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Saravi B, Goebel U, Hassenzahl LO, Jung C, David S, Feldheiser A, Stopfkuchen-Evans M, Wollborn J. Capillary leak and endothelial permeability in critically ill patients: a current overview. Intensive Care Med Exp 2023; 11:96. [PMID: 38117435 PMCID: PMC10733291 DOI: 10.1186/s40635-023-00582-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/12/2023] [Indexed: 12/21/2023] Open
Abstract
Capillary leak syndrome (CLS) represents a phenotype of increased fluid extravasation, resulting in intravascular hypovolemia, extravascular edema formation and ultimately hypoperfusion. While endothelial permeability is an evolutionary preserved physiological process needed to sustain life, excessive fluid leak-often caused by systemic inflammation-can have detrimental effects on patients' outcomes. This article delves into the current understanding of CLS pathophysiology, diagnosis and potential treatments. Systemic inflammation leading to a compromise of endothelial cell interactions through various signaling cues (e.g., the angiopoietin-Tie2 pathway), and shedding of the glycocalyx collectively contribute to the manifestation of CLS. Capillary permeability subsequently leads to the seepage of protein-rich fluid into the interstitial space. Recent insights into the importance of the sub-glycocalyx space and preserving lymphatic flow are highlighted for an in-depth understanding. While no established diagnostic criteria exist and CLS is frequently diagnosed by clinical characteristics only, we highlight more objective serological and (non)-invasive measurements that hint towards a CLS phenotype. While currently available treatment options are limited, we further review understanding of fluid resuscitation and experimental approaches to target endothelial permeability. Despite the improved understanding of CLS pathophysiology, efforts are needed to develop uniform diagnostic criteria, associate clinical consequences to these criteria, and delineate treatment options.
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Affiliation(s)
- Babak Saravi
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center, University of Freiburg, University of Freiburg, Freiburg, Germany.
| | - Ulrich Goebel
- Department of Anesthesiology and Critical Care, St. Franziskus-Hospital, Muenster, Germany
| | - Lars O Hassenzahl
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Christian Jung
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Duesseldorf, Germany
| | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Aarne Feldheiser
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Evang. Kliniken Essen-Mitte, Huyssens-Stiftung/Knappschaft, University of Essen, Essen, Germany
| | - Matthias Stopfkuchen-Evans
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Jakob Wollborn
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
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Damiani E, Carsetti A, Casarotta E, Domizi R, Scorcella C, Donati A, Adrario E. Microcirculation-guided resuscitation in sepsis: the next frontier? Front Med (Lausanne) 2023; 10:1212321. [PMID: 37476612 PMCID: PMC10354242 DOI: 10.3389/fmed.2023.1212321] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/20/2023] [Indexed: 07/22/2023] Open
Abstract
Microcirculatory dysfunction plays a key role in the pathogenesis of tissue dysoxia and organ failure in sepsis. Sublingual videomicroscopy techniques enable the real-time non-invasive assessment of microvascular blood flow. Alterations in sublingual microvascular perfusion were detected during sepsis and are associated with poor outcome. More importantly, sublingual videomicroscopy allowed to explore the effects of commonly applied resuscitative treatments in septic shock, such as fluids, vasopressors and inotropes, and showed that the optimization of macro-hemodynamic parameters may not be accompanied by an improvement in microvascular perfusion. This loss of "hemodynamic coherence," i.e., the concordance between the response of the macrocirculation and the microcirculation, advocates for the integration of microvascular monitoring in the management of septic patients. Nonetheless, important barriers remain for a widespread use of sublingual videomicroscopy in the clinical practice. In this review, we discuss the actual limitations of this technique and future developments that may allow an easier and faster evaluation of the microcirculation at the bedside, and propose a role for sublingual microvascular monitoring in guiding and titrating resuscitative therapies in sepsis.
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Affiliation(s)
- Elisa Damiani
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Andrea Carsetti
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Erika Casarotta
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Roberta Domizi
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Claudia Scorcella
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Abele Donati
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Erica Adrario
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
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3
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Huang W, Xiang H, Hu C, Wu T, Zhang D, Ma S, Hu B, Li J. Association of Sublingual Microcirculation Parameters and Capillary Refill Time in the Early Phase of ICU Admission. Crit Care Med 2023; 51:913-923. [PMID: 36942969 PMCID: PMC10262986 DOI: 10.1097/ccm.0000000000005851] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
OBJECTIVES This observational study was conducted to investigate capillary refill time (CRT) during the early phase of ICU admission in relationship with microvascular flow alteration and outcome in critically ill patients. DESIGN Prospective, observational, pilot study. SETTING ICU in a university hospital. PATIENTS Two hundred eighty-two critically ill adult patients admitted to the ICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All patients underwent simultaneous measurements by CRT and sidestream dark field imaging within 24 hours of ICU admission. Other clinical data such as demographic characteristics, hemodynamics, laboratory values, treatment, and physiologic parameters were also included simultaneously. Microcirculatory measurements were performed at 10.2 ± 5.7 hours after ICU admission. Of the 282 included patients, 106 (37.6%) were female, the median (interquartile range) age was 63 years (53-74 yr), and the median Sequential Organ Failure Assessment (SOFA) score was 5 (2-7). The primary finding was the association between CRT and simultaneous the condition of peripheral circulation (microvascular flow index [MFI]: r = -0.4430, p < 0.001; proportion of perfused vessels: r = -0.3708, p < 0.001; heterogeneity index: r = 0.4378, p < 0.001; perfused vessel density: r = -0.1835, p = 0.0020; except total vessel density: p = 0.9641; and De Backer score: p = 0.5202) in critically ill patients. In addition, this relationship was also maintained in subgroups. Microcirculatory flow abnormalities, 28-day mortality, and SOFA score appeared to be more severe for increasing CRT. In a multivariable analysis, prolonged CRT was independently associated with microvascular flow abnormalities (MFI < 2.6; odds ratio [OR], 1.608; 95% CI, 2.1-10.2; p < 0.001). Similarly, multivariable analysis identified CRT as an independent predictor of 28-day mortality (OR, 1.296; 95% CI, 1.078-1.558; p = 0.006). CONCLUSIONS In our ICU population, a single-spot prolonged CRT was independently associated with abnormal microcirculation and increased mortality.
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Affiliation(s)
- Weipeng Huang
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
| | - Hui Xiang
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
| | - Chang Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
| | - Tong Wu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
| | - Dandan Zhang
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
| | - Siqing Ma
- Department of Critical Care Medicine, Qinghai Provincial People's Hospital, Xining, Qinghai, China
| | - Bo Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
| | - Jianguo Li
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
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Abstract
PURPOSE OF REVIEW Advances in the treatment of septic shock have historically focused on resuscitation endpoints, mainly mean arterial pressure and cardiac output. As the definitions of sepsis and septic shock have shifted to focus on the diversity of causes of dysregulated host-response we have seen an emerging phenotype where tissue hypoxia persists despite adequate macrocirculatory parameters. Interest in the topic of microcirculation is re-emerging as validated bedside techniques for hemodynamic monitoring, such as video microscopes, are becoming available. We review the current understanding of how sepsis induced hypoperfusion with a focus on recent advances in monitoring the microcirculation, and how a proliferation of biomarkers and emerging therapeutic targets may impact future research. RECENT FINDINGS Conventional hemodynamic monitoring systems fail to assess the microcirculation, and it's response to treatment. Lactate and venous oxygen saturations often drive biomarker-guided sepsis management. Visual assessments such as mottling and capillary refill time are often associated with predicting outcomes, but sometimes can have issues with inter-provider reliability. Microcirculatory damage can be observed sublingually and appears to have prognostic value. SUMMARY Sepsis is associated with changes in the microcirculation that can lead to tissue hypoxia and organ dysfunction. Further studies are needed to validate the usefulness of microcirculatory bedside tools in guiding resuscitative efforts.
