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Renner J, Saugel B, Reuter DA, Kouz K, Flick M, Zitzmann A, Habicher M, Annecke T. [Intraoperative clinical application of hemodynamic monitoring in noncardiac surgery patients]. DIE ANAESTHESIOLOGIE 2024:10.1007/s00101-024-01438-w. [PMID: 39037473 DOI: 10.1007/s00101-024-01438-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/28/2024] [Indexed: 07/23/2024]
Abstract
The current S1 guidelines on the intraoperative clinical application of hemodynamic monitoring in patients scheduled for noncardiac surgery are presented based on a case report under the aspect of an optimized intraoperative anesthesiological management. The S1 guidelines were developed with the aim of identifying the questions on the intraoperative hemodynamic monitoring and management which are important for the routine daily clinical practice, to discuss them in a guideline group and to answer them based on the current state of scientific knowledge. The guidelines were written under the auspices of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and published by the AWMF in 2023 under the register number 001/049.
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Affiliation(s)
- J Renner
- Klinik für Anästhesie und Operative Intensivmedizin, Städtisches Krankenhaus Kiel, Kiel, Deutschland.
| | - B Saugel
- Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - D A Reuter
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsmedizin Rostock, Rostock, Deutschland
| | - K Kouz
- Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - M Flick
- Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - A Zitzmann
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsmedizin Rostock, Rostock, Deutschland
| | - M Habicher
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Gießen, Gießen, Deutschland
| | - T Annecke
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Köln-Merheim, Kliniken Köln, Universität Witten/Herdecke, Köln, Deutschland
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Bidart JPM, Rosa RG, Bessel M, Pedrotti LG, Goldani LZ. Mortality predictors in patients with suspected sepsis in the emergency department of a tertiary care hospital: a retrospective cohort study. Int J Emerg Med 2024; 17:74. [PMID: 38880894 PMCID: PMC11181565 DOI: 10.1186/s12245-024-00655-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 06/09/2024] [Indexed: 06/18/2024] Open
Abstract
BACKGROUND Sepsis remains a worldwide major cause of hospitalization, mortality, and morbidity. To enhance the identification of patients with suspected sepsis at high risk of mortality and adverse outcomes in the emergency department (ED), the use of mortality predictors is relevant. This study aims to establish whether quick sofa (qSOFA) and the severity criteria applied in patients with suspicion of sepsis in a monitored ED are in fact predictors of mortality. METHODS We performed a retrospective cohort study among adult patients with suspicion of sepsis at the ED of a tertiary care hospital in Brazil between January 1st, 2019 and December 31, 2020. All adult patients (ages 18 and over) with suspected sepsis that scored two or more points on qSOFA score or at least one point on the severity criteria score were included in the study. RESULTS The total of patients included in the study was 665 and the average age of the sample was 73 ± 19 years. The ratio of men to women was similar. Most patients exhibited qSOFA ≥ 2 (58.80%) and 356 patients (53.61%) scored one point in the severity criteria at admission. The overall mortality rate was 19.7% (131 patients) with 98 patients (14.74%) having positive blood cultures, mainly showing Escherichia coli as the most isolated bacteria. Neither scores of qSOFA nor the severity criteria were associated with mortality rates, but scoring any point on qSOFA was considered as an independent factor for intensive care unit (ICU) admission (qSOFA = 1 point, p = 0.02; qSOFA = 2 points, p = 0.03, and qSOFA = 3 points, p = 0.04). Positive blood cultures (RR, 1.63;95% CI, 1.10 to 2.41) and general administration of vasopressors at the ED (RR, 2.14;95% CI, 1.44 to 3.17) were associated with 30-day mortality. The administration of vasopressors at the ED (RR, 2.25; CI 95%, 1.58 to 3.21) was found to be a predictor of overall mortality. CONCLUSIONS Even though an association was found between qSOFA and ICU admission, there was no association of qSOFA or the severity criteria with mortality. Therefore, patients with a tendency toward greater severity could be identified and treated more quickly and effectively in the emergency department. Further studies are necessary to assess novel scores or biomarkers to predict mortality in sepsis patients admitted to the ED's initial care.
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Affiliation(s)
- João P M Bidart
- Emergency Department, Moinhos de Vento Hospital, 910, Ramiro Barcelos Street, Porto Alegre, Zip code, 90035-001, Brazil.
