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Skaf-Gonçalves L, Peçanha D, Kasal D, Tibirica E. Acute effects of energy drink consumption on microvascular reactivity in young male volunteers at rest: a randomized trial. Braz J Med Biol Res 2024; 57:e13624. [PMID: 39194032 PMCID: PMC11349151 DOI: 10.1590/1414-431x2024e13624] [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: 12/07/2023] [Accepted: 06/14/2024] [Indexed: 08/29/2024] Open
Abstract
Energy drinks are nonalcoholic beverages whose main ingredients are sugar, taurine, and caffeine. The consumption of energy drinks is increasing worldwide, but only a few conflicting studies have investigated the vascular effects of energy drinks in young adults. The aim of this study was to evaluate microvascular reactivity before and after energy drinks consumption in young healthy male volunteers. This was a cross-sectional prospective study. Microvascular reactivity signals were evaluated in the skin of the forearm using laser speckle contrast imaging with acetylcholine (ACh) iontophoresis before and 90 and 180 min after the randomized consumption of one ED or the same volume of water (control), followed by a postocclusive reactive hyperemia (PORH) test. Thirty-two volunteers were evaluated (age: 25.4±4.3 years). Energy drink consumption prevented the rest-induced reduction in cutaneous vascular conductance over time that was observed in the control group. In the control group, there were significant reductions in microvascular vasodilation at 90 and 180 min compared to baseline (P=0.004), but this was not the case in the energy drink group (P=0.76). Our results demonstrated that the reduction in microvascular conductance associated with prolonged immobility can be prevented by the consumption of one energy drink, highlighting the vasodilator effects of this beverage in young individuals at rest. The between-study variability in terms of the brand of energy drinks and the ingested volume, as well as the method of vascular evaluation and the inclusion criteria, may explain the discrepancies among previous studies on the vascular effects of energy drinks.
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Affiliation(s)
| | - D Peçanha
- Instituto National de Cardiologia, Rio de Janeiro, RJ, Brasil
| | - D Kasal
- Instituto National de Cardiologia, Rio de Janeiro, RJ, Brasil
- Departamento de Clínica Médica, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - E Tibirica
- Instituto National de Cardiologia, Rio de Janeiro, RJ, Brasil
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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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Dewachter P, Mouton-Faivre C, Dimby SF, Vicaut E, Beloucif S. Association Between Early Patient Characteristics and IgE-Mediated Allergy in the Perioperative Setting. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1202-1214.e3. [PMID: 38378094 DOI: 10.1016/j.jaip.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 01/24/2024] [Accepted: 02/08/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Early recognition of perioperative anaphylaxis, a life-threatening, usually IgE-mediated, immediate hypersensitivity, is essential, but bedside diagnosis is not always straightforward because clinical presentation may vary. OBJECTIVES To describe early characteristics of perioperative immediate hypersensitivity, with special attention to cutaneous phenotypes, and identify risk factors for IgE-mediated allergy. METHODS We retrospectively analyzed data from adults with suspected perioperative immediate hypersensitivity who were investigated in two academic medical centers. Multivariable logistic regression was conducted to evaluate associations among patient, clinical, and paraclinical characteristics and IgE-mediated allergy. RESULTS Of 145 enrolled patients, 99 (68.3%) and 46 (31.7%) were respectively categorized in the IgE-mediated allergy and non-allergy groups. Cutaneous vasoconstriction phenotype (pallor, piloerection, thelerethism, and sweating with or without cyanosis) occurring within minutes (or even 1 minute) of drug exposure was strongly associated with IgE-mediated allergy (adjusted odds ratio [aOR] = 28.02; 95% CI, 4.41-305.18). IgE-mediated allergy was always life-threatening in this setting. Other early factors associated with allergy were low end-tidal carbon dioxide 25 mm Hg or less (aOR = 5.45; 95% CI, 2.39-26.45), low mean arterial pressure 60 mm Hg or less (aOR = 3.82; 95% CI, 1.28-17.31), and early cutaneous vasodilation (erythema, urticaria, and/or angioedema) (aOR = 2.78; 95% CI, 0.73-20.54). Late cutaneous vasodilation after restoration of hemodynamics corroborated the diagnosis of allergy (aOR = 23.67; 95% CI, 4.94-205.09). The best-fit model including three readily available variables (cutaneous phenotype involving the three modalities [reference lack of cutaneous signs], low mean arterial pressure, and low end-tidal carbon dioxide) had an area under the curve of 0.91. CONCLUSIONS Cutaneous vasoconstriction phenotype is associated with the strongest risk of life-threatening allergy and thus may be regarded as pathognomonic of perioperative IgE-mediated anaphylaxis.