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Affiliation(s)
- Vishal Yajnik
- Department of Anesthesiology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
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Nam K, Jeon Y. Microcirculation during surgery. Anesth Pain Med (Seoul) 2022; 17:24-34. [PMID: 35139609 PMCID: PMC8841265 DOI: 10.17085/apm.22127] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 01/13/2022] [Indexed: 11/17/2022] Open
Abstract
Throughout the long history of surgery, there has been great advancement in the hemodynamic management of surgical patients. Traditionally, hemodynamic management has focused on macrocirculatory monitoring and intervention to maintain appropriate oxygen delivery. However, even after optimization of macro-hemodynamic parameters, microcirculatory dysfunction, which is related to higher postoperative complications, occurs in some patients. Although the clinical significance of microcirculatory dysfunction has been well reported, little is known about interventions to recover microcirculation and prevent microcirculatory dysfunction. This may be at least partly caused by the fact that the feasibility of monitoring tools to evaluate microcirculation is still insufficient for use in routine clinical practice. However, considering recent advancements in these research fields, with more popular use of microcirculation monitoring and more clinical trials, clinicians may better understand and manage microcirculation in surgical patients in the future. In this review, we describe currently available methods for microcirculatory evaluation. The current knowledge on the clinical relevance of microcirculatory alterations has been summarized based on previous studies in various clinical settings. In the latter part, pharmacological and clinical interventions to improve or restore microcirculation are also presented.
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Affiliation(s)
| | - Yunseok Jeon
- Corresponding author: Yunseok Jeon, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: 82-2-2072-3108, Fax: 82-2-747-8363 E-mail:
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6
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Chalkias A, Papagiannakis N, Mavrovounis G, Kolonia K, Mermiri M, Pantazopoulos I, Laou E, Arnaoutoglou E. Sublingual microcirculatory alterations during the immediate and early postoperative period: A systematic review and meta-analysis. Clin Hemorheol Microcirc 2021; 80:253-265. [PMID: 34719484 DOI: 10.3233/ch-211214] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The incidence of postoperative microcirculatory flow alterations and their effect on outcome have not been studied extensively. OBJECTIVE This systematic review and meta-analysis was designed to investigate the presence of sublingual microcirculatory flow alterations during the immediate and early postoperative period and their correlation with complications and survival. METHODS A systematic search of PubMed, Scopus, Embase, PubMed Central, and Google Scholar was conducted for relevant articles from January 2000 to March 2021. Eligibility criteria were randomized controlled and non-randomized trials. Case reports, case series, review papers, animal studies and non-English literature were excluded. The primary outcome was the assessment of sublingual microcirculatory alterations during the immediate and early postoperative period in adult patients undergoing surgery. Risk of bias was assessed with the Ottawa-Newcastle scale. Standard meta-analysis methods (random-effects models) were used to assess the difference in microcirculation variables. RESULTS Thirteen studies were included. No statistically significant difference was found between preoperative and postoperative total vessel density (p = 0.084; Standardized Mean Difference (SMD): -0.029; 95%CI: -0.31 to 0.26; I2 = 22.55%). Perfused vessel density significantly decreased postoperatively (p = 0.035; SMD: 0.344; 95%CI: 0.02 to 0.66; I2 = 65.66%), while perfused boundary region significantly increased postoperatively (p = 0.031; SMD: -0.415; 95%CI: -0.79 to -0.03; I2 = 37.21%). Microvascular flow index significantly decreased postoperatively (p = 0.028; SMD: 0.587; 95%CI: 0.06 to 1.11; I2 = 86.09%), while no statistically significant difference was found between preoperative and postoperative proportion of perfused vessels (p = 0.089; SMD: 0.53; 95%CI: -0.08 to 1.14; I2 = 70.71%). The results of the non-cardiac surgery post-hoc analysis were comparable except that no statistically significant difference in perfused vessel density was found (p = 0.69; SMD: 0.07; 95%CI: -0.26 to 0.39; I2 = 0%). LIMITATIONS The included studies investigate heterogeneous groups of surgical patients. There were no randomized controlled trials. CONCLUSIONS Significant sublingual microcirculatory flow alterations are present during the immediate and early postoperative period. Further research is required to estimate the correlation of sublingual microcirculatory flow impairment with complications and survival.
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Affiliation(s)
- Athanasios Chalkias
- Department of Anesthesiology, University ofThessaly, Faculty of Medicine, Larisa, Greece.,Outcomes Research Consortium, Cleveland, OH, USA
| | - Nikolaos Papagiannakis
- First Department of Neurology, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Georgios Mavrovounis
- Department of Emergency Medicine, University of Thessaly, Faculty of Medicine, Larisa, Greece
| | - Konstantina Kolonia
- Department of Anesthesiology, University ofThessaly, Faculty of Medicine, Larisa, Greece
| | - Maria Mermiri
- Department of Anesthesiology, University ofThessaly, Faculty of Medicine, Larisa, Greece
| | - Ioannis Pantazopoulos
- Department of Emergency Medicine, University of Thessaly, Faculty of Medicine, Larisa, Greece
| | - Eleni Laou
- Department of Anesthesiology, University ofThessaly, Faculty of Medicine, Larisa, Greece
| | - Eleni Arnaoutoglou
- Department of Anesthesiology, University ofThessaly, Faculty of Medicine, Larisa, Greece
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The Reproducibility of the Point of Care Microcirculation (POEM) Score When Used to Assess Critically Ill Patients: A Multicenter Prospective Observational Study. Shock 2021; 54:15-20. [PMID: 31764623 DOI: 10.1097/shk.0000000000001474] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The current standard of analyzing microcirculatory video microscopy is time-consuming and occurs away from the patient, limiting its clinical utility. Point-of-care assessment with incident dark field (IDF) microscopy, however, may offer greater clinical applicability. We aimed to determine the reproducibility of the Point of Care Microcirculation (POEM) tool when used at the bedside in critically ill patients. METHODS A multinational, multicenter, prospective observational study of adult intubated patients was undertaken during a 9-month period in Germany, the United Kingdom, and the United States. A user recorded a batch of four standardized video clips from each patient, calculated a POEM score and recorded the time for image acquisition. A second user blinded to the first repeated this process. Patients with video clips of poor quality were excluded. At a later date, the two users again blinded themselves to reassess both their own clips and those of the other user. Basic demographic information was recorded. Intrauser reliability (an individual user rescoring the same batch of videos after blinding), interuser reliability (a second user rescoring the other user's video batch after blinding), and test-retest reliability (two users individually capturing videos and recording POEM scores) were assessed using a linearly weighted kappa statistic for ordinal data. RESULTS Sixty-five patients were included in the final analysis. Observer agreement was substantial for all tests. Intrauser agreement was 0.73 (0.95 CI 0.64-0.81), interuser agreement 0.71 (0.95 CI 0.63-0.79), and test-retest agreement 0.75 (0.95 CI 0.65-0.86). Average time to record videos and assess POEM scores 7:34 ± 3:37 minutes. CONCLUSIONS Point-of-care assessment of the microcirculation using IDF video microscopy and POEM scoring appears to be both a feasible and reproducible approach to microcirculatory assessment. Testing of the score in critically ill patients showed substantial agreement within and between investigators, but further studies should validate its utility as a tool to guide shock resuscitation.
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8
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Xantus G, Allen P, Kanizsai P. Blind spot in sepsis management - Tissue level changes in microcirculation. Physiol Int 2021. [PMID: 33844643 DOI: 10.1556/2060.2021.00011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 01/20/2021] [Indexed: 11/19/2022]
Abstract
In sepsis cytokine-mediated inflammation, clotting cascade activation and glycocalyx shedding impair both function and structure of the microcirculation, compromising adequate tissue oxygenation/perfusion. Such mismatch results in "dysoxia", an imbalance in mitochondrial respiration.Microvessel injuries can be grouped into four types: cytotoxic oedema, micro-vessel heterogeneity, sluggish/absent flow, and focal anaemia. Recognition of such diversity in microcirculatory pathology, alongside with the implementation of novel biomarkers might reveal previously unobserved heterogeneity in adults diagnosed with sepsis. Early identification of distinct subtypes may help not only to better stratify disease severity but may also provide explanation to the often seen insufficient/absent response to resuscitative treatment. Experimental evidence suggests that impaired microcirculatory flow may correlate with organ dysfunction and mortality. Therefore, reliable/reproducible diagnostic tools, that provide real-time information about the dynamic state of the microcirculation, might be practice changers in managing the critically ill.The sublingual mucosa and the nailfolds provide easy access to microcirculation via hand-held, point-of-care devices. Accessing these windows, clinicians may recognise, understand and potentially correct the underlying tissue oxygenation/perfusion mismatch. This new clinical information might facilitate an individualised approach vs protocolised care aiming to administer the right balance of intravenous fluids/vasopressors, time/dose auxiliary treatment modalities and, most importantly, might also guide determining the optimal duration of resuscitation to avoid/minimise harm and maximise benefits in sepsis management. However, before every-day clinical use of such point-of-care microcameras, validation studies are needed to establish not only feasibility but reliability and reproducibility as well.