| | - Regis G Rosa
- Internal Medicine Department, Moinhos de Vento Hospital, Ramiro Barcelos, 630, Porto Alegre, 90035- 001, Brazil
| | - Marina Bessel
- Proadi Social Responsability, Moinhos de Vento Hospital, Ramiro Barcelos, 910, Porto Alegre, 90035- 000, Brazil
| | - Luana G Pedrotti
- Proadi Social Responsability, Moinhos de Vento Hospital, Ramiro Barcelos, 910, Porto Alegre, 90035- 000, Brazil
| | - Luciano Z Goldani
- ⁵Section of Infectious Diseases, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2400, Porto Alegre, 90035-003, Brazil
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Luo JC, Luo MH, Zhang YJ, Liu WJ, Ma GG, Hou JY, Su Y, Hao GW, Tu GW, Luo Z. Skin mottling score assesses peripheral tissue hypoperfusion in critically ill patients following cardiac surgery. BMC Anesthesiol 2024; 24:130. [PMID: 38580909 PMCID: PMC10996133 DOI: 10.1186/s12871-024-02474-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/27/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Skin mottling is a common manifestation of peripheral tissue hypoperfusion, and its severity can be described using the skin mottling score (SMS). This study aims to evaluate the value of the SMS in detecting peripheral tissue hypoperfusion in critically ill patients following cardiac surgery. METHODS Critically ill patients following cardiac surgery with risk factors for tissue hypoperfusion were enrolled (n = 373). Among these overall patients, we further defined a hypotension population (n = 178) and a shock population (n = 51). Hemodynamic and perfusion parameters were recorded. The primary outcome was peripheral hypoperfusion, defined as significant prolonged capillary refill time (CRT, > 3.0 s). The characteristics and hospital mortality of patients with and without skin mottling were compared. The area under receiver operating characteristic curves (AUROC) were used to assess the accuracy of SMS in detecting peripheral hypoperfusion. Besides, the relationships between SMS and conventional hemodynamic and perfusion parameters were investigated, and the factors most associated with the presence of skin mottling were identified. RESULTS Of the 373-case overall population, 13 (3.5%) patients exhibited skin mottling, with SMS ranging from 1 to 5 (5, 1, 2, 2, and 3 cases, respectively). Patients with mottling had lower mean arterial pressure, higher vasopressor dose, less urine output (UO), higher CRT, lactate levels and hospital mortality (84.6% vs. 12.2%, p < 0.001). The occurrences of skin mottling were higher in hypotension population and shock population, reaching 5.6% and 15.7%, respectively. The AUROC for SMS to identify peripheral hypoperfusion was 0.64, 0.68, and 0.81 in the overall, hypotension, and shock populations, respectively. The optimal SMS threshold was 1, which corresponded to specificities of 98, 97 and 91 and sensitivities of 29, 38 and 67 in the three populations (overall, hypotension and shock). The correlation of UO, lactate, CRT and vasopressor dose with SMS was significant, among them, UO and CRT were identified as two major factors associated with the presence of skin mottling. CONCLUSION In critically ill patients following cardiac surgery, SMS is a very specific yet less sensitive parameter for detecting peripheral tissue hypoperfusion.
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Affiliation(s)
- Jing-Chao Luo
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
- Shanghai Geriatric Medical Center, Shanghai, 200032, China
| | - Ming-Hao Luo
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
- Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Yi-Jie Zhang
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Wen-Jun Liu
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Guo-Guang Ma
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Jun-Yi Hou
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Ying Su
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Guang-Wei Hao
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Guo-Wei Tu
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.
| | - Zhe Luo
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.
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Zhu B, Zhou R, Qin J, Li Y. Hierarchical Capability in Distinguishing Severities of Sepsis via Serum Lactate: A Network Meta-Analysis. Biomedicines 2024; 12:447. [PMID: 38398049 PMCID: PMC10886935 DOI: 10.3390/biomedicines12020447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024] Open
Abstract
Background: Blood lactate is a potentially useful biomarker to predict the mortality and severity of sepsis. The purpose of this study is to systematically review the ability of lactate to predict hierarchical sepsis clinical outcomes and distinguish sepsis, severe sepsis and septic shock. Methods: We conducted an exhaustive search of the PubMed, Embase and Cochrane Library databases for studies published before 1 October 2022. Inclusion criteria mandated the presence of case-control, cohort studies and randomized controlled trials that established the association between before-treatment blood lactate levels and the mortality of individuals with sepsis, severe sepsis or septic shock. Data was analyzed using STATA Version 16.0. Results: A total of 127 studies, encompassing 107,445 patients, were ultimately incorporated into our analysis. Meta-analysis of blood lactate levels at varying thresholds revealed a statistically significant elevation in blood lactate levels predicting mortality (OR = 1.57, 95% CI 1.48-1.65, I2 = 92.8%, p < 0.00001). Blood lactate levels were significantly higher in non-survivors compared to survivors in sepsis patients (SMD = 0.77, 95% CI 0.74-0.79, I2 = 83.7%, p = 0.000). The prognostic utility of blood lactate in sepsis mortality was validated through hierarchical summary receiver operating characteristic curve (HSROC) analysis, yielding an area under the curve (AUC) of 0.72 (95% CI 0.68-0.76), accompanied by a summary sensitivity of 0.65 (95% CI 0.59-0.7) and a summary specificity of 0.7 (95% CI 0.64-0.75). Unfortunately, the network meta-analysis could not identify any significant differences in average blood lactate values' assessments among sepsis, severe sepsis and septic shock patients. Conclusions: This meta-analysis demonstrated that high-level blood lactate was associated with a higher risk of sepsis mortality. Lactate has a relatively accurate predictive ability for the mortality risk of sepsis. However, the network analysis found that the levels of blood lactate were not effective in distinguishing between patients with sepsis, severe sepsis and septic shock.
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Affiliation(s)
| | | | | | - Yifei Li
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu 610041, China; (B.Z.); (R.Z.); (J.Q.)
