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Huang W, Huang Y, Ke L, Hu C, Chen P, Hu B. Perspectives for capillary refill time in clinical practice for sepsis. Intensive Crit Care Nurs 2024; 84:103743. [PMID: 38896965 DOI: 10.1016/j.iccn.2024.103743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 05/11/2024] [Accepted: 06/03/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Capillary refill time (CRT) is defined as the time taken for color to return to an external capillary bed after pressure is applied to cause blanching. Recent studies demonstrated the benefits of CRT in guiding fluid therapy for sepsis. However, lack of consistency among physicians in how to perform and interpret CRT has led to a low interobserver agreement for this assessment tool, which prevents its availability in sepsis clinical settings. OBJECTIVE To give physicians a concise overview of CRT and explore recent evidence on its reliability and value in the management of sepsis. RESEARCH DESIGN A narrative review. RESULTS This narrative review summarizes the factors affecting CRT values, for example, age, sex, temperature, light, observation techniques, work experience, training level and differences in CRT measurement methods. The methods of reducing the variability of CRT are synthesized. Based on studies with highly reproducible CRT measurements and an excellent inter-rater concordance, we recommend the standardized CRT assessment method. The threshold of normal CRT values is discussed. The application of CRT in different phases of sepsis management is summarized. CONCLUSIONS Recent data confirm the value of CRT in critically ill patients. CRT should be detected by trained physicians using standardized methods and reducing the effect of ambient-related factors. Its association with severe infection, microcirculation, tissue perfusion response, organ dysfunction and adverse outcomes makes this approach a very attractive tool in sepsis. Further studies should confirm its value in the management of sepsis. IMPLICATIONS FOR CLINICAL PRACTICE As a simple assessment, CRT deserves more attention even though it has not been widely applied at the bedside. CRT could provide nursing staff with patient's microcirculatory status, which may help to develop individualized nursing plans and improve the patient's care quality and treatment outcomes.
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Affiliation(s)
- Weipeng Huang
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China; Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China.
| | - Yiyan Huang
- Nursing Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China.
| | - Li Ke
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China.
| | - Chang Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China.
| | - Pengyu Chen
- Department of Urology, Shenzhen Children's Hospital, Futian District, Shenzhen 518000, Guangdong, China.
| | - Bo Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China.
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De All JE, Caminos Eguillor JF, Cohen SM, Freilij H, Dubin A. Sublingual microcirculatory alterations in Chagas disease: an observational study in an endemic rural population. Mem Inst Oswaldo Cruz 2024; 119:e240018. [PMID: 39109708 PMCID: PMC11304841 DOI: 10.1590/0074-02760240018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 06/12/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND Chagas disease is a systemic illness with widespread microvascular involvement. Experimental and clinical studies suggest that functional and structural microcirculatory abnormalities might be relevant to the disease progression. OBJECTIVES To show the presence of sublingual microcirculatory alterations in patients with chronic Chagas disease. METHODS This was a cross-sectional study including adult patients with serologic diagnosis of Chagas disease (n = 41) and control volunteers with negative serology (n = 38), from an endemic rural population. Study participants underwent clinical, electrocardiographic, echocardiographic, and sublingual videomicroscopic assessment. Videos were acquired by a sidestream-dark-field (SDF) imaging device and evaluated by a software-assisted analysis (AVA 3.2 software). FINDINGS Most of Chagas disease patients were in the indeterminate phase (n = 34) and had lower heart rate and more echocardiographic abnormalities than control group (50 vs. 26%, p = 0.03). They also exhibited higher small microvessels total and perfused vascular density (20.12 ± 2.33 vs. 19.05 ± 2.25 and 20.03 ± 2.28 vs. 19.01 ± 2.25 mm/mm2, p < 0.05 for both). Other microvascular variables did not differ between groups. MAIN CONCLUSIONS Patients with chronic Chagas disease exhibited increases in sublingual total and perfused microvascular density. Angiogenesis might be the underlying mechanism. The videomicroscopic assessment of mucosal sublingual microcirculation might be an additional tool in the monitoring of Chagas disease.
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Affiliation(s)
- Jorge Emilio De All
- Asociación Cuerpo & Alma, Ciudad Autónoma de Buenos Aires, Argentina
- Sanatorio Otamendi, Ciudad Autónoma de Buenos Aires, Argentina
| | - Juan Francisco Caminos Eguillor
- Universidad Nacional de La Plata, Facultad de Ciencias Médicas, Cátedras de Farmacología Aplicada y Terapia Intensiva, Provincia de Buenos Aires, Argentina
| | | | - Héctor Freilij
- Hospital de Niños Ricardo Gutiérrez, Servicio de Parasitología y Enfermedad de Chagas, Ciudad Autónoma de Buenos Aires, Argentina
| | - Arnaldo Dubin
- Sanatorio Otamendi, Ciudad Autónoma de Buenos Aires, Argentina
- Universidad Nacional de La Plata, Facultad de Ciencias Médicas, Cátedras de Farmacología Aplicada y Terapia Intensiva, Provincia de Buenos Aires, Argentina
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Mirsajadi A, Erickson D, Alias S, Froese L, Singh Sainbhi A, Gomez A, Majumdar R, Herath I, Wilson M, Zarychanski R, Zeiler FA, Mendelson AA. Microvascular Autoregulation in Skeletal Muscle Using Near-Infrared Spectroscopy and Derivation of Optimal Mean Arterial Pressure in the ICU: Pilot Study and Comparison With Cerebral Near-Infrared Spectroscopy. Crit Care Explor 2024; 6:e1111. [PMID: 38904977 PMCID: PMC11196085 DOI: 10.1097/cce.0000000000001111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2024] Open
Abstract
IMPORTANCE Microvascular autoregulation (MA) maintains adequate tissue perfusion over a range of arterial blood pressure (ABP) and is frequently impaired in critical illness. MA has been studied in the brain to derive personalized hemodynamic targets after brain injury. The ability to measure MA in other organs is not known, which may inform individualized management during shock. OBJECTIVES This study determines the feasibility of measuring MA in skeletal muscle using near-infrared spectroscopy (NIRS) as a marker of tissue perfusion, the derivation of optimal mean arterial pressure (MAPopt), and comparison with indices from the brain. DESIGN Prospective observational study. SETTING Medical and surgical ICU in a tertiary academic hospital. PARTICIPANTS Adult critically ill patients requiring vasoactive support on the first day of ICU admission. MAIN OUTCOMES AND MEASURES Fifteen critically ill patients were enrolled. NIRS was applied simultaneously to skeletal muscle (brachioradialis) and brain (frontal cortex) while ABP was measured continuously via invasive catheter. MA correlation indices were calculated between ABP and NIRS from skeletal muscle total hemoglobin (MVx), muscle tissue saturation index (MOx), brain total hemoglobin (THx), and brain tissue saturation index (COx). Curve fitting algorithms derive the MAP with the lowest correlation index value, which is the MAPopt. RESULTS MAPopt values were successfully calculated for each correlation index for all patients and were frequently (77%) above 65 mm Hg. For all correlation indices, median time was substantially above impaired MA threshold (24.5-34.9%) and below target MAPopt (9.0-78.6%). Muscle and brain MAPopt show moderate correlation (MVx-THx r = 0.76, p < 0.001; MOx-COx r = 0.69, p = 0.005), with a median difference of -1.27 mm Hg (-9.85 to -0.18 mm Hg) and 0.05 mm Hg (-7.05 to 2.68 mm Hg). CONCLUSIONS AND RELEVANCE This study demonstrates, for the first time, the feasibility of calculating MA indices and MAPopt in skeletal muscle using NIRS. Future studies should explore the association between impaired skeletal muscle MA, ICU outcomes, and organ-specific differences in MA and MAPopt thresholds.
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Affiliation(s)
- Amirali Mirsajadi
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Dustin Erickson
- Section of Critical Care Medicine, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Soumya Alias
- Section of Critical Care Medicine, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Logan Froese
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Amanjyot Singh Sainbhi
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Alwyn Gomez
- Division of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, MB, Canada
| | - Raju Majumdar
- Section of Critical Care Medicine, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Isuru Herath
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Maggie Wilson
- Section of Critical Care Medicine, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Ryan Zarychanski
- Section of Critical Care Medicine, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Department of Medical Oncology and Hematology, University of Manitoba/CancerCare Manitoba, Winnipeg, MB, Canada
| | - Frederick A. Zeiler
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, MB, Canada
- Pan Am Clinic Foundation, Winnipeg, MB, Canada
| | - Asher A. Mendelson
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- Section of Critical Care Medicine, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Department of Physiology, University of Manitoba, Winnipeg, MB, Canada
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Baysan M, Broere M, Wille ME, Bergsma JE, Mik EG, Juffermans NP, Tsonaka R, van der Bom JG, Arbous SM. Description of mitochondrial oxygen tension and its variability in healthy volunteers. PLoS One 2024; 19:e0300602. [PMID: 38829894 PMCID: PMC11146699 DOI: 10.1371/journal.pone.0300602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 02/27/2024] [Indexed: 06/05/2024] Open
Abstract
OBJECTIVES Describing mitochondrial oxygenation (mitoPO2) and its within- and between-subject variability over time after 5-aminolevulinic acid (ALA) plaster application in healthy volunteers. DESIGN Prospective cohort study. SETTING Measurements were performed in Leiden University Medical Center, the Netherlands. PARTICIPANTS Healthy volunteers enrolled from July to September 2020. INTERVENTIONS Two ALA plasters were placed parasternal left and right, with a 3-hour time interval, to examine the influence of the calendar time on the value of mitoPO2. We measured mitoPO2 at 4, 5, 7, 10, 28, and 31 hours after ALA plaster 1 application, and at 4, 5, 7, 25, and 28 hours after ALA plaster 2 application. PRIMARY AND SECONDARY OUTCOME MEASURES At each time point, five mitoPO2 measurements were performed. Within-subject variability was defined as the standard deviation (SD) of the mean of five measurements per timepoint of a study participant. The between-subject variability was the SD of the mean mitoPO2 value of the study population per timepoint. RESULTS In 16 completed inclusions, median mitoPO2 values and within-subject variability were relatively similar over time at all time points for both plasters. An increase in overall between-subject variability was seen after 25 hours ALA plaster time (19.6 mm Hg vs 23.9 mm Hg after respectively 10 and 25 hours ALA plaster time). CONCLUSIONS The mitoPO2 values and within-subject variability remained relatively stable over time in healthy volunteers. An increase in between-subject variability was seen after 25 hours ALA plaster time warranting replacement of the ALA plaster one day after its application. TRIAL REGISTRATION ClinicalTrials.gov with trial number NCT04626661.
