1
|
Erdem Ö, de Graaff JC, Hilty MP, Kraemer US, de Liefde II, van Rosmalen J, Ince C, Tibboel D, Kuiper JW. Microcirculatory Monitoring in Children with Congenital Heart Disease Before and After Cardiac Surgery. J Cardiovasc Transl Res 2023; 16:1333-1342. [PMID: 37450208 PMCID: PMC10721654 DOI: 10.1007/s12265-023-10407-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023]
Abstract
In this prospective observational study, we investigated whether congenital heart disease (CHD) affects the microcirculation and whether the microcirculation is altered following cardiac surgery with cardiopulmonary bypass (CPB). Thirty-eight children with CHD undergoing cardiac surgery with CPB and 35 children undergoing elective, non-cardiac surgery were included. Repeated non-invasive sublingual microcirculatory measurements were performed with handheld vital microscopy. Before surgery, children with CHD showed similar perfused vessel densities and red blood cell velocities (RBCv) but less perfused vessels (p < 0.001), lower perfusion quality (p < 0.001), and higher small vessel densities (p = 0.039) than children without CHD. After cardiac surgery, perfused vessel densities and perfusion quality of small vessels declined (p = 0.025 and p = 0.032), while RBCv increased (p = 0.032). We demonstrated that CHD was associated with decreased microcirculatory perfusion and increased capillary recruitment. The microcirculation was further impaired after cardiac surgery. Decreased microcirculatory perfusion could be a warning sign for altered tissue oxygenation and requires further exploration.
Collapse
Affiliation(s)
- Özge Erdem
- Intensive Care and department of Pediatric Surgery, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Jurgen C de Graaff
- Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Matthias P Hilty
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Ulrike S Kraemer
- Intensive Care and department of Pediatric Surgery, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Inge I de Liefde
- Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Dick Tibboel
- Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jan Willem Kuiper
- Intensive Care and department of Pediatric Surgery, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| |
Collapse
|
2
|
A novel non-invasive method of measuring microcirculatory perfusion and blood velocity in infants: a pilot study. Sci Rep 2022; 12:7459. [PMID: 35523975 PMCID: PMC9076848 DOI: 10.1038/s41598-022-10911-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 04/08/2022] [Indexed: 11/16/2022] Open
Abstract
Current haemodynamic monitoring is mainly aimed at the macrocirculation. Multiple studies have demonstrated the importance of the microcirculation in relation to the patient’s condition and impact of treatment strategies. However, continuous monitoring of the microcirculation is not yet possible in the neonatal field. A novel dynamic light scattering (DLS) sensor technology for continuous monitoring of the microcirculation was investigated in the neonatal population. Thirty-one haemodynamically stable infants were included. Sequential measurements at the forehead, upper extremity, thorax, abdomen and lower extremity were conducted with the DLS sensor. For analyses stable measurements were selected. The DLS parameters, total blood flow (TBF) and relative blood velocity (RBV), were compared between measurement locations. Changes in relative haemodynamic indices (relHIs), indicating the distribution of blood flow in the microcirculatory blood vessels, were associated with heart rate decelerations. Measurements performed at the forehead had significantly lower TBF levels, compared to measurements at other locations. Early changes in relHIs around a heart rate deceleration were recorded a median (IQR) of 22.0 (13.5–27.0) s before the onset. Measurement of the currently unavailable parameters TBF, RBV and relHIs is possible with DLS technology. Validation of the DLS technology is needed for clinical implementation.
Collapse
|
3
|
Miranda RM, Cabral Filho JE, Diniz KT, Clough GF, Alves JGB, Lima GMS, Figueredo NPDS, França AAD, Luna JTB. Effect of Kangaroo Position on microcirculation of preterm newborns: a controlled randomized clinical trial. J Pediatr (Rio J) 2022; 98:196-203. [PMID: 34454941 PMCID: PMC9432287 DOI: 10.1016/j.jped.2021.05.012] [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: 07/19/2020] [Revised: 04/15/2021] [Accepted: 05/19/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE The objective of this study was to evaluate the effect of Kangaroo Position (KP) in microcirculation (MC) of the flexor muscles of preterm newborns. METHOD A controlled clinical trial was conducted in the city of Recife, Brazil, with 26 preterm children randomized in the Kangaroo Group (13) and in the Control Group (13). Assessments of blood flow, temperature, and tissue oxygen saturation (SO2) were made at two different times and in the biceps brachii muscle and hamstrings muscle group: before the KP and after 24 h of KP. In the Control Group, the registrations were performed at the times corresponding to those of the Kangaroo Group. The mean values among the times were analyzed by paired t-test for repeated measures. The clinical trial was recorded in Clinical Trials (NCT03611088). RESULTS In the Kangaroo Group there was an increase in tissue temperature and blood flow at the time evaluation periods (p < 0.05). In the control group, there was no statistical difference between the recording moments hamstring muscles group, but in the biceps brachii, there was a reduction in mean blood flow (p = 0.023). CONCLUSION In conclusion, the KP has effects on the microcirculation of the flexor muscles of preterm newborns.
