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Arteaga GM, Crow S. End organ perfusion and pediatric microcirculation assessment. Front Pediatr 2023; 11:1123405. [PMID: 37842022 PMCID: PMC10576530 DOI: 10.3389/fped.2023.1123405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 09/05/2023] [Indexed: 10/17/2023] Open
Abstract
Cardiovascular instability and reduced oxygenation are regular perioperative critical events associated with anesthesia requiring intervention in neonates and young infants. This review article addresses the current modalities of assessing this population's adequate end-organ perfusion in the perioperative period. Assuring adequate tissue oxygenation in critically ill infants is based on parameters that measure acceptable macrocirculatory hemodynamic parameters such as vital signs (mean arterial blood pressure, heart rate, urinary output) and chemical parameters (lactic acidosis, mixed venous oxygen saturation, base deficit). Microcirculation assessment represents a promising candidate for assessing and improving hemodynamic management strategies in perioperative and critically ill populations. Evaluation of the functional state of the microcirculation can parallel improvement in tissue perfusion, a term coined as "hemodynamic coherence". Less information is available to assess microcirculatory disturbances related to higher mortality risk in critically ill adults and pediatric patients with septic shock. Techniques for measuring microcirculation have substantially improved in the past decade and have evolved from methods that are limited in scope, such as velocity-based laser Doppler and near-infrared spectroscopy, to handheld vital microscopy (HVM), also referred to as videomicroscopy. Available technologies to assess microcirculation include sublingual incident dark field (IDF) and sublingual sidestream dark field (SDF) devices. This chapter addresses (1) the physiological basis of microcirculation and its relevance to the neonatal and pediatric populations, (2) the pathophysiology associated with altered microcirculation and endothelium, and (3) the current literature reviewing modalities to detect and quantify the presence of microcirculatory alterations.
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Affiliation(s)
- Grace M. Arteaga
- Department of Pediatric and Adolescent Medicine, Pediatric Critical Care, Mayo Clinic, Rochester MN, United States
| | - Sheri Crow
- Department of Pediatric and Adolescent Medicine, Pediatric Critical Care, Mayo Clinic, Rochester MN, United States
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Piastra M, Picconi E, Ferrari V, Morena TC, Conti G. Inhaled nitric oxide can reverse refractory hypoxemia in massive air-leak. Pediatr Pulmonol 2023; 58:348-349. [PMID: 36127749 DOI: 10.1002/ppul.26161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 08/24/2022] [Accepted: 09/05/2022] [Indexed: 01/11/2023]
Affiliation(s)
- Marco Piastra
- Emergency and Intensive Care Department, Pediatric ICU and Trauma Center, Fondazione Policlinico Gemelli IRCCS, Roma, Italy.,Emergency and Intensive Care Department, Institute of Anesthesia and Intensive Care, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Enzo Picconi
- Emergency and Intensive Care Department, Pediatric ICU and Trauma Center, Fondazione Policlinico Gemelli IRCCS, Roma, Italy
| | - Vittoria Ferrari
- Emergency and Intensive Care Department, Institute of Anesthesia and Intensive Care, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Tony Christian Morena
- Emergency and Intensive Care Department, Pediatric ICU and Trauma Center, Fondazione Policlinico Gemelli IRCCS, Roma, Italy
| | - Giorgio Conti
- Emergency and Intensive Care Department, Pediatric ICU and Trauma Center, Fondazione Policlinico Gemelli IRCCS, Roma, Italy.,Emergency and Intensive Care Department, Institute of Anesthesia and Intensive Care, Università Cattolica del Sacro Cuore, Roma, Italy
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Relevance of Microvascular Flow Assessments in Critically Ill Neonates and Children: A Systematic Review. Pediatr Crit Care Med 2020; 21:373-384. [PMID: 31834246 PMCID: PMC10061570 DOI: 10.1097/pcc.0000000000002201] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Resolution of impaired microvascular flow may lag the normalization of macrocirculatory variables. The significance of microcirculatory dysfunction in critically ill children and neonates is unknown, but microcirculatory variables can be measured using Doppler or videomicroscopy imaging techniques. We outline the current understanding of the role of the microcirculation in critical illness, review methods for its assessment, and perform a systematic review of how it has been monitored in critically ill neonates and children. DESIGN Systematic review (PROSPERO CRD42019117993). SETTING Not applicable. SUBJECTS Not applicable. INTERVENTIONS None. MEASUREMENTS AND RESULTS We systematically searched MEDLINE, EMBASE, PubMed, and Web of Science. We included studies of critically ill patients 0 to 18 years old investigating microcirculatory blood flow. Two reviewers analyzed abstracts and articles. Results were qualitatively analyzed due to study heterogeneity. A total of 2,559 abstracts met search criteria, of which 94 underwent full-text review. Of those, 36 met inclusion criteria. Seven studies investigated microcirculatory changes in critically ill children. Twenty studies investigated the microcirculatory changes in neonates with variable diagnoses compared with a diverse set of clinical endpoints. Nine studies assessed the effects of age, sex, and birth weight on microvascular flow in neonates. Across all studies, microcirculatory dysfunction was associated with poor outcomes and may not correlate with observed macrovascular function. CONCLUSIONS Assessment of microvascular flow in critically ill children and neonates is possible, although significant challenges remain. In many such patients, microvascular blood flow is disrupted despite medical management targeting normalized macrovascular variables. Future studies are needed to define normal pediatric microvascular flow variables and to assess the impact of patient and treatment factors on its function.
