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De Cuyper H, Poelaert J. Microcirculatory Alterations in Cardiac Surgery: A Comprehensive Guide. J Cardiothorac Vasc Anesth 2024; 38:829-838. [PMID: 38195271 DOI: 10.1053/j.jvca.2023.11.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/09/2023] [Accepted: 11/29/2023] [Indexed: 01/11/2024]
Abstract
Microcirculation is essential for cellular life and its functions. It comprises a complex network of capillaries, arterioles, and venules, which distributes oxygenated blood across and within organs based on regional metabolic demands. Because previous research indicated that organ function is linked to microcirculatory function, it is crucial to maintain sufficient and effective microcirculatory function during major surgery. Impaired microcirculation can lead to inadequate tissue perfusion, potentially resulting in perioperative complications and an unfavorable outcome. Indeed, changes in microcirculation in cardiovascular disease and cardiac surgery have a direct correlation with prolonged stays in the postoperative intensive care unit and high mortality rates within 30 days. Additionally, cardiopulmonary bypass, a regularly employed method in cardiac surgery, has been proven to induce microcirculatory malfunction and, thus, lead to postoperative multiple organ dysfunction. As global hemodynamic parameters can remain stable or improve, whereas microcirculation is still compromised, tracking microcirculatory variables could lead to the development of targeted microcirculatory treatment within hemodynamic management. Therefore, it is necessary to enhance the use of microcirculatory monitoring in the medical domain to assist physicians in the therapeutic management of patients undergoing cardiac surgery. This potentially can lead to better hemodynamic management and outcomes. This review article concentrates on the use of handheld video microscopes for real-time microcirculatory assessment of cardiac surgery patients in the immediate and early postoperative period. Emphasis is placed on integrating microcirculatory monitoring with conventional hemodynamic monitoring in the therapeutic management of patients undergoing cardiac surgery.
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Affiliation(s)
- Hélène De Cuyper
- Department Anesthesiology and Perioperative Medicine, UZ Brussels, Brussels, Belgium; Free University Brussels VUB, Brussels, Belgium.
| | - Jan Poelaert
- Free University Brussels VUB, Brussels, Belgium; Department Anesthesiology, ICU and Chronic Pain Therapy, Maria Middelares, Ghent, Belgium
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Flick M, Hilty MP, Duranteau J, Saugel B. The microcirculation in perioperative medicine: a narrative review. Br J Anaesth 2024; 132:25-34. [PMID: 38030549 DOI: 10.1016/j.bja.2023.10.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 09/25/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
The microcirculation describes the network of the smallest vessels in our cardiovascular system. On a microcirculatory level, oxygen delivery is determined by the flow of oxygen-carrying red blood cells in a given single capillary (capillary red blood cell flow) and the density of the capillary network in a given tissue volume (capillary vessel density). Handheld vital videomicroscopy enables visualisation of the capillary bed on the surface of organs and tissues but currently is only used for research. Measurements are generally possible on all organ surfaces but are most often performed in the sublingual area. In patients presenting for elective surgery, the sublingual microcirculation is usually intact and functional. Induction of general anaesthesia slightly decreases capillary red blood cell flow and increases capillary vessel density. During elective, even major, noncardiac surgery, the sublingual microcirculation is preserved and remains functional, presumably because elective noncardiac surgery is scheduled trauma and haemodynamic alterations are immediately treated by anaesthesiologists, usually restoring the macrocirculation before the microcirculation is substantially impaired. Additionally, surgery is regional trauma and thus likely causes regional, rather than systemic, impairment of the microcirculation. Whether or not the sublingual microcirculation is impaired after noncardiac surgery remains a subject of ongoing research. Similarly, it remains unclear if cardiac surgery, especially with cardiopulmonary bypass, impairs the sublingual microcirculation. The effects of therapeutic interventions specifically targeting the microcirculation remain to be elucidated and tested. Future research should focus on further improving microcirculation monitoring methods and investigating how regional microcirculation monitoring can inform clinical decision-making and treatment.