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Affiliation(s)
- Pascale Dewachter
- Department of Anesthesiology and Intensive Care, Assistance Publique-Hôpitaux de Paris, University Hospitals Paris Seine-Saint-Denis and Sorbonne Paris Nord University, Bobigny, France.
| | | | - Solohaja Faniaha Dimby
- Clinical Research Unit, Assistance Publique-Hôpitaux de Paris, University Hospitals Saint-Louis, Lariboisière and Fernand-Widal and Paris-Cité University, Paris, France
| | - Eric Vicaut
- Clinical Research Unit, Assistance Publique-Hôpitaux de Paris, University Hospitals Saint-Louis, Lariboisière and Fernand-Widal and Paris-Cité University, Paris, France
| | - Sadek Beloucif
- Department of Anesthesiology and Intensive Care, Assistance Publique-Hôpitaux de Paris, University Hospitals Paris Seine-Saint-Denis and Sorbonne Paris Nord University, Bobigny, France
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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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Taccone FS, Sterchele ED, Piagnerelli M. Multimodal neuromonitoring in traumatic brain injury patients: the search for the Holy Graal. Crit Care 2023; 27:396. [PMID: 37845770 PMCID: PMC10577936 DOI: 10.1186/s13054-023-04679-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 10/07/2023] [Indexed: 10/18/2023] Open
Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Elda Diletta Sterchele
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Michael Piagnerelli
- Department of Intensive Care, Centre Hospitalier Universitaire (CHU)- Charleroi, Marie Curie, Université Libre de Bruxelles (ULB), Charleroi, Belgium
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Cai X, Zhuang W. Application value of Doppler ultrasound in renal hemodynamic monitoring in patients with septic shock. Panminerva Med 2023; 65:108-110. [PMID: 34142791 DOI: 10.23736/s0031-0808.21.04423-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Xue Cai
- Emergency Intensive Care Unit, Huizhou Municipal Central Hospital, Huizhou, China -
| | - Wenwen Zhuang
- Department of General Practice, Huizhou Municipal Central Hospital, Huizhou, 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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Wang S, Liu G, Chen L, Xu X, Jia T, Zhu C, Xiong J. EFFECTS OF SHENFU INJECTION ON SUBLINGUAL MICROCIRCULATION IN SEPTIC SHOCK PATIENTS: A RANDOMIZED CONTROLLED TRIAL. Shock 2022; 58:196-203. [PMID: 35959775 DOI: 10.1097/shk.0000000000001975] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Background and Objective: The optimization of macrocirculatory hemodynamics is recommended by current sepsis guidelines. However, microcirculatory dysfunction is considered the cause of severe sepsis. In the present study, we designed to verify whether the application of Shenfu injection (SFI) restores microcirculation, thereby improving tissue perfusion and inhibiting organ dysfunction, resulting in improved outcomes. Design: We conducted a prospective, single-center, randomized, double-blind, placebo-controlled clinical trial. Intervention: Patients were randomly assigned to group receiving SFI (n = 20) or placebo (n = 20) for 5 days. We administered SFI or glucose injection for 5 days and blinded the investigators and clinical staff by applying light-proof infusion equipment that concealed therapy allocation. Measurements and Results: We measured the systemic dynamics and lactate levels, biomarkers of endothelial dysfunction, and inflammatory cytokines in the plasma. The parameters of sublingual microcirculation were assessed using side-stream dark-field imaging. Sequential Organ Failure Assessment (SOFA) score, Acute Physiology and Chronic Health Evaluation (APACHE) score, total dose, and duration of vasopressor use, emergency intensive care unit (EICU) stay, and 28-day mortality were evaluated. After treatment with SFI, the disturbance of the sublingual microcirculation was considerably alleviated, as indicated by the significant increase in total vessel density, perfused vessel density, and microvascular flow index. Moreover, the plasma biomarker levels of endothelial dysfunction, including Ang-2, Syn-1, and ET-1, were reversed after SFI treatment. Importantly, the SFI group had a more favorable prognosis than the control group in terms of the APACHE-II score, SOFA score, duration of vasopressor administration, and length of EICU stay. However, the difference in mortality at day 28 was not statistically different between the SFI (15%, 3/20) and placebo (25%, 5/20) groups ( P = 0.693). Conclusions : Shenfu injection provided apparent effects in improving sublingual microcirculatory perfusion in patients with septic shock, and this protection may be related with the inhibition of endothelial dysfunction and vasodilatory effects.