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González R, Urbano J, Solana MJ, Hervías M, Pita A, Pérez R, Álvarez R, Teigell E, Gil-Jaurena JM, Zamorano J, Sobrino A, López-Herce J. Microcirculatory Differences in Children With Congenital Heart Disease According to Cyanosis and Age. Front Pediatr 2019; 7:264. [PMID: 31312623 PMCID: PMC6613439 DOI: 10.3389/fped.2019.00264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 06/10/2019] [Indexed: 12/11/2022] Open
Abstract
Background: Congenital heart disease (CHD) is one of the main causes of morbidity and mortality in children. Microcirculatory changes in CHD patients have previously been investigated using a variety of techniques. Handheld videomicroscopy enables non-invasive direct visualization of the microcirculatory bed. The aim of our study was to determine if there are microcirculatory differences among CHD patients based on age and the presence of cyanosis. Methods: A prospective observational study was carried out. Patients with CHD undergoing corrective surgery were evaluated after anesthetic induction prior to surgery. Microcirculation was evaluated using sidestream dark field (SDF) imaging. Hemodynamics and respiratory, biochemical, and tissue perfusion parameters were analyzed. Results: A total of 30 patients were included, of whom 14 were classified as cyanotic and 16 as non-cyanotic. Cyanotic patients had a higher total vessel density (TVD) (p = 0.016), small vessel density (p = 0.004), and perfused small vessel density (p = 0.013), while their microvascular flow index (MFI) was lower (p = 0.013). After adjustment for age and PaO2, cyanotic patients showed increased TVD (p = 0.023), and small vessel density (p = 0.025) compared to non-cyanotic patients but there were no differences on the MFI. Age was directly correlated with total MFI (spearman's rho = 0.499, p = 0.005) and small vessel MFI (spearman's rho = 0.420, p = 0.021). After adjustment for the type of CHD (cyanotic vs. non-cyanotic) patients with MFI and small MFI vessels <3 were younger than those with values ≥3 (p = 0.033 and p = 0.037). Conclusions: SDF-based evaluation of microcirculation in CHD patients showed that patients with cyanotic defects had higher vascular density, as compared to patients with non-cyanotic defects. Younger patients were more likely to have a low MFI regardless of their type of CHD.
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Affiliation(s)
- Rafael González
- Service of Paediatric Intensive Care, Gregorio Marañón General University Hospital, Madrid, Spain.,Mother and Child Health and Development Network (REDSAMID), Madrid, Spain
| | - Javier Urbano
- Service of Paediatric Intensive Care, Gregorio Marañón General University Hospital, Madrid, Spain.,Mother and Child Health and Development Network (REDSAMID), Madrid, Spain.,Department of Paediatrics, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - María J Solana
- Service of Paediatric Intensive Care, Gregorio Marañón General University Hospital, Madrid, Spain.,Mother and Child Health and Development Network (REDSAMID), Madrid, Spain
| | - Mónica Hervías
- Paediatric Anaesthesia, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Ana Pita
- Paediatric Cardiac Surgery, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Rosario Pérez
- Paediatric Hemoperfusionist, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Reyes Álvarez
- Paediatric Cardiology, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Enrique Teigell
- Paediatric Anaesthesia, Gregorio Marañón General University Hospital, Madrid, Spain
| | | | - José Zamorano
- Paediatric Hemoperfusionist, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Adolfo Sobrino
- Paediatric Cardiology, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Jesús López-Herce
- Service of Paediatric Intensive Care, Gregorio Marañón General University Hospital, Madrid, Spain.,Mother and Child Health and Development Network (REDSAMID), Madrid, Spain.,Department of Paediatrics, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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Erdem Ö, Ince C, Tibboel D, Kuiper JW. Assessing the Microcirculation With Handheld Vital Microscopy in Critically Ill Neonates and Children: Evolution of the Technique and Its Potential for Critical Care. Front Pediatr 2019; 7:273. [PMID: 31338353 PMCID: PMC6629784 DOI: 10.3389/fped.2019.00273] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 06/17/2019] [Indexed: 12/17/2022] Open
Abstract
Assuring adequate tissue oxygenation in the critically ill, but still developing child is challenging. Conventional hemodynamic monitoring techniques fall short in assessing tissue oxygenation as these are directed at the macrocirculation and indirect surrogates of tissue oxygenation. The introduction of handheld vital microscopy (HVM) has allowed for the direct visualization of the microcirculation and with this has offered insight into tissue oxygenation on a microcirculatory level. Since its introduction, technical improvements have been made to HVM, to both hardware and software, and guidelines have been developed through expert consensus on image assessment and analysis. Using HVM, the microcirculation of the skin, the buccal mucosa, and the sublingual mucosa of healthy and (critically) ill neonates and children have been visualized and investigated. Yet, integration of HVM in hemodynamic monitoring has been limited due to technical shortcomings. Only superficial microcirculatory beds can be visualized, inter-observer and intra-observer variabilities are not accounted for and image analysis happens offline and is semi-automated and time-consuming. More importantly, patients need to be cooperative or fully sedated to prevent pressure and movement artifacts, which is often not the case in children. Despite these shortcomings, observational research with HVM in neonates and children has revealed the following: (1) age-related developmental changes in the microcirculation, (2) loss of hemodynamic coherence, i.e., microcirculatory disturbances in the presence of a normal macrocirculation and, (3) microcirculatory disturbances which were independently associated with increased mortality risk. Although these observations underline the importance of microcirculatory monitoring, several steps have to be taken before integration in the decision process during critical care can happen. These steps include technological innovations to ease the use of HVM in the pediatric age group, measuring additional functional parameters of microvascular blood flow and integrated automated analysis software. As a next step, reference values for microcirculatory parameters need to be established, while also accounting for developmental changes. Finally, studies on microcirculatory guided therapies are necessary to assess whether the integration of microcirculatory monitoring will actually improve patient outcome. Nevertheless, HVM remains a promising, non-invasive tool to help physicians assure tissue oxygenation in the critically ill child.