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Affiliation(s)
- Meryem Baysan
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Jon J van Rood Center for Clinical Transfusion Research, Sanquin/Leiden University Medical Center, Leiden, the Netherlands
| | - Mark Broere
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Jon J van Rood Center for Clinical Transfusion Research, Sanquin/Leiden University Medical Center, Leiden, the Netherlands
| | - Maarten E. Wille
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Jule E. Bergsma
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Egbert G. Mik
- Department of Anesthesiology, Laboratory of Experimental Anesthesiology, Erasmus MC- University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Nicole P. Juffermans
- Department of Intensive Care Medicine, OLVG Hospital, Amsterdam, the Netherlands
- Department of Laboratory of Translation Intensive Care, Erasmus MC- University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Roula Tsonaka
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Johanna G. van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Jon J van Rood Center for Clinical Transfusion Research, Sanquin/Leiden University Medical Center, Leiden, the Netherlands
| | - Sesmu M. Arbous
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
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González R, Urbano J, López-Herce J. Resuscitating the macro- vs. microcirculation in septic shock. Curr Opin Pediatr 2024; 36:274-281. [PMID: 38446225 DOI: 10.1097/mop.0000000000001345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
PURPOSE OF REVIEW This review summarizes current literature about the relationships between macro and microcirculation and their practical clinical implications in children with septic shock. RECENT FINDINGS Current evidence from experimental and clinical observational studies in children and adults with septic shock reveals that the response to treatment and resuscitation is widely variable. Furthermore, there is a loss of hemodynamic coherence, as resuscitation-induced improvement in macrocirculation (systemic hemodynamic parameters) does not necessarily result in a parallel improvement in the microcirculation. Therefore, patient-tailored monitoring is essential in order to adjust treatment requirements during resuscitation in septic shock. Optimal monitoring must integrate macrocirculation (heart rate, blood pressure, cardiac output, and ultrasound images), microcirculation (videomicroscopy parameters and capillary refill time) and cellular metabolism (lactic acid, central venous blood oxygen saturation, and difference of central venous to arterial carbon dioxide partial pressure). SUMMARY There is a dire need for high-quality studies to assess the relationships between macrocirculation, microcirculation and tissue metabolism in children with septic shock. The development of reliable and readily available microcirculation and tissue perfusion biomarkers (other than lactic acid) is also necessary to improve monitoring and treatment adjustment in such patients.
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Affiliation(s)
- Rafael González
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón
- Health Research Institute of the Gregorio Marañón Hospital
- Maternal and Child Public Health Department. School of Medicine, Complutense University of Madrid
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
| | - Javier Urbano
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón
- Health Research Institute of the Gregorio Marañón Hospital
- Maternal and Child Public Health Department. School of Medicine, Complutense University of Madrid
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
| | - Jesús López-Herce
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón
- Health Research Institute of the Gregorio Marañón Hospital
- Maternal and Child Public Health Department. School of Medicine, Complutense University of Madrid
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
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Acevedo RU, Sánchez LO, Londoño SV, Mejía-Mejía E, Villa RT, Goez YM. Non-invasive assessment of sublingual microcirculation using flow derived from green light PPG: evaluation and reference values. JOURNAL OF BIOMEDICAL OPTICS 2024; 29:017001. [PMID: 38188965 PMCID: PMC10768685 DOI: 10.1117/1.jbo.29.1.017001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/30/2023] [Accepted: 10/31/2023] [Indexed: 01/09/2024]
Abstract
Significance The study of sublingual microcirculation offers valuable insights into vascular changes and overcomes some limitations of peripheral microcirculation assessment. Videomicroscopy and pulse oximetry have been used to assess microcirculation, providing insights into organ perfusion beyond macrohemodynamics parameters. However, both techniques have important limitations that preclude their use in clinical practice. Aim To address this, we propose a non-invasive approach using photoplethysmography (PPG) to assess microcirculation. Approach Two experiments were performed on different samples of 31 subjects. First, multi-wavelength, finger PPG signals were compared before and while applying pressure on the sensor to determine if PPG signals could detect changes in peripheral microcirculation. For the second experiment, PPG signals were acquired from the ventral region of the tongue, aiming to assess the microcirculation through features calculated from the PPG signal and its first derivative. Results In experiment 1, 13 out of 15 features extracted from green PPG signals showed significant differences (p < 0.05 ) before and while pressure was applied to the sensor, suggesting that green light could detect flow distortion in superficial capillaries. In experiment 2, 15 features showed potential application of PPG signal for sublingual microcirculation assessment. Conclusions The PPG signal and its first derivative have the potential to effectively assess microcirculation when measured from the fingertip and the tongue. The assessment of sublingual microcirculation was done through the extraction of 15 features from the green PPG signal and its first derivative. Future studies are needed to standardize and gain a deeper understanding of the evaluated features.
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Affiliation(s)
- Rafael Uribe Acevedo
- Universidad EIA, Medellín, Colombia
- Hospital Alma Máter de Antioquia, Servicio de Medicina Crítica y Cuidados Intensivos, Medellín, Colombia
| | | | | | - Elisa Mejía-Mejía
- King’s College London, Centre for Human and Applied Physiological Sciences, London, United Kingdom
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Penny JD, Hur L, Salerno FR, Wong D, Jan MH, McIntyre CW. Non-invasive intradialytic percutaneous perfusion monitoring: a view to the heart through the skin. FRONTIERS IN NEPHROLOGY 2023; 3:1124130. [PMID: 37675381 PMCID: PMC10479609 DOI: 10.3389/fneph.2023.1124130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 06/14/2023] [Indexed: 09/08/2023]
Abstract
Introduction The life-sustaining treatment of hemodialysis (HD) induces recurrent and cumulative systemic circulatory stress resulting in cardiovascular injury. These recurrent insults compound preexisting cardiovascular sequalae leading to the development of myocardial injury and resulting in extremely high morbidity/mortality. This is largely a consequence of challenged microcirculatory flow within the myocardium (evidenced by detailed imaging-based studies). Currently, monitoring during HD is performed at the macrovascular level. Non-invasive monitoring of organ perfusion would allow the detection and therapeutic amelioration of this pathophysiological response to HD. Non-invasive percutaneous perfusion monitoring of the skin (using photoplethysmography-PPG) has been shown to be predictive of HD-induced myocardial stunning (a consequence of segmental ischemia). In this study, we extended these observations to include a dynamic assessment of skin perfusion during HD compared with directly measured myocardial perfusion during dialysis and cardiac contractile function. Methods We evaluated the intradialytic microcirculatory response in 12 patients receiving conventional HD treatments using continuous percutaneous perfusion monitoring throughout HD. Cardiac echocardiography was performed prior to the initiation of HD, and again at peak-HD stress, to assess the development of regional wall motion abnormalities (RWMAs). Myocardial perfusion imaging was obtained at the same timepoints (pre-HD and peak-HD stress), utilizing intravenous administered contrast and a computerized tomography (CT)-based method. Intradialytic changes in pulse strength (derived from PPG) were compared with the development of HD-induced RWMAs (indicative of myocardial stunning) and changes in myocardial perfusion. Results We found an association between the lowest pulse strength reduction (PPG) and the development of RWMAs (p = 0.03) and also with changes in global myocardial perfusion (CT) (p = 0.05). Ultrafiltration rate (mL/kg/hour) was a significant driver of HD-induced circulatory stress [(associated with the greatest pulse strength reduction (p = 0.01), a reduction in global myocardial perfusion (p = 0.001), and the development of RWMAs (p = 0.03)]. Discussion Percutaneous perfusion monitoring using PPG is a useful method of assessing intradialytic hemodynamic stability and HD-induced circulatory stress. The information generated at the microcirculatory level of the skin is reflective of direct measures of myocardial perfusion and the development of HD-induced myocardial stunning. This approach for the detection and management of HD-induced cardiac injury warrants additional evaluation.