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Affiliation(s)
- Shiwei Wang
- Department of Emergency Medicine, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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Li Z, He P, Xu Y, Deng Y, Gao Y, Chen SL. In vivo evaluation of a lipopolysaccharide-induced ear vascular leakage model in mice using photoacoustic microscopy. BIOMEDICAL OPTICS EXPRESS 2022; 13:4802-4816. [PMID: 36187238 PMCID: PMC9484413 DOI: 10.1364/boe.471079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/05/2022] [Accepted: 08/05/2022] [Indexed: 06/16/2023]
Abstract
Sepsis is caused by dysregulated host inflammatory response to infection. During sepsis, early identification and monitoring of vascular leakage are pivotal for improved diagnosis, treatment, and prognosis. However, there is a lack of research on noninvasive observation of inflammation-related vascular leakage. Here, we investigate the use of photoacoustic microscopy (PAM) for in vivo visualization of lipopolysaccharide (LPS)-induced ear vascular leakage in mice using Evans blue (EB) as an indicator. A model combining needle pricking on the mouse ear, topical smearing of LPS on the mouse ear, and intravenous tail injection of EB is developed. Topical application of LPS is expected to induce local vascular leakage in skin. Inflammatory response is first validated by ex vivo histology and enzyme-linked immunosorbent assay. Then, local ear vascular leakage is confirmed by ex vivo measurement of swelling, thickening, and EB leakage. Finally, PAM for in vivo identification and evaluation of early vascular leakage using the model is demonstrated. For PAM, common excitation wavelength of 532 nm is used, and an algorithm is developed to extract quantitative metrics for EB leakage. The results show potential of PAM for noninvasive longitudinal monitoring of peripheral skin vascular leakage, which holds promise for clinical sepsis diagnosis and management.
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Affiliation(s)
- Zhe Li
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
- These authors contributed equally to this work
| | - Pengbo He
- University of Michigan-Shanghai Jiao Tong University Joint Institute, Shanghai Jiao Tong University, Shanghai 200240, China
- These authors contributed equally to this work
| | - Yuqing Xu
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Yuxiao Deng
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Yuan Gao
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Sung-Liang Chen
- University of Michigan-Shanghai Jiao Tong University Joint Institute, Shanghai Jiao Tong University, Shanghai 200240, China
- Engineering Research Center of Digital Medicine and Clinical Translation, Ministry of Education, Shanghai 200030, China
- State Key Laboratory of Advanced Optical Communication Systems and Networks, Shanghai Jiao Tong University, Shanghai 200240, China
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Abstract
PURPOSE OF REVIEW Advances in the treatment of septic shock have historically focused on resuscitation endpoints, mainly mean arterial pressure and cardiac output. As the definitions of sepsis and septic shock have shifted to focus on the diversity of causes of dysregulated host-response we have seen an emerging phenotype where tissue hypoxia persists despite adequate macrocirculatory parameters. Interest in the topic of microcirculation is re-emerging as validated bedside techniques for hemodynamic monitoring, such as video microscopes, are becoming available. We review the current understanding of how sepsis induced hypoperfusion with a focus on recent advances in monitoring the microcirculation, and how a proliferation of biomarkers and emerging therapeutic targets may impact future research. RECENT FINDINGS Conventional hemodynamic monitoring systems fail to assess the microcirculation, and it's response to treatment. Lactate and venous oxygen saturations often drive biomarker-guided sepsis management. Visual assessments such as mottling and capillary refill time are often associated with predicting outcomes, but sometimes can have issues with inter-provider reliability. Microcirculatory damage can be observed sublingually and appears to have prognostic value. SUMMARY Sepsis is associated with changes in the microcirculation that can lead to tissue hypoxia and organ dysfunction. Further studies are needed to validate the usefulness of microcirculatory bedside tools in guiding resuscitative efforts.