Collapse
Affiliation(s)
- Rafael Moura Miranda
- Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Programa de Pós-Graduação, Recife, PE, Brazil.
| | - José Eulálio Cabral Filho
- Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Programa de Pós-Graduação, Recife, PE, Brazil
| | - Kaísa Trovão Diniz
- Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Programa de Pós-Graduação, Recife, PE, Brazil
| | | | - João Guilherme Bezerra Alves
- Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Programa de Pós-Graduação, Recife, PE, Brazil
| | | | | | | | | |
Collapse
|
4
|
Goloba M, Raghuraman R, Botros N, Khan U, Klein M, Brown A, Duffy D, Anim-Nyame N, Wang D, Manyonda I, Antonios TF. Early Life Microcirculatory Plasticity and Blood Pressure Changes in Low Birth Weight Infants Born to Normotensive Mothers: A Cohort Study. Am J Hypertens 2019; 32:570-578. [PMID: 30821323 PMCID: PMC6508166 DOI: 10.1093/ajh/hpz034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 02/20/2019] [Accepted: 02/27/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Capillary rarefaction (CR) is an established hallmark of essential hypertension (EH). The aim of this study was to examine early changes in capillary density (CD) and blood pressure (BP) in low birth weight (LBW) infants who are at risk of developing EH in later life. METHODS We studied 77 LBW infants and 284 normal birth weight (NBW) infants, all born to mothers with normotension, in a longitudinal multicenter study. Intravital capillaroscopy was used to measure functional basal capillary density (BCD) and maximal capillary density (MCD) at birth, 3, 6, and 12 months. RESULTS We found that LBW infants, born preterm and at term, had a significantly higher CD at birth, then underwent significant CR in the 1st 3 months culminating in a CD similar to that seen in NBW infants. NBW infants showed a gradual reduction in CD between birth and 12 months. Non-Caucasian ethnicity and preterm birth were significant predictors of a higher CD at birth. Systolic BP in NBW infants increased significantly from birth to 3 months, and we identified a significant negative correlation between systolic BP and MCD. CONCLUSIONS This study has identified a process of early “accelerated capillary remodeling” in LBW infants, which corrects their higher CD at birth. This remodeling is unlikely to explain the CR seen in adult individuals with, or at risk of developing EH. Further follow-up studies are required to determine the timing and mechanisms involved in CR, which is likely to occur after the 1st year of life but before early adulthood.
Collapse
Affiliation(s)
- Muti Goloba
- Molecular and Clinical Sciences Research Institute, St George’s, University of London, London, UK
- Blood Pressure Unit, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Rajendra Raghuraman
- Molecular and Clinical Sciences Research Institute, St George’s, University of London, London, UK
| | - Nansi Botros
- Molecular and Clinical Sciences Research Institute, St George’s, University of London, London, UK
| | - Uzma Khan
- Molecular and Clinical Sciences Research Institute, St George’s, University of London, London, UK
| | - Monique Klein
- Molecular and Clinical Sciences Research Institute, St George’s, University of London, London, UK
| | - Amelia Brown
- Molecular and Clinical Sciences Research Institute, St George’s, University of London, London, UK
| | - Donovan Duffy
- Neonatal Unit, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Nick Anim-Nyame
- Obstetrics and Gynaecology Department, Kingston Hospital NHS Foundation Trust, London, UK
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Isaac Manyonda
- Obstetrics and Gynaecology Department, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Tarek F Antonios
- Molecular and Clinical Sciences Research Institute, St George’s, University of London, London, UK
- Blood Pressure Unit, St George’s University Hospitals NHS Foundation Trust, London, UK
| |
Collapse
|
5
|
Raghuraman RP, Duffy D, Carroll VA, Manyonda I, Antonios TF. Oxygen therapy in premature low birth weight infants is associated with capillary loss and increases in blood pressure: a pilot study. J Hum Hypertens 2019; 34:278-285. [PMID: 31073155 DOI: 10.1038/s41371-019-0211-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/28/2019] [Accepted: 04/15/2019] [Indexed: 11/09/2022]
Abstract
Low birth weight (LBW) and premature birth are known risk factors for future cardiovascular disease and in particular essential hypertension (EH). Capillary rarefaction (CR) is an established hallmark of EH and is known to occur in individuals with a history of LBW. We previously reported that LBW infants do not have CR at birth but rather increased capillary density (CD). We hypothesized that LBW infants undergo a process of accelerated CR in early life, triggered in part by oxygen therapy. We studied 26 LBW infants, of whom 10 infants received oxygen therapy, and compared them to 14 normal birth weight (NBW) infants. We measured CD at 1, 5 and 10 days after birth and again after 40 weeks adjusted gestational age equivalent to birth at full term. We confirmed that LBW infants had higher CD at birth compared to NBW infants and found that significant structural CR occurred at term age in LBW infants who had received oxygen therapy (mean difference -22 capillaries/field, p = 0.007) and in those who did not receive oxygen therapy (mean difference -29 capillaries/field, p < 0.001) compared to baseline at birth. Both LBW groups showed a significant rise in BP at 40 weeks adjusted term age and the rise in systolic (mean difference 24 mm Hg, p < 0.0001) and diastolic BP (mean difference 14 mm Hg, p < 0.001) was more pronounced in the oxygen treated group compared to the nonoxygen group (mean difference 14 mm Hg, p = 0.043 and mean difference = 9 mm Hg p = 0.056 respectively). In conclusion, oxygen therapy in premature LBW infants may induce significant increases in their BP in early life.