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Affiliation(s)
- Özge Erdem
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Translational Physiology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Jan Willem Kuiper
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, Netherlands
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Affiliation(s)
- Edmund F LaGamma
- 1 Professor of Pediatrics, Biochemistry, and Molecular Biology, Chief of the Division of Newborn Medicine, and Director of the Neonatal-Perinatal Fellowship Program, New York Medical College , Valhalla, New York.,2 Chief of the Regional Neonatal Intensive Care Unit (NICU) of Maria Fareri Children's Hospital at Westchester Medical Center , Valhalla, New York
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7
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Wagner M, Anzinger E, Hey F, Reiter K, Wermelt JZ, Pastor-Villaescusa B, Genzel-Boroviczény O, Nussbaum C. Monitoring of the microcirculation in children undergoing major abdominal and thoracic surgery: A pilot study. Clin Hemorheol Microcirc 2017; 83:217-229. [PMID: 36502307 PMCID: PMC10116146 DOI: 10.3233/ch-221617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND: Monitoring of the macrocirculation during surgery provides limited information on the quality of organ perfusion. OBJECTIVE: We investigated the feasibility of perioperative microcirculatory measurements in children. METHODS: Sublingual microvessels were visualized by handheld videomicroscopy in 11 children (19 mo – 10 yrs) undergoing surgery > 120 min at four time points: T0) after induction of anesthesia; T1) before end of anesthesia, T2) 6 h post surgery and T3) 24 h post surgery. RESULTS: Measurements were feasible in all children at T0 and T1. At T2 and T3, imaging was restricted to 6 and 4 infants, respectively, due to respiratory compromise and missing cooperation. The capillary density was reduced at T1 compared to T0 (8.1 mm/mm2 [4.0-17.0] vs. 10.6 mm/mm2 [5.1-19.3]; p = 0.01), and inversely related to norepinephrine dose (Pearson r = -0.65; p = 0.04). Microvascular flow and serum glycocalyx makers Syndecan-1 and Hyaluronan increased significantly from T0 to T1. CONCLUSION: Perioperative microcirculatory monitoring in children requires a high amount of personal and logistic resources still limiting its routine use. Major surgery is associated with microvascular alterations and glycocalyx perturbation. The possible consequences on patient outcome need further evaluation. Efforts should concentrate on the development of next generation devices designed to facilitate microcirculatory monitoring in children.