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Merdji H, Bataille V, Curtiaud A, Bonello L, Roubille F, Levy B, Lim P, Schneider F, Khachab H, Dib JC, Seronde MF, Schurtz G, Harbaoui B, Vanzetto G, Marchand S, Gebhard CE, Henry P, Combaret N, Marchandot B, Lattuca B, Biendel C, Leurent G, Gerbaud E, Puymirat E, Bonnefoy E, Meziani F, Delmas C. Mottling as a prognosis marker in cardiogenic shock. Ann Intensive Care 2023; 13:80. [PMID: 37672139 PMCID: PMC10482815 DOI: 10.1186/s13613-023-01175-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/22/2023] [Indexed: 09/07/2023] Open
Abstract
AIMS Impact of skin mottling has been poorly studied in patients admitted for cardiogenic shock. This study aimed to address this issue and identify determinants of 30-day and 1-year mortality in a large cardiogenic shock cohort of all etiologies. METHODS AND RESULTS FRENSHOCK is a prospective multicenter observational registry conducted in French critical care units between April and October, 2016. Among the 772 enrolled patients (mean age 65.7 ± 14.9 years; 71.5% male), 660 had skin mottling assessed at admission (85.5%) with almost 39% of patients in cardiogenic shock presenting mottling. The need for invasive respiratory support was significantly higher in patients with mottling (50.2% vs. 30.1%, p < 0.001) and likewise for the need for renal replacement therapy (19.9% vs. 12.4%, p = 0.09). However, the need for mechanical circulatory support was similar in both groups. Patients with mottling at admission presented a higher length of stay (19 vs. 16 days, p = 0.033), a higher 30-day mortality rate (31% vs. 23.3%, p = 0.031), and also showed significantly higher mortality at 1-year (54% vs. 42%, p = 0.003). The subgroup of patients in whom mottling appeared during the first 24 h after admission had the worst prognosis at 30 days. CONCLUSION Skin mottling at admission in patients with cardiogenic shock was statistically associated with prolonged length of stay and poor outcomes. As a perfusion-targeted resuscitation parameter, mottling is a simple, clinical-based approach and may thus help to improve and guide immediate goal-directed therapy to improve cardiogenic shock patients' outcomes.
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Affiliation(s)
- Hamid Merdji
- Faculté de Médecine, Strasbourg University Hospital, Nouvel Hôpital Civil, Medical Intensive Care Unit, Université de Strasbourg (UNISTRA), Strasbourg, France
| | - Vincent Bataille
- Department of Cardiology, Toulouse Rangueil University Hospital, UMR 1295 INSERM, Toulouse, France
| | - Anais Curtiaud
- Faculté de Médecine, Strasbourg University Hospital, Nouvel Hôpital Civil, Medical Intensive Care Unit, Université de Strasbourg (UNISTRA), Strasbourg, France
| | - Laurent Bonello
- Aix-Marseille Université, 13385, Marseille, France
- Intensive Care Unit, Department of Cardiology, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, 13385, Marseille, France
- Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), Marseille, France
| | - François Roubille
- PhyMedExp, Université de Montpellier, INSERM, CNRS, Cardiology Department, INI-CRT, CHU de Montpellier, Montpellier, France
| | - Bruno Levy
- CHRU Nancy, Réanimation Médicale Brabois, Vandoeuvre-les Nancy, France
| | - Pascal Lim
- Univ Paris Est Créteil, INSERM, IMRB, 94010, Créteil, France
- AP-HP, Hôpital Universitaire Henri-Mondor, Service de Cardiologie, 94010, Créteil, France
| | - Francis Schneider
- Médecine Intensive-Réanimation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Hadi Khachab
- Intensive Cardiac Care Unit, Department of Cardiology, CH d'Aix en Provence, Aix-en-Provence, France
- Avenue des Tamaris, 13616, Aix-en-Provence cedex 1, France
| | | | | | - Guillaume Schurtz
- Urgences et Soins Intensifs de Cardiologie, CHU Lille, University of Lille, Inserm U1167, 59000, Lille, France
| | - Brahim Harbaoui
- Cardiology Department, Hôpital Croix-Rousse and Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France
- University of Lyon, CREATIS UMR5220, INSERM U1044, INSA-15, Lyon, France
| | - Gerald Vanzetto
- Department of Cardiology, Hôpital de Grenoble, 38700, La Tronche, France
| | | | - Caroline Eva Gebhard
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Patrick Henry
- Department of Cardiology, AP-HP, Lariboisière University Hospital, Paris, France
| | - Nicolas Combaret
- Department of Cardiology, CHU Clermont-Ferrand, CNRS, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Benjamin Marchandot
- Université de Strasbourg, Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, 67091, Strasbourg, France
| | - Benoit Lattuca
- Department of Cardiology, Nîmes University Hospital, Montpellier University, Nîmes, France
| | - Caroline Biendel
- Intensive Cardiac Care Unit, Rangueil University Hospital, 1 Avenue Jean Poulhes, 31059, Toulouse Cedex, France
- Institute of Metabolic and Cardiovascular Diseases (I2MC), UMR-1048, National Institute of Health and Medical Research (INSERM), Toulouse, France
| | - Guillaume Leurent
- Department of Cardiology, CHU Rennes, Inserm, LTSI-UMR 1099, Univ Rennes 1, 35000, Rennes, France
| | - Edouard Gerbaud
- Intensive Cardiac Care Unit and Interventional Cardiology, Hôpital Cardiologique du Haut Lévêque, 5 Avenue de Magellan, 33604, Pessac, France
- Bordeaux Cardio-Thoracic Research Centre, U1045, Bordeaux University, Hôpital Xavier Arnozan, Avenue du Haut Lévêque, 33600, Pessac, France
| | - Etienne Puymirat
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, 75015, Paris, France
- Université de Paris, 75006, Paris, France
| | - Eric Bonnefoy
- Intensive Cardiac Care Unit, Lyon Bron University Hospital, Lyon, France
| | - Ferhat Meziani
- Faculté de Médecine, Strasbourg University Hospital, Nouvel Hôpital Civil, Medical Intensive Care Unit, Université de Strasbourg (UNISTRA), Strasbourg, France
| | - Clément Delmas
- Intensive Cardiac Care Unit, Rangueil University Hospital, 1 Avenue Jean Poulhes, 31059, Toulouse Cedex, France.