Collapse
Affiliation(s)
- Rajendra P Raghuraman
- Molecular & Clinical Sciences Research Institute, St. George's, University of London, London, UK
| | - Donovan Duffy
- Neonatal Intensive Care Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Veronica A Carroll
- Molecular & Clinical Sciences Research Institute, St. George's, University of London, London, UK
| | - Isaac Manyonda
- Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Tarek F Antonios
- Molecular & Clinical Sciences Research Institute, St. George's, University of London, London, UK. .,Blood Pressure Unit, St George's University Hospitals NHS Foundation Trust, London, UK.
| |
Collapse
|
6
|
Puchwein-Schwepcke A, Grzybowski AK, Genzel-Boroviczény O, Nussbaum C. Effects of Prematurity on the Cutaneous Microcirculatory Network in the First Weeks of Life. Front Pediatr 2019; 7:198. [PMID: 31179253 PMCID: PMC6542985 DOI: 10.3389/fped.2019.00198] [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: 12/22/2018] [Accepted: 04/29/2019] [Indexed: 12/26/2022] Open
Abstract
Background: Preterm infants are at increased risk for hypertension in adolescence. Microcirculatory dysfunction has been identified as an underlying cause for cardiovascular disease. Our goal was to document the development of the cutaneous microcirculation in preterm infants during the first weeks of life and to compare it to the situation in term infants at birth. Methods: In 20 preterm infants, microcirculatory parameters were obtained prospectively by Sidestream Dark Field (SDF) Imaging at the upper inner arm once a week until discharge or 37 weeks of gestational age. A single microcirculatory measurement was obtained in 30 term infants during the first 3 days of life. Videos were blinded and analyzed with the AVA software. Results: Microcirculatory parameters in preterm infants differ significantly from term infants with a lower vessel surface (VS), a lower percentage of large and medium but higher percentage of small vessels, a higher Functional Vessel Density (FVD), and a higher Microcirculatory Flow Index (MFI). In multivariable linear regression models we could demonstrate a statistically significant association between the dependent microcirculatory variables (VS, diameter distribution, MFI) and gestational age as independent predictor variable while adjusting for postnatal days of life. Looking at the longitudinal follow-up data of preterm infants by means of a multivariable mixed-effects linear regression model adjusting for clinical variables, there is a significant decrease in FVD with increasing postnatal age, however no other significant changes in microcirculatory parameters over time. Accordingly, comparing the microcirculatory parameters of near term former preterm infants with term born neonates, we could still find significant differences with a higher FVD, lower VS and differences in vessel diameters in the former premature group. Conclusion: Infants born prematurely exhibit distinct microcirculatory alterations compared to term neonates with gestational age at birth being associated with microvascular parameters. Interestingly, this premature vascular phenotype persists even close to corrected term age. In view of the known increased cardiovascular risk of former preterm infants, our observations might have important clinical impact. The factors governing the development of the microvascular network in preterm infants and the contribution of microcirculatory changes observed here to vascular pathology in later life need to be further investigated.