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Affiliation(s)
- Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Matthias P Hilty
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Outcomes Research Consortium, Cleveland, OH, USA
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3
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Uz Z, Dilken O, Milstein DMJ, Hilty MP, de Haan D, Ince Y, Shen L, Houtzager J, Franken LC, van Gulik TM, Ince C. Identifying a sublingual triangle as the ideal site for assessment of sublingual microcirculation. J Clin Monit Comput 2023; 37:639-649. [PMID: 36355276 PMCID: PMC10068634 DOI: 10.1007/s10877-022-00936-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 10/15/2022] [Indexed: 11/11/2022]
Abstract
The sublingual mucosa is a commonly used intraoral location for identifying microcirculatory alterations using handheld vital microscopes (HVMs). The anatomic description of the sublingual cave and its related training have not been adequately introduced. The aim of this study was to introduce anatomy guided sublingual microcirculatory assessment. Measurements were acquired from the floor of the mouth using incident dark-field (IDF) imaging before (T0) and after (T1) sublingual cave anatomy instructed training. Instructions consists of examining a specific region of interested identified through observable anatomical structures adjacent and bilaterally to the lingual frenulum which is next to the sublingual papilla. The anatomical location called the sublingual triangle, was identified as stationed between the lingual frenulum, the sublingual fold and ventrally to the tongue. Small, large, and total vessel density datasets (SVD, LVD and TVD respectively) obtained by non-instructed and instructed measurements (NIN (T0) and IM (T1) respectively) were compared. Microvascular structures were analyzed, and the presence of salivary duct-related microcirculation was identified. A total of 72 video clips were used for analysis in which TVD, but not LVD and SVD, was higher in IM compared to NIM (NIM vs. IM, 25 ± 2 vs. 27 ± 3 mm/mm2 (p = 0.044), LVD NIM vs. IM: 7 ± 1 vs. 8 ± 1mm/mm2 (p = 0.092), SVD NIM vs. IM: 18 ± 2 vs. 20 ± 3 mm/mm2 (p = 0.103)). IM resulted in microcirculatory assessments which included morphological properties such as capillaries, venules and arterioles, without salivary duct-associated microcirculation. The sublingual triangle identified in this study showed consistent network-based microcirculation, without interference from microcirculation associated with specialized anatomic structures. These findings suggest that the sublingual triangle, an anatomy guided location, yielded sublingual based measurements that conforms with international guidelines. IM showed higher TVD values, and future studies are needed with larger sample sizes to prove differences in microcirculatory parameters.
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Affiliation(s)
- Zühre Uz
- Department of Translational Physiology, Location: AMC, Amsterdam University Medical Centre (UMC), University of Amsterdam, Amsterdam, The Netherlands.
- Department of Surgery, Location: AMC, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Department of Intensive Care, Erasmus MC, University Medical Centre, Rotterdam, the Netherlands.
| | - Olcay Dilken
- Department of Translational Physiology, Location: AMC, Amsterdam University Medical Centre (UMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Dan M J Milstein
- Department of Oral & Maxillofacial Surgery, Location: AMC, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Oral Medicine, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, Amsterdam, The Netherlands
| | - Matthias Peter Hilty
- Department of Translational Physiology, Location: AMC, Amsterdam University Medical Centre (UMC), University of Amsterdam, Amsterdam, The Netherlands
| | - David de Haan
- Department of Translational Physiology, Location: AMC, Amsterdam University Medical Centre (UMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Yasin Ince
- Department of Translational Physiology, Location: AMC, Amsterdam University Medical Centre (UMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Lucinda Shen
- Department of Translational Physiology, Location: AMC, Amsterdam University Medical Centre (UMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Julia Houtzager
- Department of Surgery, Location: AMC, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Lotte C Franken
- Department of Surgery, Location: AMC, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Location: AMC, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Can Ince
- Department of Translational Physiology, Location: AMC, Amsterdam University Medical Centre (UMC), University of Amsterdam, Amsterdam, The Netherlands
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Li X, Tan T, Wu H, Zhang C, Luo D, Zhu W, Li B, Zhuang J. Characteristics of sublingual microcirculatory changes during the early postoperative period following cardiopulmonary bypass-assisted cardiac surgery-a prospective cohort study. J Thorac Dis 2022; 14:3992-4002. [PMID: 36389306 PMCID: PMC9641360 DOI: 10.21037/jtd-22-1159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/28/2022] [Indexed: 02/27/2024]
Abstract
BACKGROUND Persistent microcirculatory dysfunction associated with increased morbidity and mortality. Interventions in the early resuscitation can be tailored to the changes of microcirculation and patient's need. However, there is usually an uncoupling of macrocirculatory and microcirculatory hemodynamics during resuscitation. Current research on the patterns of microcirculatory changes and recovery after cardiopulmonary bypass (CPB)-assisted cardiac surgery is limited. This study aimed to analyze changes in the microcirculatory parameters after CPB and their correlation with macrocirculation and to explore the characteristics of microcirculatory changes following CPB-assisted cardiac surgery. METHODS Between December 2018 and January 2019, 24 adult patients with indwelling pulmonary artery catheters after elective cardiac surgery using CPB were enrolled in this study. Both microcirculatory and macrocirculatory parameters were collected at 0, 6, 16, and 24 hours after admission to the intensive care unit (ICU). Video images of sublingual microcirculation were analyzed to obtain the microcirculatory parameters, including total vascular density (TVD), perfused small vessel density (PSVD), the proportion of perfused small vessels (PPV), microvascular flow index (MFI), and flow heterogeneity index (HI). The characteristics of microcirculatory parameter change following cardiac surgery and the correlation between microcirculatory parameters and macroscopic hemodynamic indicators, oxygen metabolic indicators, and carbon dioxide partial pressure difference (PCO2gap) were analyzed. RESULTS There were significant differences in the changes of TVD (P=0.012) and PSVD (P=0.005) during the first 24 hours postoperatively in patients who underwent CPB-assisted cardiac surgery. The microcirculatory density parameters (TVD: r=-0.5059, P=0.0456; PVD: r=-0.5499, P=0.0273) were correlated with oxygen delivery index (DO2I) at 24 hours after surgery. The microcirculatory flow parameters (PPV: r=0.4370, P=0.0327; MFI: r=0.6496, P=0.0006; and HI: r=-0.5350, P=0.0071) had a strong correlation with PCO2gap at 0 hour after surgery. CONCLUSIONS TVD and PSVD might be two most sensitive indicators affected by CPB-assisted cardiac surgery. There was no consistency between microcirculation and macrocirculation until 24 hours following cardiac surgery, meaning the improvement of systemic hemodynamic indicators does not guarantee correspondently improvement in microcirculation. Early controlled oxygen supply after CPB-assisted cardiac surgery may be conducive to the resuscitation of patients to a certain extent.