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Affiliation(s)
- Marie Wagner
- Department of Pediatrics, Division of Neonatology, Dr von Hauner Children’s Hospital, University Hospital, LMU Munich, Germany
| | - Eveline Anzinger
- Department of Pediatrics, Division of Neonatology, Dr von Hauner Children’s Hospital, University Hospital, LMU Munich, Germany
| | - Florian Hey
- Department of Pediatrics, Pediatric Intensive Care Unit, Dr von Hauner Children’s Hospital, University Hospital, LMU, Munich, Germany
| | - Karl Reiter
- Department of Pediatrics, Pediatric Intensive Care Unit, Dr von Hauner Children’s Hospital, University Hospital, LMU, Munich, Germany
| | - Julius Z. Wermelt
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
- Department of Anesthesiology, Bürgerhospital und Clementine Kinderhospital gGmbH, Teaching Hospital of the University Frankfurt, Frankfurt, Germany
| | - Belén Pastor-Villaescusa
- Metabolism in Childhood Research Group, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Córdoba, Spain
| | - Orsolya Genzel-Boroviczény
- Department of Pediatrics, Division of Neonatology, Dr von Hauner Children’s Hospital, University Hospital, LMU Munich, Germany
| | - Claudia Nussbaum
- Department of Pediatrics, Division of Neonatology, Dr von Hauner Children’s Hospital, University Hospital, LMU Munich, Germany
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8
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Wright IMR, Latter JL, Dyson RM, Levi CR, Clifton VL. Videomicroscopy as a tool for investigation of the microcirculation in the newborn. Physiol Rep 2017; 4:4/19/e12941. [PMID: 27694527 PMCID: PMC5064131 DOI: 10.14814/phy2.12941] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 08/06/2016] [Indexed: 11/24/2022] Open
Abstract
The perinatal period remains a time of significant risk of death or disability. Increasing evidence suggests that this depends on microcirculatory behavior. Sidestream dark‐field orthogonal polarized light videomicroscopy (OPS) has emerged as a useful assessment of adult microcirculation but the values derived are not delineated for the newborn. We aimed to define these parameters in well term newborn infants. Demographic details were collected prospectively on 42 healthy term neonates (n = 20 females, n = 22 males). OPS videomicroscopy (Microscan) was used to view ear conch skin microcirculation at 6, 24, and 72 h of age. Stored video was analyzed by a masked observer using proprietary software. There were no significant differences between the sexes for any structural parameters at any time point. There was a significant increase over time in small vessel perfusion in female infants only (P = 0.009). A number of 6‐ and 72‐h measurements were significantly correlated, but differed from the 24‐h values. These observations confirm the utility of the ear conch for neonatal microvascular videomicroscopy. They provide a baseline for studies into the use of OPS videomicroscopy in infants. The changes observed are comparable with previous studies of term infants using these and other microvascular techniques. It is recommended that studies for examining the mature neonatal microvascular structure be delayed until 72 h of life, but studies of the physiology of cardiovascular transition should include the 24‐h time point after delivery.
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Affiliation(s)
- Ian M R Wright
- Hunter Medical Research Institute, Newcastle, New South Wales, Australia Discipline of Paediatrics and Child Health, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia Kaleidoscope Neonatal Intensive Care Unit, John Hunter Children's Hospital, Newcastle, New South Wales, Australia Graduate School of Medicine and Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - Joanna L Latter
- Hunter Medical Research Institute, Newcastle, New South Wales, Australia Discipline of Paediatrics and Child Health, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Rebecca M Dyson
- Hunter Medical Research Institute, Newcastle, New South Wales, Australia Discipline of Paediatrics and Child Health, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia Graduate School of Medicine and Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - Chris R Levi
- Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Vicki L Clifton
- Mater Medical Research Institute, University of Queensland, Brisbane, Queensland, Australia
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González R, López J, Urbano J, Solana MJ, Fernández SN, Santiago MJ, López-Herce J. Evaluation of sublingual microcirculation in a paediatric intensive care unit: prospective observational study about its feasibility and utility. BMC Pediatr 2017; 17:75. [PMID: 28298202 PMCID: PMC5353860 DOI: 10.1186/s12887-017-0837-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 03/08/2017] [Indexed: 11/25/2022] Open
Abstract