- Recherche et Enseignement en Insuffisance Cardiaque Avancée Assistance et Transplantation (REICATRA), Institut Saint Jacques, CHU Toulouse, Toulouse, France.
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Muzaffar SN, Pradhan A, Siddiqui SS, Roy S, Suresh T. Monitoring Macro- and Microcirculation in the Critically Ill: A Narrative Review. Avicenna J Med 2023; 13:138-150. [PMID: 37799180 PMCID: PMC10550369 DOI: 10.1055/s-0043-1772175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
Circulatory shock is a common and important diagnosis in the critical care environment. Hemodynamic monitoring is quintessential in the management of shock. The currently used hemodynamic monitoring devices not only measure cardiac output but also provide data related to the prediction of fluid responsiveness, extravascular lung water, and also pulmonary vascular permeability. Additionally, these devices are minimally invasive and associated with fewer complications. The area of hemodynamic monitoring is progressively evolving with a trend toward the use of minimally invasive devices in this area. The critical care physician should be well-versed with current hemodynamic monitoring limitations and stay updated with the upcoming advances in this field so that optimal therapy can be delivered to patients in circulatory shock.
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Affiliation(s)
- Syed Nabeel Muzaffar
- Department of Critical Care Medicine, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India
| | - Akshyaya Pradhan
- Department of Cardiology, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India
| | - Suhail Sarwar Siddiqui
- Department of Critical Care Medicine, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India
| | - Shubhajeet Roy
- Faculty of Medical Sciences, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India
| | - Timil Suresh
- Faculty of Medical Sciences, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India
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De Backer D. Novelties in the evaluation of microcirculation in septic shock. JOURNAL OF INTENSIVE MEDICINE 2023; 3:124-130. [PMID: 37188120 PMCID: PMC10175708 DOI: 10.1016/j.jointm.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/25/2022] [Accepted: 09/01/2022] [Indexed: 05/17/2023]
Abstract
Microvascular alterations were first described in critically ill patients about 20 years ago. These alterations are characterized by a decrease in vascular density and presence of non-perfused capillaries close to well-perfused vessels. In addition, heterogeneity in microvascular perfusion is a key finding in sepsis. In this narrative review, we report our actual understanding of microvascular alterations, their role in the development of organ dysfunction, and the implications for outcome. Herein, we discuss the state of the potential therapeutic interventions and the potential impact of novel therapies. We also discuss how recent technologic development may affect the evaluation of microvascular perfusion.
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Dubin A. The relationship of postocclusive reactive hyperemia assessed by the plethysmographic perfusion index to lactate clearance: a new piece in the unsolved puzzle of tissue perfusion and oxygenation in septic shock. CRITICAL CARE SCIENCE 2023; 35:115-116. [PMID: 37712801 PMCID: PMC10406412 DOI: 10.5935/2965-2774.2023.edit-2.v35n2-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 06/10/2023] [Indexed: 09/16/2023]
Affiliation(s)
- Arnaldo Dubin
- Servicio de Terapia Intensiva, Sanatorio Otamendi - Buenos Aires,
Argentina
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9
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Peng Y, Wang K, Tang G, Sun M, Li R, Li C, Zhou X, Guan J. Renal venous density in the arterial phase of contrast-enhanced CT predicts prognosis in septic shock. Br J Radiol 2023; 96:20220948. [PMID: 36715145 PMCID: PMC10078879 DOI: 10.1259/bjr.20220948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/14/2022] [Accepted: 01/03/2023] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE To evaluate a series of vascular parameters derived from abdominal dual-phase contrast-enhanced CT as predictors of 14-day mortality and AKI within 7 days in septic shock. METHODS 144 patients with septic shock and 60 negative cases were included. The vascular parameters from CT were measured and calculated, including aortic density in arterial (Dena-A) and venous phase (Dena-V), renal vein density in arterial (Denrv-A) and venous phase (Denrv-V), and renal vein-to-aortic density ratio in arterial (DenRrv/a-A) and venous phase (DenRrv/a-V). The parameters were compared between patients and controls, and between patients with different clinical outcomes, and assessed for predictive value of 14-day mortality and AKI within 7 days. RESULTS Patients with septic shock presented significantly lower Denrv-A (p < 0.001) and DenRrv/a-A (p = 0.002) levels than the controls. In the septic shock group, patients who died had significantly lower Denrv-A (p = 0.001) and lower DenRrv/a-A (p < 0.001) than those who survived. Patients who developed AKI had significantly lower Denrv-A (p < 0.001) and DenRrv/a-A (p = 0.011) than those who did not. Multivariate analysis suggested DenRrv/a-A as an independent predictor of 14-day mortality (OR 0.012; 95% confidence interval [CI]:0.002,0.086; p < 0.001) and Denrv-A as an independent predictor of AKI (OR 0.989;95% CI:0.982,0.997; p = 0.006). CONCLUSION In septic shock, significant decreases in Denrv-A and DenRrv/a-A were associated with the onset of AKI and predicted higher 14-day mortality. ADVANCES IN KNOWLEDGE The renal vein density and renal vein-aortic density ratio in arterial phase of dual-phase contrast-enhanced CT may serve as good predictors of AKI and mortality in septic shock.
