non-hypoxic sources of lactate might predominate in an unknown proportion of patients. Peripheral perfusion-targeted resuscitation might provide a real-time response to increases in flow that could lead to a more timely decision to stop resuscitation, thus avoiding fluid overload and the risks of over-resuscitation. This article reports the rationale, study design and analysis plan of the ANDROMEDA-SHOCK Study. Methods ANDROMEDA-SHOCK is a randomized controlled trial which aims to determine if a peripheral perfusion-targeted resuscitation is associated with lower 28-day mortality compared to a lactate-targeted resuscitation in patients with septic shock with less than 4 h of diagnosis. Both groups will be treated with the same sequential approach during the 8-hour study period pursuing normalization of capillary refill time versus normalization or a decrease of more than 20% of lactate every 2 h. The common protocol starts with fluid responsiveness assessment and fluid loading in responders, followed by a vasopressor and an inodilator test if necessary. The primary outcome is 28-day mortality, and the secondary outcomes are: free days of mechanical ventilation, renal replacement therapy and vasopressor support during the first 28 days after randomization; multiple organ dysfunction during the first 72 h after randomization; intensive care unit and hospital lengths of stay; and all-cause mortality at 90-day. A sample size of 422 patients was calculated to detect a 15% absolute reduction in mortality in the peripheral perfusion group with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle. Conclusions If peripheral perfusion-targeted resuscitation improves 28-day mortality, this could lead to simplified algorithms, assessing almost in real-time the reperfusion process, and pursuing more physiologically sound objectives. At the end, it might prevent the risk of over-resuscitation and lead to a better utilization of intensive care unit resources. Trial registration ClinicalTrials.gov Identifier: NCT03078712 (registered retrospectively March 13th, 2017)
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Affiliation(s)
- Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile.
| | - Alexandre Biasi Cavalcanti
- Research Institute HCor, Hospital do Coração, R. Des. Eliseu Guilherme, 147 - Paraíso, São Paulo, Brazil
| | - Gustavo Ospina-Tascón
- Department of Intensive Care Medicine, Fundación Valle del Lili, Universidad ICESI, Carrera 98 # 18-49, Cali, Colombia
| | - Fernando Godinho Zampieri
- Research Institute HCor, Hospital do Coração, R. Des. Eliseu Guilherme, 147 - Paraíso, São Paulo, Brazil
| | - Arnaldo Dubin
- Servicio de Terapia Intensiva, Sanatorio Otamendi y Miroli, Azcuénaga 894, Ciudad Autónoma de Buenos Aires, Argentina
| | - F Javier Hurtado
- Centro de Tratamiento Intensivo, Hospital Español, Escuela de Medicina, Universidad de la República, Avda. Gral. Garibaldi, 1729 esq. Rocha, Montevideo, Uruguay
| | - Gilberto Friedman
- Departamento de Medicina Interna, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, R. Ramiro Barcelos 2350 - Santa Cecilia, Porto Alegre, Brazil
| | - Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - Leyla Alegría
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - Maurizio Cecconi
- St George's University Hospitals NHS Foundation Trust, Rd, London, SW17 0QT, UK
| | - Jean-Louis Teboul
- Service de Réanimation médicale, Hôpitaux universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jan Bakker
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile.,Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, 630 W 168th St, New York, USA.,Department Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, CA, The Netherlands.,Division of Pulmonary, and Critical Care Medicine, New York University-Langone, New York, USA
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28
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Capillary refill time during fluid resuscitation in patients with sepsis-related hyperlactatemia at the emergency department is related to mortality. PLoS One 2017; 12:e0188548. [PMID: 29176794 PMCID: PMC5703524 DOI: 10.1371/journal.pone.0188548] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 11/03/2017] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Acute circulatory dysfunction in patients with sepsis can evolve rapidly into a progressive stage associated with high mortality. Early recognition and adequate resuscitation could improve outcome. However, since the spectrum of clinical presentation is quite variable, signs of hypoperfusion are frequently unrecognized in patients just admitted to the emergency department (ED). Hyperlactatemia is considered a key parameter to disclose tissue hypoxia but it is not universally available and getting timely results can be challenging in low resource settings. In addition, non-hypoxic sources can be involved in hyperlactatemia, and a misinterpretation could lead to over-resuscitation in an unknown number of cases. Capillary refill time (CRT) is a marker of peripheral perfusion that worsens during circulatory failure. An abnormal CRT in septic shock patients after ICU-based resuscitation has been associated with poor outcome. The aim of this study was to determine the prevalence of abnormal CRT in patients with sepsis-related hyperlactatemia in the early phase after ED admission, and its relationship with outcome. METHODS We performed a prospective observational study. Septic patients with hyperlactemia at ED admission subjected to an initial fluid resuscitation (FR) were included. CRT and other parameters were assessed before and after FR. CRT-normal or CRT-abnormal subgroups were defined according to the status of CRT following initial FR, and major outcomes were registered. RESULTS Ninety-five hyperlactatemic septic patients were included. Thirty-one percent had abnormal CRT at ED arrival. After FR, 87 patients exhibited normal CRT, and 8 an abnormal one. Patients with abnormal CRT had an increased risk of adverse outcomes (88% vs. 20% p<0.001; RR 4.4 [2.7-7.4]), and hospital mortality (63% vs. 9% p<0.001; RR 6.7 [2.9-16]) as compared to those with normal CRT after FR. Specifically, CRT-normal patients required less frequently mechanical ventilation, renal replacement therapy, and ICU admission, and exhibited a lower hospital mortality. CONCLUSIONS Hyperlactatemic sepsis patients with abnormal CRT after initial fluid resuscitation exhibit higher mortality and worse clinical outcomes than patients with normal CRT.
