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Wollborn J, Hassenzahl LO, Reker D, Staehle HF, Omlor AM, Baar W, Kaufmann KB, Ulbrich F, Wunder C, Utzolino S, Buerkle H, Kalbhenn J, Heinrich S, Goebel U. Diagnosing capillary leak in critically ill patients: development of an innovative scoring instrument for non-invasive detection. Ann Intensive Care 2021; 11:175. [PMID: 34910264 PMCID: PMC8674404 DOI: 10.1186/s13613-021-00965-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 12/02/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The concomitant occurrence of the symptoms intravascular hypovolemia, peripheral edema and hemodynamic instability is typically named Capillary Leak Syndrome (CLS) and often occurs in surgical critical ill patients. However, neither a unitary definition nor standardized diagnostic criteria exist so far. We aimed to investigate common characteristics of this phenomenon with a subsequent scoring system, determining whether CLS contributes to mortality. METHODS We conducted this single-center, observational, multidisciplinary, prospective trial in two separately run surgical ICUs of a tertiary academic medical center. 200 surgical patients admitted to the ICU and 30 healthy volunteers were included. Patients were clinically diagnosed as CLS or No-CLS group (each N = 100) according to the grade of edema, intravascular hypovolemia, hemodynamic instability, and positive fluid balance by two independent attending physicians with > 10 years of experience in ICU. We performed daily measurements with non-invasive body impedance electrical analysis, ultrasound and analysis of serum biomarkers to generate objective diagnostic criteria. Receiver operating characteristics were used, while we developed machine learning models to increase diagnostic specifications for our scoring model. RESULTS The 30-day mortility was increased among CLS patients (12 vs. 1%, P = 0.002), while showing higher SOFA-scores. Extracellular water was increased in patients with CLS with higher echogenicity of subcutaneous tissue [29(24-31) vs. 19(16-21), P < 0.001]. Biomarkers showed characteristic alterations, especially with an increased angiopoietin-2 concentration in CLS [9.9(6.2-17.3) vs. 3.7(2.6-5.6)ng/mL, P < 0.001]. We developed a score using seven parameters (echogenicity, SOFA-score, angiopoietin-2, syndecan-1, ICAM-1, lactate and interleukin-6). A Random Forest prediction model boosted its diagnostic characteristics (AUC 0.963, P < 0.001), while a two-parameter decision tree model showed good specifications (AUC 0.865). CONCLUSIONS Diagnosis of CLS in critically ill patients is feasible by objective, non-invasive parameters using the CLS-Score. A simplified two-parameter diagnostic approach can enhance clinical utility. CLS contributes to mortality and should, therefore, classified as an independent entity. TRIAL REGISTRATION German Clinical Trials Registry (DRKS No. 00012713), Date of registration 10/05/2017, www.drks.de.
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Affiliation(s)
- Jakob Wollborn
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany. .,Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA. .,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.
| | - Lars O Hassenzahl
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Daniel Reker
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Hans Felix Staehle
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Anne Marie Omlor
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Wolfgang Baar
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Kai B Kaufmann
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Felix Ulbrich
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Christian Wunder
- Department of Anesthesiology and Critical Care, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Stefan Utzolino
- Department of General and Visceral Surgery, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Hartmut Buerkle
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Johannes Kalbhenn
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Sebastian Heinrich
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Ulrich Goebel
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.,Department of Anesthesiology and Critical Care, St. Franziskus-Hospital, Muenster, Germany
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