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Affiliation(s)
- Yang Peng
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ke Wang
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Guanglei Tang
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Mengya Sun
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ruixi Li
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Chang Li
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xuhui Zhou
- Department of Radiology, The Eighth Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
| | - Jian Guan
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
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Macdonald S, Peake SL, Corfield AR, Delaney A. Fluids or vasopressors for the initial resuscitation of septic shock. Front Med (Lausanne) 2022; 9:1069782. [PMID: 36507525 PMCID: PMC9729725 DOI: 10.3389/fmed.2022.1069782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 11/07/2022] [Indexed: 11/25/2022] Open
Abstract
Intravenous fluid resuscitation is recommended first-line treatment for sepsis-associated hypotension and/or hypoperfusion. The rationale is to restore circulating volume and optimize cardiac output in the setting of shock. Nonetheless, there is limited high-level evidence to support this practice. Over the past decade emerging evidence of harm associated with large volume fluid resuscitation among patients with septic shock has led to calls for a more conservative approach. Specifically, clinical trials undertaken in Africa have found harm associated with initial fluid resuscitation in the setting of infection and hypoperfusion. While translating these findings to practice in other settings is problematic, there has been a re-appraisal of current practice with some recommending earlier use of vasopressors rather than repeated fluid boluses as an alternative to restore perfusion in septic shock. There is consequently uncertainty and variation in practice. The question of fluids or vasopressors for initial resuscitation in septic shock is the subject of international multicentre clinical trials.
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Affiliation(s)
- Stephen Macdonald
- Medical School, University of Western Australia, Perth, WA, Australia
- Department of Emergency Medicine, Royal Perth Hospital, Perth, WA, Australia
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia
| | - Sandra L. Peake
- Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, SA, Australia
- Department of Critical Care Research, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Alasdair R. Corfield
- Consultant Emergency Medicine, Royal Alexandra Hospital, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, United Kingdom
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
- Division of Critical Care, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- Faculty of Medicine, Northern Clinical School, University of Sydney, Sydney, NSW, Australia
- Department of Epidemiology and Preventative Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
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11
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Klanovicz TM, Franzosi OS, Nunes DSL, Loss SH, Batassini É, Turra EE, Teixeira C, Vieira SRR. Acute gastrointestinal failure is associated with worse hemodynamic and perfusion parameters over 48 h after admission in patients with septic shock: Retrospective cohort study. Nutr Clin Pract 2022; 38:617-627. [PMID: 36351616 DOI: 10.1002/ncp.10928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 09/01/2022] [Accepted: 10/02/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND This study aimed to investigate the relationship between acute gastrointestinal injury (AGI) and hemodynamic and perfusion parameters in the first week of intensive care unit (ICU) admission and evaluate the association of AGI with ICU and hospital outcomes in patients with septic shock undergoing mechanical ventilation. METHODS This retrospective cohort study applied the criteria proposed by the European Society of Intensive Medicine to classify the participants into risk/dysfunction group (AGI grade I and II) and failure group (AGI grade III and IV). Hemodynamic and perfusion parameters data previously collected in the first 48 h after ICU admission (admission, 12, 24, 48 h) were analyzed. RESULTS A total of 163 were included and classified into AGI grades I (n = 79), II (n = 64), III (n = 20), and IV (none). Groups consisted of AGI risk/dysfunction (n = 143, 87.8%) and AGI failure (n = 20, 12.2%) patients. Patients with AGI failure had higher heart rate and mottling score (MS) at admission, lower mean arterial pressure, and an oliguria incidence at 12 h compared with those without AGI failure. Skin MS and abdominal primary site of infection were risk factors for AGI failure. AGI failure tended to be a risk factor for ICU mortality (risk ratio [95% CI]: 1.37 [0.99-1.89]; P = 0.053). CONCLUSION AGI was frequently observed in patients with septic shock in the first week of ICU admission. Higher heart rate and MS and lower mean arterial pressure and incidence of oliguria were identified in patients with AGI failure compared with those without. AGI failure was associated with ICU mortality.