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Affiliation(s)
- Xiaofeng Li
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Tong Tan
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Hongxiang Wu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Chongjian Zhang
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Dandong Luo
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Weizhong Zhu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Boyu Li
- Department of Center for Private Medical Service & Healthcare, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jian Zhuang
- Department of Cardiovascular Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Laboratory of Artificial Intelligence and 3D Technologies for Cardiovascular Diseases, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
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Chommeloux J, Montero S, Franchineau G, Lebreton G, Bréchot N, Barhoum P, Lefèvre L, de Chambrun MP, Hékimian G, Luyt CE, Combes A, Schmidt M. Venoarterial extracorporeal membrane oxygenation flow or dobutamine to improve microcirculation during ECMO for refractory cardiogenic shock. J Crit Care 2022; 71:154090. [PMID: 35700546 DOI: 10.1016/j.jcrc.2022.154090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/16/2022] [Accepted: 05/28/2022] [Indexed: 11/15/2022]
Abstract
PURPOSE Venoarterial extracorporeal membrane oxygenation (VA ECMO) effectively supports refractory cardiogenic shock (rCS), and sustains macro- and microcirculations. We investigated the respective impact of increasing VA ECMO flow or dobutamine dose on microcirculation in stabilized VA ECMO-treated patients with rCS. METHODS In this prospective interventional study, we included consecutive intubated patients, with ECMO-supported rCS and hemodynamic stability, able to tolerate stepwise incremental dobutamine doses (from 5 to 20 gamma/kg/min) or ECMO flows (progressive increase by 25% above baseline ECMO flow. Baseline was defined as the lowest VA ECMO flow and dobutamine 5 μg/kg/min (DOBU5) to maintain mean arterial pressure (MAP) ≥ 65 mmHg. Macro- and microcirculations were evaluated after 30 min at each level. RESULTS Fourteen patients were included. Macro- and microcirculations were assessed 2 [2-5] days post-ECMO onset. Dobutamine-dose increments did not modify any microcirculation parameters. Only the De Backer score tended to be reduced (p = 0.08) by ECMO-flow increments whereas other microcirculation parameters were not affected. These findings did not differ between patients successfully weaned-off ECMO (n = 6) or not. CONCLUSIONS When macrocirculation has already been restored in patients with ECMO-supported rCS, increasing dobutamine (above 5 μg/kg/min) or ECMO flow did not further improve microcirculation.
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Affiliation(s)
- Juliette Chommeloux
- Sorbonne Université, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France; Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651 Paris Cedex 13, France
| | - Santiago Montero
- Acute and Intensive Cardiovascular Care Unit, Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Guillaume Franchineau
- Sorbonne Université, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France; Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651 Paris Cedex 13, France
| | - Guillaume Lebreton
- Sorbonne Université, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France; Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Thoracic and Cardiovascular Department, 75651 Paris Cedex 13, France
| | - Nicolas Bréchot
- Sorbonne Université, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France; Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651 Paris Cedex 13, France
| | - Petra Barhoum
- Sorbonne Université, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France; Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651 Paris Cedex 13, France
| | - Lucie Lefèvre
- Sorbonne Université, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France; Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651 Paris Cedex 13, France
| | - Marc Pineton de Chambrun
- Sorbonne Université, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France; Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651 Paris Cedex 13, France
| | - Guillaume Hékimian
- Sorbonne Université, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France; Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651 Paris Cedex 13, France
| | - Charles-Edouard Luyt
- Sorbonne Université, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France; Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651 Paris Cedex 13, France
| | - Alain Combes
- Sorbonne Université, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France; Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651 Paris Cedex 13, France
| | - Matthieu Schmidt
- Sorbonne Université, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France; Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651 Paris Cedex 13, France.