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Affiliation(s)
- G Xantus
- 1School of Medicine, Cardiff University, Cardiff CF10 3AT, UK
| | - P Allen
- 2Rural Clinical School, College of Health and Medicine, Burnie, Tasmania, 7320, Australia
| | - P Kanizsai
- 3Department of Emergency Medicine, Clinical Centre, University of Pécs, Pécs, Hungary
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9
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Khanna AK, Karamchandani K. Macrocirculation and Microcirculation: The "Batman and Superman" Story of Critical Care Resuscitation. Anesth Analg 2021; 132:280-283. [PMID: 33177325 DOI: 10.1213/ane.0000000000005272] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Ashish K Khanna
- From the Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Wake Forest Baptist Health Network, Winston-Salem, North Carolina.,Outcomes Research Consortium, Cleveland, Ohio
| | - Kunal Karamchandani
- Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
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10
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Dubin A, Kanoore Edul VS, Caminos Eguillor JF, Ferrara G. Monitoring Microcirculation: Utility and Barriers - A Point-of-View Review. Vasc Health Risk Manag 2020; 16:577-589. [PMID: 33408477 PMCID: PMC7780856 DOI: 10.2147/vhrm.s242635] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/27/2020] [Indexed: 12/22/2022] Open
Abstract
Microcirculation is a particular organ of the cardiovascular system. The goal of this narrative review is a critical reappraisal of the present knowledge of microcirculation monitoring, mainly focused on the videomicroscopic evaluation of sublingual microcirculation in critically ill patients. We discuss the technological developments in handheld videomicroscopy, which have resulted in adequate tools for the bedside monitoring of microcirculation. By means of these techniques, a large body of evidence has been acquired about the role of microcirculation in the pathophysiological mechanisms of shock, especially septic shock. We review the characteristics of sublingual microcirculation in septic shock, which mainly consist in a decrease in the perfused vascular density secondary to a reduction in the proportion of perfused vessels along with a high heterogeneity in perfusion. Even in patients with high cardiac output, red blood cell velocity is decreased. Thus, hyperdynamic flow is absent in the septic microcirculation. We also discuss the dissociation between microcirculation and systemic hemodynamics, particularly after shock resuscitation, and the different behavior among microvascular beds. In addition, we briefly comment the effects of some treatments on microcirculation. Despite the fact that sublingual microcirculation arises as a valuable goal for the resuscitation in critically ill patients, significant barriers remain present for its clinical application. Most of them are related to difficulties in video acquisition and analysis. We comprehensively analyzed these shortcomings. Unfortunately, a simpler approach, such as the central venous minus arterial PCO2 difference, is a misleading surrogate for sublingual microcirculation. As conclusion, the monitoring of sublingual microcirculation is an appealing method for monitoring critically ill patients. Nevertheless, the lack of controlled studies showing benefits in terms of outcome, as well as technical limitations for its clinical implementation, render this technique mainly as a research tool.
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Affiliation(s)
- Arnaldo Dubin
- Cátedra de Farmacología Aplicada, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, La Plata, Argentina
| | | | | | - Gonzalo Ferrara
- Cátedra de Farmacología Aplicada, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, La Plata, Argentina
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11
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Abstract
PURPOSE OF REVIEW Currently, the treatment of patients with shock is focused on the clinical symptoms of shock. In the early phase, this is usually limited to heart rate, blood pressure, lactate levels and urine output. However, as the ultimate goal of resuscitation is the improvement in microcirculatory perfusion the question is whether these currently used signs of shock and the improvement in these signs actually correspond to the changes in the microcirculation. RECENT FINDINGS Recent studies have shown that during the development of shock the deterioration in the macrocirculatory parameters are followed by the deterioration of microcirculatory perfusion. However, in many cases the restoration of adequate macrocirculatory parameters is frequently not associated with improvement in microcirculatory perfusion. This relates not only to the cause of shock, where there are some differences between different forms of shock, but also to the type of treatment. SUMMARY The improvement in macrohemodynamics during the resuscitation is not consistently followed by subsequent changes in the microcirculation. This may result in both over-resuscitation and under-resuscitation leading to increased morbidity and mortality. In this article the principles of coherence and the monitoring of the microcirculation are reviewed.
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12
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De Backer D, Vincent JL. Noninvasive Monitoring in the Intensive Care Unit. Semin Respir Crit Care Med 2020; 42:40-46. [PMID: 33065744 DOI: 10.1055/s-0040-1718387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
There has been considerable development in the field of noninvasive hemodynamic monitoring in recent years. Multiple devices have been proposed to assess blood pressure, cardiac output, and tissue perfusion. All have their own advantages and disadvantages and selection should be based on individual patient requirements and disease severity and adjusted according to ongoing patient evolution.
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Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, CHIREC Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
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13
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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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14
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Aldecoa C, Llau JV, Nuvials X, Artigas A. Role of albumin in the preservation of endothelial glycocalyx integrity and the microcirculation: a review. Ann Intensive Care 2020; 10:85. [PMID: 32572647 PMCID: PMC7310051 DOI: 10.1186/s13613-020-00697-1] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 06/05/2020] [Indexed: 12/11/2022] Open
Abstract
The endothelial glycocalyx comprises a complex layer of membrane-bound proteoglycans, secreted glycosaminoglycans, glycoproteins, glycolipids and bound plasma proteins such as albumin and antithrombin associated with the endothelial surface. The glycocalyx plays an important role in vascular homeostasis, regulating vascular permeability and cell adhesion, and acts as a mechanosensor for hemodynamic shear stresses; it also has antithrombotic and anti-inflammatory functions. Plasma proteins such as albumin are physiologically bound within the glycocalyx, thus contributing to stability of the layer. Albumin is the major determinant of plasma colloid osmotic pressure. In addition, albumin transports sphingosine-1-phosphate which has protective endothelial effects, acts as a free radical scavenger, and has immunomodulatory and anti-inflammatory effects. This review examines the physiological function of the endothelial glycocalyx and the role of human albumin in preserving glycocalyx integrity and the microcirculation.
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Affiliation(s)
- Cesar Aldecoa
- Department of Anaesthesiology and Surgical Critical Care, Hospital Universitario Rio Hortega, c/Dulzaina 2, 47012, Valladolid, Spain
| | - Juan V Llau
- Department of Anaesthesiology and Surgical Critical Care, Hospital Universitario Dr. Peset, Universitat de València, c/Gaspar Aguilar 90, 46017, Valencia, Spain
| | - Xavier Nuvials
- Intensive Care Unit, and SODIR Research Group, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Antonio Artigas
- Critical Care Center, Corporacion Sanitaria Universitaria Parc Tauli, CIBER Enfermedades Respiratorias, Autonomous University of Barcelona, Parc Tauli 1, 08028, Sabadell, Spain.
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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.
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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
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Abstract
PURPOSE OF REVIEW The present review discusses the current role of microcirculatory assessment in the hemodynamic monitoring of critically ill patients. RECENT FINDINGS Videomicroscopic techniques have demonstrated that microvascular perfusion is altered in critically ill patients, and especially in sepsis. These alterations are associated with organ dysfunction and poor outcome. Handheld microscopes can easily be applied on the sublingual area of critically ill patients. Among the specific limitations of these techniques, the most important is that these can mostly investigate the sublingual microcirculation. The representativity of the sublingual area may be questioned, especially as some areas may sometimes be more affected than the sublingual area. Also, evaluation of the sublingual area may be difficult in nonintubated hypoxemic patients. Alternative techniques include vasoreactivity tests using either transient occlusion or performing a thermal challenge. These techniques evaluate the maximal dilatory properties of the microcirculation but do not really evaluate the actual microvascular perfusion. Focusing on the glycocalyx may be another option, especially with biomarkers of glycocalyx degradation and shedding. Evaluation of the glycocalyx is still largely experimental, with different tools still in investigation and lack of therapeutic target. Venoarterial differences in PCO2 are inversely related with microvascular perfusion, and can thus be used as surrogate for microcirculation assessment. Several limitations prevent the regular use in clinical practice. The first is the difficult use of some of these techniques outside research teams, whereas nurse-driven measurements are probably desired. The second important limitation for daily practice use is the lack of uniformly defined endpoint. The final limitation is that therapeutic interventions affecting the microcirculation are not straightforward. SUMMARY Clinical and biological surrogates of microcirculatory assessment can be used at bedside. The role of microvideoscopic techniques is still hampered by the lack of clearly defined targets as well as interventions specifically targeting the microcirculation.