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Affiliation(s)
- Jarrin D. Penny
- The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, ON, Canada
- Department of Medical Biophysics, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Lisa Hur
- The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, ON, Canada
- Department of Medical Biophysics, Western University, London, ON, Canada
| | - Fabio R. Salerno
- The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, ON, Canada
- Department of Medical Biophysics, Western University, London, ON, Canada
| | - Dickson Wong
- The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, ON, Canada
| | - M. Hussain Jan
- The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, ON, Canada
| | - Christopher W. McIntyre
- The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, ON, Canada
- Department of Medical Biophysics, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
- Division of Nephrology, London Health Sciences Centre, London, ON, Canada
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Muzaffar SN, Pradhan A, Siddiqui SS, Roy S, Suresh T. Monitoring Macro- and Microcirculation in the Critically Ill: A Narrative Review. Avicenna J Med 2023; 13:138-150. [PMID: 37799180 PMCID: PMC10550369 DOI: 10.1055/s-0043-1772175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
Circulatory shock is a common and important diagnosis in the critical care environment. Hemodynamic monitoring is quintessential in the management of shock. The currently used hemodynamic monitoring devices not only measure cardiac output but also provide data related to the prediction of fluid responsiveness, extravascular lung water, and also pulmonary vascular permeability. Additionally, these devices are minimally invasive and associated with fewer complications. The area of hemodynamic monitoring is progressively evolving with a trend toward the use of minimally invasive devices in this area. The critical care physician should be well-versed with current hemodynamic monitoring limitations and stay updated with the upcoming advances in this field so that optimal therapy can be delivered to patients in circulatory shock.
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Affiliation(s)
- Syed Nabeel Muzaffar
- Department of Critical Care Medicine, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India
| | - Akshyaya Pradhan
- Department of Cardiology, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India
| | - Suhail Sarwar Siddiqui
- Department of Critical Care Medicine, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India
| | - Shubhajeet Roy
- Faculty of Medical Sciences, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India
| | - Timil Suresh
- Faculty of Medical Sciences, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India
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Huang W, Xiang H, Hu C, Wu T, Zhang D, Ma S, Hu B, Li J. Association of Sublingual Microcirculation Parameters and Capillary Refill Time in the Early Phase of ICU Admission. Crit Care Med 2023; 51:913-923. [PMID: 36942969 PMCID: PMC10262986 DOI: 10.1097/ccm.0000000000005851] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
OBJECTIVES This observational study was conducted to investigate capillary refill time (CRT) during the early phase of ICU admission in relationship with microvascular flow alteration and outcome in critically ill patients. DESIGN Prospective, observational, pilot study. SETTING ICU in a university hospital. PATIENTS Two hundred eighty-two critically ill adult patients admitted to the ICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All patients underwent simultaneous measurements by CRT and sidestream dark field imaging within 24 hours of ICU admission. Other clinical data such as demographic characteristics, hemodynamics, laboratory values, treatment, and physiologic parameters were also included simultaneously. Microcirculatory measurements were performed at 10.2 ± 5.7 hours after ICU admission. Of the 282 included patients, 106 (37.6%) were female, the median (interquartile range) age was 63 years (53-74 yr), and the median Sequential Organ Failure Assessment (SOFA) score was 5 (2-7). The primary finding was the association between CRT and simultaneous the condition of peripheral circulation (microvascular flow index [MFI]: r = -0.4430, p < 0.001; proportion of perfused vessels: r = -0.3708, p < 0.001; heterogeneity index: r = 0.4378, p < 0.001; perfused vessel density: r = -0.1835, p = 0.0020; except total vessel density: p = 0.9641; and De Backer score: p = 0.5202) in critically ill patients. In addition, this relationship was also maintained in subgroups. Microcirculatory flow abnormalities, 28-day mortality, and SOFA score appeared to be more severe for increasing CRT. In a multivariable analysis, prolonged CRT was independently associated with microvascular flow abnormalities (MFI < 2.6; odds ratio [OR], 1.608; 95% CI, 2.1-10.2; p < 0.001). Similarly, multivariable analysis identified CRT as an independent predictor of 28-day mortality (OR, 1.296; 95% CI, 1.078-1.558; p = 0.006). CONCLUSIONS In our ICU population, a single-spot prolonged CRT was independently associated with abnormal microcirculation and increased mortality.
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Affiliation(s)
- Weipeng Huang
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
| | - Hui Xiang
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
| | - Chang Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
| | - Tong Wu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
| | - Dandan Zhang
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
| | - Siqing Ma
- Department of Critical Care Medicine, Qinghai Provincial People's Hospital, Xining, Qinghai, China
| | - Bo Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
| | - Jianguo Li
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
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Bogatu L, Turco S, Mischi M, Schmitt L, Woerlee P, Bezemer R, Bouwman AR, Korsten EHHM, Muehlsteff J. New Hemodynamic Parameters in Peri-Operative and Critical Care-Challenges in Translation. SENSORS (BASEL, SWITZERLAND) 2023; 23:2226. [PMID: 36850819 PMCID: PMC9961222 DOI: 10.3390/s23042226] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/03/2023] [Accepted: 02/06/2023] [Indexed: 06/18/2023]
Abstract
Hemodynamic monitoring technologies are evolving continuously-a large number of bedside monitoring options are becoming available in the clinic. Methods such as echocardiography, electrical bioimpedance, and calibrated/uncalibrated analysis of pulse contours are becoming increasingly common. This is leading to a decline in the use of highly invasive monitoring and allowing for safer, more accurate, and continuous measurements. The new devices mainly aim to monitor the well-known hemodynamic variables (e.g., novel pulse contour, bioreactance methods are aimed at measuring widely-used variables such as blood pressure, cardiac output). Even though hemodynamic monitoring is now safer and more accurate, a number of issues remain due to the limited amount of information available for diagnosis and treatment. Extensive work is being carried out in order to allow for more hemodynamic parameters to be measured in the clinic. In this review, we identify and discuss the main sensing strategies aimed at obtaining a more complete picture of the hemodynamic status of a patient, namely: (i) measurement of the circulatory system response to a defined stimulus; (ii) measurement of the microcirculation; (iii) technologies for assessing dynamic vascular mechanisms; and (iv) machine learning methods. By analyzing these four main research strategies, we aim to convey the key aspects, challenges, and clinical value of measuring novel hemodynamic parameters in critical care.
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Affiliation(s)
- Laura Bogatu
- Biomedical Diagnostics Lab (BM/d), Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands
- Patient Care and Measurements, Philips Research, 5656 AE Eindhoven, The Netherlands
| | - Simona Turco
- Biomedical Diagnostics Lab (BM/d), Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands
| | - Massimo Mischi
- Biomedical Diagnostics Lab (BM/d), Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands
| | - Lars Schmitt
- Patient Care and Measurements, Philips Research, 5656 AE Eindhoven, The Netherlands
| | - Pierre Woerlee
- Biomedical Diagnostics Lab (BM/d), Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands
| | - Rick Bezemer
- Patient Care and Measurements, Philips Research, 5656 AE Eindhoven, The Netherlands
| | - Arthur R. Bouwman
- Department of Anesthesiology, Intensive Care and Pain Medicine, Catharina Ziekenhuis, 5623 EJ Eindhoven, The Netherlands
| | - Erik H. H. M. Korsten
- Department of Anesthesiology, Intensive Care and Pain Medicine, Catharina Ziekenhuis, 5623 EJ Eindhoven, The Netherlands
| | - Jens Muehlsteff
- Patient Care and Measurements, Philips Research, 5656 AE Eindhoven, The Netherlands
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Monitoring of mitochondrial oxygen tension in the operating theatre: An observational study with the novel COMET® monitor. PLoS One 2023; 18:e0278561. [PMID: 36758026 PMCID: PMC9910761 DOI: 10.1371/journal.pone.0278561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/20/2022] [Indexed: 02/10/2023] Open
Abstract
INTRODUCTION The newly introduced Cellular Oxygen METabolism (COMET®) monitor enables the measurement of mitochondrial oxygen tension (mitoPO2) using the protoporphyrin IX triplet state lifetime technique (PpIX-TSLT). This study aims to investigate the feasibility and applicability of the COMET® measurements in the operating theatre and study the behavior of the new parameter mitoPO2 during stable operating conditions. METHODS In this observational study mitochondrial oxygenation was measured in 20 patients during neurosurgical procedures using the COMET® device. Tissue oxygenation and local blood flow were measured by the Oxygen to See (O2C). Primary outcomes included mitoPO2, skin temperature, mean arterial blood pressure, local blood flow and tissue oxygenation. RESULTS All patients remained hemodynamically stable during surgery. Mean baseline mitoPO2 was 60 ± 19 mmHg (mean ± SD) and mean mitoPO2 remained between 40-60 mmHg during surgery, but tended to decrease over time in line with increasing skin temperature. CONCLUSION This study presents the feasibility of mitochondrial oxygenation measurements as measured by the COMET® monitor in the operating theatre and shows the parameter mitoPO2 to behave in a stable and predictable way in the absence of notable hemodynamic alterations. The results provide a solid base for further research into the added value of mitochondrial oxygenation measurements in the perioperative trajectory.
