1
|
Asmar R, Stergiou G, de la Sierra A, Jelaković B, Millasseau S, Topouchian J, Shirai K, Blacher J, Avolio A, Jankowski P, Parati G, Bilo G, Rewiuk K, Mintale I, Rajzer M, Agabiti-Rosei E, Ince C, Postadzhiyan A, Zimlichman R, Struijker-Boudier H, Benetos A, Bäck M, Tasic N, Sirenko Y, Zelveian P, Wang H, Fantin F, Kotovskaya Y, Ezhov M, Kotsis V. Blood pressure measurement and assessment of arterial structure and function: an expert group position paper. J Hypertens 2024:00004872-990000000-00493. [PMID: 38899971 DOI: 10.1097/hjh.0000000000003787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Measuring blood pressure (BP) and investigating arterial hemodynamics are essential in understanding cardiovascular disease and assessing cardiovascular risk. Several methods are used to measure BP in the doctor's office, at home, or over 24 h under ambulatory conditions. Similarly, several noninvasive methods have been introduced for assessing arterial structure and function; these methods differ for the large arteries, the small ones, and the capillaries. Consequently, when studying arterial hemodynamics, the clinician is faced with a multitude of assessment methods whose technical details, advantages, and limitations are sometimes unclear. Moreover, the conditions and procedures for their optimal implementation, and/or the reference normality values for the parameters they yield are not always taken into sufficient consideration. Therefore, a practice guideline summarizing the main methods and their use in clinical practice is needed. This expert group position paper was developed by an international group of scientists after a two-day meeting during which each of the most used methods and techniques for blood pressure measurement and arterial function and structure evaluation were presented and discussed, focusing on their advantages, limitations, indications, normal values, and their pragmatic clinical application.
Collapse
Affiliation(s)
- Roland Asmar
- Foundation-Medical Research Institutes. Paris France
| | - George Stergiou
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece
| | - Alejandro de la Sierra
- Hypertension Unit. Department of Internal Medicine. Hospital Mutua Terrassa. University of Barcelona, Spain
| | - Bojan Jelaković
- University hospital Centre Zagreb and University of Zagreb, School of Medicine. Zagreb, Croatia
| | | | - Jirar Topouchian
- Centre de diagnostic et de thérapeutique, Hôpital Hôtel-Dieu. Paris, France
| | - Kohji Shirai
- Toho University Sakura medical center, Department of Internal Medicine. Toho Japan
| | - Jacques Blacher
- Centre de diagnostic et de thérapeutique, Hôpital Hôtel-Dieu; AP-HP; Université Paris Cité, Paris, France
| | - Alberto Avolio
- Macquarie Medical School, Faculty of Medicine, Health and Humans Sciences, Macquarie University, Sydney, Australia
| | - Piotr Jankowski
- Department of Internal Medicine and Geriatric Cardiology, Medical Centre for Postgraduate Education, Warsaw, Poland
| | - Gianfranco Parati
- Department of Medicine and Surgery, University of Milano-Bicocca Milan, Italy
- IRCCS, Istituto Auxologico Italiano, Departmentof Cardiology, Milan, Italy
| | - Grzegorz Bilo
- Department of Medicine and Surgery, University of Milano-Bicocca Milan, Italy
- IRCCS, Istituto Auxologico Italiano, Departmentof Cardiology, Milan, Italy
| | - Krzysztof Rewiuk
- Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, Cracow, Poland
| | - Iveta Mintale
- Institute of Cardiology and Regenerative Medicine, Latvian Centre of Cardiology; Riga Latvia
| | - Marek Rajzer
- First Department of Cardiology, Interventional Electro-cardiology and Hypertension, Jagiellonian University Medical College, Krakow, Poland
| | - Enrico Agabiti-Rosei
- Department of Clinical and Experimental Sciences, University of Brescia and IRCCS Multimedica, Milan, Italy
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center, Dr Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | | | - Reuven Zimlichman
- The Brunner Institute for Cardiovascular Research, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | | | - Magnus Bäck
- Department of Medicine Solna, Karolinska Institutet and Department of Cardiology Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | - Hongyu Wang
- Department of Heart and Vascular Medicine, PKU Shougang Hospital, Beijing China
| | - Francesco Fantin
- Centre for Medical Sciences - CISMed, Department of Psychology and Cognitive Science, Section of Geriatric Medicine, University of Trento, Rovereto, Italy
| | - Yulia Kotovskaya
- Russian Clinical and Research Center of Gerontology - Pirogov Russian National Research Medical University, Moscow, Russia
| | - Marat Ezhov
- Myasnikov Clinical Cardiology Research Institute. Chazov National Medical Research Center of Cardiology. Moscow, Russia
| | - Vasilios Kotsis
- Department of Internal Medicine, Papageorgiou Hospital, Thessaloniki Greece
| |
Collapse
|
2
|
Bagramyan A, Lin CP. Miniaturized microscope for non-invasive imaging of leukocyte-endothelial interaction in human microcirculation. Sci Rep 2023; 13:17881. [PMID: 37857684 PMCID: PMC10587353 DOI: 10.1038/s41598-023-45018-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 10/14/2023] [Indexed: 10/21/2023] Open
Abstract
We present a miniature oblique back-illumination microscope (mOBM) for imaging the microcirculation of human oral mucosa, enabling real-time, label-free phase contrast imaging of individual leukocytes circulating in the bloodstream, as well as their rolling and adhesion on vascular walls-the initial steps in leukocyte recruitment that is a hallmark of inflammation. Using the mOBM system, we studied the leukocyte-endothelial interactions in healthy and locally inflamed tissue and observed drastic changes in leukocyte movement (velocity and displacement profile). Our findings suggest that real-time imaging of leukocyte dynamics can provide new diagnostic insights (assessment of inflammation, temporal progression of disease, evaluation of therapeutic response, etc.) that are not available using conventional static parameters such as cell number and morphology.