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Bruno RR, Reed M, Bimpong-Buta NY, Muessig JM, Masyuk M, Binneboessel S, Franz M, Kelm M, Jung C. Sublingual microcirculation in prehospital critical care medicine: A proof-of-concept study. Microcirculation 2020; 27:e12614. [PMID: 32065682 DOI: 10.1111/micc.12614] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 02/11/2020] [Accepted: 02/14/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Diagnostic and risk stratification are limited in emergencies. The measurement of microcirculation might identify patients with poor perfusion but compensated macrocirculation such as in beginning shock. This proof-of-concept study examines whether sublingual prehospital sidestream dark-field microscopy is feasible. METHODS This prospective observational study included patients receiving medical aid by an emergency ambulance who had a spontaneous circulation and offered access to the sublingual mucosa. Sublingual measurement of microcirculation was performed using a sidestream dark field camera. Video quality was evaluated with microcirculation image quality score (microcirculation image quality score). AVA 4.3C software calculated microcirculatory parameters. RESULTS Thirty patients (47% male) were included. The average age was 63 years (±20 years SD), the severity of the disease (quantified by National Advisory Committee on Aeronautics) was 3.4 (±0.7 SD). Macrocirculation presented within the normal range. The most frequent cause preventing the measurement was a time-critical disease (64%). In 17 patients (57%), the videos could be analyzed immediately. The average quality of the video was 2.2 ± 0.45 points ('acceptable'). There were minor restrictions of microcirculation. Microcirculation correlated with National Advisory Committee on Aeronautics, but not with the macrocirculation. No complications occurred. CONCLUSION The prehospital sublingual measurement is safe and valid. Despite normal macrocirculation, microcirculation was impaired and correlated with National Advisory Committee on Aeronautics.
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Affiliation(s)
- Raphael Romano Bruno
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Dusseldorf, Germany
| | - Markus Reed
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Dusseldorf, Germany
| | - Nana-Yaw Bimpong-Buta
- Clinic for Cardiology, Electrophysiology and Internal Intensive Care Medicine, EVK Hagen-Haspe, Hagen, Germany
| | - Johanna M Muessig
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Dusseldorf, Germany
| | - Maryna Masyuk
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Dusseldorf, Germany
| | - Stephan Binneboessel
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Dusseldorf, Germany
| | - Marcus Franz
- Clinic for Cardiology, Internal Intensive Care Medicine, Angiology, Pneumology/Allergology, University Hospital Jena, Jena, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Dusseldorf, Germany.,Cardiovascular Research Institute Düsseldorf, Düsseldorf, Germany
| | - Christian Jung
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Dusseldorf, Germany
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Tavy ALM, de Bruin AFJ, Smits AB, Boerma EC, Ince C, Noordzij PG, Boerma D, van Iterson M. Intestinal Mucosal and Serosal Microcirculation at the Planned Anastomosis during Abdominal Surgery. Eur Surg Res 2020; 60:248-256. [PMID: 31935725 DOI: 10.1159/000505325] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 12/10/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Intestinal blood flow is often named as a key factor in the pathophysiology of anastomotic leakage. The distribution between mucosal and serosal microperfusion during surgery remains to be elucidated. OBJECTIVE The aim of this study was to assess if the mucosal microcirculation of the intestine is more vulnerable to a surgical hit than the serosal microcirculation during surgery. METHODS In an observational cohort study (n = 9 patients), the microcirculation of the bowel serosa and mucosa was visualized with incident dark-field imaging during surgery. At the planned anastomosis, the following microcirculatory parameters were determined: microvascular flow index (MFI), percentage of perfused vessels (PPV), perfused vessel density (PVD), and total vessel density (TVD). Data are presented as median (interquartile range [IQR]). RESULTS Perfusion parameters and vessel density were significantly higher for the mucosa than the serosal microcirculation at the planned site for anastomosis or stoma. Mucosal MFI was 3.00 (IQR 3.00-3.00) compared to a serosal MFI of 2.75 (IQR 2.21-2.94), p = 0.03. The PPV was 99% (IQR 98-100) versus 92% (IQR 66-94), p = 0.01. The TVD was 16.77 mm/mm2 (IQR 13.04-18.01) versus 10.42 mm/mm2 (IQR 9.36-11.81), p = 0.01, and the PVD was 15.44 mm/mm2 (IQR 13.04-17.78) versus 9.02 mm/mm2 (IQR 6.43-9.43), p = 0.01. CONCLUSIONS The mucosal microcirculation was preserved, while lower perfusion of the serosa was found at the planned anastomosis or stoma during surgery. Further research is needed to link our observations to the clinically relevant endpoint of anastomotic leakage.
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Affiliation(s)
- Arthur L M Tavy
- Department of Anesthesiology, Intensive Care and Pain Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands,
| | - Anton F J de Bruin
- Department of Anesthesiology, Intensive Care and Pain Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Anke B Smits
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - E Christiaan Boerma
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Can Ince
- Department of Intensive Care Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Peter G Noordzij
- Department of Anesthesiology, Intensive Care and Pain Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Djamila Boerma
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Mat van Iterson
- Department of Anesthesiology, Intensive Care and Pain Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
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Sardinha J, MacKinnon S, Lehmann C. Rapid clinical assessment of the sublingual microcirculation - Visual scoring using microVAS in comparison to standard semi-automated analysis. Clin Hemorheol Microcirc 2019; 72:229-238. [PMID: 30320559 DOI: 10.3233/ch-180427] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
RATIONALE Alterations in human microcirculation occur in many disease states leading to morbidity and mortality, however assessing the microcirculation is not standard clinical practice. Standard microcirculation analysis using semi-automated analysis is expensive, time consuming, and expertise dependent making it unfeasible. We proposed a novel visual scoring system (microVAS) for the analysis of microcirculation videos that can be performed at the patient bedside in real time. OBJECTIVE Validate our microVAS score by training health professionals unfamiliar with the microcirculation field to use our microVAS score and compare their scores to the standard method of semi-automated analysis using AVA3 software. METHODS Using a prospective double-blind study design, we recruited and trained 20 participants to use our microVAS score. Participants scored 40 videos (from 22 healthy and 18 septic patients) for MFI and PPV. The same 40 videos were analysed by an expert using the gold standard semi-automated method of analysis. The results of the participants and the expert were analysed by Pearson's linear regression. Krippendorff's alpha was used to assess inter-rater reliability of the participants. RESULTS Overall correlation of MFI was r = 0.33 (95% CI 0.27-0.39), p < 0.05; overall correlation of PPV was r = -0.11 (95% CI -0.18 to -0.04), p < 0.05. The Krippendorff's alpha for MFI was 0.56 (healthy videos: α= 0.34, sepsis videos: α= 0.31). For PPV Krippendorff's alpha was 0.43 (healthy videos: α= 0.56, sepsis videos: α= 0.17). CONCLUSIONS Overall for both MFI and PPV, there was a small correlation between our microVAS score and AVA 3 scores. Regarding inter-rater reliability both MFI and PPV showed fair agreement between raters. Going forward multiple improvements to the microVAS scoring system as well as the training program are suggested to improve reliability and consistency.