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Luo JC, Zhang JD, Zhao QY, Wang H, Tu GW, Luo MH, Huang DL, Zhang JY, Lu W, Gao F, Luo Z. INFRARED THERMOGRAPHY-BASED BODY-SURFACE THERMAL INHOMOGENEITY MONITORING TO ASSESS THE SEVERITY OF HYPOPERFUSION IN CRITICALLY ILL PATIENTS. Shock 2022; 58:366-373. [PMID: 36155398 DOI: 10.1097/shk.0000000000001998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
ABSTRACT Background: Uneven body-surface thermal distribution is a manifestation of hypoperfusion and can be quantified by infrared thermography. Our aim was to investigate whether body-surface thermal inhomogeneity could accurately evaluate the severity of patients at risk of hypoperfusion. Methods: This was a prospective cohort study in which infrared thermography images were taken from unilateral legs of critically ill patients at high risk of hypoperfusion in a cardiac surgical intensive care unit. For each patient, five body-surface thermal inhomogeneity parameters, including standard deviation (SD), kurtosis, skewness, entropy, and low-temperature area rate (LTAR), were calculated. Demographic, clinical, and thermal characteristics of deceased and living patients were compared. The risk of mortality and capillary refill time (CRT) were chosen as the primary outcome and benchmarking parameter for hypoperfusion, respectively. The area under the receiver operating characteristic curve (AUROC) was used to evaluate predictive accuracy. Results: Three hundred seventy-three patients were included, and 55 (14.7%) died during hospital stay. Of inhomogeneity parameters, SD (0.738) and LTAR (0.768) had similar AUROC to CRT (0.757) for assessing mortality risk. Besides, there was a tendency for LTAR (1%-3%-7%) and SD (0.81°C-0.88°C-0.94°C) to increase in normotensive, hypotensive, and shock patients. These thermal parameters are associated with CRT, lactate, and blood pressure. The AUROC of a combined prediction incorporating three thermal inhomogeneity parameters (SD, kurtosis, and entropy) was considerably higher at 0.866. Conclusions: Body-surface thermal inhomogeneity provided a noninvasive and accurate assessment of the severity of critically ill patients at high risk of hypoperfusion.
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Affiliation(s)
- Jing-Chao Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jia-Dong Zhang
- Hybrid Imaging System Laboratory, Shanghai Engineering Research Center of Intelligent Vision and Imaging, School of Information Science and Technology, ShanghaiTech University, Shanghai, China
| | - Qin-Yu Zhao
- College of Engineering and Computer Science, Australian National University, Canberra, ACT, Australia
| | - Huan Wang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ming-Hao Luo
- Shanghai Medical College, Fudan University, Shanghai, China
| | - Dan-Lei Huang
- Shanghai Medical College, Fudan University, Shanghai, China
| | - Ji-Yang Zhang
- Department of Information and Intelligence Development, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wei Lu
- School of Physical Science and Technology, ShanghaiTech University, Shanghai, China
| | - Fei Gao
- Hybrid Imaging System Laboratory, Shanghai Engineering Research Center of Intelligent Vision and Imaging, School of Information Science and Technology, ShanghaiTech University, Shanghai, China
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Li X, Tan T, Wu H, Zhang C, Luo D, Zhu W, Li B, Zhuang J. Characteristics of sublingual microcirculatory changes during the early postoperative period following cardiopulmonary bypass-assisted cardiac surgery-a prospective cohort study. J Thorac Dis 2022; 14:3992-4002. [PMID: 36389306 PMCID: PMC9641360 DOI: 10.21037/jtd-22-1159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/28/2022] [Indexed: 02/27/2024]
Abstract
BACKGROUND Persistent microcirculatory dysfunction associated with increased morbidity and mortality. Interventions in the early resuscitation can be tailored to the changes of microcirculation and patient's need. However, there is usually an uncoupling of macrocirculatory and microcirculatory hemodynamics during resuscitation. Current research on the patterns of microcirculatory changes and recovery after cardiopulmonary bypass (CPB)-assisted cardiac surgery is limited. This study aimed to analyze changes in the microcirculatory parameters after CPB and their correlation with macrocirculation and to explore the characteristics of microcirculatory changes following CPB-assisted cardiac surgery. METHODS Between December 2018 and January 2019, 24 adult patients with indwelling pulmonary artery catheters after elective cardiac surgery using CPB were enrolled in this study. Both microcirculatory and macrocirculatory parameters were collected at 0, 6, 16, and 24 hours after admission to the intensive care unit (ICU). Video images of sublingual microcirculation were analyzed to obtain the microcirculatory parameters, including total vascular density (TVD), perfused small vessel density (PSVD), the proportion of perfused small vessels (PPV), microvascular flow index (MFI), and flow heterogeneity index (HI). The characteristics of microcirculatory parameter change following cardiac surgery and the correlation between microcirculatory parameters and macroscopic hemodynamic indicators, oxygen metabolic indicators, and carbon dioxide partial pressure difference (PCO2gap) were analyzed. RESULTS There were significant differences in the changes of TVD (P=0.012) and PSVD (P=0.005) during the first 24 hours postoperatively in patients who underwent CPB-assisted cardiac surgery. The microcirculatory density parameters (TVD: r=-0.5059, P=0.0456; PVD: r=-0.5499, P=0.0273) were correlated with oxygen delivery index (DO2I) at 24 hours after surgery. The microcirculatory flow parameters (PPV: r=0.4370, P=0.0327; MFI: r=0.6496, P=0.0006; and HI: r=-0.5350, P=0.0071) had a strong correlation with PCO2gap at 0 hour after surgery. CONCLUSIONS TVD and PSVD might be two most sensitive indicators affected by CPB-assisted cardiac surgery. There was no consistency between microcirculation and macrocirculation until 24 hours following cardiac surgery, meaning the improvement of systemic hemodynamic indicators does not guarantee correspondently improvement in microcirculation. Early controlled oxygen supply after CPB-assisted cardiac surgery may be conducive to the resuscitation of patients to a certain extent.
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Affiliation(s)
- Xiaofeng Li
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Tong Tan
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Hongxiang Wu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Chongjian Zhang
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Dandong Luo
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Weizhong Zhu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Boyu Li
- Department of Center for Private Medical Service & Healthcare, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jian Zhuang
- Department of Cardiovascular Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Laboratory of Artificial Intelligence and 3D Technologies for Cardiovascular Diseases, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
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AÇIKGÖZ E, PİŞKİN Ö, AYDIN BG, OKYAY RD, KÜÇÜKOSMAN G, AYOĞLU H. İnfraklaviküler ve interskalen bloğun önkol oksijenasyonuna etkisi: randomize kontrollü bir çalışma. CUKUROVA MEDICAL JOURNAL 2022. [DOI: 10.17826/cumj.1031005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Amaç: Ultrasonografi görüntüleme (USG) eşliğinde yapılan infraklaviküler blok (İKB) ve interskalen blok (İSB), üst ekstremite ameliyatlarında en sık kullanılan brakiyal pleksus blok teknikleridir. Bu blokların uygulanmasından sonra sempatik blokaj oluştuğu ve blokajın neden olduğu vazodilatasyon ile kan akımının arttığı bilinmektedir. Bu çalışmada USG ile birlikte uygulanan İKB ve İSB'nin önkol doku oksijenasyonuna etkisinin karşılaştırılması amaçlandı.
Gereç ve Yöntem: Bu çalışmaya elektif veya acil kol, dirsek veya önkol cerrahisi planlanan 18-65 yaş arası ASA I-III risk gruplarına ait yüz dört hasta dahil edildi. Hastalar iki gruba ayrıldı: Grup İKB ve Grup İSB. Bazal hemodinamik ölçümlere ek olarak, blok öncesi ve blok tamamlandıktan sonra 10., 20. ve 30. dakikalarda Perfüzyon indeksi(PI), ortalama akım hızı(TAV), brakiyal arter çapı(BAÇ), brakiyal arter alanı(BAA), brakiyal arter atım akımı (BF) ve doku oksijen satürasyonu(rSO2) verileri önceden kaydedildi.
Bulgular: Grup İSB ve Grup İKB'deki hastaların demografik verileri karşılaştırıldı, gruplar arasında anlamlı fark saptanmadı. PI ve rSO2 değerlerindeki artış yüzdelerinin zamana göre dağılımı incelendiğinde, gruplar arasında anlamlı farklılıklar bulundu. 0. dakika ile 10., 20. ve 30. dakikalar arasında BF, TAV, BAA ve BAÇ değerlerindeki yüzde artışlarında anlamlı fark yoktu. Grup İSB'de 8 hastada (%15) Horner sendromu, 3 hastada (%5) ani ses kısıklığı gözlendi. Grup İKB'de komplikasyon gelişmedi.
Sonuç: Bu çalışmada İKB ve İSB'nin önkol doku oksijenasyonu üzerindeki etkilerinin karşılaştırıldığı ve İKB'nin rSO2 ve PI değerlerini arttırdığı tespit edilmiştir.