Collapse
Affiliation(s)
- Arutyun Bagramyan
- Wellman Center for Photomedicine and Center for Systems Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Charles P Lin
- Wellman Center for Photomedicine and Center for Systems Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
3
|
De Backer D. Novelties in the evaluation of microcirculation in septic shock. JOURNAL OF INTENSIVE MEDICINE 2023; 3:124-130. [PMID: 37188120 PMCID: PMC10175708 DOI: 10.1016/j.jointm.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/25/2022] [Accepted: 09/01/2022] [Indexed: 05/17/2023]
Abstract
Microvascular alterations were first described in critically ill patients about 20 years ago. These alterations are characterized by a decrease in vascular density and presence of non-perfused capillaries close to well-perfused vessels. In addition, heterogeneity in microvascular perfusion is a key finding in sepsis. In this narrative review, we report our actual understanding of microvascular alterations, their role in the development of organ dysfunction, and the implications for outcome. Herein, we discuss the state of the potential therapeutic interventions and the potential impact of novel therapies. We also discuss how recent technologic development may affect the evaluation of microvascular perfusion.
Collapse
|
4
|
Mota-Silva I, Castanho MARB, Silva-Herdade AS. Towards Non-Invasive Intravital Microscopy: Advantages of Using the Ear Lobe Instead of the Cremaster Muscle. Life (Basel) 2023; 13:life13040887. [PMID: 37109417 PMCID: PMC10145854 DOI: 10.3390/life13040887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/10/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023] Open
Abstract
Inflammation is essential in the protection of the organism and wound repair, but in cases of chronic inflammation can also cause microvasculature deterioration. Thus, inflammation monitorization studies are important to test potential therapeutics. The intravital microscopy (IVM) technique monitors leukocyte trafficking in vivo, being a commonly used procedure to report systemic conditions. Although the cremaster muscle, an established protocol for IVM, may affect the hemodynamics because of its surgical preparation, only male animals are used, and longitudinal studies over time are not feasible. Thinking how this impacts future studies, our aim is to understand if the IVM technique can be successfully performed using the ear lobe instead of the cremaster muscle. Elevated IL-1β plasmatic concentrations confirmed the systemic inflammation developed in a diabetic animal model, while the elevated number of adherent and rolling leukocytes in the ear lobe allowed for the same conclusion. Thus, this study demonstrates that albeit its thickness, the ear lobe protocol for IVM is efficient, non-invasive, more reliable, cost-effective and timesaving.
Collapse
|
5
|
Hof S, Marcus C, Kuebart A, Schulz J, Truse R, Raupach A, Bauer I, Flögel U, Picker O, Herminghaus A, Temme S. A Toolbox to Investigate the Impact of Impaired Oxygen Delivery in Experimental Disease Models. Front Med (Lausanne) 2022; 9:869372. [PMID: 35652064 PMCID: PMC9149176 DOI: 10.3389/fmed.2022.869372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/25/2022] [Indexed: 12/29/2022] Open
Abstract
Impaired oxygen utilization is the underlying pathophysiological process in different shock states. Clinically most important are septic and hemorrhagic shock, which comprise more than 75% of all clinical cases of shock. Both forms lead to severe dysfunction of the microcirculation and the mitochondria that can cause or further aggravate tissue damage and inflammation. However, the detailed mechanisms of acute and long-term effects of impaired oxygen utilization are still elusive. Importantly, a defective oxygen exploitation can impact multiple organs simultaneously and organ damage can be aggravated due to intense organ cross-talk or the presence of a systemic inflammatory response. Complexity is further increased through a large heterogeneity in the human population, differences in genetics, age and gender, comorbidities or disease history. To gain a deeper understanding of the principles, mechanisms, interconnections and consequences of impaired oxygen delivery and utilization, interdisciplinary preclinical as well as clinical research is required. In this review, we provide a "tool-box" that covers widely used animal disease models for septic and hemorrhagic shock and methods to determine the structure and function of the microcirculation as well as mitochondrial function. Furthermore, we suggest magnetic resonance imaging as a multimodal imaging platform to noninvasively assess the consequences of impaired oxygen delivery on organ function, cell metabolism, alterations in tissue textures or inflammation. Combining structural and functional analyses of oxygen delivery and utilization in animal models with additional data obtained by multiparametric MRI-based techniques can help to unravel mechanisms underlying immediate effects as well as long-term consequences of impaired oxygen delivery on multiple organs and may narrow the gap between experimental preclinical research and the human patient.