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Affiliation(s)
- Vishal Yajnik
- Department of Anesthesiology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
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Vedrenne-Cloquet M, Chareyre J, Léger PL, Genuini M, Renolleau S, Oualha M. Low Dosing Norepinephrine Effects on Cerebral Oxygenation and Perfusion During Pediatric Shock. Front Pediatr 2022; 10:898444. [PMID: 35874564 PMCID: PMC9298794 DOI: 10.3389/fped.2022.898444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cerebral hypoperfusion and impaired oxygen delivery during pediatric critical illness may result in acute neurologic injury with subsequent long-term effects on neurodevelopmental outcome. Yet, the impact of norepinephrine on cerebral hemodynamics is unknown in children with shock. We aimed to describe the norepinephrine effects on cerebral perfusion and oxygenation during pediatric shock. PATIENTS AND METHODS We conducted an observational multicentre prospective study in 3 French pediatric intensive care units. Children <18 years of age excluding traumatic brain injury were included in the study if they need norepinephrine for shock. Systemic and cerebral hemodynamics were compared between the time of initiation of norepinephrine (T0), and the steady-state (Tss). Cardiac output (CO) was measured using ultrasound. Cerebral perfusion was assessed on middle cerebral arteries (MCA) using transcranial doppler ultrasound. Cerebral tissue oxygen saturation (rScO2) was recorded using near infrared spectroscopy, and we calculated cerebral fractional tissue oxygen extraction (cFTOE = SpO2-rScO2/SpO2). MAIN RESULTS Fourteen children (median [IQR] age of 3.5[1; 13.5] years) were included. Norepinephrine at 0.2[0.1; 0.32] μg/kg/min significantly increased mean arterial blood pressure (61[56; 73] mmHg at Tss vs. 49[42;54] mmHg at T0, p=10-3) without change of CO. MCA velocities, pulsatility index, rScO2, and cFTOE did not significantly change between T0 and Tss. Some individuals observed variations in estimated CBF, which slightly improved in 7 patients, remained unchanged in 5, and was impaired in 2. No patient experienced significant variations of rScO2. CONCLUSIONS Low-dosing norepinephrine, despite a homogeneous and significant increase in arterial blood pressure, had little effects on cerebral perfusion and oxygenation during pediatric shock. This reinforces the need for personalized tailored therapies in this population. TRIAL REGISTRATION Clinicaltrials.gov, NCT03731104. Registered 6 November, 2018. https://clinicaltrials.gov/ct2/show/NCT03731104.
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Affiliation(s)
| | - Judith Chareyre
- Pediatric Intensive Care Unit, AP-HP CHU Necker-Enfants Malades, Paris, France
| | - Pierre-Louis Léger
- Pediatric Intensive Care Unit, AP-HP CHU Trousseau-La Roche Guyon, Paris, France
| | - Mathieu Genuini
- Pediatric Intensive Care Unit, AP-HP CHU Robert Debré, Paris, France.,Pediatric Intensive Care Transport Unit, AP-HP CHU Robert Debré, Paris, France
| | - Sylvain Renolleau
- Pediatric Intensive Care Unit, AP-HP CHU Necker-Enfants Malades, Paris, France
| | - Mehdi Oualha
- Pediatric Intensive Care Unit, AP-HP CHU Necker-Enfants Malades, Paris, France
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12
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Hu T, Qiao Z, Mei Y. Urine Output Is Associated With In-hospital Mortality in Intensive Care Patients With Septic Shock: A Propensity Score Matching Analysis. Front Med (Lausanne) 2021; 8:737654. [PMID: 34869431 PMCID: PMC8637111 DOI: 10.3389/fmed.2021.737654] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 10/20/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The relationship between urine output (UO) and in-hospital mortality in intensive care patients with septic shock is currently inconclusive. Methods: The baseline data, UO, and in-hospital prognosis of intensive care patients with septic shock were retrieved from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. By drawing receiver operating characteristic (ROC) curves and comparing the areas under the ROC curves (AUC) to determine the predictive value of UO for in-hospital mortality, and by drawing the Kaplan-Meier curves to compare the difference in in-hospital mortality between different groups of UO. Results: Before and after the propensity score matching (PSM) analysis, UO was always a risk factor for in-hospital mortality in patients with septic shock. The AUC of UO was comparable to the Sequential Organ Failure Assessment (SOFA) scoring system, while the AUC of combining UO and SOFA was greater than that of SOFA. The median survival time of the high-UO group (UO > 0.39 ml/kg/h, before PSM; UO > 0.38 ml/kg/h, after PSM) was longer than that of the low-UO group. Compared with the high-UO group, the hazard ratios (HR) of the low-UO group were 2.6857 (before PSM) and 1.7879 (after PSM). Conclusions: UO is an independent risk factor for septic shock. Low levels of UO significantly increase the in-hospital mortality of intensive care patients with septic shock. The predictive value of UO is comparable to the SOFA scoring system, and the combined predictive value of the two surpasses SOFA alone.