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Bose R, Singh G, Singh P, Sampath A, Singh R, Patel B, Pakhare AP, Joshi R, Khadanga S. Predictors of Requirement of Inotrope Among Patients With Early Sepsis: Special Reference to Microcirculatory Parameters. Cureus 2022; 14:e24762. [PMID: 35686248 PMCID: PMC9170368 DOI: 10.7759/cureus.24762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction The management of septic shock and refractory septic shock is essential in preventing sepsis-related death. The handheld vital microscope is a new modality of investigation for sepsis for microcirculatory assessment. This study aimed to identify predictors of inotrope requirements among patients with early sepsis and impending septic shock with particular reference to sublingual microcirculation assessment parameters. Methodology We conducted an observational cross-sectional hospital-based study in central India. The formal sample size was calculated to be 52 patients using a convenient sampling technique. The study was initiated with ethics approval (IHEC-LOP/2019/ MD0090) with consent from the patients. We used the MicroScan (MicroVision Medical, Netherlands) Video Microscope System (No.16A00102) to obtain sidestream dark-field imaging along with the AVA 4.3C software (MicroVision Medical). Results Of 51 cases, 60.8% were women, and 39.2% were men, and the study population had a mean age of 41.0 ± 14.9 years. Patients were recruited from medical wards (64.7%) and emergency departments (35.3%). The most common site of infection was gastrointestinal (33.3%), followed by respiratory infections (25.5%) and genitourinary infections (11.8%). The quick sequential organ failure assessment score was 2.0 ± 0.1. Eight patients required inotropes, and six patients died. High respiratory rates and lactate levels were important predictors of inotrope requirements in patients with early sepsis. Sublingual microcirculatory parameters at baseline did not significantly affect the requirement of inotropes consequently. Conclusions Sublingual microscopy is a suggested tool for the management of sepsis. However, without clearly defined cut-off values, handheld vital microscopy could not predict fluid responsiveness among patients with early sepsis. Also, it would be difficult to incorporate this technology into regular practice without equipment upgrades and image acquisition software.
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Chirnoaga D, Coeckelenbergh S, Ickx B, Van Obbergh L, Lucidi V, Desebbe O, Carrier FM, Michard F, Vincent JL, Duranteau J, Van der Linden P, Joosten A. Impact of conventional vs. goal-directed fluid therapy on urethral tissue perfusion in patients undergoing liver surgery: A pilot randomised controlled trial. Eur J Anaesthesiol 2022; 39:324-332. [PMID: 34669645 DOI: 10.1097/eja.0000000000001615] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although fluid administration is a key strategy to optimise haemodynamic status and tissue perfusion, optimal fluid administration during liver surgery remains controversial. OBJECTIVE To test the hypothesis that a goal-directed fluid therapy (GDFT) strategy, when compared with a conventional fluid strategy, would better optimise systemic blood flow and lead to improved urethral tissue perfusion (a new variable to assess peripheral blood flow), without increasing blood loss. DESIGN Single-centre prospective randomised controlled superiority study. SETTING Erasme Hospital. PATIENTS Patients undergoing liver surgery. INTERVENTION Forty patients were randomised into two groups: all received a basal crystalloid infusion (maximum 2 ml kg-1 h-1). In the conventional fluid group, the goal was to maintain central venous pressure (CVP) as low as possible during the dissection phase by giving minimal additional fluid, while in the posttransection phase, anaesthetists were free to compensate for any presumed fluid deficit. In the GDFT group, patients received in addition to the basal infusion, multiple minifluid challenges of crystalloid to maintain stroke volume (SV) variation less than 13%. Noradrenaline infusion was titrated to keep mean arterial pressure more than 65 mmHg in all patients. MAIN OUTCOME MEASURE The mean intra-operative urethral perfusion index. RESULTS The mean urethral perfusion index was significantly higher in the GDFT group than in the conventional fluid group (8.70 [5.72 to 13.10] vs. 6.05 [4.95 to 8.75], P = 0.046). SV index (ml m-2) and cardiac index (l min-1 m-2) were higher in the GDFT group (48 ± 9 vs. 33 ± 7 and 3.5 ± 0.7 vs. 2.4 ± 0.4, respectively; P < 0.001). Although CVP was higher in the GDFT group (9.3 ± 2.5 vs. 6.5 ± 2.9 mmHg; P = 0.003), intra-operative blood loss was not significantly different in the two groups. CONCLUSION In patients undergoing liver surgery, a GDFT strategy resulted in a higher mean urethral perfusion index than did a conventional fluid strategy and did not increase blood loss despite higher CVP. TRIAL REGISTRATION NCT04092608.
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Affiliation(s)
- Dragos Chirnoaga
- From the Department of Anaesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels (DC, SC, BI, LVO, AJ), Unit of Hepatobiliary Surgery and Liver Transplantation, Department of Digestive Surgery, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium (VL), Department of Anesthesiology, Sauvegarde Clinic, Ramsay Santé, Lyon, France (OD), Department of Anesthesiology and Pain Medicine, Université de Montréal, Centre de recherche du CHUM, Montreal, Québec, Canada (F-MC), MiCo, Denens, Switzerland (FM), Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium (J-LV), Department of Anaesthesiology and Intensive Care, Assistance Publique Hôpitaux de Paris, Paris-Saclay University, Bicetre Hospital, Paris, France (JD) and Department of Anaesthesiology, Brugmann Hospital, Université Libre de Bruxelles, Brussels, Belgium (PVdL)
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Current practice and evolving concepts in septic shock resuscitation. Intensive Care Med 2021; 48:148-163. [PMID: 34910228 DOI: 10.1007/s00134-021-06595-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/27/2021] [Indexed: 12/12/2022]
Abstract
Clinical and pathophysiological understanding of septic shock has progressed exponentially in the previous decades, translating into a steady decrease in septic shock-related morbidity and mortality. Even though large randomized, controlled trials have addressed fundamental aspects of septic shock resuscitation, many questions still exist. In this review, we will describe the current standards of septic shock resuscitation, but the emphasis will be placed on evolving concepts in different domains such as clinical resuscitation targets, adequate use of fluids and vasoactive drugs, refractory shock, and the use of extracorporeal therapies. Multiple research opportunities remain open, and collaborative endeavors should be performed to fill in these gaps.
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Mendelson AA, Rajaram A, Bainbridge D, Lawrence KS, Bentall T, Sharpe M, Diop M, Ellis CG. Dynamic tracking of microvascular hemoglobin content for continuous perfusion monitoring in the intensive care unit: pilot feasibility study. J Clin Monit Comput 2021; 35:1453-1465. [PMID: 33104968 PMCID: PMC7586414 DOI: 10.1007/s10877-020-00611-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/20/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE There is a need for bedside methods to monitor oxygen delivery in the microcirculation. Near-infrared spectroscopy commonly measures tissue oxygen saturation, but does not reflect the time-dependent variability of microvascular hemoglobin content (MHC) that attempts to match oxygen supply with demand. The objective of this study is to determine the feasibility of MHC monitoring in critically ill patients using high-resolution near-infrared spectroscopy to assess perfusion in the peripheral microcirculation. METHODS Prospective observational cohort of 36 patients admitted within 48 h at a tertiary intensive care unit. Perfusion was measured on the quadriceps, biceps, and/or deltoid, using the temporal change in optical density at the isosbestic wavelength of hemoglobin (798 nm). Continuous wavelet transform was applied to the hemoglobin signal to delineate frequency ranges corresponding to physiological oscillations in the cardiovascular system. RESULTS 31/36 patients had adequate signal quality for analysis, most commonly affected by motion artifacts. MHC signal demonstrates inter-subject heterogeneity in the cohort, indicated by different patterns of variability and frequency composition. Signal characteristics were concordant between muscle groups in the same patient, and correlated with systemic hemoglobin levels and oxygen saturation. Signal power was lower for patients receiving vasopressors, but not correlated with mean arterial pressure. Mechanical ventilation directly impacts MHC in peripheral tissue. CONCLUSION MHC can be measured continuously in the ICU with high-resolution near-infrared spectroscopy, and reflects the dynamic variability of hemoglobin distribution in the microcirculation. Results suggest this novel hemodynamic metric should be further evaluated for diagnosing microvascular dysfunction and monitoring peripheral perfusion.
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Affiliation(s)
- Asher A Mendelson
- Department of Medical Biophysics, Western University, London, ON, Canada
- Centre for Critical Illness Research, Lawson Health Research Institute, London, ON, Canada
| | - Ajay Rajaram
- Department of Medical Biophysics, Western University, London, ON, Canada
- Imaging Program, Lawson Health Research Institute, London, ON, Canada
| | - Daniel Bainbridge
- Department of Anesthesia and Peri-operative Medicine, Western University, London, ON, Canada
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
| | - Keith St Lawrence
- Department of Medical Biophysics, Western University, London, ON, Canada
- Imaging Program, Lawson Health Research Institute, London, ON, Canada
| | - Tracey Bentall
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
| | - Michael Sharpe
- Department of Anesthesia and Peri-operative Medicine, Western University, London, ON, Canada
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
| | - Mamadou Diop
- Department of Medical Biophysics, Western University, London, ON, Canada
- Imaging Program, Lawson Health Research Institute, London, ON, Canada
| | - Christopher G Ellis
- Department of Medical Biophysics, Western University, London, ON, Canada.
- Centre for Critical Illness Research, Lawson Health Research Institute, London, ON, Canada.
- Robarts Research Institute, Rm 3205, London, ON, N6A 5B7, Canada.
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Podzolkov VI, Dragomiretskaya NA, Beliaev YG, Rusinov IS. Skin microcirculation in patients with heart failure with different left ventricular systolic dysfunction. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2021. [DOI: 10.15829/1728-8800-2021-2989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Aim. To study the relationship of mechanisms of microcirculation regulation and intracardiac hemodynamics in patients with heart failure (HF).Material and methods. In eighty patients with NYHA class II-IV HF, microcirculation was assessed by laser Doppler flowmetry and intracardiac hemodynamics — by echocardiography.Results. The patients were divided into 3 groups depending on HF type: with preserved ejection fraction (CHpEF) (>50%) — 27 patients, mid-range EF (CHmrEF) (40-50%) — 25 patients, reduced EF (CHrEF) (<40%) — 28 patients. Comparative analysis revealed a significant decrease in the coefficient of variation (CV) in all groups without microcirculation differences. The greatest number of significant correlations was found between the myogenic component of microcirculation frequency range and the following echocardiographic parameters: left ventricular EF (r=0,351, p<0,05); end-diastolic dimension (r=-0,492, p<0,05), end-systolic dimension (r=-0,474, p<0,05), end-diastolic volume (r=-0,544, p<0,05), end-systolic volume (r=-0,449, p<0,05), etc.Conclusion. In patients, regardless of left ventricular EF, satisfactory perfusion was obtained, which is achieved due to inhibition of active mechanisms and compensatory activation of passive mechanisms of microcirculation regulation. The relationship between the development of myocardial remodeling and microcirculatory dysfunction is noted.