Collapse
Affiliation(s)
- Stefan Hof
- Department of Anaesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Carsten Marcus
- Department of Anaesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Anne Kuebart
- Department of Anaesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Jan Schulz
- Department of Anaesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Richard Truse
- Department of Anaesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Annika Raupach
- Department of Anaesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Inge Bauer
- Department of Anaesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Ulrich Flögel
- Experimental Cardiovascular Imaging, Department of Molecular Cardiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Olaf Picker
- Department of Anaesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Anna Herminghaus
- Department of Anaesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Sebastian Temme
- Department of Anaesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| |
Collapse
|
6
|
Bottari G, Ince C, Confalone V, Perdichizzi S, Casamento Tumeo C, Nunziata J, Bernardi S, Calò Carducci F, Lancella L, Bernaschi P, Russo C, Perno CF, Cecchetti C, Villani A. Case report: Microcirculatory leukocytes in a pediatric patient with severe SARS-CoV-2 pneumonia. Findings of leukocytes trafficking beyond the lungs. Front Pediatr 2022; 10:978381. [PMID: 36160802 PMCID: PMC9493019 DOI: 10.3389/fped.2022.978381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/09/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND SARS-CoV-2 can lead to excessive coagulation and thrombo-inflammation with deposition of microthrombi and microvascular dysfunction. Several studies in human and animal models have already evidenced biomarkers of endothelial injury during SARS-CoV-2 infection. Real-time observation of sublingual microcirculation using an handheld vital microscopy with an Incident Dark Field (IDF) technique could represent a non-invasive way to assess early signs of microvascular dysfunction and endothelial inflammation in patients with severe COVID-19 infection. CLINICAL CASE We report for the first time in a pediatric patient with severe SARS-CoV-2 pneumonia findings about microcirculatory leukocytes in the sublingual microcirculation of a 7 month-old patient admitted to our PICU using handheld vital microscopy with IDF technique. RESULTS Sublingual microcirculation analysis revealed the presence of microcirculatory alterations and an extensive presence of leukocytes in the patient's sublingual microcirculation. It's significant to underline how the patient didn't show a contextual significant increase in inflammatory biomarkers or other clinical signs related to an inflammatory response, beyond the presence of severe hypoxic respiratory failure. CONCLUSION Leukocyte activation in multiple organs can occur at the endothelial lining of the microvasculature where a surge of pro-inflammatory mediators can result in accumulation of activated leukocytes and degradation of the endothelium. The introduction of a method to assess in a non-invasive, real-time manner the extent of inflammation in a patient with COVID19 could lead to potential clinical and therapeutic implications. However, more studies are required to prove that studying leukocytes microcirculation using sublingual microcirculation analysis could be useful as a bedside point of care monitor to predict the presence of systemic inflammation associated with the impact of COVID-19, leading in a late phase of severe SARS-CoV-2 infection to a microvascular dysfunction and micro-thrombosis.
Collapse
Affiliation(s)
- Gabriella Bottari
- Pediatric Intensive Care Unit, Department of Emergency and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Valerio Confalone
- Pediatric Intensive Care Unit, Department of Emergency and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Salvatore Perdichizzi
- Pediatric Intensive Care Unit, Department of Emergency and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Chiara Casamento Tumeo
- Department of Pediatrics, Residency School of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, University of Rome Tor Vergata, Rome, Italy
| | - Joseph Nunziata
- Pediatric Intensive Care Unit, Department of Emergency and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Stefania Bernardi
- Infectious Diseases and Immuno-Infectiology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesca Calò Carducci
- Infectious Diseases and Immuno-Infectiology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Laura Lancella
- Infectious Diseases and Immuno-Infectiology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paola Bernaschi
- Unit of Microbiology and Diagnostic Immunology, Department of Diagnostic and Laboratory Medicine, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Cristina Russo
- Virology and Mycobacteria Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.,Multimodal Medicine Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Carlo Federico Perno
- Multimodal Medicine Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.,Unit of Microbiology and Diagnostic Immunology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Corrado Cecchetti
- Pediatric Intensive Care Unit, Department of Emergency and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alberto Villani
- General Pediatric and Infectious Disease Unit, Department of Emergency and General Pediatrics, Bambino Gesù Children's Hospital, IRCSS, Rome, Italy
| |
Collapse
|
7
|
Zhao Z, Patrinely JR, Saknite I, Byrne M, Tkaczyk ER. Guideline for in vivo assessment of adherent and rolling leukocytes in human skin microvasculature via reflectance confocal videomicroscopy. Microcirculation 2021; 28:e12725. [PMID: 34409720 DOI: 10.1111/micc.12725] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 06/23/2021] [Accepted: 08/11/2021] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To develop a guideline that reliably identifies cutaneous adherent and rolling leukocytes from mimicking scenarios via in vivo reflectance confocal videomicroscopy. METHODS We used a clinical reflectance confocal microscope, the VivaScope 1500, to acquire 1522 videos of the upper dermal microcirculation from 12 healthy subjects and 60 patients after allogeneic hematopoietic cell transplantation. Blinded to clinical information, two trained raters independently counted the number of adherent and rolling leukocytes in 88 videos. Based on discrepancies in the initial assessments, we developed a guideline to identify both types of leukocyte-endothelial interactions via a modified Delphi method (without anonymity). To test the guideline's ability to improve the inter-rater reliability, the two raters assessed the remaining 1434 videos by using the guideline. RESULTS We demonstrate a guideline that consists of definitions, a step-by-step flowchart, and corresponding visuals of adherent and rolling leukocytes and mimicking scenarios. The guideline improved the inter-rater reliability of the manual assessment of both interactions. The intraclass correlation coefficient (ICC) of adherent leukocyte counts increased from 0.056 (95% confidence interval: 0-0.236, n = 88 videos, N = 10 subjects) to 0.791 (0.770-0.809, n = 1434, N = 67). The ICC of rolling leukocyte counts increased from 0.385 (0.191-0.550, n = 88, N = 10) to 0.626 (0.593-0.657, n = 1434, N = 67). Intra-rater ICC post-guideline was 0.953 (0.886-0.981, n = 20, N = 12) and 0.956 (0.894-0.983, n = 20, N = 12) for adherent and rolling, respectively. CONCLUSION The guideline aids in the manual identification of adherent and rolling leukocytes via in vivo reflectance confocal videomicroscopy.