Collapse
Affiliation(s)
| | - Ann-Kristin Grzybowski
- Divsion of Neonatology, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Orsolya Genzel-Boroviczény
- Divsion of Neonatology, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Claudia Nussbaum
- Divsion of Neonatology, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Erdem Ö, Kuiper JW, van Rosmalen J, Houmes RJ, Wildschut ED, Ince C, Tibboel D. The Sublingual Microcirculation Throughout Neonatal and Pediatric Extracorporeal Membrane Oxygenation Treatment: Is It Altered by Systemic Extracorporeal Support? Front Pediatr 2019; 7:272. [PMID: 31355165 PMCID: PMC6636383 DOI: 10.3389/fped.2019.00272] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 06/17/2019] [Indexed: 11/17/2022] Open
Abstract
Background: Extracorporeal membrane oxygenation (ECMO) treatment alleviates systemic cardiorespiratory failure. However, it is unclear whether ECMO also improves microcirculatory function, as the microcirculation can be disturbed despite normal systemic hemodynamics. We therefore aimed to study the sublingual microcirculation (SMC) throughout neonatal and pediatric ECMO treatment. We hypothesized that the SMC improves after starting ECMO, that the SMC differs between venovenous (VV) and venoarterial (VA) ECMO, and that insufficient recovery of microcirculatory disturbances during ECMO predicts mortality. Methods: This single-center prospective longitudinal observational study included 34 consecutive children (April 2016-September 2018). The SMC was assessed daily with a handheld vital microscope (integrated with incident dark field illumination) before, during, and after ECMO. Validated parameters of vessel density, perfusion, and flow quality were assessed for all vessels (diameter <100 μm) and small vessels (<20 μm). Linear mixed models and logistic regression models were built to assess changes over time and identify significant covariates. Using ROC curves, the predictive values of microcirculatory parameters were assessed for mortality on ECMO and overall mortality. Results: The study population comprised 34 patients (median age 0.27 years, 16 neonates, 16 females). Twelve patients were treated with VV and 22 with VA ECMO. Twelve patients died during ECMO (stopped due to futility) and 3 died after ECMO but before discharge. Microcirculatory parameters did not change significantly before, during or after ECMO. Except between microcirculatory flow index (MFI) and mean arterial pressure (MAP), no significant associations were found between microcirculatory parameters and global systemic hemodynamics. The probability of an undisturbed MFI (>2.6) increased with higher MAP (OR: 1.050, 95%CI: 1.008-1.094). Microcirculatory parameters did not significantly differ between VV and VA ECMO or between survivors and non-survivors. None of the microcirculatory parameters could predict mortality on ECMO or overall mortality. Conclusion: In this heterogeneous study population, we were not able to demonstrate an effect of ECMO on the sublingual microcirculation. Microcirculatory parameters did not change throughout ECMO treatment and did not differ between VV and VA ECMO or between survivors and non-survivors. Future research should focus on determining which neonatal and pediatric ECMO patients would benefit from microcirculatory monitoring and how.
Collapse
Affiliation(s)
- Özge Erdem
- 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
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Robert Jan Houmes
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Enno D Wildschut
- 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
| |
Collapse
|
9
|
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: 9] [Impact Index Per Article: 1.8] [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.
Collapse
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
| |
Collapse
|
10
|
Kara A, Akin S, Dos Reis Miranda D, Struijs A, Caliskan K, van Thiel RJ, Dubois EA, de Wilde W, Zijlstra F, Gommers D, Ince C. Microcirculatory assessment of patients under VA-ECMO. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:344. [PMID: 27776535 PMCID: PMC5078964 DOI: 10.1186/s13054-016-1519-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 09/30/2016] [Indexed: 12/03/2022]
Abstract
Background Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an effective technique for providing emergency mechanical circulatory support for patients with cardiogenic shock. VA-ECMO enables a rapid restoration of global systemic organ perfusion, but it has not been found to always show a parallel improvement in the microcirculation. We hypothesized in this study that the response of the microcirculation to the initiation of VA-ECMO might identify patients with increased chances of intensive care unit (ICU) survival. Methods Twenty-four patients were included in this study. Sublingual microcirculation measurements were performed using the CytoCam-IDF (incident dark field) imaging device. Microcirculatory measurements were performed at baseline, after VA-ECMO insertion (T1), 48–72 h after initiation of VA-ECMO (T2), 5–6 days after (T3), 9–10 days after (T4), and within 24 h of VA-ECMO removal. Results Of the 24 patients included in the study population, 15 survived and 9 died while on VA-ECMO. There was no significant difference between the systemic global hemodynamic variables at initiation of VA-ECMO between the survivors and non-survivors. There was, however, a significant difference in the microcirculatory parameters of both small and large vessels at all time points between the survivors and non-survivors. Perfused vessel density (PVD) at baseline (survivor versus non-survivor, 19.21 versus 13.78 mm/mm2, p = 0.001) was able to predict ICU survival on initiation of VA-ECMO; the area under the receiver operating characteristic curve (ROC) was 0.908 (95 % confidence interval 0.772–1.0). Conclusion PVD of the sublingual microcirculation at initiation of VA-ECMO can be used to predict ICU mortality in patients with cardiogenic shock. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1519-7) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Atila Kara
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. .,Department of Intensive Care, Hacettepe University Faculty of Medicine, Ankara, Turkey. .,Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.
| | - Sakir Akin
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.,Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Dinis Dos Reis Miranda
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Ard Struijs
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Kadir Caliskan
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Robert J van Thiel
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Eric A Dubois
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Wouter de Wilde
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| |
Collapse
|