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Measurement of capillary refill time with a handheld prototype device: a comparative validation study in healthy volunteers. J Clin Monit Comput 2021; 36:1271-1278. [PMID: 34550528 DOI: 10.1007/s10877-021-00757-2] [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: 05/26/2021] [Accepted: 09/08/2021] [Indexed: 10/20/2022]
Abstract
Validity and reproducibility of clinical capillary refill time (CRT) measurement depend on many factors in daily routine practice. We conducted a prospective validation study of an automatized handheld prototype device providing standardized CRT assessment (DiCART™) in 20 healthy volunteers. Three different methods of CRT measurement were compared before and during dynamic circulatory changes induced by venous and arterial occlusion tests at both upper and lower limb levels: CRTCLIN corresponding to basic clinical assessment and considered as the reference method; CRTVIDEO corresponding to off-line videos reviewed by investigators recorded by DiCART™; and CRTDiCART corresponding to on-line videos analysed by a built-in proprietary mathematical algorithm included in DiCART™. Five subjects were excluded because of a DiCART™ dysfunction. ROCAUC to detect arterial occlusion test changes at the upper limb level were 1.00 (95%CI 1.00; 1.00), 0.96 (95%CI 0.88; 1.00), and 0.92 (95%CI 0.79; 1.00) for CRTCLIN, CRTVIDEO, and CRTDiCART, respectively. Precision of CRTCLIN and CRTVIDEO were significantly better than CRTDiCART (0.18 and 0.20 vs. 0.28; P < 0.05). Percentages of error were 76% and 87% for CRTVIDEO and CRTDiCART, respectively. DiCART™ had an excellent discrimination to detect major changes in CRT induced by arterial ischemia. However, the perfectible precision, the poor agreement with clinical assessment and numerous device dysfunctions give leads to the development of a further version of the prototype before promoting its use in clinical practice.Trial registration clinicaltrial.gov. Identifier: NCT04538612.
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21
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Li P, Pan Q, Jiang S, Yan M, Yan J, Ning G. Development of Novel Fractal Method for Characterizing the Distribution of Blood Flow in Multi-Scale Vascular Tree. Front Physiol 2021; 12:711247. [PMID: 34393827 PMCID: PMC8358817 DOI: 10.3389/fphys.2021.711247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/09/2021] [Indexed: 11/13/2022] Open
Abstract
Blood perfusion is an important index for the function of the cardiovascular system and it can be indicated by the blood flow distribution in the vascular tree. As the blood flow in a vascular tree varies in a large range of scales and fractal analysis owns the ability to describe multi-scale properties, it is reasonable to apply fractal analysis to depict the blood flow distribution. The objective of this study is to establish fractal methods for analyzing the blood flow distribution which can be applied to real vascular trees. For this purpose, the modified methods in fractal geometry were applied and a special strategy was raised to make sure that these methods are applicable to an arbitrary vascular tree. The validation of the proposed methods on real arterial trees verified the ability of the produced parameters (fractal dimension and multifractal spectrum) in distinguishing the blood flow distribution under different physiological states. Furthermore, the physiological significance of the fractal parameters was investigated in two situations. For the first situation, the vascular tree was set as a perfect binary tree and the blood flow distribution was adjusted by the split ratio. As the split ratio of the vascular tree decreases, the fractal dimension decreases and the multifractal spectrum expands. The results indicate that both fractal parameters can quantify the degree of blood flow heterogeneity. While for the second situation, artificial vascular trees with different structures were constructed and the hemodynamics in these vascular trees was simulated. The results suggest that both the vascular structure and the blood flow distribution affect the fractal parameters for blood flow. The fractal dimension declares the integrated information about the heterogeneity of vascular structure and blood flow distribution. In contrast, the multifractal spectrum identifies the heterogeneity features in blood flow distribution or vascular structure by its width and height. The results verified that the proposed methods are capable of depicting the multi-scale features of the blood flow distribution in the vascular tree and further are potential for investigating vascular physiology.
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Affiliation(s)
- Peilun Li
- Department of Biomedical Engineering, Zhejiang University, Hangzhou, China
| | - Qing Pan
- College of Information Engineering, Zhejiang University of Technology, Hangzhou, China
| | - Sheng Jiang
- Department of Biomedical Engineering, Zhejiang University, Hangzhou, China
| | - Molei Yan
- Department of Intensive Care Medicine, Zhejiang Hospital, Hangzhou, China
| | - Jing Yan
- Department of Intensive Care Medicine, Zhejiang Hospital, Hangzhou, China
| | - Gangmin Ning
- Department of Biomedical Engineering, Zhejiang University, Hangzhou, China
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22
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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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23
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Er MC, Kaya C, Ustun YB, Sahinoglu AH. Predictive value of perfusion index for mortality in mechanically ventilated patients. Aging Male 2020; 23:1251-1258. [PMID: 32372675 DOI: 10.1080/13685538.2020.1760816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
AIM This study aimed to examine the prognostic significance of the perfusion index (PI) in mechanically ventilated patients. METHODS Study included sixty patients who had the risk factors for the development of acute respiratory distress syndrome and received mechanical ventilator (MV) support in intensive care unit (ICU) unit between January 2017/January 2018. The demographic characteristics, vital signs, blood gas parameters, lactate levels, prognostic scores, and use of inotropic drugs were recorded. Arterial blood gas and PI measurements at the frontal region were performed at the time of and 12th and 24th hours of admission to the ICU. The patients were followed up for 60 days, and the outcome was recorded. RESULTS Twelve patients (20%) died during the first 7 days, and 27 patients (45%) died within 60 days of the admission. Multivariate analyses to determine potential predictors of 7 and 30-day mortality showed that only 24th-hour lactate level was independent predictor of 60-day mortality, and the PI at 24th was the sole independent predictor of 7-day mortality. CONCLUSION The PI did not predict 60-day mortality in MV patients who had risk factors for the development of Acute Respiratory Distress Syndrome (ARDS). However, the PI at 24th may be a significant predictor of 7-day mortality.
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Affiliation(s)
- Mehmet Can Er
- Department of Anesthesiology and Reanimation, School of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Cengiz Kaya
- Department of Anesthesiology and Reanimation, School of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Yasemin Burcu Ustun
- Department of Anesthesiology and Reanimation, School of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Ali Haydar Sahinoglu
- Department of Anesthesiology and Reanimation, School of Medicine, Ondokuz Mayıs University, Samsun, Turkey
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24
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Pan P, Su L, Liu D, Wang X. Microcirculation-guided protection strategy in hemodynamic therapy. Clin Hemorheol Microcirc 2020; 75:243-253. [PMID: 31903987 DOI: 10.3233/ch-190784] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Microcirculatory shock is a condition defined by the presence of tissue hypoperfusion despite the normalization of systemic and regional blood flow. Currently, more evidence shows that intrinsic septic shock is microcirculatory shock, which results in septic shock that is difficult to resuscitate. At present, treatments are aimed at recovering macro-circulation functions and include fluid resuscitation, vasoactive drugs, positive inotropic drugs, de-obstruction, and even mechanical assistance to improve oxygen delivery. However, the application of these treatments to more accurately improve microcirculation or avoid further microcirculatory damage is more important in clinics. In this article, we discuss the need for microcirculation protection and microcirculation-guided protection strategies in hemodynamic therapies.
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Affiliation(s)
- Pan Pan
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China.,Center of Respiratory and Critical Care Medicine, Chinese PLA General Hospital, Beijing, China
| | - Longxiang Su
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
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25
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Dilken O, Ergin B, Ince C. Assessment of sublingual microcirculation in critically ill patients: consensus and debate. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:793. [PMID: 32647718 PMCID: PMC7333125 DOI: 10.21037/atm.2020.03.222] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The main concern in shock and resuscitation is whether the microcirculation can carry adequate oxygen to the tissues and remove waste. Identification of an intact coherence between macro- and microcirculation during states of shock and resuscitation shows a functioning regulatory mechanism. However, loss of hemodynamic coherence between the macro and microcirculation can be encountered frequently in sepsis, cardiogenic shock, or any hemodynamically compromised patient. This loss of hemodynamic coherence results in an improvement in macrohemodynamic parameters following resuscitation without a parallel improvement in microcirculation resulting in tissue hypoxia and tissue compromise. Hand-held vital microscopes (HVMs) can visualize the microcirculation and help to diagnose the nature of microcirculatory shock. Although treatment with the sole aim of recruiting the microcirculation is as yet not realized, interventions can be tailored to the needs of the patient while monitoring sublingual microcirculation. With the help of the newly introduced software, called MicroTools, we believe sublingual microcirculation monitoring and diagnosis will be an essential point-of-care tool in managing shock patients.