Collapse
Affiliation(s)
- Zijun Zhao
- Dermatology Service and Research Service, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN, USA.,Department of Dermatology, Vanderbilt University Medical Center, Vanderbilt Dermatology Translational Research Clinic, Nashville, TN, USA.,Vanderbilt University School of Medicine, Nashville, TN, USA
| | - James Randall Patrinely
- Dermatology Service and Research Service, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN, USA.,Department of Dermatology, Vanderbilt University Medical Center, Vanderbilt Dermatology Translational Research Clinic, Nashville, TN, USA.,Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Inga Saknite
- Department of Dermatology, Vanderbilt University Medical Center, Vanderbilt Dermatology Translational Research Clinic, Nashville, TN, USA
| | - Michael Byrne
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
| | - Eric R Tkaczyk
- Dermatology Service and Research Service, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN, USA.,Department of Dermatology, Vanderbilt University Medical Center, Vanderbilt Dermatology Translational Research Clinic, Nashville, TN, USA.,Vanderbilt University School of Medicine, Nashville, TN, USA.,Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA.,Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
| |
Collapse
|
8
|
Favaron E, Ince C, Hilty MP, Ergin B, van der Zee P, Uz Z, Wendel Garcia PD, Hofmaenner DA, Acevedo CT, van Boven WJ, Akin S, Gommers D, Endeman H. Capillary Leukocytes, Microaggregates, and the Response to Hypoxemia in the Microcirculation of Coronavirus Disease 2019 Patients. Crit Care Med 2021; 49:661-670. [PMID: 33405410 PMCID: PMC7963442 DOI: 10.1097/ccm.0000000000004862] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES In this study, we hypothesized that coronavirus disease 2019 patients exhibit sublingual microcirculatory alterations caused by inflammation, coagulopathy, and hypoxemia. DESIGN Multicenter case-controlled study. SETTING Two ICUs in The Netherlands and one in Switzerland. PATIENTS Thirty-four critically ill coronavirus disease 2019 patients were compared with 33 healthy volunteers. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The microcirculatory parameters quantified included total vessel density (mm × mm-2), functional capillary density (mm × mm-2), proportion of perfused vessels (%), capillary hematocrit (%), the ratio of capillary hematocrit to systemic hematocrit, and capillary RBC velocity (μm × s-1). The number of leukocytes in capillary-postcapillary venule units per 4-second image sequence (4 s-1) and capillary RBC microaggregates (4 s-1) was measured. In comparison with healthy volunteers, the microcirculation of coronavirus disease 2019 patients showed increases in total vessel density (22.8 ± sd 5.1 vs 19.9 ± 3.3; p < 0.0001) and functional capillary density (22.2 ± 4.8 vs 18.8 ± 3.1; p < 0.002), proportion of perfused vessel (97.6 ± 2.1 vs 94.6 ± 6.5; p < 0.01), RBC velocity (362 ± 48 vs 306 ± 53; p < 0.0001), capillary hematocrit (5.3 ± 1.3 vs 4.7 ± 0.8; p < 0.01), and capillary-hematocrit-to-systemic-hematocrit ratio (0.18 ± 0.0 vs 0.11 ± 0.0; p < 0.0001). These effects were present in coronavirus disease 2019 patients with Sequential Organ Failure Assessment scores less than 10 but not in patients with Sequential Organ Failure Assessment scores greater than or equal to 10. The numbers of leukocytes (17.6 ± 6.7 vs 5.2 ± 2.3; p < 0.0001) and RBC microaggregates (0.90 ± 1.12 vs 0.06 ± 0.24; p < 0.0001) was higher in the microcirculation of the coronavirus disease 2019 patients. Receiver-operating-characteristics analysis of the microcirculatory parameters identified the number of microcirculatory leukocytes and the capillary-hematocrit-to-systemic-hematocrit ratio as the most sensitive parameters distinguishing coronavirus disease 2019 patients from healthy volunteers. CONCLUSIONS The response of the microcirculation to coronavirus disease 2019-induced hypoxemia seems to be to increase its oxygen-extraction capacity by increasing RBC availability. Inflammation and hypercoagulation are apparent in the microcirculation by increased numbers of leukocytes and RBC microaggregates.