Background Evaluation of the microcirculation in critically ill patients is usually done by means of indirect parameters. The aim of our study was to evaluate the functional state of the microcirculation by direct visualization of sublingual microcirculation using Sidestream Dark Field Imaging, to determine the correlation between these findings and other parameters that are commonly used in the clinical practice and to assess the applicability of the systematic use of this technique in critically ill children. Methods A prospective observational study was carried out in a Pediatric Intensive Care Unit (PICU) of a tertiary referral hospital. All patients admitted to the PICU during a three-month period were included in the study after obtaining the informed consent from the patient. Systematic evaluation of sublingual microcirculation was done in these patients (Total Vessel Density, Proportion of Perfused Vessels, Perfused Vessel Density, De Backer Score, Microvascular Flow Index, Heterogeneity Index) within the first day of admission (T1) and between the second and third day of admission (T2). Other clinical, hemodynamic, and biochemical parameters were measured and registered simultaneously. When the evaluation of the microcirculation was not feasible, the reason was registered. Descriptive analysis of our findings are expressed as means, medians, standard deviations and interquartile ranges. Mann–Whitney-Wilcoxon and Fisher tests were used to compare variables between patients with and without evaluation of the microcirculation. Pearson Correlation Coefficient (ρ) was used to evaluate the correlation between microcirculatory parameters and other clinical parameters. Results One hundred fine patients were included during the study period. Evaluation of the microcirculation was feasible in 18 patients (17.1%). 95.2% of them were intubated. The main reason for not evaluating microcirculation was the presence of respiratory difficulty or the absence of collaboration (95.1% on T1 and 68.9% on T2). Evaluated patients had a higher prevalence of intubation and ECMO at admission (72.2% vs. 14.9% and 16.6% vs. 1.1%, respectively), and longer median duration of mechanical ventilation (0 vs. 6.5 days), vasoactive drugs (0 vs. 3.5 days) and length of stay (3 vs. 16.5 days) than non-evaluated patients. There was a moderate correlation between microcirculatory parameters and systolic arterial pressure, central venous pressure, serum lactate and other biochemical parameters used for motoring critically ill children. Conclusions Systematic evaluation of microcirculation in critically ill children is not feasible in the unstable critically ill patient, but it is feasible in stable critically ill children. Microcirculatory parameters show a moderate correlation with other parameters that are usually monitored in critically ill children. Electronic supplementary material The online version of this article (doi:10.1186/s12887-017-0837-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rafael González
- Paediatric Intensive Care Unit, Gregorio Marañón General University Hospital, Calle Doctor Castelo 47, Madrid, 28009, Spain.,Gregorio Marañón Health Research Institute, Calle Doctor Castelo 47, Madrid, 28009, Spain.,Mother and Child Health and Development Network (Red SAMID), RETICS funded by the PN I+D+I 2008-2011, ISCIII-Sub-Directorate General for Research Assessment and Promotion and the European Regional 10.1186/s12887-017-0837-5 Development Fund, ref. RD12/0026., Madrid, Spain
| | - Jorge López
- Paediatric Intensive Care Unit, Gregorio Marañón General University Hospital, Calle Doctor Castelo 47, Madrid, 28009, Spain.,Gregorio Marañón Health Research Institute, Calle Doctor Castelo 47, Madrid, 28009, Spain.,Mother and Child Health and Development Network (Red SAMID), RETICS funded by the PN I+D+I 2008-2011, ISCIII-Sub-Directorate General for Research Assessment and Promotion and the European Regional 10.1186/s12887-017-0837-5 Development Fund, ref. RD12/0026., Madrid, Spain
| | - Javier Urbano
- Paediatric Intensive Care Unit, Gregorio Marañón General University Hospital, Calle Doctor Castelo 47, Madrid, 28009, Spain.,Gregorio Marañón Health Research Institute, Calle Doctor Castelo 47, Madrid, 28009, Spain.,Mother and Child Health and Development Network (Red SAMID), RETICS funded by the PN I+D+I 2008-2011, ISCIII-Sub-Directorate General for Research Assessment and Promotion and the European Regional 10.1186/s12887-017-0837-5 Development Fund, ref. RD12/0026., Madrid, Spain
| | - María José Solana
- Paediatric Intensive Care Unit, Gregorio Marañón General University Hospital, Calle Doctor Castelo 47, Madrid, 28009, Spain.,Gregorio Marañón Health Research Institute, Calle Doctor Castelo 47, Madrid, 28009, Spain.,Mother and Child Health and Development Network (Red SAMID), RETICS funded by the PN I+D+I 2008-2011, ISCIII-Sub-Directorate General for Research Assessment and Promotion and the European Regional 10.1186/s12887-017-0837-5 Development Fund, ref. RD12/0026., Madrid, Spain
| | - Sarah Nicole Fernández
- Paediatric Intensive Care Unit, Gregorio Marañón General University Hospital, Calle Doctor Castelo 47, Madrid, 28009, Spain.,Gregorio Marañón Health Research Institute, Calle Doctor Castelo 47, Madrid, 28009, Spain.,Mother and Child Health and Development Network (Red SAMID), RETICS funded by the PN I+D+I 2008-2011, ISCIII-Sub-Directorate General for Research Assessment and Promotion and the European Regional 10.1186/s12887-017-0837-5 Development Fund, ref. RD12/0026., Madrid, Spain
| | - María José Santiago
- Gregorio Marañón Health Research Institute, Calle Doctor Castelo 47, Madrid, 28009, Spain.,Mother and Child Health and Development Network (Red SAMID), RETICS funded by the PN I+D+I 2008-2011, ISCIII-Sub-Directorate General for Research Assessment and Promotion and the European Regional 10.1186/s12887-017-0837-5 Development Fund, ref. RD12/0026., Madrid, Spain
| | - Jesús López-Herce
- Paediatric Intensive Care Unit, Gregorio Marañón General University Hospital, Calle Doctor Castelo 47, Madrid, 28009, Spain. .,Gregorio Marañón Health Research Institute, Calle Doctor Castelo 47, Madrid, 28009, Spain. .,Mother and Child Health and Development Network (Red SAMID), RETICS funded by the PN I+D+I 2008-2011, ISCIII-Sub-Directorate General for Research Assessment and Promotion and the European Regional 10.1186/s12887-017-0837-5 Development Fund, ref. RD12/0026., Madrid, Spain. .,School of Medicine, Complutense University of Madrid, Madrid, Spain.