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Affiliation(s)
- Olcay Dilken
- Department of Intensive Care Med, Laboratory of Translational Intensive Care Med, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Intensive Care, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Bulent Ergin
- Department of Intensive Care Med, Laboratory of Translational Intensive Care Med, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care Med, Laboratory of Translational Intensive Care Med, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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26
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Kattan E, Castro R, Vera M, Hernández G. Optimal target in septic shock resuscitation. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:789. [PMID: 32647714 PMCID: PMC7333135 DOI: 10.21037/atm-20-1120] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Septic shock presents a high risk of morbidity and mortality. Through therapeutic strategies, such as fluid administration and vasoactive agents, clinicians intend to rapidly restore tissue perfusion. Nonetheless, these interventions have narrow therapeutic margins. Adequate perfusion monitoring is paramount to avoid progressive hypoperfusion or detrimental over-resuscitation. During early stages of septic shock, macrohemodynamic derangements, such as hypovolemia and decreased cardiac output (CO) tend to predominate. However, during late septic shock, endothelial and coagulation dysfunction induce severe alterations of the microcirculation, making it more difficult to achieve tissue reperfusion. Multiple perfusion variables have been described in the literature, from bedside clinical examination to complex laboratory tests. Moreover, all of them present inherent flaws and limitations. After the ANDROMEDA-SHOCK trial, there is evidence that capillary refill time (CRT) is an interesting resuscitation target, due to its rapid kinetics and correlation with deep hypoperfusion markers. New concepts such as hemodynamic coherence and flow responsiveness may be used at the bedside to select the best treatment strategies at any time-point. A multimodal perfusion monitoring and an integrated analysis with macrohemodynamic parameters is mandatory to optimize the resuscitation of septic shock patients.
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Affiliation(s)
- Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Magdalena Vera
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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27
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Dubin A, Pozo MO, Hurtado J. Central venous minus arterial carbon dioxide pressure to arterial minus central venous oxygen content ratio as an indicator of tissue oxygenation: a narrative review. Rev Bras Ter Intensiva 2020; 32:115-122. [PMID: 32401981 PMCID: PMC7206946 DOI: 10.5935/0103-507x.20200017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 06/09/2019] [Indexed: 12/18/2022] Open
Abstract
The central venous minus arterial carbon dioxide pressure to arterial minus central venous oxygen content ratio (Pcv-aCO2/Ca-cvO2) has been proposed as a surrogate for respiratory quotient and an indicator of tissue oxygenation. Some small observational studies have found that a Pcv-aCO2/Ca-cvO2 > 1.4 was associated with hyperlactatemia, oxygen supply dependency, and increased mortality. Moreover, Pcv-aCO2/Ca-cvO2 has been incorporated into algorithms for tissue oxygenation evaluation and resuscitation. However, the evidence for these recommendations is quite limited and of low quality. The goal of this narrative review was to analyze the methodological bases, the pathophysiologic foundations, and the experimental and clinical evidence supporting the use of Pcv-aCO2/Ca-cvO2 as a surrogate for respiratory quotient. Physiologically, the increase in respiratory quotient secondary to critical reductions in oxygen transport is a life-threatening and dramatic event. Nevertheless, this event is easily noticeable and probably does not require further monitoring. Since the beginning of anaerobic metabolism is indicated by the sudden increase in respiratory quotient and the normal range of respiratory quotient is wide, the use of a defined cutoff of 1.4 for Pcv-aCO2/Ca-cvO2 is meaningless. Experimental studies have shown that Pcv-aCO2/Ca-cvO2 is more dependent on factors that modify the dissociation of carbon dioxide from hemoglobin than on respiratory quotient and that respiratory quotient and Pcv-aCO2/Ca-cvO2 may have distinct behaviors. Studies performed in critically ill patients have shown controversial results regarding the ability of Pcv-aCO2/Ca-cvO2 to predict outcome, hyperlactatemia, microvascular abnormalities, and oxygen supply dependency. A randomized controlled trial also showed that Pcv-aCO2/Ca-cvO2 is useless as a goal of resuscitation. Pcv-aCO2/Ca-cvO2 should be carefully interpreted in critically ill patients.
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Affiliation(s)
- Arnaldo Dubin
- Cátedra de Farmacología Aplicada, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, La Plata, Argentina
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28
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Hessler M, Nelis P, Ertmer C, Alnawaiseh M, Lehmann F, Schmidt C, Kampmeier TG, Rehberg SW, Arnemann PH, Rovas A. Optical coherence tomography angiography as a novel approach to contactless evaluation of sublingual microcirculation: A proof of principle study. Sci Rep 2020; 10:5408. [PMID: 32214141 PMCID: PMC7096522 DOI: 10.1038/s41598-020-62128-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 03/03/2020] [Indexed: 01/06/2023] Open
Abstract
Microcirculatory disorders are crucial in pathophysiology of organ dysfunction in critical illness. Evaluation of sublingual microcirculation is not routinely conducted in daily practice due to time-consuming analysis and susceptibility to artifacts. We investigated the suitability of optical coherence tomography angiography (OCTA) for contactless evaluation of sublingual microcirculation. Sublingual microcirculation was imaged in 10 healthy volunteers, using an OCTA device and an incident dark field (IDF) illumination microscopy (current gold standard). OCTA images were analyzed with regard to flow density and perfused vessel density (PVDbyOCTA). IDF videos were analyzed following current recommendations. Flow density was automatically extracted from OCTA images (whole en face 48.9% [43.2; 54.5]; central ring 52.6% [43.6; 60.6]). PVDbyOCTA did not differ from the PVD calculated from IDF videos (PVDbyOCTA 18.6 mm/mm² [18.0; 21.7]) vs. PVDbyIDF 21.0 mm/mm² [17.5; 22.9]; p = 0.430). Analysis according to Bland-Altman revealed a mean bias of 0.95 mm/mm² (95% Confidence interval −1.34 to 3.25) between PVDbyOCTA and PVDbyIDF with limits of agreement of −5.34 to 7.24 mm/mm². This study is the first to demonstrate the suitability of OCTA for evaluating sublingual microcirculation. Comparison of the perfused vessel density between methods showed a plausible level of agreement.
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Affiliation(s)
- Michael Hessler
- Department of Anesthesiology, Intensive Care, and Pain Therapy, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building A1, Muenster, Germany
| | - Pieter Nelis
- Department of Ophthalmology, University Hospital Muenster, Domagkstraße 15, Muenster, Germany.,Department of Ophthalmology, University of Brussels (VUB), Laarbeeklaan 101, Jette, Belgium
| | - Christian Ertmer
- Department of Anesthesiology, Intensive Care, and Pain Therapy, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building A1, Muenster, Germany.
| | - Maged Alnawaiseh
- Department of Ophthalmology, University Hospital Muenster, Domagkstraße 15, Muenster, Germany
| | - Florian Lehmann
- Department of Anesthesiology, Intensive Care, and Pain Therapy, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building A1, Muenster, Germany
| | - Christina Schmidt
- Department of Anesthesiology, Intensive Care, and Pain Therapy, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building A1, Muenster, Germany
| | - Tim-Gerald Kampmeier
- Department of Anesthesiology, Intensive Care, and Pain Therapy, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building A1, Muenster, Germany
| | - Sebastian Willy Rehberg
- Department of Anesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine and Pain Therapy, Protestant Hospital of the Bethel Foundation, Burgsteig, Bielefeld, Germany
| | - Philip-Helge Arnemann
- Department of Anesthesiology, Intensive Care, and Pain Therapy, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building A1, Muenster, Germany
| | - Alexandros Rovas
- Department of Medicine D, Division of General Internal Medicine, Nephrology, and Rheumatology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
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29
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Filho RR, de Freitas Chaves RC, Assunção MSC, Neto AS, De Freitas FM, Romagnoli ML, Silva E, Lattanzio B, Dubin A, Corrêa TD. Assessment of the peripheral microcirculation in patients with and without shock: a pilot study on different methods. J Clin Monit Comput 2019; 34:1167-1176. [PMID: 31754965 PMCID: PMC7548274 DOI: 10.1007/s10877-019-00423-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 11/13/2019] [Indexed: 01/10/2023]
Abstract
Microvascular dysfunction has been associated with adverse outcomes in critically ill patients, and the current concept of hemodynamic incoherence has gained attention. Our objective was to perform a comprehensive analysis of microcirculatory perfusion parameters and to investigate the best variables that could discriminate patients with and without circulatory shock during early intensive care unit (ICU) admission. This prospective observational study comprised a sample of 40 adult patients with and without circulatory shock (n = 20, each) admitted to the ICU within 24 h. Peripheral clinical [capillary refill time (CRT), peripheral perfusion index (PPI), skin-temperature gradient (Tskin-diff)] and laboratory [arterial lactate and base excess (BE)] perfusion parameters, in addition to near-infrared spectroscopy (NIRS)-derived variables were simultaneously assessed. While lactate, BE, CRT, PPI and Tskin-diff did not differ significantly between the groups, shock patients had lower baseline tissue oxygen saturation (StO2) [81 (76–83) % vs. 86 (76–90) %, p = 0.044], lower StO2min [50 (47–57) % vs. 55 (53–65) %, p = 0.038] and lower StO2max [87 (80–92) % vs. 93 (90–95) %, p = 0.017] than patients without shock. Additionally, dynamic NIRS variables [recovery time (r = 0.56, p = 0.010), descending slope (r = − 0.44, p = 0.05) and ascending slope (r = − 0.54, p = 0.014)] and not static variable [baseline StO2 (r = − 0.24, p = 0.28)] exhibited a significant correlation with the administered dose of norepinephrine. In our study with critically ill patients assessed within the first twenty-four hours of ICU admission, among the perfusion parameters, only NIRS-derived parameters could discriminate patients with and without shock.