Collapse
Affiliation(s)
- Emanuele Favaron
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Matthias P Hilty
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zürich, Switzerland
| | - Bülent Ergin
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Philip van der Zee
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Zühre Uz
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Pedro D Wendel Garcia
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zürich, Switzerland
| | - Daniel A Hofmaenner
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zürich, Switzerland
| | - Claudio T Acevedo
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, Zürich, Switzerland
| | - Wim Jan van Boven
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Sakir Akin
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Intensive Care, Haga Hospital, The Hague, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
9
|
Uz Z, Ince C, Shen L, Ergin B, van Gulik TM. Real-time observation of microcirculatory leukocytes in patients undergoing major liver resection. Sci Rep 2021; 11:4563. [PMID: 33633168 PMCID: PMC7907405 DOI: 10.1038/s41598-021-83677-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 02/01/2021] [Indexed: 12/12/2022] Open
Abstract
Ischemia/reperfusion injury and inflammation are associated with microcirculatory dysfunction, endothelial injury and glycocalyx degradation. This study aimed to assess microcirculation in the sublingual, intestinal and the (remnant) liver in patients undergoing major liver resection, to define microcirculatory leukocyte activation and its association with glycocalyx degradation. In this prospective observational study, the microcirculation was assessed at the beginning of surgery (T0), end of surgery (T1) and 24 h after surgery (T2) using Incident Dark Field imaging. Changes in vessel density, blood flow and leukocyte behaviour were monitored, as well as clinical parameters. Syndecan-1 levels as a parameter of glycocalyx degradation were analysed. 19 patients were included. Sublingual microcirculation showed a significant increase in the number of rolling leukocytes between T0 and T1 (1.5 [0.7-1.8] vs. 3.7 [1.7-5.4] Ls/C-PCV/4 s respectively, p = 0.001), and remained high at T2 when compared to T0 (3.8 [3-8.5] Ls/C-PCV/4 s, p = 0.006). The microvascular flow decreased at T2 (2.4 ± 0.3 vs. baseline 2.8 ± 0.2, respectively, p < 0.01). Duration of vascular inflow occlusion was associated with significantly higher numbers of sublingual microcirculatory rolling leukocytes. Syndecan-1 increased from T0 to T1 (42 [25-56] vs. 107 [86-164] ng/mL, p < 0.001). The microcirculatory perfusion was characterized by low convection capacity and high number of rolling leukocytes. The ability to sublingually monitor the rolling behaviour of the microcirculatory leukocytes allows for early identification of patients at risk of increased inflammatory response following major liver resection.
Collapse
Affiliation(s)
- Zühre Uz
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Department of Translational Physiology, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - C Ince
- Department of Translational Physiology, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Intensive Care Adults, Erasmus MC, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - L Shen
- Department of Translational Physiology, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Intensive Care Adults, Erasmus MC, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - B Ergin
- Department of Intensive Care Adults, Erasmus MC, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - T M van Gulik
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| |
Collapse
|
10
|
Uz Z, Shen L, Milstein DMJ, van Lienden KP, Swijnenburg RJ, Ince C, van Gulik TM. Intraoperative Imaging Techniques to Visualize Hepatic (Micro)Perfusion: An Overview. Eur Surg Res 2020; 61:2-13. [PMID: 32659780 DOI: 10.1159/000508348] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 04/14/2020] [Indexed: 12/13/2022]
Abstract
The microcirculation plays a crucial role in the distribution of perfusion to organs. Studies have shown that microcirculatory dysfunction is an independent predictor of morbidity and mortality. Hence, assessment of liver perfusion offers valuable information on the (patho)physiological state of the liver. The current review explores techniques in perfusion imaging that can be used intraoperatively. Available modalities include dynamic contrast-enhanced ultrasound, handheld vital microscopes, indocyanine green fluorescence angiography, and laser contrast speckle imaging. Dynamic contrast-enhanced ultrasound relays information on deep tissue perfusion and is a commonly used technique to assess tumor perfusion. Handheld vital microscopes provide direct visualization of the sinusoidal architectural structure of the liver, which is a unique feature of this technique. Intraoperative fluorescence imaging uses indocyanine green, a dye that is administered intravenously to visualize microvascular perfusion when excited using near-infrared light. Laser speckle contrast imaging produces non-contact large surface-based tissue perfusion imaging free from movement- or pressure-related artefacts. In this review, we discuss the intrinsic advantages and disadvantages of these techniques and their clinical and/or scientific applications.
Collapse
Affiliation(s)
- Zühre Uz
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands, .,Department of Translational Physiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands,
| | - Lucinda Shen
- Department of Translational Physiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care Adults, Erasmus MC, Rotterdam, The Netherlands
| | - Dan M J Milstein
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Krijn P van Lienden
- Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Rutger-Jan Swijnenburg
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Can Ince
- Department of Translational Physiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care Adults, Erasmus MC, Rotterdam, The Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
11
|
Dilken O, Ergin B, Ince C. Assessment of sublingual microcirculation in critically ill patients: consensus and debate. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:793. [PMID: 32647718 PMCID: PMC7333125 DOI: 10.21037/atm.2020.03.222] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The main concern in shock and resuscitation is whether the microcirculation can carry adequate oxygen to the tissues and remove waste. Identification of an intact coherence between macro- and microcirculation during states of shock and resuscitation shows a functioning regulatory mechanism. However, loss of hemodynamic coherence between the macro and microcirculation can be encountered frequently in sepsis, cardiogenic shock, or any hemodynamically compromised patient. This loss of hemodynamic coherence results in an improvement in macrohemodynamic parameters following resuscitation without a parallel improvement in microcirculation resulting in tissue hypoxia and tissue compromise. Hand-held vital microscopes (HVMs) can visualize the microcirculation and help to diagnose the nature of microcirculatory shock. Although treatment with the sole aim of recruiting the microcirculation is as yet not realized, interventions can be tailored to the needs of the patient while monitoring sublingual microcirculation. With the help of the newly introduced software, called MicroTools, we believe sublingual microcirculation monitoring and diagnosis will be an essential point-of-care tool in managing shock patients.