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Affiliation(s)
- Tianyang Hu
- Department of Cardiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Zhao Qiao
- Department of Cardiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Ying Mei
- Health Management Center, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
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Sanfilippo F, Messina A, Cecconi M, Astuto M. Ten answers to key questions for fluid management in intensive care. Med Intensiva 2021; 45:552-562. [PMID: 34839886 DOI: 10.1016/j.medine.2020.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/17/2020] [Indexed: 11/25/2022]
Abstract
This review focuses on fluid management of critically ill patients. The topic is addressed based on 10 single questions with simplified answers that provide clinicians with the basic information needed at the point of care in treating patients in the Intensive Care Unit. The review has didactic purposes and may serve both as an update on fluid management and as an introduction to the subject for novices in critical care. There is an urgent need to increase awareness regarding the potential risks associated with fluid overload. Clinicians should be mindful not only of the indications for administering fluid loads and of the type of fluids administered, but also of the importance to set safety limits. Lastly, it is important to implement proactive strategies seeking to establish negative fluid balance as soon as the clinical conditions are considered to be stable and the risk of deterioration is low.
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Affiliation(s)
- F Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. "Policlinico-Vittorio Emanuele", Catania, Italy.
| | - A Messina
- Humanitas Clinical and Research Center - IRCCS, Milano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | - M Cecconi
- Humanitas Clinical and Research Center - IRCCS, Milano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | - M Astuto
- Department of Anaesthesia and Intensive Care, A.O.U. "Policlinico-Vittorio Emanuele", Catania, Italy; School of Anaesthesia and Intensive Care, University Hospital "G. Rodolico", University of Catania, Catania, Italy; Department of General Surgery and Medical-Surgical Specialties, Section of Anesthesia and Intensive Care, University of Catania, Catania, Italy
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14
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Muir WW, Hughes D, Silverstein DC. Editorial: Fluid Therapy in Animals: Physiologic Principles and Contemporary Fluid Resuscitation Considerations. Front Vet Sci 2021; 8:744080. [PMID: 34746284 PMCID: PMC8563835 DOI: 10.3389/fvets.2021.744080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/21/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- William W. Muir
- College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, United States
| | - Dez Hughes
- Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Deborah C. Silverstein
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
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15
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Comparison of Vasopressin versus Norepinephrine in a Pig Model of Refractory Cardiogenic Shock Complicated by Cardiac Arrest and Resuscitated with Veno-arterial ECMO. Shock 2021; 56:473-478. [PMID: 33555846 DOI: 10.1097/shk.0000000000001747] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The choice of the best vasopressor after ExtraCorporeal Membrane Oxygenation (ECMO) implantation after cardiac arrest is not well defined. Circulatory flow recovery with ECMO is associated with vasoplegia and vasopressor need. The present study aimed to compare the effects of norepinephrine and vasopressin in the first 6 h after ECMO initiation. METHODS Cardiac arrest was induced in 20 pigs by coronary surgical ligature and veno-arterial-ECMO was started after a 30-min period of cardio-pulmonary resuscitation. Pigs were randomized into two groups, arginine vasopressin (AVP) or norepinephrine (NE), with the drugs titrated to maintain a mean arterial pressure (MAP) at 65 mm Hg. Macrocirculatory and metabolic parameters were assessed by lactate clearance. Microcirculatory parameters were assessed by sublingual microcirculation with Sidestream Dark Field imaging and peripheral Near InfraRed Spectroscopy. Pulmonary edema was evaluated by measuring lung wet/dry weight ratio. RESULTS No difference was found between groups regarding ECMO flow and MAP. Fluid resuscitation volume was higher in the NE group (14,000 [11,250-15,250] mL vs. 3,500 [1,750-4,000] mL in the AVP group, P < 0.05). Lung wet/dry weight ratio was higher in the Norepinephrine group. Lactate clearance between H0 and H6 was higher in the AVP group (47.84 [13.42-82.73]% vs. the NE group 25.66 [-7.31 to 35.34)% vs. P < 0.05). No significant difference was observed for sublingual microcirculation values. Baseline tissue oxygen saturation was comparable and higher at both H3 and H6 in the Vasopressin group comparatively to the Norepinephrine group (P < 0.05). Renal and liver function evolution also remained similar in the two groups throughout the study. CONCLUSIONS AVP administration in refractory cardiac arrest resuscitated by veno-arterial-ECMO is associated with a faster lactate clearance, less fluid resuscitation, and less pulmonary edema when compared with NE for similar global and regional hemodynamic effects.