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Affiliation(s)
- Roberto Rabello Filho
- Departamento de Terapia Intensiva, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, 5th Floor, São Paulo, 05651-901, Brazil.
| | - Renato Carneiro de Freitas Chaves
- Departamento de Terapia Intensiva, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, 5th Floor, São Paulo, 05651-901, Brazil.,Departamento de Anestesiologia, Irmandade da Santa Casa de Misericórdia de Santos, Santos, Brazil
| | - Murillo Santucci Cesar Assunção
- Departamento de Terapia Intensiva, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, 5th Floor, São Paulo, 05651-901, Brazil
| | - Ary Serpa Neto
- Departamento de Terapia Intensiva, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, 5th Floor, São Paulo, 05651-901, Brazil.,Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Flavia Manfredi De Freitas
- Departamento de Terapia Intensiva, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, 5th Floor, São Paulo, 05651-901, Brazil
| | - Maria Laura Romagnoli
- Departamento de Terapia Intensiva, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, 5th Floor, São Paulo, 05651-901, Brazil
| | - Eliézer Silva
- Departamento de Terapia Intensiva, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, 5th Floor, São Paulo, 05651-901, Brazil
| | - Bernardo Lattanzio
- Cátedra de Farmacología Aplicada, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, La Plata, Argentina
| | - Arnaldo Dubin
- Cátedra de Farmacología Aplicada, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, La Plata, Argentina.,Servicio de Terapia Intensiva, Sanatorio Otamendi, Buenos Aires, Argentina
| | - Thiago Domingos Corrêa
- Departamento de Terapia Intensiva, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, 5th Floor, São Paulo, 05651-901, Brazil
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30
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Monitoring tissue perfusion: a pilot clinical feasibility and safety study of a urethral photoplethysmography-derived perfusion device in high-risk patients. J Clin Monit Comput 2019; 34:961-969. [DOI: 10.1007/s10877-019-00414-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/25/2019] [Indexed: 10/25/2022]
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31
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Horak J, Martinkova V, Radej J, Matejovič M. Back to Basics: Recognition of Sepsis with New Definition. J Clin Med 2019; 8:jcm8111838. [PMID: 31683991 PMCID: PMC6912498 DOI: 10.3390/jcm8111838] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/23/2019] [Accepted: 10/24/2019] [Indexed: 12/12/2022] Open
Abstract
Patients with serious infections at risk of deterioration represent highly challenging clinical situations, and in particular for junior doctors. A comprehensive clinical examination that integrates the assessment of vital signs, hemodynamics, and peripheral perfusion into clinical decision making is key to responding promptly and effectively to evolving acute medical illnesses, such as sepsis or septic shock. Against this background, the new concept of sepsis definition may provide a useful link between junior doctors and consultant decision making. The purpose of this article is to introduce the updated definition of sepsis and suggest its practical implications, with particular emphasis on integrative clinical assessment, allowing for the rapid identification of patients who are at risk of further deterioration.
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Affiliation(s)
- Jan Horak
- Department of Internal Medicine, Faculty of Medicine in Pilsen, Pilsen University Hospital, Charles University Prague, Alej Svobody 80, 323 00 Pilsen, Czech Republic.
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University Prague, Alej Svobody 80, 323 00 Pilsen, Czech Republic.
| | - Vendula Martinkova
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University Prague, Alej Svobody 80, 323 00 Pilsen, Czech Republic.
- Third Department of Surgery, University Hospital Motol and First Medical School, Charles University, V Uvalu 84, 150 06 Prague, Czech Republic.
| | - Jaroslav Radej
- Department of Internal Medicine, Faculty of Medicine in Pilsen, Pilsen University Hospital, Charles University Prague, Alej Svobody 80, 323 00 Pilsen, Czech Republic.
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University Prague, Alej Svobody 80, 323 00 Pilsen, Czech Republic.
| | - Martin Matejovič
- Department of Internal Medicine, Faculty of Medicine in Pilsen, Pilsen University Hospital, Charles University Prague, Alej Svobody 80, 323 00 Pilsen, Czech Republic.
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University Prague, Alej Svobody 80, 323 00 Pilsen, Czech Republic.
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32
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Hessler M, Lehmann F, Arnemann PH, Eter N, Ertmer C, Alnawaiseh M. [Optical coherence tomography angiography in intensive care medicine : A new field of application?]. Ophthalmologe 2019; 116:728-734. [PMID: 31139886 DOI: 10.1007/s00347-019-0893-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Many critically ill patients show a disturbance of the microcirculation, which is not yet regularly examined in the clinical routine; however, for treatment decisions and estimation of the prognosis it would be important to obtain detailed information about the microcirculation in critically ill patients. Optical coherence tomography angiography (OCTA) is a non-invasive, contact-free technique, which enables visualization of the blood flow in the retinal microcirculation within a few seconds. Therefore, it may have the potential to diagnose microcirculation disorders in critically ill patients. OBJECTIVE The aims of the study were to assess the importance of the microcirculation in intensive care medicine, a comparison of the methods of video microscopy and OCTA and analysis of preclinical and clinical data on the use of OCTA in intensive care medicine. MATERIAL AND METHODS A selective literature review and data analysis were carried out. RESULTS A direct visualization of the microcirculation has been possible for many years with the technique of video microscopy but this has not become established in the clinical routine due to the susceptibility to interferences and a time-consuming manual analysis. The OCTA is a non-invasive and contact-free method for the visualization of retinal blood flow. First preclinical data in septic and hemorrhagic shock show good results of OCTA for analysis of the microcirculation. CONCLUSION The non-invasive technique of OCTA is a promising measurement method to enable bedside analysis of the microcirculation in critically ill paients in the future; however, some technical limitations must still be overcome.
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Affiliation(s)
- Michael Hessler
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland.
| | - Florian Lehmann
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| | - Philip-Helge Arnemann
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| | - Nicole Eter
- Klinik für Augenheilkunde, Universitätsklinikum Münster, 48149, Münster, Deutschland
| | - Christian Ertmer
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| | - Maged Alnawaiseh
- Klinik für Augenheilkunde, Universitätsklinikum Münster, 48149, Münster, Deutschland
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Flynn Makic MB. Sepsis: Noninvasive Assessment. J Perianesth Nurs 2019; 34:861-863. [PMID: 31204268 DOI: 10.1016/j.jopan.2019.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 05/12/2019] [Indexed: 10/26/2022]
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Huber W, Zanner R, Schneider G, Schmid R, Lahmer T. Assessment of Regional Perfusion and Organ Function: Less and Non-invasive Techniques. Front Med (Lausanne) 2019; 6:50. [PMID: 30968023 PMCID: PMC6438879 DOI: 10.3389/fmed.2019.00050] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 02/25/2019] [Indexed: 12/13/2022] Open
Abstract
Sufficient organ perfusion essentially depends on preserved macro- and micro-circulation. The last two decades brought substantial progress in the development of less and non-invasive monitoring of macro-hemodynamics. However, several recent studies suggest a frequent incoherence of macro- and micro-circulation. Therefore, this review reports on interactions of macro- and micro-circulation as well as on specific regional and micro-circulation. Regarding global micro-circulation the last two decades brought advances in a more systematic approach of clinical examination including capillary refill time, a graded assessment of mottling of the skin and accurate measurement of body surface temperatures. As a kind of link between macro- and microcirculation, a number of biochemical markers can easily be obtained. Among those are central-venous oxygen saturation (ScvO2), plasma lactate and the difference between central-venous and arterial CO2 (cv-a-pCO2-gap). These inexpensive markers have become part of clinical routine and guideline recommendations. While their potential to replace parameters of macro-circulation such as cardiac output (CO) is limited, they facilitate the interpretation of the adequacy of CO and other macro-circulatory markers. Furthermore, they give additional hints on micro-circulatory impairment. In addition, a number of more sophisticated technical approaches to quantify and visualize micro-circulation including video-microscopy, laser flowmetry, near-infrared spectroscopy (NIRS), and partial oxygen pressure measurement have been introduced within the last 20 years. These technologies have been extensively used for scientific purposes. Moreover, they have been successfully used for educational purposes and to visualize micro-circulatory disturbances during sepsis and other causes of shock. Despite several studies demonstrating the association of these techniques and parameters with outcome, their practical application still is limited. However, future improvements in automated and “online” diagnosis will help to make these technologies more applicable in clinical routine. This approach is promising with regard to several studies which demonstrated the potential to guide therapy in different types of shock. Finally several organs have specific patterns of circulation related to their special anatomy (liver) or their auto-regulatory capacities (brain, kidney). Therefore, this review also discusses specific issues of monitoring liver, brain, and kidney circulation and function.
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Affiliation(s)
- Wolfgang Huber
- Medizinische Klinik und Poliklinik II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Robert Zanner
- Klinik für Anästhesiologie, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Gerhard Schneider
- Klinik für Anästhesiologie, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Roland Schmid
- Medizinische Klinik und Poliklinik II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Tobias Lahmer
- Medizinische Klinik und Poliklinik II, Klinikum rechts der Isar, Technische Universität München, München, Germany
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