Collapse
Affiliation(s)
- Olcay Dilken
- Department of Intensive Care Med, Laboratory of Translational Intensive Care Med, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Intensive Care, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Bulent Ergin
- Department of Intensive Care Med, Laboratory of Translational Intensive Care Med, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care Med, Laboratory of Translational Intensive Care Med, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
12
|
Coppel J, Bountziouka V, Martin D, Gilbert-Kawai E. A comparison of the quality of image acquisition between two different sidestream dark field video-microscopes. J Clin Monit Comput 2020; 35:577-583. [PMID: 32372288 PMCID: PMC8084773 DOI: 10.1007/s10877-020-00514-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 04/27/2020] [Indexed: 12/18/2022]
Abstract
Sidestream dark field (SDF) imaging enables direct visualisation of the microvasculature from which quantification of key variables is possible. The new MicroScan USB3 (MS-U) video-microscope is a hand-held SDF device that has undergone significant technical upgrades from its predecessor, the MicroScan Analogue (MS-A). The MS-U claims superior quality of sublingual microcirculatory image acquisition over the MS-A, however, this has yet to be robustly confirmed. In this manuscript, we therefore compare the quality of image acquisition between these two devices. The microcirculation of healthy volunteers was visualised to generate thirty video images for each device. Two independent raters, blinded to the device type, graded the quality of the images according to the six different traits in the Microcirculation Image Quality Score (MIQS) system. Chi-squared tests and Kappa statistics were used to compare not only the distribution of scores between the devices, but also agreement between raters. MS-U showed superior image quality over MS-A in three of out six MIQS traits; MS-U had significantly more optimal images by illumination (MS-U 95% optimal images, MS-A 70% optimal images (p-value 0.003)), by focus (MS-U 70% optimal images, MS-A 35% optimal images (p-value 0.002)) and by pressure (MS-U 72.5% optimal images, MS-A 47.5% optimal images (p-value 0.02)). For each trait, there was at least 85% agreement between the raters, and all the scores for each trait were independent of the rater (all p-values > 0.05). These results show that the new MS-U provides a superior quality of sublingual microcirculatory image acquisition when compared to old MS-A
Collapse
Affiliation(s)
- Jonny Coppel
- University College London Centre for Altitude Space and Extreme Environment Medicine, UCLH NIHR Biomedical Research Centre, Institute of Sport Exercise and Health, 170 Tottenham Court Road, London, W1T 7HA, UK.
| | - Vassiliki Bountziouka
- Statistical Support Service, Population, Policy and Practice Programme, Institute of Child Health, University College London, London, England
| | - Daniel Martin
- University College London Centre for Altitude Space and Extreme Environment Medicine, UCLH NIHR Biomedical Research Centre, Institute of Sport Exercise and Health, 170 Tottenham Court Road, London, W1T 7HA, UK.,University College London Division of Surgery and Interventional Science, Royal Free Hospital, London, NW3 2QG, UK
| | - Edward Gilbert-Kawai
- University College London Centre for Altitude Space and Extreme Environment Medicine, UCLH NIHR Biomedical Research Centre, Institute of Sport Exercise and Health, 170 Tottenham Court Road, London, W1T 7HA, UK
| |
Collapse
|
13
|
Guven G, Hilty MP, Ince C. Microcirculation: Physiology, Pathophysiology, and Clinical Application. Blood Purif 2019; 49:143-150. [PMID: 31851980 DOI: 10.1159/000503775] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 09/28/2019] [Indexed: 12/17/2022]
Abstract
This paper briefly reviews the physiological components of the microcirculation, focusing on its function in homeostasis and its central function in the realization of oxygen transport to tissue cells. Its pivotal role in the understanding of circulatory compromise in states of shock and renal compromise is discussed. Our introduction of hand-held vital microscopes (HVM) to clinical medicine has revealed the importance of the microcirculation as a central target organ in states of critical illness and inadequate response to therapy. Technical and methodological developments have been made in hardware and in software including our recent introduction and validation of automatic analysis software called MicroTools, which now allows point-of-care use of HVM imaging at the bedside for instant availability of functional microcirculatory parameters needed for microcirculatory targeted resuscitation procedures to be a reality.
Collapse
Affiliation(s)
- Goksel Guven
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Matthias P Hilty
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands,
| |
Collapse
|
14
|
Kastelein AW, Diedrich CM, de Waal L, Ince C, Roovers JPWR. The vaginal microcirculation after prolapse surgery. Neurourol Urodyn 2019; 39:331-338. [PMID: 31691336 PMCID: PMC7004127 DOI: 10.1002/nau.24203] [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: 07/31/2019] [Accepted: 10/20/2019] [Indexed: 01/08/2023]
Abstract
Aims Oxygen plays a crucial role in wound healing after prolapse surgery. Trauma to the vaginal vasculature might limit the delivery of oxygen to the surgical wound, which may negatively affect wound healing and regeneration of connective tissue. This possibly increases the future risk of recurrence. We aimed to determine the effects of vaginal prolapse surgery on the microcirculation of the vaginal wall. Methods We evaluated the vaginal microcirculation in healthy participants without known vascular disease undergoing anterior and/or posterior colporrhaphy. We used incident dark‐field imaging for in vivo assessment before and after (1 day, 2 weeks, and 6 weeks) surgery. We studied perfusion (microvascular flow index [MFI]), angioarchitecture (morphology/layout of microvessels) and capillary density. Results Ten women were included. Interindividual differences were observed 1 day postoperatively with regard to perfusion and angioarchitecture. Microvascular flow at the surgical site was absent or significantly reduced in some participants, whereas normal microvascular flow was observed in others (MFI range 0–3). Perfusion and angioarchitecture had been restored in all participants after 6 weeks (MFI range 2–3), regardless of the extent of vascular trauma 1 day postoperatively. Conclusions The difference in the extent of vascular trauma between women undergoing seemingly identical surgical procedures suggests that some individuals are more susceptible to vascular trauma than others. Delivery of oxygen to the wound and subsequent wound healing may be compromised in these cases, which could be related to the development of anatomical recurrence. Future studies should investigate whether there is a relationship between the vaginal microvasculature and the recurrence of prolapse.