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Miyamoto T, Sunagawa G, Dessoffy R, Karimov JH, Grady P, Naber JP, Vincent D, Sale SM, Kvernebo K, Tran VNP, Moazami N, Fukamachi K. Hemodynamic evaluation of a new pulsatile blood pump during low flow cardiopulmonary bypass support. Artif Organs 2021; 46:643-652. [PMID: 34780074 DOI: 10.1111/aor.14119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 10/05/2021] [Accepted: 11/11/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The VentriFlo® True Pulse Pump (VentriFlo, Inc, Pelham, NH, USA) is a new pulsatile blood pump intended for use during short-term circulatory support. The purpose of this study was to evaluate the feasibility of the VentriFlo and compare it to a conventional centrifugal pump (ROTAFLOW, Getinge, Gothenberg, Sweden) in acute pig experiments. METHODS Pigs (40-45 kg) were supported by cardiopulmonary bypass (CPB) with the VentriFlo (n = 9) or ROTAFLOW (n = 5) for 6 h. Both VentriFlo and ROTAFLOW circuits utilized standard CPB components. We evaluated hemodynamics, blood chemistry, gas analysis, plasma hemoglobin, and microcirculation at the groin skin with computer-assisted video microscopy (Optilia, Sollentuna, Sweden). RESULTS Pigs were successfully supported by CPB for 6 h without any pump-related complications in either group. The VentriFlo delivered an average stroke volume of 29.2 ± 4.8 ml. VentriFlo delivered significantly higher pulse pressure (29.1 ± 7.2 mm Hg vs. 4.4 ± 7.0 mm Hg, p < 0.01) as measured in the carotid artery, with mean aortic pressure and pump flow comparable with those in ROTAFLOW. In blood gas analysis, arterial pH was significantly lower after five hours support in the VentriFlo group (7.30 ± 0.07 vs. 7.43 ± 0.03, p = 0.001). There was no significant difference in plasma hemoglobin level in both groups after six hours of CPB support. In microcirculatory assessment, VentriFlo tended to keep normal capillary flow, but it was not statistically significant. CONCLUSIONS VentriFlo-supported pigs showed comparable hemodynamic parameters with significantly higher pulse pressure compared to ROTAFLOW without hemolysis.
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Affiliation(s)
- Takuma Miyamoto
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gengo Sunagawa
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Raymond Dessoffy
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jamshid H Karimov
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Patrick Grady
- Department of Thoracic and Cardiovascular Surgery, Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - Shiva M Sale
- Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Knut Kvernebo
- Department of Cardio-thoracic Surgery, Oslo University Hospital, Ullevaal, Oslo, Norway
| | - Van N P Tran
- Department of Cardio-thoracic Surgery, Oslo University Hospital, Ullevaal, Oslo, Norway
| | - Nader Moazami
- Department of Cardiothoracic surgery, New York University's Langone Health, New York, New York, USA
| | - Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Guay CS, Khebir M, Shiva Shahiri T, Szilagyi A, Cole EE, Simoneau G, Badawy M. Evaluation of automated microvascular flow analysis software AVA 4: a validation study. Intensive Care Med Exp 2021; 9:15. [PMID: 33796954 PMCID: PMC8017044 DOI: 10.1186/s40635-021-00380-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 03/03/2021] [Indexed: 11/28/2022] Open
Abstract
Background Real-time automated analysis of videos of the microvasculature is an essential step in the development of research protocols and clinical algorithms that incorporate point-of-care microvascular analysis. In response to the call for validation studies of available automated analysis software by the European Society of Intensive Care Medicine, and building on a previous validation study in sheep, we report the first human validation study of AVA 4. Methods Two retrospective perioperative datasets of human microcirculation videos (P1 and P2) and one prospective healthy volunteer dataset (V1) were used in this validation study. Video quality was assessed using the modified Microcirculation Image Quality Selection (MIQS) score. Videos were initially analyzed with (1) AVA software 3.2 by two experienced investigators using the gold standard semi-automated method, followed by an analysis with (2) AVA automated software 4.1. Microvascular variables measured were perfused vessel density (PVD), total vessel density (TVD), and proportion of perfused vessels (PPV). Bland–Altman analysis and intraclass correlation coefficients (ICC) were used to measure agreement between the two methods. Each method’s ability to discriminate between microcirculatory states before and after induction of general anesthesia was assessed using paired t-tests. Results Fifty-two videos from P1, 128 videos from P2 and 26 videos from V1 met inclusion criteria for analysis. Correlational analysis and Bland–Altman analysis revealed poor agreement and no correlation between AVA 4.1 and AVA 3.2. Following the induction of general anesthesia, TVD and PVD measured using AVA 3.2 increased significantly for P1 (p < 0.05) and P2 (p < 0.05). However, these changes could not be replicated with the data generated by AVA 4.1. Conclusions AVA 4.1 is not a suitable tool for research or clinical purposes at this time. Future validation studies of automated microvascular flow analysis software should aim to measure the new software’s agreement with the gold standard, its ability to discriminate between clinical states and the quality thresholds at which its performance becomes unacceptable. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-021-00380-0.