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Affiliation(s)
- Joel Sardinha
- Department of Anesthesia, Pain Management and Perioperative Management Dalhousie University, Halifax, NS, Canada
| | - Sean MacKinnon
- Department of Anesthesia, Pain Management and Perioperative Management Dalhousie University, Halifax, NS, Canada
| | - Christian Lehmann
- Department of Anesthesia, Pain Management and Perioperative Management Dalhousie University, Halifax, NS, Canada
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Microcirculatory Impairment Is Associated With Multiple Organ Dysfunction Following Traumatic Hemorrhagic Shock: The MICROSHOCK Study. Crit Care Med 2019; 46:e889-e896. [PMID: 29957708 DOI: 10.1097/ccm.0000000000003275] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES To assess the relationship between microcirculatory perfusion and multiple organ dysfunction syndrome in patients following traumatic hemorrhagic shock. DESIGN Multicenter prospective longitudinal observational study. SETTING Three U.K. major trauma centers. PATIENTS Fifty-eight intubated and ventilated patients with traumatic hemorrhagic shock. INTERVENTIONS Sublingual incident dark field microscopy was performed within 12 hours of ICU admission (D0) and repeated 24 and 48 hours later. Cardiac output was assessed using oesophageal Doppler. Multiple organ dysfunction syndrome was defined as Serial Organ Failure Assessment score greater than or equal to 6 at day 7 post injury. MEASUREMENTS AND MAIN RESULTS Data from 58 patients were analyzed. Patients had a mean age of 43 ± 19 years, Injury Severity Score of 29 ± 14, and initial lactate of 7.3 ± 6.1 mmol/L and received 6 U (interquartile range, 4-11 U) of packed RBCs during initial resuscitation. Compared with patients without multiple organ dysfunction syndrome at day 7, patients with multiple organ dysfunction syndrome had lower D0 perfused vessel density (11.2 ± 1.8 and 8.6 ± 1.8 mm/mm; p < 0.01) and microcirculatory flow index (2.8 [2.6-2.9] and 2.6 [2.2-2.8]; p < 0.01) but similar cardiac index (2.5 [± 0.6] and 2.1 [± 0.7] L/min//m; p = 0.11). Perfused vessel density demonstrated the best discrimination for predicting subsequent multiple organ dysfunction syndrome (area under curve 0.87 [0.76-0.99]) compared with highest recorded lactate (area under curve 0.69 [0.53-0.84]), cardiac index (area under curve 0.66 [0.49-0.83]) and lowest recorded systolic blood pressure (area under curve 0.54 [0.39-0.70]). CONCLUSIONS Microcirculatory hypoperfusion immediately following traumatic hemorrhagic shock and resuscitation is associated with increased multiple organ dysfunction syndrome. Microcirculatory variables are better prognostic indicators for the development of multiple organ dysfunction syndrome than more traditional indices. Microcirculatory perfusion is a potential endpoint of resuscitation following traumatic hemorrhagic shock.
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21
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Rovas A, Seidel LM, Vink H, Pohlkötter T, Pavenstädt H, Ertmer C, Hessler M, Kümpers P. Association of sublingual microcirculation parameters and endothelial glycocalyx dimensions in resuscitated sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:260. [PMID: 31340868 PMCID: PMC6657098 DOI: 10.1186/s13054-019-2542-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 07/16/2019] [Indexed: 02/07/2023]
Abstract
Background The endothelial glycocalyx (eGC) covers the luminal surface of the vascular endothelium and plays an important protective role in systemic inflammatory states and particularly in sepsis. Its breakdown leads to capillary leak and organ dysfunction. Moreover, sepsis-induced alterations of sublingual microcirculation are associated with a worse clinical outcome. The present study was performed to investigate the associations between eGC dimensions and established parameters of microcirculation dysfunction in sepsis. Methods This observational, prospective, cross-sectional study included 40 participants, of which 30 critically ill septic patients were recruited from intensive care units of a university hospital and 10 healthy volunteers served as controls. The established microcirculation parameters were obtained sublingually and analyzed according to the current recommendations. In addition, the perfused boundary region (PBR), an inverse parameter of the eGC dimensions, was measured sublingually, using novel data acquisition and analysis software (GlycoCheck™). Moreover, we exposed living endothelial cells to 5% serum from a subgroup of study participants, and the delta eGC breakdown, measured with atomic force microscopy (AFM), was correlated with the paired PBR values. Results In septic patients, sublingual microcirculation was impaired, as indicated by a reduced microvascular flow index (MFI) and a reduced proportion of perfused vessels (PPV) compared to those in healthy controls (MFI, 2.93 vs 2.74, p = 0.002; PPV, 98.53 vs 92.58, p = 0.0004). PBR values were significantly higher in septic patients compared to those in healthy controls, indicating damage of the eGC (2.04 vs 2.34, p < 0.0001). The in vitro AFM data correlated exceptionally well with paired PBR values obtained at the bedside (rs = − 0.94, p = 0.02). Both PBR values and microcirculation parameters correlated well with the markers of critical illness. Interestingly, no association was observed between the PBR values and established microcirculation parameters. Conclusion Our findings suggest that eGC damage can occur independently of microcirculatory impairment as measured by classical consensus parameters. Further studies in critically ill patients are needed to unravel the relationship of glycocalyx damage and microvascular impairment, as well as their prognostic and therapeutic importance in sepsis. Trial registration Retrospectively registered: Clinicaltrials.gov, NCT03960307 Electronic supplementary material The online version of this article (10.1186/s13054-019-2542-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alexandros Rovas
- Department of Medicine D, Division of General Internal Medicine, Nephrology, and Rheumatology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Laura Mareen Seidel
- Department of Anesthesiology, Intensive Care, and Pain Therapy, University Hospital Muenster, Münster, Germany
| | - Hans Vink
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Timo Pohlkötter
- Department of Medicine D, Division of General Internal Medicine, Nephrology, and Rheumatology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Hermann Pavenstädt
- Department of Medicine D, Division of General Internal Medicine, Nephrology, and Rheumatology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Christian Ertmer
- Department of Anesthesiology, Intensive Care, and Pain Therapy, University Hospital Muenster, Münster, Germany
| | - Michael Hessler
- Department of Anesthesiology, Intensive Care, and Pain Therapy, University Hospital Muenster, Münster, Germany
| | - Philipp Kümpers
- Department of Medicine D, Division of General Internal Medicine, Nephrology, and Rheumatology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
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Deitchman AR, McCurdy MT, Fargaly H, Gilani M, Sorensen EN, Mazzeffi MA. Microcirculatory Coherence in Patients with Left Ventricular Assist Devices. J Cardiothorac Vasc Anesth 2019; 33:2608-2610. [PMID: 31076298 DOI: 10.1053/j.jvca.2019.03.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 03/24/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Andrew R Deitchman
- University of Maryland School of Medicine, Department of Medicine, Baltimore, MD
| | - Michael T McCurdy
- University of Maryland School of Medicine, Department of Medicine, Baltimore, MD
| | - Hithem Fargaly
- University of Maryland School of Medicine, Department of Medicine, Baltimore, MD
| | - Muhammad Gilani
- University of Maryland School of Medicine, Department of Medicine, Baltimore, MD
| | | | - Michael A Mazzeffi
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD
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Abstract
PURPOSE OF REVIEW Microcirculatory alterations play a major role in the pathogenesis of shock. Monitoring tissue perfusion might be a relevant goal for shock resuscitation. The goal of this review was to revise the evidence supporting the monitoring of peripheral perfusion and microcirculation as goals of resuscitation. For this purpose, we mainly focused on skin perfusion and sublingual microcirculation. RECENT FINDINGS Although there are controversies about the reproducibility of capillary refill time in monitoring peripheral perfusion, it is a sound physiological variable and suitable for the ICU settings. In addition, observational studies showed its strong ability to predict outcome. Moreover, a preliminary study suggested that it might be a valuable goal for resuscitation. These results should be confirmed by the ongoing ANDROMEDA-SHOCK randomized controlled trial. On the other hand, the monitoring of sublingual microcirculation might also provide relevant physiological and prognostic information. On the contrary, methodological drawbacks mainly related to video assessment hamper its clinical implementation at the present time. SUMMARY Measurements of peripheral perfusion might be useful as goal of resuscitation. The results of the ANDROMEDA-SHOCK will clarify the role of skin perfusion as a guide for the treatment of shock. In contrast, the assessment of sublingual microcirculation mainly remains as a research tool.