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Sanfilippo F, Messina A, Cecconi M, Astuto M. Ten answers to key questions for fluid management in intensive care. Med Intensiva 2020; 45:S0210-5691(20)30338-7. [PMID: 33323286 DOI: 10.1016/j.medin.2020.10.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/05/2020] [Accepted: 10/17/2020] [Indexed: 12/16/2022]
Abstract
This review focuses on fluid management of critically ill patients. The topic is addressed based on 10 single questions with simplified answers that provide clinicians with the basic information needed at the point of care in treating patients in the Intensive Care Unit. The review has didactic purposes and may serve both as an update on fluid management and as an introduction to the subject for novices in critical care. There is an urgent need to increase awareness regarding the potential risks associated with fluid overload. Clinicians should be mindful not only of the indications for administering fluid loads and of the type of fluids administered, but also of the importance to set safety limits. Lastly, it is important to implement proactive strategies seeking to establish negative fluid balance as soon as the clinical conditions are considered to be stable and the risk of deterioration is low.
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Affiliation(s)
- F Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. "Policlinico-Vittorio Emanuele", Catania, Italy.
| | - A Messina
- Humanitas Clinical and Research Center - IRCCS, Milano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | - M Cecconi
- Humanitas Clinical and Research Center - IRCCS, Milano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | - M Astuto
- Department of Anaesthesia and Intensive Care, A.O.U. "Policlinico-Vittorio Emanuele", Catania, Italy; School of Anaesthesia and Intensive Care, University Hospital "G. Rodolico", University of Catania, Catania, Italy; Department of General Surgery and Medical-Surgical Specialties, Section of Anesthesia and Intensive Care, University of Catania, Catania, Italy
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17
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Wollborn J, Jung C, Göbel U, Bruno RR. [Evaluation of the microcirculation in critically ill patients : Relevance, practical possibilities and scientific evidence]. Anaesthesist 2020; 69:753-757. [PMID: 32803320 PMCID: PMC7653807 DOI: 10.1007/s00101-020-00832-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Für die Aufrechterhaltung der Organdurchblutung ist eine intakte Makro- und Mikrozirkulation essentiell. Sowohl das wachsende Verständnis um die Bedeutung der Mikrozirkulation im Organversagen als auch die Möglichkeit, diese zu visualisieren, lenken die Aufmerksamkeit der Intensivmedizin auf die mikrovaskuläre Endstrombahn. Als Surrogat-Parameter sind die Rekapillarisierungszeit, der „mottling score“ und die Messung des Serum-Laktats bereits lange in der klinischen Praxis etabliert. Neuere Studien messen der Echtzeit-Darstellung der sublingualen Mikrozirkulation mittels Intravital-Videomikroskopie eine immer größere Bedeutung bei. Verschiedene Studien unterstreichen hierbei die Mikrozirkulation als prognostischen Parameter. Darüber hinaus ermöglicht die Erhebung von objektivierbaren Messwerten, diese in der Zukunft zur individuellen Therapiesteuerung weitergehend zu untersuchen.
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Affiliation(s)
- J Wollborn
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Hugstetter Str. 55, 79106, Freiburg, Deutschland.
| | - C Jung
- Klinik für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - U Göbel
- Klinik für Anästhesiologie und operative Intensivmedizin, St. Franziskus-Hospital Münster, Münster, Deutschland
| | - R R Bruno
- Klinik für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
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