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10
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Hemodynamic coherence in critically ill pediatric patients. Best Pract Res Clin Anaesthesiol 2016; 30:499-510. [PMID: 27931653 DOI: 10.1016/j.bpa.2016.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 10/24/2016] [Indexed: 01/22/2023]
Abstract
Differences in physiology and pathophysiology make the treatment of developing, critically ill children particularly challenging as compared to that of adults. Significant differences in the cardiovascular system of neonates and children in size, weight, body proportions, and metabolism should be considered. Hemodynamic monitoring is crucial for early warning of pending deterioration and to guide therapy. Current monitoring is limited to the macrocirculation, but an adequately functioning macrocirculation does not guarantee a well-functioning microcirculation. Research in children revealed loss of hemodynamic coherence, i.e., microcirculatory alterations despite normal systemic hemodynamics. Implementing the framework of hemodynamic coherence in microcirculatory monitoring in children can aid physicians in titrating therapy on both macrocirculatory and microcirculatory effects to assure optimal oxygen delivery. Monitoring the microcirculation at the bedside requires further technical development. Although more research is necessary to validate the concept of hemodynamic coherence in children, the possibilities of applying this concept in children seem promising.
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11
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Kuiper JW, Tibboel D, Ince C. The vulnerable microcirculation in the critically ill pediatric patient. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:352. [PMID: 27794361 PMCID: PMC5086412 DOI: 10.1186/s13054-016-1496-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In neonates, cardiovascular system development does not stop after the transition from intra-uterine to extra-uterine life and is not limited to the macrocirculation. The microcirculation (MC), which is essential for oxygen, nutrient, and drug delivery to tissues and cells, also develops. Developmental changes in the microcirculatory structure continue to occur during the initial weeks of life in healthy neonates. The physiologic hallmarks of neonates and developing children make them particularly vulnerable during critical illness; however, the cardiovascular monitoring possibilities are limited compared with critically ill adult patients. Therefore, the development of non-invasive methods for monitoring the MC is necessary in pediatric critical care for early identification of impending deterioration and to enable the initiation and titration of therapy to ensure cell survival. To date, the MC may be non-invasively monitored at the bedside using hand-held videomicroscopy, which provides useful information regarding the microcirculation. There is an increasing number of studies on the MC in neonates and pediatric patients; however, additional steps are necessary to transition MC monitoring from bench to bedside. The recently introduced concept of hemodynamic coherence describes the relationship between changes in the MC and macrocirculation. The loss of hemodynamic coherence may result in a depressed MC despite an improvement in the macrocirculation, which represents a condition associated with adverse outcomes. In the pediatric intensive care unit, the concept of hemodynamic coherence may function as a framework to develop microcirculatory measurements towards implementation in daily clinical practice.
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Affiliation(s)
- J W Kuiper
- Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Postbox 2040, 3000 CA, Rotterdam, The Netherlands.
| | - D Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Postbox 2040, 3000 CA, Rotterdam, The Netherlands
| | - C Ince
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
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Cutaneous microcirculation in preterm neonates: comparison between sidestream dark field (SDF) and incident dark field (IDF) imaging. J Clin Monit Comput 2015; 29:543-8. [PMID: 26021740 PMCID: PMC4565887 DOI: 10.1007/s10877-015-9708-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 05/22/2015] [Indexed: 11/28/2022]
Abstract
Incident dark field imaging (IDF) is a new generation handheld microscope for bedside visualization and quantification of microcirculatory alterations. IDF is the technical successor of sidestream dark field imaging (SDF), currently the most used device for microcirculatory measurements. In (pre)term neonates the reduced thickness of the skin allows non-invasive transcutaneous measurements. The goal of this study was to compare the existing device (SDF) and its technical successor (IDF) in preterm neonates. We hypothesized that IDF imaging produces higher quality images resulting in a higher vessel density. After written informed consent was given by the parents, skin microcirculation was consecutively measured on the inner upper arm with de SDF and IDF device. Images were exported and analyzed offline using existing software (AVA 3.0). Vessel density and perfusion were calculated using the total vessel density (TVD) proportion of perfused vessels (PPV) and perfused vessel density. The microcirculation images quality score was used to evaluate the quality of the video images. In a heterogeneous group of twenty preterm neonates (median GA 27.6 weeks, range 24–33.4) IDF imaging visualized 19.9 % more vessels resulting in a significantly higher vessel density (TVD 16.9 vs. 14.1/mm, p value < 0.001). The perfusion of vessels could be determined more accurately in the IDF images, resulting in a significant lower PPV (88.7 vs. 93.9 %, p value 0.002). The IDF video images scored optimal in a higher percentage compared to the SDF video images. IDF imaging of the cutaneous microcirculation in preterm neonates resulted in a higher vessel density and lower perfusion compared to the existing SDF device.