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Affiliation(s)
- Christian S Guay
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, 660 S. Euclid Avenue, St Louis, MO, 63110, USA.,Department of Anesthesia and Critical Care Medicine, The Montreal Neurological Institute and Hospital, McGill University, 3801 University Street, Room 554, Montreal, QC, H3A 2B4, Canada
| | - Mariam Khebir
- Department of Anesthesia and Critical Care Medicine, The Montreal Neurological Institute and Hospital, McGill University, 3801 University Street, Room 554, Montreal, QC, H3A 2B4, Canada.,Department of Anesthesia, McGill University, Montreal, QC, Canada
| | - T Shiva Shahiri
- Ingram School of Nursing, McGill University, Montreal, QC, Canada
| | - Ariana Szilagyi
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Erin Elizabeth Cole
- Clinical Research Unit, The Montreal Neurological Institute and Hospital, Montreal, QC, Canada
| | - Gabrielle Simoneau
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Mohamed Badawy
- Department of Anesthesia and Critical Care Medicine, The Montreal Neurological Institute and Hospital, McGill University, 3801 University Street, Room 554, Montreal, QC, H3A 2B4, Canada. .,Department of Anesthesia, McGill University, Montreal, QC, Canada.
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8
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Flick M, Duranteau J, Scheeren TW, Saugel B. Monitoring of the Sublingual Microcirculation During Cardiac Surgery: Current Knowledge and Future Directions. J Cardiothorac Vasc Anesth 2020; 34:2754-2765. [DOI: 10.1053/j.jvca.2019.10.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 09/29/2019] [Accepted: 10/21/2019] [Indexed: 11/11/2022]
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den Os MM, van den Brom CE, van Leeuwen ALI, Dekker NAM. Microcirculatory perfusion disturbances following cardiopulmonary bypass: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:218. [PMID: 32404120 PMCID: PMC7222340 DOI: 10.1186/s13054-020-02948-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 05/05/2020] [Indexed: 12/11/2022]
Abstract
Background Microcirculatory perfusion disturbances are associated with increased morbidity and mortality in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Technological advancements made it possible to monitor sublingual microcirculatory perfusion over time. The goal of this review is to provide an overview of the course of alterations in sublingual microcirculatory perfusion following CPB. The secondary goal is to identify which parameter of sublingual microcirculatory perfusion is most profoundly affected by CPB. Methods PubMed and Embase databases were systematically searched according to PRISMA guidelines and as registered in PROSPERO. Studies that reported sublingual microcirculatory perfusion measurements before and after onset of CPB in adult patients undergoing cardiac surgery were included. The primary outcome was sublingual microcirculatory perfusion, represented by functional capillary density (FCD), perfused vessel density (PVD), total vessel density (TVD), proportion of perfused vessels (PPV), and microvascular flow index (MFI). Results The search identified 277 studies, of which 19 fulfilled all eligibility criteria. Initiation of CPB had a profound effect on FCD, PVD, or PPV. Seventeen studies (89%) reported one or more of these parameters, and in 11 of those studies (65%), there was a significant decrease in these parameters during cardiac surgery; the other 6 studies (35%) reported no effect. In 29% of the studies, FCD, PVD, or PPV normalized by the end of cardiac surgery, and in 24% percent of the studies, this effect lasted at least 24 h. There was no clear effect of CPB on TVD and a mixed effect on MFI. Conclusion CPB during cardiac surgery impaired sublingual microcirculatory perfusion as reflected by reduced FCD, PVD, and PPV. Four studies reported this effect at least 24 h after surgery. Further research is warranted to conclude on the duration of CPB-induced microcirculatory perfusion disturbances and the relationship with clinical outcome. Trial registration PROSPERO, CRD42019127798
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Affiliation(s)
- Matthijs M den Os
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Charissa E van den Brom
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Department of Physiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Anoek L I van Leeuwen
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Department of Physiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Cardiothoracic surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Nicole A M Dekker
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands. .,Department of Physiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
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10
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Pulmonary complications following cardiac surgery. ACTA ACUST UNITED AC 2020; 4:e280-e285. [PMID: 32368683 PMCID: PMC7191937 DOI: 10.5114/amsad.2019.91432] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 10/24/2019] [Indexed: 12/19/2022]
Abstract
Coronary heart disease is a common diseases of atherosclerosis. Despite the development of noninvasive therapies and the advancement of pharmacological methods and extensive drug regimens, coronary artery bypass grafting surgery is still the ultimate treatment option in many patients. Among the various complications following open heart surgery, one of the common difficulties is pulmonary complications associated with subsequent morbidity and mortality, which should be studied according to preoperative, perioperative, and postoperative factors. Preoperative factors include genetics, age, family history of pulmonary disease, smoking, coexisting disease, etc. Perioperative factors include surgical procedures like sternotomy incision, cardioplegia, and internal mammary artery harvesting; anaesthesia procedure effects like pulmonary collapse, maintenance drugs and morphine administration; and cardiopulmonary bypass pump by systemic inflammatory response syndromes. And finally, postoperative factors, especially mediastinitis and the role of nursing in the intensive care unit. Pulmonary complications after cardiac surgery include atelectasis, pleural effusions, pneumonia, pulmonary oedema, cardiogenic pulmonary oedema, acute respiratory distress syndrome, pulmonary embolism, phrenic nerve injury, pneumothorax, sternal wound infection, and mediastinitis, with different outbreaks in patients reported. Although the preoperative, perioperative, and postoperative factors play an important role in the occurrence of these complications, the preoperative factors, as factors that can be adjusted, should be considered more than the others and explained to the patient, and the preoperative patient’s assessment should be noted. Also, postoperative care with the goal of reducing infections and pulmonary complications should be addressed by the nursing team.