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Uz Z, Ince C, Guerci P, Ince Y, P Araujo R, Ergin B, Hilty MP, van Gulik TM, de Mol BA. Recruitment of sublingual microcirculation using handheld incident dark field imaging as a routine measurement tool during the postoperative de-escalation phase-a pilot study in post ICU cardiac surgery patients. Perioper Med (Lond) 2018; 7:18. [PMID: 30116524 PMCID: PMC6083575 DOI: 10.1186/s13741-018-0091-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 04/30/2018] [Indexed: 02/07/2023] Open
Abstract
Background Management of tissue perfusion following cardiac surgery is a challenging task where common clinical parameters do not reflect microcirculatory dysfunction. Heterogeneity in blood flow perfusion and abnormalities in capillary density characterize microcirculatory dysfunction. The restoration of a normal microcirculation may become a novel target for therapy in the future in addition to macrocirculatory parameters. The aim of this study is to determine how the sublingual microcirculatory parameters vary at the bedside in post-cardiac surgery patients which underwent diuretic therapy to correct fluid overload. Methods In this prospective observational pilot study, video clips of sublingual microcirculation in post-cardiac surgery patients receiving furosemide and/or spironolactone to achieve normal fluid balance were recorded using Cytocam-IDF imaging. Data was obtained on the first (T0), second (T1), and third (T2) day after the patients left the intensive care unit (ICU). Measurements were analyzed off-line to obtain the following microcirculatory parameters: total vessel density (TVD), microcirculatory flow index (MFI), proportion of perfused vessel (PPV), and perfused vessel density (PVD). Macrocirculatory parameters and body weight were also collected at these time points. Results Ninety measurements were performed in ten post ICU cardiac surgery patients. Thirteen measurements were excluded due to quality reasons; these excluded measurements were spread across the patients and time points, and there was no loss of patients or time points. An increase in TVD was observed from T0 to T1 (20 ± 2.7 to 24 ± 3.2 mm/mm2; p = 0.0410) and from T0 to T2 (20 ± 2.7 to 26 ± 3.3 mm/mm2; p = 0.0005). An increase in PVD was present from T0 to T1 (19 ± 2.3 to 24 ± 3.5 mm/mm2; p = 0.0072) and from T0 to T2 (19 ± 2.3 to 26 ± 3.4 mm/mm2, p = 0.0008). Fluid overload was assessed through a positive cumulative fluid balance on the day of ICU discharge. Conclusions Cytocam-IDF imaging to monitor microcirculation as a daily parameter is feasible and could become a valuable tool to non-invasively assess the tissue oxygenation at the bedside. An increase in TVD and PVD (functional capillary density) indicated the recruitment of the sublingual microcirculation in patients with diuretic therapy. Future research is needed to prove the correlation between the recruitment of the sublingual microcirculation and the de-escalation phase of the fluid management.
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Affiliation(s)
- Zühre Uz
- 1Department of Experimental Surgery and Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Can Ince
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Philippe Guerci
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Yasin Ince
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Renata P Araujo
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Bulent Ergin
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Matthias P Hilty
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Thomas M van Gulik
- 1Department of Experimental Surgery and Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Bas A de Mol
- 3Department of Cardio-Thoracic Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Could resuscitation be based on microcirculation data? No. Intensive Care Med 2018; 44:947-949. [PMID: 29736788 DOI: 10.1007/s00134-018-5095-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 02/11/2018] [Indexed: 12/28/2022]
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Abstract
PURPOSE OF REVIEW Tissue monitoring is one of the main strategies at the bedside to guide resuscitation of shock. Advances in tissue monitoring technologies have established noninvasive optical methods and transcutaneous oximetry as modalities of considerable value in the critical care setting for tissue monitoring in shock. The purpose of this article is to highlight the latest developments into the clinical applications of near-infrared spectroscopy, direct visualization of sublingual microcirculation, and transcutaneous oxygen measurements (PtcO2). RECENT FINDINGS Near-infrared spectroscopy has been successfully applied in patients with septic shock during vasopressor and blood transfusion therapy to identify patients at high risk for microcirculatory failure. A new generation incident dark field imaging-based handheld microscope has been introduced for quantification of microcirculatory alterations at bedside. Preliminary comparisons with previous versions have shown better quality and superiority of incident dark field in detecting more vessels. PtcO2 measurements have been applied mainly to detect a peripheral low-flow state in circulatory failure using the oxygen challenge test. Altered lung function might have an influence on PtcO2, and thus affect the oxygen challenge test. SUMMARY The latest developments of noninvasive optical monitoring and transcutaneous oximetry technologies have helped early identification of septic patients at high risk for microcirculatory failure and could allow more targeted interventions in shock.
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Bedside analysis of the sublingual microvascular glycocalyx in the emergency room and intensive care unit - the GlycoNurse study. Scand J Trauma Resusc Emerg Med 2018; 26:16. [PMID: 29444696 PMCID: PMC5813422 DOI: 10.1186/s13049-018-0483-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 02/04/2018] [Indexed: 01/25/2023] Open
Abstract
Background Deterioration of the endothelial glycocalyx (eGC), a protective carbohydrate-rich layer lining the luminal surface of the endothelium, plays a key role in vascular barrier dysfunction and eventually organ-failure in systemic inflammatory response syndrome and sepsis. Early detection of glycocalyx damage could thus become an important goal in critical care. This study was designed to determine the feasibility and reproducibility of quantitative, real-time glycocalyx measurements performed at bedside in the emergency room (ER) and intensive care unit (ICU). Methods The observational study included 70 patients admitted to the ER or ICU of a university hospital. A physician and the nurse in charge of the patient performed sublingual microcirculatory measurements using sidestream dark field (SDF) imaging. A novel data acquisition and analysis software (GlycoCheck™) was used to analyze the perfused boundary region (PBR), an inverse parameter of endothelial glycocalyx dimensions in vessels with diameters of between 5 and 25 μm. Results The method showed a good intra-observer reproducibility. Specifically, intraclass correlation coefficient analysis showed an excellent reproducibility between the physician’s measurements (0.77 [CI 95%: 0.52–0.89]). The bias between the two PBRs was − 0.077 ± 0.24 μm. Moreover, there were no significant differences in the PBR values obtained by the nurses when compared to those reported by the physician (regarded as the “gold standard” measurement). Intraclass correlation coefficient analysis showed excellent reproducibility between the nurses’ and physician’s PBRs (0.75 [95% CI: 0.52–0.87]). The mean difference between the two PBRs (i.e., the bias) was 0.007 ± 0.25 μm. The nurses’ PBR assessment had a 90% sensitivity (95% CI: 60–99%) and 90% specificity (95% CI: 80–93%) to identify a severely impaired glycocalyx. Conclusion Glycocalyx dimensions can be measured at patients’ bedside precisely by non-invasive assessment of the PBR. This assessment could become part of standard monitoring and contribute to clinical decision-making and resuscitation protocols in clinical trials and daily practice. Electronic supplementary material The online version of this article (10.1186/s13049-018-0483-4) contains supplementary material, which is available to authorized users.
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Abstract
Microcirculatory abnormalities have been shown to be frequent in patients with septic shock despite "normalization" of systemic hemodynamics. Several studies have explored the impact of vasodilator therapy (prostacyclin, inhaled nitric oxide, topic acetylcholine, and nitroglycerin) on microcirculation and tissue perfusion, with contradictory findings.In this narrative review, we briefly present the pathophysiological aspects of microcirculatory dysfunction, and depict the evidence supporting the use of vasodilators and other therapeutic interventions (fluid administration, blood transfusion, vasopressors, and dobutamine) aiming to improve the microcirculatory flow in septic shock patients.