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Affiliation(s)
- Tamires M. Klanovicz
- Medical Sciences Postgraduate Program, Faculdade de Medicina Universidade Federal do Rio Grande do Sul Porto Alegre RS Brazil
| | - Oellen S. Franzosi
- Medical Sciences Postgraduate Program, Faculdade de Medicina Universidade Federal do Rio Grande do Sul Porto Alegre RS Brazil
- Nutrition and Dietetic Division, Hospital de Clínicas de Porto Alegre Universidade Federal do Rio Grande do Sul Porto Alegre RS Brazil
| | - Diego S. L. Nunes
- Medical Sciences Postgraduate Program, Faculdade de Medicina Universidade Federal do Rio Grande do Sul Porto Alegre RS Brazil
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre Porto Alegre RS Brazil
| | - Sergio H. Loss
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre Porto Alegre RS Brazil
- Medical Sciences Postgraduate Program: Endocrinology Faculdade de Medicina Universidade Federal do Rio Grande do Sul Porto Alegre RS Brazil
| | - Érica Batassini
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre Porto Alegre RS Brazil
| | - Eduardo E. Turra
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre Porto Alegre RS Brazil
| | - Cassiano Teixeira
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre Porto Alegre RS Brazil
| | - Silvia R. R. Vieira
- Medical Sciences Postgraduate Program, Faculdade de Medicina Universidade Federal do Rio Grande do Sul Porto Alegre RS Brazil
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre Porto Alegre RS Brazil
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12
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Fage N, Demiselle J, Seegers V, Merdji H, Grelon F, Mégarbane B, Anguel N, Mira JP, Dequin PF, Gergaud S, Weiss N, Legay F, Le Tulzo Y, Conrad M, Coudroy R, Gonzalez F, Guitton C, Tamion F, Tonnelier JM, Bedos JP, Van Der Linden T, Vieillard-Baron A, Mariotte E, Pradel G, Lesieur O, Ricard JD, Hervé F, Du Cheyron D, Guerin C, Mercat A, Teboul JL, Radermacher P, Asfar P. Effects of mean arterial pressure target on mottling and arterial lactate normalization in patients with septic shock: a post hoc analysis of the SEPSISPAM randomized trial. Ann Intensive Care 2022; 12:78. [PMID: 35984574 PMCID: PMC9391564 DOI: 10.1186/s13613-022-01053-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 08/08/2022] [Indexed: 11/24/2022] Open
Abstract
Background In patients with septic shock, the impact of the mean arterial pressure (MAP) target on the course of mottling remains uncertain. In this post hoc analysis of the SEPSISPAM trial, we investigated whether a low-MAP (65 to 70 mmHg) or a high-MAP target (80 to 85 mmHg) would affect the course of mottling and arterial lactate in patients with septic shock. Methods The presence of mottling was assessed every 2 h from 2 h after inclusion to catecholamine weaning. We compared mottling and lactate time course between the two MAP target groups. We evaluated the patient’s outcome according to the presence or absence of mottling. Results We included 747 patients, 374 were assigned to the low-MAP group and 373 to the high-MAP group. There was no difference in mottling and lactate evolution during the first 24 h between the two MAP groups. After adjustment for MAP and confounding factors, the presence of mottling ≥ 6 h during the first 24 h was associated with a significantly higher risk of death at day 28 and 90. Patients without mottling or with mottling < 6 h and lactate ≥ 2 mmol/L have a higher probability of survival than those with mottling ≥ 6 h and lactate < 2 mmol/L. Conclusion Compared with low MAP target, higher MAP target did not alter mottling and lactate course. Mottling lasting for more than 6 h was associated with higher mortality. Compared to arterial lactate, mottling duration appears to be a better marker of mortality. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01053-1.
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Affiliation(s)
- Nicolas Fage
- Department of Medical Intensive Care, University Hospital of Angers, Angers, France.,MITOVASC Laboratory UMR INSERM (French National Institute of Health and Medical Research), 1083 - CNRS 6015, University of Angers, Angers, France
| | - Julien Demiselle
- Department of Intensive Care (Service de Médecine Intensive - Réanimation), Nouvel Hôpital Civil, University Hospital of Strasbourg, Strasbourg, France.,INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS (Fédération de Médecine Translationnelle de Strasbourg), University of Strasbourg, Strasbourg, France
| | - Valérie Seegers
- Service de Biométrie, Institut de Cancérologie de L'Ouest, Centre Paul Papin, Angers, France
| | - Hamid Merdji
- Department of Intensive Care (Service de Médecine Intensive - Réanimation), Nouvel Hôpital Civil, University Hospital of Strasbourg, Strasbourg, France.,INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS (Fédération de Médecine Translationnelle de Strasbourg), University of Strasbourg, Strasbourg, France
| | - Fabien Grelon
- Medical and Surgical Intensive Care Unit, Le Mans Hospital, Le Mans, France
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, Paris University, INSERM UMRS-1144, Paris, France
| | - Nadia Anguel
- Department of Medical Intensive Care, Bicêtre University Hospital, AP-HP, Paris-Saclay University, Le Kremlin Bicêtre, France
| | - Jean-Paul Mira
- Department of Medical Intensive Care, Cochin University Hospital, Paris, France
| | | | - Soizic Gergaud
- Department of Surgical Intensive Care, University Hospital of Angers, Angers, France
| | - Nicolas Weiss
- Department of Medical Intensive Care, Georges Pompidou European Hospital, Assistance Publique - Hôpitaux de Paris, University of Paris, Paris, France
| | - François Legay
- Medical and Surgical Intensive Care Unit, Saint Brieuc Hospital, Saint Brieuc, France
| | - Yves Le Tulzo
- Department of Infectious Diseases and Medical Intensive Care, Rennes University Hospital, Rennes, France
| | - Marie Conrad