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11
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Slovinski AP, Hajjar LA, Ince C. Microcirculation in Cardiovascular Diseases. J Cardiothorac Vasc Anesth 2019; 33:3458-3468. [PMID: 31521493 DOI: 10.1053/j.jvca.2019.08.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 08/01/2019] [Accepted: 08/05/2019] [Indexed: 12/12/2022]
Abstract
Microcirculation is a system composed of interconnected microvessels, which is responsible for the distribution of oxygenated blood among and within organs according to regional metabolic demand. Critical medical conditions, e. g., sepsis, and heart failure are known triggers of microcirculatory disturbance, which usually develops early in such clinical pictures and represents an independent risk factor for mortality. Therefore, hemodynamic resuscitation aiming at restoring microcirculatory perfusion is of paramount importance. Until recently, however, resuscitation protocols were based on macrohemodynamic variables, which increases the risk of under or over resuscitation. The introduction of hand-held video-microscopy (HVM) into clinical practice has allowed real-time analysis of microcirculatory variables at the bedside and, hence, favored a more individualized approach. In the cardiac intensive care unit scenario, HVM provides essential information on patients' hemodynamic status, e. g., to classify the type of shock, to adequate the dosage of vasopressors or inotropes according to demand and define safer limits, to guide fluid therapy and red blood cell transfusion, to evaluate response to treatment, among others. Nevertheless, several drawbacks have to be addressed before HVM becomes a standard of care.
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Affiliation(s)
| | | | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, 's-Gravendijkwal 230, 3015 CE Rotterdam, the Netherlands
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12
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Dekker NAM, Veerhoek D, Koning NJ, van Leeuwen ALI, Elbers PWG, van den Brom CE, Vonk ABA, Boer C. Postoperative microcirculatory perfusion and endothelial glycocalyx shedding following cardiac surgery with cardiopulmonary bypass. Anaesthesia 2019; 74:609-618. [PMID: 30687934 PMCID: PMC6590376 DOI: 10.1111/anae.14577] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2018] [Indexed: 12/16/2022]
Abstract
We investigated microcirculatory perfusion disturbances following cardiopulmonary bypass in the early postoperative period and whether the course of these disturbances mirrored restoration of endothelial glycocalyx integrity. We performed sublingual sidestream dark field imaging of the microcirculation during the first three postoperative days in patients who had undergone on‐pump coronary artery bypass graft surgery. We calculated the perfused vessel density, proportion of perfused vessels and perfused boundary region. Plasma was obtained to measure heparan sulphate and syndecan‐1 levels as glycocalyx shedding markers. We recruited 17 patients; the mean (SD) duration of non‐pulsatile cardiopulmonary bypass was 103 (18) min, following which 491 (29) ml autologous blood was transfused through cell salvage. Cardiopulmonary bypass immediately decreased both microcirculatory perfused vessel density; 11 (3) vs. 16 (4) mm.mm−2, p = 0.052 and the proportion of perfused vessels; 92 (5) vs. 69 (9) %, p < 0.0001. The proportion of perfused vessels did not increase after transfusion of autologous salvaged blood following cardiopulmonary bypass; 72 (7) %, p = 0.19 or during the first three postoperative days; 71 (5) %, p < 0.0001. The perfused boundary region increased after cardiopulmonary bypass; 2.2 (0.3) vs. 1.9 (0.3) μm, p = 0.037 and during the first three postoperative days; 2.4 (0.3) vs. 1.9 (0.3) μm, p = 0.003. Increased plasma heparan sulphate levels were inversely associated with the proportion of perfused vessels during cardiopulmonary bypass; R = −0.49, p = 0.02. Plasma syndecan‐1 levels were inversely associated with the proportion of perfused vessels during the entire study period; R = −0.51, p < 0.0001. Our study shows that cardiopulmonary bypass‐induced acute microcirculatory perfusion disturbances persist in the first three postoperative days, and are associated with prolonged endothelial glycocalyx shedding. This suggests prolonged impairment and delayed recovery of both microcirculatory perfusion and function after on‐pump cardiac surgery.