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29
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Haahr-Raunkjær C, Meyhoff CS, Sørensen HBD, Olsen RM, Aasvang EK. Technological aided assessment of the acutely ill patient - The case of postoperative complications. Eur J Intern Med 2017; 45:41-45. [PMID: 28986156 DOI: 10.1016/j.ejim.2017.09.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 09/22/2017] [Accepted: 09/24/2017] [Indexed: 11/18/2022]
Abstract
Surgical interventions come with complications and highly reported mortality after major surgery. The mortality may be a result of delayed detection of severe complications due to lower monitoring frequency in the general wards. Several studies have shown that continuous monitoring is superior to the manually intermittent recorded monitoring in terms of detecting abnormal physiological signs. Hopefully improved observations may result in earlier detection and clinical intervention. This narrative review will describe current monitoring possibilities for postoperative patients and how it may prevent complications. Several wireless systems are being developed for monitoring vital parameters, but many of these are not yet validated for critically ill patients. The ultimate goal with patient monitoring and detect of events is to prevent postoperative complications, death and costs in the health care system. A few studies indicate that monitoring systems detect deteriorating patients earlier than the nurses, and this was associated with less clinical instability. An important caveat of future devices is to assess their effect in relevant patient populations and not only in healthy test-subjects. Implementation of novel technologies is expensive although expected to be cost-effective if just few adverse events can be prevented. The future is here with promising devices and the possibility to give an unprecedented precise risk estimation of adverse post-surgical events. Next step is to integrate existing evidence based treatment algorithms to demonstrate the clinical efficacy of implementing the new technology.
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Affiliation(s)
- C Haahr-Raunkjær
- Department of Anesthesiology, The Abdominal Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - C S Meyhoff
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - H B D Sørensen
- Biomedical Engineering, Department of Electrical Engineering, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - R M Olsen
- Biomedical Engineering, Department of Electrical Engineering, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - E K Aasvang
- Department of Anesthesiology, The Abdominal Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Sansone CM, Prendin F, Giordano G, Casati P, Destrebecq A, Terzoni S. Relationship between Capillary Refill Time at Triage and Abnormal Clinical Condition: A Prospective Study. Open Nurs J 2017; 11:84-90. [PMID: 28839512 PMCID: PMC5543682 DOI: 10.2174/1874434601711010084] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 04/05/2017] [Accepted: 05/23/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Capillary refill time has been studied in literature as a perfusion indicator. Two pilot studies have proposed possible reference values in healthy adults. No data exist regarding capillary refill time as an indicator of abnormal clinical conditions in adults, which might be of help for triage nurses. OBJECTIVE We wanted to assess if any relationships existed, between altered capillary refill time and abnormal clinical conditions in the emergency department. We investigated relations between capillary refill time and vital signs recorded in triage and blood tests, by analyzing the clinical records. Mortality at 24 hours, 7 days and over 14 days was investigated by calling the patients after discharge. METHOD Observational, single-center study on a sample of consecutive patients aged ≥ 18 years in the Emergency Department of a major Milan hospital, from June to October 2014. Multivariate logistic regression was used to investigate the impact of clinical variables on capillary refill time. RESULTS 1001 patients were enrolled, aged 59 ± 21 (473 aged 65 or more). Longer refill times were found in patients admitted to hospital units after medical consultations in the emergency department compared to those discharged or sent to outpatients. In elderly patients, statistically significant association was found between increased capillary refill time and sepsis (sensitivity 100%, specificity 83.33%, area under the receiver operating characteristics curve 65.95% CI 47-83), oxygen saturation, mean blood pressure, and lactates. In persons aged 45 to 64, altered refill times were associated with abnormal values of glicemia, platelets, and urea. CONCLUSION Capillary refill time can be used by nurses at triage as a complementary parameter to normal vital signs. This is one of the few studies investigating refill time in adult patients.