- Department of Medical Intensive Care, Nancy University Hospital, Nancy, France
| | - Remi Coudroy
- Department of Medical Intensive Care, Université de Poitiers, CHU Poitiers, Poitiers, France
| | - Frédéric Gonzalez
- Department of Medical and Surgical Intensive Care, Avicenne Teaching Hospital, Bobigny, France
| | - Christophe Guitton
- Department of Medical Intensive Care, Nantes University Hospital, Nantes, France
| | - Fabienne Tamion
- Department of Medical Intensive Care, Rouen University Hospital, Rouen, France
| | | | | | - Thierry Van Der Linden
- Department of Intensive Care, Saint Philibert Hospital, Catholic University of Lille, Lille, France
| | - Antoine Vieillard-Baron
- Department of Medical Intensive Care, University Hospital of Ambroise Paré, Boulogne Billancourt, France.,Inserm U1018, Center for Research in Epidemiology and Population Health (CESP), Faculty of Paris Saclay, Villejuif, France
| | - Eric Mariotte
- Department of Intensive Care, Saint Louis Hospital, Paris, France
| | - Gaël Pradel
- Department of Intensive Care, Avignon Hospital, Avignon, France
| | - Olivier Lesieur
- Department of Medical and Surgical Intensive Care, La Rochelle Saint Louis Hospital, La Rochelle, France
| | - Jean-Damien Ricard
- Université de Paris, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Médecine Intensive Réanimation, Colombes, France
| | - Fabien Hervé
- Department of Medical and Surgical Intensive Care, Quimper Hospital, Quimper, France
| | - Damien Du Cheyron
- Department of Medical Intensive Care, Caen University Hospital, Caen, France
| | - Claude Guerin
- Department of Medical Intensive Care, Edouard Herriot Hospital, Lyon, France
| | - Alain Mercat
- Department of Medical Intensive Care, University Hospital of Angers, Angers, France
| | - Jean-Louis Teboul
- Department of Medical Intensive Care, Bicêtre University Hospital, AP-HP, Paris-Saclay University, Le Kremlin Bicêtre, France
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Helmholtzstrasse 8-1, Ulm, Germany
| | - Pierre Asfar
- Department of Medical Intensive Care, University Hospital of Angers, Angers, France.
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13
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Raia L, Gabarre P, Bonny V, Urbina T, Missri L, Boelle PY, Baudel JL, Guidet B, Maury E, Joffre J, Ait-Oufella H. Kinetics of capillary refill time after fluid challenge. Ann Intensive Care 2022; 12:74. [PMID: 35962860 PMCID: PMC9375797 DOI: 10.1186/s13613-022-01049-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/26/2022] [Indexed: 11/17/2022] Open
Abstract
Background Capillary refill time (CRT) is a valuable tool for triage and to guide resuscitation. However, little is known about CRT kinetics after fluid infusion. Methods We conducted a prospective observational study in a tertiary teaching hospital. First, we analyzed the intra-observer variability of CRT. Next, we monitored fingertip CRT in sepsis patients during volume expansion within the first 24 h of ICU admission. Fingertip CRT was measured every 2 min during 30 min following crystalloid infusion (500 mL over 15 min). Results First, the accuracy of repetitive fingertip CRT measurements was evaluated on 40 critically ill patients. Reproducibility was excellent, with an intra-class correlation coefficient of 99.5% (CI 95% [99.3, 99.8]). A CRT variation larger than 0.2 s was considered as significant. Next, variations of CRT during volume expansion were evaluated on 29 septic patients; median SOFA score was 7 [5–9], median SAPS II was 57 [45–72], and ICU mortality rate was 24%. Twenty-three patients were responders as defined by a CRT decrease > 0.2 s at 30 min after volume expansion, and 6 were non-responders. Among responders, we observed that fingertip CRT quickly improved with a significant decrease at 6–8 min after start of crystalloid infusion, the maximal improvement being observed after 10–12 min (−0.7 [−0.3;−0.9] s) and maintained at 30 min. CRT variations significantly correlated with baseline CRT measurements (R = 0.39, P = 0.05). Conclusions CRT quickly improved during volume expansion with a significant decrease 6–8 min after start of fluid infusion and a maximal drop at 10–12 min. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01049-x.
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Affiliation(s)
- Lisa Raia
- Service de Médecine Intensive-Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris cedex 12, France
| | - Paul Gabarre
- Service de Médecine Intensive-Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris cedex 12, France.,Sorbonne Université, Paris, France
| | - Vincent Bonny
- Service de Médecine Intensive-Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris cedex 12, France.,Sorbonne Université, Paris, France
| | - Tomas Urbina
- Service de Médecine Intensive-Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris cedex 12, France
| | - Louai Missri
- Service de Médecine Intensive-Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris cedex 12, France
| | - Pierre-Yves Boelle
- Sorbonne Université, Paris, France.,Service de Santé Publique, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Paris, France
| | - Jean-Luc Baudel
- Service de Médecine Intensive-Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris cedex 12, France
| | - Bertrand Guidet
- Service de Médecine Intensive-Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris cedex 12, France
| | - Eric Maury
- Service de Médecine Intensive-Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris cedex 12, France.,Sorbonne Université, Paris, France
| | - Jeremie Joffre
- Service de Médecine Intensive-Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris cedex 12, France.,Sorbonne Université, Paris, France
| | - Hafid Ait-Oufella
- Service de Médecine Intensive-Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris cedex 12, France. .,Sorbonne Université, Paris, France. .,Inserm U970, Paris Research Cardiovascular Center, Paris, France.