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van den Berg VJ, van Elteren HA, Buijs EAB, Ince C, Tibboel D, Reiss IKM, de Jonge RCJ. Reproducibility of Microvascular Vessel Density Analysis in Sidestream Dark-Field-Derived Images of Healthy Term Newborns. Microcirculation 2015; 22:37-43. [DOI: 10.1111/micc.12163] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 08/12/2014] [Indexed: 12/26/2022]
Affiliation(s)
- Victor J. van den Berg
- Department of Pediatrics; Division of Neonatology; Erasmus MC-Sophia; University Medical Center; Rotterdam the Netherlands
| | - Hugo A. van Elteren
- Department of Pediatrics; Division of Neonatology; Erasmus MC-Sophia; University Medical Center; Rotterdam the Netherlands
| | - Erik A. B. Buijs
- Intensive Care and Department of Pediatric Surgery; Erasmus MC-Sophia; University Medical Center; Rotterdam the Netherlands
| | - Can Ince
- Department of Intensive Care; Erasmus MC; University Medical Center; Rotterdam the Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery; Erasmus MC-Sophia; University Medical Center; Rotterdam the Netherlands
| | - Irwin K. M. Reiss
- Department of Pediatrics; Division of Neonatology; Erasmus MC-Sophia; University Medical Center; Rotterdam the Netherlands
| | - Rogier C. J. de Jonge
- Department of Pediatrics; Division of Neonatology; Erasmus MC-Sophia; University Medical Center; Rotterdam the Netherlands
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Microcirculatory analysis in the management of sepsis-Occam's razor or Achilles' heel?*. Crit Care Med 2014; 42:2628-30. [PMID: 25402282 DOI: 10.1097/ccm.0000000000000585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Increasing mean arterial blood pressure and heart rate with catecholaminergic drugs does not improve the microcirculation in children with congenital diaphragmatic hernia: a prospective cohort study. Pediatr Crit Care Med 2014; 15:343-54. [PMID: 24622167 DOI: 10.1097/pcc.0000000000000105] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To study whether dopamine, norepinephrine, and epinephrine improve not only mean arterial blood pressure and heart rate but also microcirculatory perfusion in children with congenital diaphragmatic hernia. DESIGN Prospective observational cohort study from November 2009 to July 2012. SETTING ICU of a level III university children's hospital. PATIENTS Twenty-eight consecutive congenital diaphragmatic hernia newborns of whom seven did not receive any catecholaminergic support and 21 received dopamine as the drug of first choice. Fourteen of the latter also received either norepinephrine or epinephrine in addition to dopamine. Twenty-eight healthy neonates, matched for gestational age, postnatal age, and gender, served as controls. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data were obtained before and after dopamine start and before and after norepinephrine or epinephrine start in case it was given. For the congenital diaphragmatic hernia without catecholaminergic support, data were obtained at admission days 1 and 2 and for the controls on day 1 of life. The buccal microcirculation was studied using Sidestream Dark Field imaging. Also macrocirculatory, respiratory, and biochemical variables were collected. Mean arterial blood pressure had improved after dopamine start, whereas the microcirculation had not. After the start of either norepinephrine or epinephrine, both blood pressure and heart rate had increased. However, the microcirculation failed to improve again. The microcirculation in the healthy controls was better than that in the congenital diaphragmatic hernia patients with catecholaminergic support. After cutoff values for abnormal microcirculation had been defined, abnormal microcirculation after dopamine start predicted the need for additional catecholaminergic support (area under the curve, 0.74-0.88; sensitivity, 77-77%; specificity, 69-77%). Likewise, microcirculatory impairment was associated with the need for extracorporeal membrane oxygenation. CONCLUSIONS Catecholaminergic drug support with dopamine, norepinephrine, and/or epinephrine improved macrocirculatory function but did not improve the microcirculation in neonates with congenital diaphragmatic hernia. The microcirculation was not only impaired but it also predicted poor outcome.
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Microcirculatory mechanisms in postnatal hypotension affecting premature infants. Pediatr Res 2013; 74:186-90. [PMID: 23802219 DOI: 10.1038/pr.2013.78] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 12/19/2012] [Indexed: 11/08/2022]
Abstract
BACKGROUND Hypotension remains a common complication in preterm infants and is associated with high neonatal morbidity and mortality. The underlying mechanisms are still not fully understood. We studied the microcirculation in extremely low birth weight infants to understand the relationship between blood pressure and skin perfusion. METHODS In 21 patients (gestational age <30 wk, birth weight <1,225 g), functional vessel density (FVD) and diameter distribution were obtained prospectively by side stream dark-field imaging at the right arm in the first 48 h after birth. Infants with blood pressure below gestational age and receiving catecholamines were defined as hypotensive as compared with the remaining normotensive control group. RESULTS In the first 6 h after birth, FVD was significantly higher in the hypotensive group than in the control group. After 12 h, there were no significant differences in either blood pressure or FVD between the two groups. FVD did not change significantly during the observation period in either group. CONCLUSION Hypotensive infants have a higher FVD, possibly due to loss of microvascular tone leading to vasodilation and flow redistribution. However, the link between blood pressure and perfusion remains unclear, and no definitive correlation could be found.