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Affiliation(s)
- Claudia M. Sansone
- Nurse, Azienda Ospedaliero-Universitaria Maggiore della Carità di Novara, Corso Mazzini 18, 28100 Novara, Italy
| | - Fabiano Prendin
- Nurse, Emergency Department, San Paolo teaching hospital, Via A. di Rudinì, 8 – 20142 Milan, Italy
| | - Greta Giordano
- Nurse, ASST Santi Paolo e Carlo, presidio San Paolo, Via A. di Rudinì, 8 – 20142 Milan, Italy
| | - Paola Casati
- Operating theatre, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Anne Destrebecq
- Associate professor of Nursing, University of Milan, Via Ovada, 26 – 20142 Milan, Italy
| | - Stefano Terzoni
- PhD, Tutor Nurse, San Paolo bachelor school of Nursing, San Paolo teaching hospital, Via Ovada, 26 – 20142 Milan, Italy
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Bourcier S, Pichereau C, Boelle PY, Nemlaghi S, Dubée V, Lejour G, Baudel JL, Galbois A, Lavillegrand JR, Bigé N, Tahiri J, Leblanc G, Maury E, Guidet B, Ait-Oufella H. Toe-to-room temperature gradient correlates with tissue perfusion and predicts outcome in selected critically ill patients with severe infections. Ann Intensive Care 2016; 6:63. [PMID: 27401441 PMCID: PMC4940318 DOI: 10.1186/s13613-016-0164-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 06/27/2016] [Indexed: 12/11/2022] Open
Abstract
Background Microcirculatory disorders leading to tissue hypoperfusion play a central role in the pathophysiology of organ failure in severe sepsis and septic shock. As microcirculatory disorders have been identified as strong predictive factors of unfavourable outcome, there is a need to develop accurate parameters at the bedside to evaluate tissue perfusion. We evaluated whether different body temperature gradients could relate to sepsis severity and could predict outcome in critically ill patients with severe sepsis and septic shock. Method We conducted a prospective observational study in a tertiary teaching hospital in France. During a 10-month period, all consecutive adult patients with severe sepsis or septic shock who required ICU admission were included. Six hours after initial resuscitation (H6), we recorded the hemodynamic parameters and four temperature gradients: central-to-toe, central-to-knee, toe-to-room and knee-to-room. Results We evaluated 40 patients with severe sepsis (40/103, 39 %) and 63 patients with septic shock (63/103, 61 %). In patients with septic shock, central-to-toe temperature gradient was significantly higher (12.5 [9.2; 13.8] vs 6.9 [3.4; 12.0] °C, P < 0.001) and toe-to-room temperature gradient significantly lower (1.2 [−0.3; 5.2] vs 6.0 [0.6; 9.5] °C, P < 0.001) than in patients with severe sepsis. Overall ICU mortality rate due to multiple organ failure (MOF) was 21 %. After initial resuscitation, toe-to-room temperature gradient was significantly lower in patients dead from MOF than in the survivors (−0.2 [−1.1; +1.3] °C vs +3.9 [+0.5; +7.2] °C, P < 0.001) and the difference in gradients increased during the first 24 h. Furthermore, toe-to-room temperature gradient was related to tissue perfusion parameters such as arterial lactate level (r = −0.54, P < 0.0001), urine output (r = 0.37, P = 0.0002), knee capillary refill time (r = −0.42, P < 0.0001) and mottling score (P = 0.001). Conclusions Toe-to-room temperature gradient reflects tissue perfusion at the bedside and is a strong prognosis factor in critically ill patients with severe infections. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0164-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Simon Bourcier
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Claire Pichereau
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Pierre-Yves Boelle
- Service de santé publique, AP-HP, Hôpital Saint-Antoine, 75571, Paris Cedex 12, France
| | - Safaa Nemlaghi
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Service de Réanimation polyvalente Quincy-sous-Sénart, Générale de Santé, Hôpital Privé Claude Galien, Quincy-Sous-Sénart, France
| | - Vincent Dubée
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Gabriel Lejour
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Jean-Luc Baudel
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Arnaud Galbois
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Service de Réanimation polyvalente Quincy-sous-Sénart, Générale de Santé, Hôpital Privé Claude Galien, Quincy-Sous-Sénart, France
| | - Jean-Rémi Lavillegrand
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Naïke Bigé
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Jalel Tahiri
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Guillaume Leblanc
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Eric Maury
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Université Pierre et Marie Curie-Paris 6, Paris, France.,Inserm U1136, 75012, Paris, France
| | - Bertrand Guidet
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Université Pierre et Marie Curie-Paris 6, Paris, France.,Inserm U1136, 75012, Paris, France
| | - Hafid Ait-Oufella
- Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France. .,Université Pierre et Marie Curie-Paris 6, Paris, France. .,Inserm U970, Centre de recherche cardiovasculaire de Paris (PARCC), Paris, France.
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