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Ince C, Boerma EC, Cecconi M, De Backer D, Shapiro NI, Duranteau J, Pinsky MR, Artigas A, Teboul JL, Reiss IKM, Aldecoa C, Hutchings SD, Donati A, Maggiorini M, Taccone FS, Hernandez G, Payen D, Tibboel D, Martin DS, Zarbock A, Monnet X, Dubin A, Bakker J, Vincent JL, Scheeren TWL. Second consensus on the assessment of sublingual microcirculation in critically ill patients: results from a task force of the European Society of Intensive Care Medicine. Intensive Care Med 2018; 44:281-299. [DOI: 10.1007/s00134-018-5070-7] [Citation(s) in RCA: 219] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 01/17/2018] [Indexed: 12/17/2022]
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Poor microcirculatory flow dynamics are associated with endothelial cell damage and glycocalyx shedding after traumatic hemorrhagic shock. J Trauma Acute Care Surg 2018; 84:81-88. [DOI: 10.1097/ta.0000000000001695] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Booth MA, Gowers SAN, Leong CL, Rogers ML, Samper IC, Wickham AP, Boutelle MG. Chemical Monitoring in Clinical Settings: Recent Developments toward Real-Time Chemical Monitoring of Patients. Anal Chem 2017; 90:2-18. [PMID: 29083872 DOI: 10.1021/acs.analchem.7b04224] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Marsilea A Booth
- Department of Bioengineering, Imperial College London , London, SW7 2AZ, United Kingdom
| | - Sally A N Gowers
- Department of Bioengineering, Imperial College London , London, SW7 2AZ, United Kingdom
| | - Chi Leng Leong
- Department of Bioengineering, Imperial College London , London, SW7 2AZ, United Kingdom
| | - Michelle L Rogers
- Department of Bioengineering, Imperial College London , London, SW7 2AZ, United Kingdom
| | - Isabelle C Samper
- Department of Bioengineering, Imperial College London , London, SW7 2AZ, United Kingdom
| | - Aidan P Wickham
- Department of Bioengineering, Imperial College London , London, SW7 2AZ, United Kingdom
| | - Martyn G Boutelle
- Department of Bioengineering, Imperial College London , London, SW7 2AZ, United Kingdom
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Intestinal microcirculation and mucosal oxygenation during hemorrhagic shock and resuscitation at different inspired oxygen concentrations. J Trauma Acute Care Surg 2017; 83:476-484. [PMID: 28538634 DOI: 10.1097/ta.0000000000001573] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Hypotensive resuscitation is the standard of care of hemorrhagic shock resuscitation. The optimal level of arterial pressure is debated and there is a lack of data on relationships between arterial pressure, microcirculation and tissue oxygenation. We investigated the relationship between mean arterial pressure, intestinal microcirculation and mucosal oxygen tension during hemorrhagic shock and resuscitation at different inspired oxygen fraction concentration. METHODS The study was divided into two phases: 32 mice were progressively exsanguinated and then transfused in mean arterial pressure (MAP)-titrated steps of 10 mm Hg. Mice were randomized to four experimental groups: a control group in which sham mice underwent a laparotomy and three interventional groups with a common phase of exsanguination followed by progressive resuscitation at three different inspired oxygen concentrations (FIO2) (15%, 30%, and 100%). Intestinal mucosal oxygenation (intestinal PO2) and microcirculatory parameters were recorded at each 10 mm Hg MAP step. RESULTS During exsanguination, intestinal PO2 decreased linearly with MAP levels. Microcirculatory parameters decreased nonlinearly with MAP levels while they had a linear relationship with intestinal PO2. Intestinal mucosal hypoxia (PO2 ≤ 20 mm Hg) began at a MAP of 60 mm Hg and MAP < 60 mm Hg was associated with a high percentage of animal with intestinal hypoxia (≥32%). Combination of MAP and microcirculatory parameters was superior to MAP alone at predicting mucosal oxygenation. Inversely, during resuscitation with FIO2 = 30%, the microcirculatory parameters increased linearly with MAP levels while they had a nonlinear relationship with intestinal PO2. Hypoxia (FIO2 = 15%) was poorly tolerated. In hyperoxic group (FIO2 = 100%) intestinal PO2 became significantly higher than baseline values as soon as 50 mm Hg MAP. CONCLUSION During hemorrhagic shock, intestinal PO2 decreased linearly with MAP levels and microcirculatory parameters. Associating MAP and microcirculatory parameters allowed a better prediction of intestinal PO2 than MAP alone. A MAP < 60 mm Hg was associated with a high percentage of animal with intestinal hypoxia. Normoxic resuscitation (FIO2 = 30%) was sufficient to restore intestinal PO2.
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Hasanin A, Mukhtar A, Nassar H. Perfusion indices revisited. J Intensive Care 2017; 5:24. [PMID: 28331621 PMCID: PMC5351209 DOI: 10.1186/s40560-017-0220-5] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 03/07/2017] [Indexed: 12/18/2022] Open
Abstract
Monitoring of tissue perfusion is an essential step in the management of acute circulatory failure. The presence of cellular dysfunction has been a basic component of shock definition even in the absence of hypotension. Monitoring of tissue perfusion includes biomarkers of global tissue perfusion and measures for assessment of perfusion in non-vital organs. The presence of poor tissue perfusion in a shocked patient is usually associated with worse outcome. Persistently impaired perfusion despite adequate resuscitation is also associated with worse outcome. Thus, normalization of some perfusion indices has become one of the resuscitation targets in patients with septic shock. Although the collective evidence shows the clear relation between impaired peripheral perfusion and mortality, the use of different perfusion indices as a resuscitation target needs more research.
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Affiliation(s)
- Ahmed Hasanin
- Anesthesia and Critical Care Medicine, Cairo University, Giza, Egypt.,Critical Care Department, El-Ameen Hospital, Taif, Kingdom of Saudi Arabia
| | - Ahmed Mukhtar
- Anesthesia and Critical Care Medicine, Cairo University, Giza, Egypt
| | - Heba Nassar
- Anesthesia and Critical Care Medicine, Cairo University, Giza, Egypt
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Microcirculatory monitoring in septic patients: Where do we stand? Med Intensiva 2017; 41:44-52. [PMID: 28104277 DOI: 10.1016/j.medin.2016.11.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 11/09/2016] [Accepted: 11/13/2016] [Indexed: 11/23/2022]
Abstract
Microcirculatory alterations play a pivotal role in sepsis-related morbidity and mortality. However, since the microcirculation has been a "black box", current hemodynamic management of septic patients is still guided by macrocirculatory parameters. In the last decades, the development of several technologies has shed some light on microcirculatory evaluation and monitoring, and the possibility of incorporating microcirculatory variables to clinical practice no longer seems to be beyond reach. The present review provides a brief summary of the current technologies for microcirculatory evaluation, and attempts to explore the potential role and benefits of their integration to the resuscitation process in critically ill septic patients.
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Ocak I, Kara A, Ince C. Monitoring microcirculation. Best Pract Res Clin Anaesthesiol 2016; 30:407-418. [DOI: 10.1016/j.bpa.2016.10.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 10/27/2016] [Indexed: 12/20/2022]
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37
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Vincent JL, Taccone FS. Microvascular monitoring – Do ‘global’ markers help? Best Pract Res Clin Anaesthesiol 2016; 30:399-405. [DOI: 10.1016/j.bpa.2016.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 10/27/2016] [Indexed: 12/19/2022]
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Libert N, Harrois A, Duranteau J. Haemodynamic coherence in haemorrhagic shock. Best Pract Res Clin Anaesthesiol 2016; 30:429-435. [DOI: 10.1016/j.bpa.2016.11.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 11/07/2016] [Indexed: 01/22/2023]
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Arnemann PH, Hessler M, Kampmeier T, Morelli A, Van Aken HK, Westphal M, Rehberg S, Ertmer C. Comparison of an automatic analysis and a manual analysis of conjunctival microcirculation in a sheep model of haemorrhagic shock. Intensive Care Med Exp 2016; 4:37. [PMID: 27864774 PMCID: PMC5116019 DOI: 10.1186/s40635-016-0110-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 11/07/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Life-threatening diseases of critically ill patients are known to derange microcirculation. Automatic analysis of microcirculation would provide a bedside diagnostic tool for microcirculatory disorders and allow immediate therapeutic decisions based upon microcirculation analysis. METHODS After induction of general anaesthesia and instrumentation for haemodynamic monitoring, haemorrhagic shock was induced in ten female sheep by stepwise blood withdrawal of 3 × 10 mL per kilogram body weight. Before and after the induction of haemorrhagic shock, haemodynamic variables, samples for blood gas analysis, and videos of conjunctival microcirculation were obtained by incident dark field illumination microscopy. Microcirculatory videos were analysed (1) manually with AVA software version 3.2 by an experienced user and (2) automatically by AVA software version 4.2 for total vessel density (TVD), perfused vessel density (PVD) and proportion of perfused vessels (PPV). Correlation between the two analysis methods was examined by intraclass correlation coefficient and Bland-Altman analysis. RESULTS The induction of haemorrhagic shock decreased the mean arterial pressure (from 87 ± 11 to 40 ± 7 mmHg; p < 0.001); stroke volume index (from 38 ± 14 to 20 ± 5 ml·m-2; p = 0.001) and cardiac index (from 2.9 ± 0.9 to 1.8 ± 0.5 L·min-1·m-2; p < 0.001) and increased the heart rate (from 72 ± 9 to 87 ± 11 bpm; p < 0.001) and lactate concentration (from 0.9 ± 0.3 to 2.0 ± 0.6 mmol·L-1; p = 0.001). Manual analysis showed no change in TVD (17.8 ± 4.2 to 17.8 ± 3.8 mm*mm-2; p = 0.993), whereas PVD (from 15.6 ± 4.6 to 11.5 ± 6.5 mm*mm-2; p = 0.041) and PPV (from 85.9 ± 11.8 to 62.7 ± 29.6%; p = 0.017) decreased significantly. Automatic analysis was not able to identify these changes. Correlation analysis showed a poor correlation between the analysis methods and a wide spread of values in Bland-Altman analysis. CONCLUSIONS As characteristic changes in microcirculation during ovine haemorrhagic shock were not detected by automatic analysis and correlation between automatic and manual analyses (current gold standard) was poor, the use of the investigated software for automatic analysis of microcirculation cannot be recommended in its current version at least in the investigated model. Further improvements in automatic vessel detection are needed before its routine use.