Collapse
Affiliation(s)
- Arnoud W Kastelein
- Department of Obstetrics and Gynaecology, University of Amsterdam, Amsterdam, The Netherlands
| | - Chantal M Diedrich
- Department of Obstetrics and Gynaecology, University of Amsterdam, Amsterdam, The Netherlands
| | - Laura de Waal
- Department of Obstetrics and Gynaecology, University of Amsterdam, Amsterdam, The Netherlands
| | - Can Ince
- Department of Translational Physiology, University of Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jan-Paul W R Roovers
- Department of Obstetrics and Gynaecology, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
15
|
Uz Z, Aykut G, Massey M, Ince Y, Ergin B, Shen L, Toraman F, van Gulik TM, Ince C. Leukocyte-Endothelium Interaction in the Sublingual Microcirculation of Coronary Artery Bypass Grafting Patients. J Vasc Res 2019; 57:8-15. [PMID: 31505501 DOI: 10.1159/000501826] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 07/01/2019] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE The aim of this study was to apply an innovative methodology to incident dark-field (IDF) imaging in coronary artery bypass grafting (CABG) patients for the identification and quantification of rolling leukocytes along the sublingual microcirculatory endothelium. METHODS This study was a post hoc analysis of a prospective study that evaluated the perioperative course of the sublingual microcirculation in CABG patients. Video images were captured using IDF imaging following the induction of anesthesia (T0) and cardiopulmonary bypass (CPB) (T1) in 10 patients. Rolling leukocytes were identified and quantified using frame averaging, which is a technique that was developed for correctly identifying leukocytes. RESULTS The number of rolling leukocytes increased significantly from T0 (7.5 [6.4-9.1] leukocytes/capillary-postcapillary venule/4 s) to T1 (14.8 [13.2-15.5] leukocytes/capillary-postcapillary venule/4 s) (p < 0.0001). A significant increase in systemic leukocyte count was also detected from 7.4 ± 0.9 × 109/L (preoperative) to 12.4 ± 4.4 × 109/L (postoperative) (p < 0.01). CONCLUSION The ability to directly visualize leukocyte-endothelium interaction using IDF imaging facilitates the diagnosis of a systemic inflammatory response after CPB via the identification of rolling leukocytes. Integration of the frame averaging algorithm into the software of handheld vital microscopes may enable the use of microcirculatory leukocyte count as a real-time parameter at the bedside.
Collapse
Affiliation(s)
- Zühre Uz
- Department of Translational Physiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands, .,Department of Experimental Surgery and Translational Physiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands,
| | - Güçlü Aykut
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Michael Massey
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Yasin Ince
- Department of Translational Physiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bülent Ergin
- Department of Translational Physiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Lucinda Shen
- Department of Translational Physiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Fevzi Toraman
- Department of Anesthesiology and Reanimation, Acıbadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Turkey
| | - Thomas M van Gulik
- Department of Experimental Surgery and Translational Physiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Can Ince
- Department of Translational Physiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
16
|
Marini JJ, DeBacker D, Gattinoni L, Ince C, Martin-Loeches I, Singer P, Singer M, Westphal M, Vincent JL. Thinking forward: promising but unproven ideas for future intensive care. Crit Care 2019; 23:197. [PMID: 31200781 PMCID: PMC6570630 DOI: 10.1186/s13054-019-2462-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 04/29/2019] [Indexed: 12/22/2022] Open
Abstract
Progress toward determining the true worth of ongoing practices or value of recent innovations can be glacially slow when we insist on following the conventional stepwise scientific pathway. Moreover, a widely accepted but flawed conceptual paradigm often proves difficult to challenge, modify or reject. Yet, most experienced clinicians, educators and clinical scientists privately entertain untested ideas about how care could or should be improved, even if the supporting evidence base is currently thin or non-existent. This symposium encouraged experts to share such intriguing but unproven concepts, each based upon what the speaker considered a logical but unproven rationale. Such free interchange invited dialog that pointed toward new or neglected lines of research needed to improve care of the critically ill. In this summary of those presentations, a brief background outlines the rationale for each novel and deliberately provocative unconfirmed idea endorsed by the presenter.