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Affiliation(s)
- N A M Dekker
- Departments of Anaesthesiology, Physiology, and Cardiothoracic Surgery, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - D Veerhoek
- Departments of Anaesthesiology, Physiology, and Cardiothoracic Surgery, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - N J Koning
- Departments of Anaesthesiology, Physiology, and Cardiothoracic Surgery, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - A L I van Leeuwen
- Departments of Anaesthesiology, Physiology, and Cardiothoracic Surgery, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - P W G Elbers
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU University, Amsterdam Infection and Immunity Institute, Amsterdam, the Netherlands
| | - C E van den Brom
- Departments of Anaesthesiology, Physiology, and Cardiothoracic Surgery, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - A B A Vonk
- Department of Cardiothoracic Surgery, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - C Boer
- Department of Anaesthesiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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13
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Veenstra G, Ince C, Barendrecht BW, Zijlstra HW, Boerma EC. Differences in capillary recruitment between cardiac surgery and septic patients after fluid resuscitation. Microvasc Res 2018; 123:14-18. [PMID: 30448399 DOI: 10.1016/j.mvr.2018.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 11/12/2018] [Accepted: 11/14/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Clinical evaluation of the effects of fluid therapy remains cumbersome and strategies are based on the assumption that normalization of macrohemodynamic variables will result in parallel improvement in organ perfusion. Recently, we and others suggested the use of direct in-vivo observation of the microcirculation to evaluate the effects of fluid therapy. METHODS A single-centre observational study, using in-vivo microscopy to assess total vessel density (TVD) in two subsets of ICU patients. RESULTS After fluid resuscitation TVD showed no difference between sepsis patients (N = 47) and cardiac surgery patients (N = 52): 18.4[16.8-20.8] vs 18.7[16.8-20.9] mm/mm2, p = 0.59. In cardiac surgery patients there was a significant correlation between the amount of fluids administered and TVD, with an optimum in the third quartile. However, such correlation was absent in septic patients. CONCLUSIONS TVD after fluid administration is not different between 2 subtypes of intensive care patients. However, only in septic patients we observed a lack of coherence between the amount of fluids administered and TVD. Further research is needed to determine if TVD may serve as potential endpoint for fluid administration.
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Affiliation(s)
- Gerke Veenstra
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands; Department of Translational Physiology, Amsterdam UMC, Amsterdam, The Netherlands.
| | - Can Ince
- Department of Translational Physiology, Amsterdam UMC, Amsterdam, The Netherlands; Department of Intensive Care, Erasmus MC University Hospital Rotterdam, Rotterdam, The Netherlands.
| | - Bart W Barendrecht
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Hendrik W Zijlstra
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - E Christiaan Boerma
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands
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14
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Abstract
PURPOSE OF REVIEW Critical illness includes a wide range of conditions from sepsis to high-risk surgery. All these diseases are characterized by reduced tissue oxygenation. Macrohemodynamic parameters may be corrected by fluids and/or vasoactive compounds; however, the microcirculation and its tissues may be damaged and remain hypoperfused. An evaluation of microcirculation may enable more physiologically based approaches for understanding the pathogenesis, diagnosis, and treatment of critically ill patients. RECENT FINDINGS Microcirculation plays a pivotal role in delivering oxygen to the cells and maintains tissue perfusion. Negative results of several studies, based on conventional hemodynamic resuscitation procedures to achieve organ perfusion and decrease morbidity and mortality following conditions of septic shock and other cardiovascular compromise, have highlighted the need to monitor microcirculation. The loss of hemodynamic coherence between the macrocirculation and microcirculation, wherein improvement of hemodynamic variables of the systemic circulation does not cause a parallel improvement of microcirculatory perfusion and oxygenation of the essential organ systems, may explain why these studies have failed. SUMMARY Critical illness is usually accompanied by abnormalities in microcirculation and tissue hypoxia. Direct monitoring of sublingual microcirculation using hand-held microscopy may provide a more physiological approach. Evaluating the coherence between macrocirculation and microcirculation in response to therapy seems to be essential in evaluating the efficacy of therapeutic interventions.