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Affiliation(s)
- Philip-Helge Arnemann
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Muenster University Hospital, Albert-Schweitzer-Campus 1, Building A1, 49149, Muenster, Germany.
| | - Michael Hessler
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Muenster University Hospital, Albert-Schweitzer-Campus 1, Building A1, 49149, Muenster, Germany
| | - Tim Kampmeier
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Muenster University Hospital, Albert-Schweitzer-Campus 1, Building A1, 49149, Muenster, Germany
| | - Andrea Morelli
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, University of Rome, "La Sapienza", Viale del Policlinico 155, 00161, Rome, Italy
| | - Hugo Karel Van Aken
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Muenster University Hospital, Albert-Schweitzer-Campus 1, Building A1, 49149, Muenster, Germany
| | - Martin Westphal
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Muenster University Hospital, Albert-Schweitzer-Campus 1, Building A1, 49149, Muenster, Germany
| | - Sebastian Rehberg
- Department of Anaesthesiology, Greifswald University Hospital, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
| | - Christian Ertmer
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Muenster University Hospital, Albert-Schweitzer-Campus 1, Building A1, 49149, Muenster, Germany
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Kara A, Akin S, Dos Reis Miranda D, Struijs A, Caliskan K, van Thiel RJ, Dubois EA, de Wilde W, Zijlstra F, Gommers D, Ince C. Microcirculatory assessment of patients under VA-ECMO. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:344. [PMID: 27776535 PMCID: PMC5078964 DOI: 10.1186/s13054-016-1519-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 09/30/2016] [Indexed: 12/03/2022]
Abstract
Background Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an effective technique for providing emergency mechanical circulatory support for patients with cardiogenic shock. VA-ECMO enables a rapid restoration of global systemic organ perfusion, but it has not been found to always show a parallel improvement in the microcirculation. We hypothesized in this study that the response of the microcirculation to the initiation of VA-ECMO might identify patients with increased chances of intensive care unit (ICU) survival. Methods Twenty-four patients were included in this study. Sublingual microcirculation measurements were performed using the CytoCam-IDF (incident dark field) imaging device. Microcirculatory measurements were performed at baseline, after VA-ECMO insertion (T1), 48–72 h after initiation of VA-ECMO (T2), 5–6 days after (T3), 9–10 days after (T4), and within 24 h of VA-ECMO removal. Results Of the 24 patients included in the study population, 15 survived and 9 died while on VA-ECMO. There was no significant difference between the systemic global hemodynamic variables at initiation of VA-ECMO between the survivors and non-survivors. There was, however, a significant difference in the microcirculatory parameters of both small and large vessels at all time points between the survivors and non-survivors. Perfused vessel density (PVD) at baseline (survivor versus non-survivor, 19.21 versus 13.78 mm/mm2, p = 0.001) was able to predict ICU survival on initiation of VA-ECMO; the area under the receiver operating characteristic curve (ROC) was 0.908 (95 % confidence interval 0.772–1.0). Conclusion PVD of the sublingual microcirculation at initiation of VA-ECMO can be used to predict ICU mortality in patients with cardiogenic shock. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1519-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Atila Kara
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. .,Department of Intensive Care, Hacettepe University Faculty of Medicine, Ankara, Turkey. .,Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Room H-603 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.
| | - Sakir Akin
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.,Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Dinis Dos Reis Miranda
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Ard Struijs
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Kadir Caliskan
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Robert J van Thiel
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Eric A Dubois
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Wouter de Wilde
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
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Digging into the microcirculation: the rush for gold may excavate apples and oranges. J Clin Monit Comput 2016; 31:665-667. [PMID: 27730451 PMCID: PMC5500674 DOI: 10.1007/s10877-016-9935-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 09/15/2016] [Indexed: 11/20/2022]
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Naumann DN, Mellis C, Husheer SLG, Hopkins P, Bishop J, Midwinter MJ, Hutchings SD. Real-time point of care microcirculatory assessment of shock: design, rationale and application of the point of care microcirculation (POEM) tool. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:310. [PMID: 27716373 PMCID: PMC5045597 DOI: 10.1186/s13054-016-1492-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 09/15/2016] [Indexed: 01/01/2023]
Abstract
Background Despite over a decade of research and technological advances, sublingual microcirculatory monitoring has not yet reached clinical utility. Offline analysis is time consuming and occurs away from the patient. A system to assess the microcirculation at the point of care is desirable. We present a novel 5-point grading system (the point of care microcirculation (POEM) scoring system) that can be used at the point of care during non-invasive sublingual microcirculatory monitoring. Methods The POEM score is an ordinal scale from 1 (worst) to 5 (best), based on a composite assessment of flow and heterogeneity of four individual sublingual video-microscopy clips. Thirty-two healthcare professionals were trained in how to assign POEM scores. Following training they assigned scores to five test sequences (each consisting of four video clips). They were blinded to clinical status. Inter-user consistency and agreement were assessed using intra-class correlation coefficient (ICC) analysis. In addition, blinded expert scores for 68 video clips were compared to offline computer analysis using traditional microcirculatory parameters including total vessel density (TVD), perfused vessel density (PVD), proportion of perfused vessels (PPV), microcirculatory flow index (MFI) and microcirculatory heterogeneity index (MHI). The time taken to assign each was recorded. Results Participants showed good inter-rater consistency (ICC 0.83, 95 % CI 0.626, 0.976) and agreement (ICC 0.815, 95 % CI 0.602, 0.974) for assigned POEM scores. Expert scoring of videos correlated with offline values for PVD (R2 = 0.39; p < 0.05), PPV (R2 = 0.71; p < 0.001), MFI (R2 = 0.75; p < 0.001), and MHI (R2 = 0.68; p < 0.001). POEM scores took less time to assign than conventional offline computer analysis (2 minutes versus 44 minutes). Conclusion We present for the first time a novel 5-point ordinal scale of microcirculatory flow and heterogeneity that can be used at the point of care. It has minimal inter-user variability amongst healthcare professionals after just 1 hour of training. POEM scores take a short time to assign, and correspond well to traditional offline computer-analyzed parameters. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1492-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David N Naumann
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, B152TH, UK.
| | - Clare Mellis
- Kings College Hospital, Denmark Hill, London, UK
| | | | | | - Jon Bishop
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, B152TH, UK
| | - Mark J Midwinter
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, B152TH, UK
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Hernández G, Teboul JL. Is the macrocirculation really dissociated from the microcirculation in septic shock? Intensive Care Med 2016; 42:1621-1624. [DOI: 10.1007/s00134-016-4416-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 06/01/2016] [Indexed: 10/21/2022]
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44
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Naumann DN, Midwinter MJ, Hutchings S. Venous-to-arterial CO2 differences and the quest for bedside point-of-care monitoring to assess the microcirculation during shock. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:37. [PMID: 26889490 DOI: 10.3978/j.issn.2305-5839.2015.12.61] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The microcirculation is the anatomical location of perfusion and substrate exchange, and its functional impairment is of paramount importance during the state of shock. The difference in venous-to-arterial carbon dioxide partial pressures (Pv-aCO2) has recently been reported to correlate with microcirculatory dysfunction during early septic shock with greater fidelity than global hemodynamic parameters. This makes it a potential candidate as a point-of-care test in goal directed therapy that aims to restore microcirculatory function in an emergency clinical context. This early work needs to be explored further, and a better understanding of Pv-aCO2 during the resuscitation and subsequent patient progression is required. The quest for an ideal bedside point-of-care test for microcirculatory behavior is ongoing, and is likely to consist of a combination of non-invasive sublingual microcirculatory monitoring and biochemical tests that reflect tissue perfusion. These tools have the potential to provide more accurate and clinically relevant data with regards to the microcirculation that more conventional resuscitative monitoring such as blood pressure, cardiac output, and serum lactate.
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Affiliation(s)
- David N Naumann
- 1 NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, B152TH, UK ; 2 Kings College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Mark J Midwinter
- 1 NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, B152TH, UK ; 2 Kings College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Sam Hutchings
- 1 NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, B152TH, UK ; 2 Kings College Hospital, Denmark Hill, London, SE5 9RS, UK
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