Collapse
Affiliation(s)
- John J. Marini
- Regions Hospital, University of Minnesota, MS11203B, 640 Jackson Street, Minneapolis/St.Paul, MN 55101 USA
| | | | | | - Can Ince
- Erasmus University Medical Center, Rotterdam, Netherlands
| | | | | | - Mervyn Singer
- University College London Medical School, London, UK
| | | | | |
Collapse
|
17
|
He H, Hu Q, Long Y, Wang X, Zhang R, Su L, Liu D, Ince C. Effects of high PEEP and fluid administration on systemic circulation, pulmonary microcirculation, and alveoli in a canine model. J Appl Physiol (1985) 2019; 127:40-46. [PMID: 31070956 DOI: 10.1152/japplphysiol.00571.2018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
This study aimed to determine the response of systemic circulation, pulmonary microcirculation, and alveoli to high positive end-expiratory pressure (PEEP) in a canine model. This study was conducted in nine mixed-breed dogs on mechanical ventilation under anesthesia. The PEEP was initially set at 5 cmH2O (PEEP5), the PEEP was then increased to 25 cmH2O (PEEP25), and then saline was used for fluid loading. Data were obtained at the following time points: PEEP5; PEEP25 prefluid loading; and PEEP25 postfluid loading. The images of subpleural lung microcirculation were assessed by sidestream dark-field microscopy, and the hemodynamic data were collected from pulse contour waveform-derived measurements. Compared with PEEP5, the lung microvascular flow index (MFI, 2.3 ± 0.8 versus 0.9 ± 0.8, P = 0.001), lung perfused vessel density (PVD, 4.2 ± 2 versus 1.5 ± 1.8, P = 0.004), lung proportion of perfused vessel (PPV, 93 ± 14 versus 40 ± 4, P = 0.003), cardiac output (2.5 ± 0.6 versus 1.4 ± 0.5, P = 0.001), and mean blood pressure (116 ± 24 versus 91 ± 31, P = 0.012) were significantly lower at PEEP25 prefluid loading. After fluid loading, there were no significant differences in cardiac output or mean arterial pressure between the PEEP5 and PEEP25 postfluid loading levels. However, the lung microcirculatory MFI, PVD, and PPV at PEEP25 postfluid loading remain lower than at PEEP5. A significant increase in septal thickness was found at PEEP25 postfluid loading relative to septal thickness at PEEP25 prefluid loading (25.98 ± 5.31 versus 40.76 ± 7.9, P = 0.001). Under high PEEP, systemic circulation was restored after fluid loading, but lung microcirculation was not. Moreover, the septal thickness of alveoli significantly increased after fluid loading.NEW & NOTEWORTHY An excessively high positive end-expiratory pressure (PEEP) can impair the systemic circulation and alveolar microcirculation. In the high-PEEP condition, fluid loading restored the systemic circulation but did not affect the impaired lung microcirculation. The septal thickness of the alveoli significantly increased after fluid loading in the high-PEEP condition.
Collapse
Affiliation(s)
- Huaiwu He
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Qinhe Hu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China.,Department of Critical Care Medicine, Affiliated Hospital of Jining Medical University, Jining, China
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Xu Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Rui Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Longxiang Su
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Can Ince
- Department of Intensive Care, Erasmus MC University Hospital Rotterdam, Netherlands
| |
Collapse
|
18
|
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
|
19
|
Pietrasanta C, Pugni L, Ronchi A, Bottino I, Ghirardi B, Sanchez-Schmitz G, Borriello F, Mosca F, Levy O. Vascular Endothelium in Neonatal Sepsis: Basic Mechanisms and Translational Opportunities. Front Pediatr 2019; 7:340. [PMID: 31456998 PMCID: PMC6700367 DOI: 10.3389/fped.2019.00340] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 07/30/2019] [Indexed: 12/27/2022] Open
Abstract
Neonatal sepsis remains a major health issue worldwide, especially for low-birth weight and premature infants, with a high risk of death and devastating sequelae. Apart from antibiotics and supportive care, there is an unmet need for adjunctive treatments to improve the outcomes of neonatal sepsis. Strong and long-standing research on adult patients has shown that vascular endothelium is a key player in the pathophysiology of sepsis and sepsis-associated organ failure, through a direct interaction with pathogens, leukocytes, platelets, and the effect of soluble circulating mediators, in part produced by endothelial cells themselves. Despite abundant evidence that the neonatal immune response to sepsis is distinct from that of adults, comparable knowledge on neonatal vascular endothelium is much more limited. Neonatal endothelial cells express lower amounts of adhesion molecules compared to adult ones, and present a reduced capacity to neutralize reactive oxygen species. Conversely, available evidence on biomarkers of endothelial damage in neonates is not as robust as in adult patients, and endothelium-targeted therapeutic opportunities for neonatal sepsis are almost unexplored. Here, we summarize current knowledge on the structure of neonatal vascular endothelium, its interactions with neonatal immune system and possible endothelium-targeted diagnostic and therapeutic tools for neonatal sepsis. Furthermore, we outline areas of basic and translational research worthy of further study, to shed light on the role of vascular endothelium in the context of neonatal sepsis.
Collapse
Affiliation(s)
- Carlo Pietrasanta
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Precision Vaccines Program, Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, United States
| | - Lorenza Pugni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Andrea Ronchi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Ilaria Bottino
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Beatrice Ghirardi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Guzman Sanchez-Schmitz
- Precision Vaccines Program, Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Francesco Borriello
- Precision Vaccines Program, Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States.,Division of Immunology, Boston Children's Hospital, Boston, MA, United States.,Department of Translational Medical Sciences, Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,World Allergy Organisation Center of Excellence, Naples, Italy
| | - Fabio Mosca
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Ofer Levy
- Precision Vaccines Program, Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States.,Broad Institute of MIT and Harvard, Cambridge, MA, United States
| |
Collapse
|