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15
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Akin S, Dos Reis Miranda D, Caliskan K, Soliman OI, Guven G, Struijs A, van Thiel RJ, Jewbali LS, Lima A, Gommers D, Zijlstra F, Ince C. Functional evaluation of sublingual microcirculation indicates successful weaning from VA-ECMO in cardiogenic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:265. [PMID: 29073930 PMCID: PMC5658964 DOI: 10.1186/s13054-017-1855-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 10/05/2017] [Indexed: 12/23/2022]
Abstract
Background Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly adopted for the treatment of cardiogenic shock (CS). However, a marker of successful weaning remains largely unknown. Our hypothesis was that successful weaning is associated with sustained microcirculatory function during ECMO flow reduction. Therefore, we sought to test the usefulness of microcirculatory imaging in the same sublingual spot, using incident dark field (IDF) imaging in assessing successful weaning from VA-ECMO and compare IDF imaging with echocardiographic parameters. Methods Weaning was performed by decreasing the VA-ECMO flow to 50% (F50) from the baseline. The endpoint of the study was successful VA-ECMO explantation within 48 hours after weaning. The response of sublingual microcirculation to a weaning attempt (WA) was evaluated. Microcirculation was measured in one sublingual area (single spot (ss)) using CytoCam IDF imaging during WA. Total vessel density (TVDss) and perfused vessel density (PVDss) of the sublingual area were evaluated before and during 50% flow reduction (TVDssF50, PVDssF50) after a WA and compared to conventional echocardiographic parameters as indicators of the success or failure of the WA. Results Patients (n = 13) aged 49 ± 18 years, who received VA-ECMO for the treatment of refractory CS due to pulmonary embolism (n = 5), post cardiotomy (n = 3), acute coronary syndrome (n = 2), myocarditis (n = 2) and drug intoxication (n = 1), were included. TVDssF50 (21.9 vs 12.9 mm/mm2, p = 0.001), PVDssF50 (19.7 vs 12.4 mm/mm2, p = 0.01) and aortic velocity–time integral (VTI) at 50% flow reduction (VTIF50) were higher in patients successfully weaned vs not successfully weaned. The area under the curve (AUC) was 0.99 vs 0.93 vs 0.85 for TVDssF50 (small vessels) >12.2 mm/mm2, left ventricular ejection fraction (LVEF) >15% and aortic VTI >11 cm. Likewise, the AUC was 0.91 vs 0.93 vs 0.85 for the PVDssF50 (all vessels) >14.8 mm/mm2, LVEF >15% and aortic VTI >11 cm. Conclusion This study identified sublingual microcirculation as a novel potential marker for identifying successful weaning from VA-ECMO. Sustained values of TVDssF50 and PVDssF50 were found to be specific and sensitive indicators of successful weaning from VA-ECMO as compared to echocardiographic parameters. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1855-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sakir Akin
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. .,Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.
| | - Dinis Dos Reis Miranda
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Kadir Caliskan
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Osama I Soliman
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Goksel Guven
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.,Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Ard Struijs
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Robert J van Thiel
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Lucia S Jewbali
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.,Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Alexandre Lima
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
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De Blasi RA, Romagnoli S, Rocco M. Bedside Assessment of the Microvascular Venous Compartment in Cardiac Surgery Patients With Valvular Diseases Undergoing Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2016; 31:105-114. [PMID: 27546828 DOI: 10.1053/j.jvca.2016.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Blood volume reserve for venous return and the effects of cardiopulmonary bypass (CPB) on microvascular bed partitioning and blood flow were examined in patients with valvular diseases. DESIGN Prospective, consecutive, case-control study. SETTING Single university hospital. PARTICIPANTS The study comprised 20 adult cardiac surgery patients and 20 healthy volunteers. INTERVENTIONS Cardiovascular and microvascular variables were collected soon after the induction of anesthesia, after commencement of CPB, 20 minutes after separation from CPB, and in the intensive care unit. MEASUREMENTS AND MAIN RESULTS The unstressed and stressed volumes (Vu, Vs) and pressures therein (Pit, Ps) were measured in the brachioradial muscle with near-infrared spectroscopy, applying incremental venous occlusions. At the first time point, Vs and Pit showed lower and higher values, respectively, than those of control patients, but Vs increased with Vu during the study, whereas Pit remained unchanged. Fluid balance correlated with Pit (r = 0.83, p<0.001) and hemoglobin (r = 0.78, p = 0.004). A nonlinear regression was found between fluid balance and ΔVu (r = 0.90, p<0.001) [y = 1.85+37.43(-0.01×x)]. The Vu/Pit and Vs/Ps ratios were lower than those of the control patients. Blood flow correlated to Vs/Ps (r = 0.75, p<0.001). The time constant was lower than reference (p = 0.005) and increased 10 times after CPB. CONCLUSIONS Cardiac surgery patients have a limited blood volume reserve for venous return due to a reduced microvascular bed capacitance. This study demonstrated that during CPB a positive fluid balance induced an extravascular pressure increase and further reduced blood volume reserve.
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Affiliation(s)
- Roberto Alberto De Blasi
- Intensive Care Unit, Department of Medical and Surgical Science and Translational Medicine, Faculty of Medicine and Psychology, University of Rome "Sapienza," Roma, Italy.
| | - Stefano Romagnoli
- Intensive Care Unit, Department of Health Science, University of Florence, University Hospital Careggi, Florence, Italy
| | - Monica Rocco
- Intensive Care Unit, Department of Medical and Surgical Science and Translational Medicine, Faculty of Medicine and Psychology, University of Rome "Sapienza," Roma, Italy
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