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Tytgat SHAJ, van der Zee DC, Ince C, Milstein DMJ. Carbon dioxide gas pneumoperitoneum induces minimal microcirculatory changes in neonates during laparoscopic pyloromyotomy. Surg Endosc 2013; 27:3465-73. [DOI: 10.1007/s00464-013-2927-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Accepted: 02/22/2013] [Indexed: 10/27/2022]
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Buijs EAB, Zwiers AJM, Ista E, Tibboel D, de Wildt SN. Biomarkers and clinical tools in critically ill children: are we heading toward tailored drug therapy? Biomark Med 2012; 6:239-57. [PMID: 22731898 DOI: 10.2217/bmm.12.28] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
In pediatric critical care, validated biomarkers are essential for guiding drug therapy. The aim of this article is to present examples of current biomarker developments in its full breadth, including biochemical substances, physiological measurements and clinical scoring tools, with a focus on the field of circulatory, renal and neurophysiologic failure. Within each field we consecutively discuss the rationale for the selected biomarkers, studies in critically ill children, biomarker validation stage and biomarker use or potential use in drug studies and clinical drug dosing. This article demonstrates that there is paucity of properly validated biomarkers. Nevertheless, recent developments in, for instance, the field of sepsis, point us toward a future wherein, for critically ill children, drug therapy may be personalized using proteomic profiling instead of a small number of biomarkers, in order to establish a personal and dynamic disease profile.
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Affiliation(s)
- Erik A B Buijs
- Intensive Care & Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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He X, Su F, Velissaris D, Salgado DR, de Souza Barros D, Lorent S, Taccone FS, Vincent JL, De Backer D. Administration of tetrahydrobiopterin improves the microcirculation and outcome in an ovine model of septic shock. Crit Care Med 2012; 40:2833-40. [PMID: 22846780 DOI: 10.1097/ccm.0b013e31825b88ba] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Supplementation with tetrahydrobiopterin, a nitric oxide synthase cofactor, may reduce microvascular endothelial dysfunction in severe sepsis. We studied whether tetrahydrobiopterin administration exerts beneficial effects in an ovine septic shock model. DESIGN Randomized animal study. SETTING University hospital animal research laboratory. SUBJECTS Fourteen adult female sheep. INTERVENTIONS Fecal peritonitis was induced, and the sheep were randomized to receive tetrahydrobiopterin (n=7), given intravenously as 20 mg/kg boluses at 4 and 12 hrs after sepsis induction, or placebo (n=7). All animals were fluid resuscitated. The experiment was continued until death or for a maximum of 30 hrs. MEASUREMENTS AND MAIN RESULTS In addition to standard hemodynamic assessment, the sublingual microcirculation was evaluated using sidestream dark-field videomicroscopy. The first bolus of tetrahydrobiopterin blunted the increase in heart rate and cardiac index seen in the control group without affecting mean arterial pressure, and the second bolus of tetrahydrobiopterin prevented the decreases in cardiac index and mean arterial pressure. The reduction in mixed venous blood oxygen saturation and the increase in blood lactate seen in the control group were also delayed. Tetrahydrobiopterin significantly attenuated the deterioration in perfused small vessel proportion and density, microvascular flow index, and the increase in microvascular heterogeneity observed in the control group. Tetrahydrobiopterin was associated with better preserved lung compliance and PaO2/FIO2 ratio, which were associated with a lower lung wet/dry weight ratio at the end of the study. Median survival time was significantly prolonged in the tetrahydrobiopterin group (25.0 vs. 17.8 hrs, p<.01). CONCLUSION In this clinically relevant model of sepsis, tetrahydrobiopterin supplementation attenuated the impairment in sublingual microvascular perfusion and permeability, which was accompanied by better preserved gas exchange, renal flow and urine output, and prolonged survival.
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Affiliation(s)
- Xinrong He
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Raffay TM, Martin RJ, Reynolds JD. Can nitric oxide-based therapy prevent bronchopulmonary dysplasia? Clin Perinatol 2012; 39:613-38. [PMID: 22954273 PMCID: PMC3437658 DOI: 10.1016/j.clp.2012.06.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A growing understanding of endogenous nitric oxide (NO) biology is helping to explain how and when exogenous NO may confer benefit or harm; this knowledge is also helping to identify new better-targeted NO-based therapies. In this review, results of the bronchopulmonary dysplasia clinical trials that used inhaled NO in the preterm population are placed in context, the biologic basis for novel NO therapeutics is considered, and possible future directions for NO-focused clinical and basic research in developmental lung disease are identified.
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Affiliation(s)
- Thomas M. Raffay
- Division of Neonatology, Department of Pediatrics Rainbow Babies & Children’s Hospital, Case Medical Center/University Hospitals, Cleveland, Ohio
| | - Richard J. Martin
- Division of Neonatology, Department of Pediatrics Rainbow Babies & Children’s Hospital, Case Medical Center/University Hospitals, Cleveland, Ohio
| | - James D. Reynolds
- Department of Anesthesia and Perioperative Medicine, Case Medical Center/University Hospitals, Cleveland, Ohio
,Institute for Transformative Molecular Medicine, Case Medical Center/University Hospitals, Cleveland, Ohio
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22
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Top APC, Tasker RC, Ince C. The microcirculation of the critically ill pediatric patient. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:213. [PMID: 21457503 PMCID: PMC3219409 DOI: 10.1186/cc9995] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Anke P C Top
- Pediatric Intensive Care Unit, Cambridge University NHS Foundation Trust Hospital, Box 7, Hills Road, Cambridge, CB2 0QQ, UK.
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