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14
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Dubée V, Hariri G, Joffre J, Hagry J, Raia L, Bonny V, Gabarre P, Ehrminger S, Bigé N, Baudel JL, Guidet B, Maury E, Dumas G, Ait-Oufella H. Peripheral tissue hypoperfusion predicts post intubation hemodynamic instability. Ann Intensive Care 2022; 12:68. [PMID: 35843960 PMCID: PMC9288942 DOI: 10.1186/s13613-022-01043-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/01/2022] [Indexed: 11/25/2022] Open
Abstract
Background Tracheal intubation and invasive mechanical ventilation initiation is a procedure at high risk for arterial hypotension in intensive care unit. However, little is known about the relationship between pre-existing peripheral microvascular alteration and post-intubation hemodynamic instability (PIHI). Methods Prospective observational monocenter study conducted in an 18-bed medical ICU. Consecutive patients requiring tracheal intubation were eligible for the study. Global hemodynamic parameters (blood pressure, heart rate, cardiac function) and tissue perfusion parameters (arterial lactate, mottling score, capillary refill time [CRT], toe-to-room gradient temperature) were recorded before, 5 min and 2 h after tracheal intubation (TI). Post intubation hemodynamic instability (PIHI) was defined as any hemodynamic event requiring therapeutic intervention. Results During 1 year, 120 patients were included, mainly male (59%) with a median age of 68 [57–77]. The median SOFA score and SAPS II were 6 [4–9] and 47 [37–63], respectively. The main indications for tracheal intubation were hypoxemia (51%), hypercapnia (13%), and coma (29%). In addition, 48% of patients had sepsis and 16% septic shock. Fifty-one (42%) patients develop PIHI. Univariate analysis identified several baseline factors associated with PIHI, including norepinephrine prior to TI, sepsis, tachycardia, fever, higher SOFA and high SAPSII score, mottling score ≥ 3, high lactate level and prolonged knee CRT. By contrast, mean arterial pressure, baseline cardiac index, and ejection fraction were not different between PIHI and No-PIHI groups. After adjustment on potential confounders, the mottling score was associated with a higher risk for PIHI (adjusted OR: 1.84 [1.21–2.82] per 1 point increased; p = 0.005). Among both global haemodynamics and tissue perfusion parameters, baseline mottling score was the best predictor of PIHI (AUC: 0.72 (CI 95% [0.62–0.81]). Conclusions In non-selected critically ill patients requiring invasive mechanical ventilation, tissue hypoperfusion parameters, especially the mottling score, could be helpful to predict PIHI. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01043-3.
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Affiliation(s)
- Vincent Dubée
- Service de Maladies Infectieuses et Tropicales, CHU Angers, Angers, France.,Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Geoffroy Hariri
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Sorbonne Université, Paris, France.,Inserm U1136, 75012, Paris, France
| | - Jérémie Joffre
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Sorbonne Université, Paris, France
| | - Julien Hagry
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Lisa Raia
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Vincent Bonny
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Paul Gabarre
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Sebastien Ehrminger
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Naike Bigé
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Jean-Luc Baudel
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Bertrand Guidet
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Sorbonne Université, Paris, France.,Inserm U1136, 75012, Paris, France
| | - Eric Maury
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Sorbonne Université, Paris, France
| | - Guillaume Dumas
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Hafid Ait-Oufella
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France. .,Sorbonne Université, Paris, France. .,Inserm U970, Centre de Recherche Cardiovasculaire de Paris (PARCC), Paris, France.
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15
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Raia L, Urbina T, Gabarre P, Bonny V, Hariri G, Ehrminger S, Bigé N, Baudel JL, Guidet B, Maury E, Joffre J, Ait-Oufella H. Impaired skin microvascular endothelial reactivity in critically ill COVID-19 patients. Ann Intensive Care 2022; 12:51. [PMID: 35696007 PMCID: PMC9188908 DOI: 10.1186/s13613-022-01027-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 06/01/2022] [Indexed: 11/25/2022] Open
Abstract
Background Some clinical and histological studies have reported that SARS-CoV-2 infection may damage the endothelium. However, the impact of this virus on endothelial function in vivo remains poorly characterized. In this single-center pilot observational study, we performed iontophoresis of acetylcholine coupled with Laser doppler to investigate microvascular endothelial reactivity in COVID-19 patients compared to patients with non-COVID-19 bacterial pneumonia (NCBP) patients. Results During three consecutive months, 32 COVID-19 patients and 11 control NCBP patients with acute respiratory failure were included. The median age was 59 [50–68] and 69 [57–75] years in COVID-19 and NCBP groups, respectively (P = 0.11). There was no significant difference in comorbidities or medications between the two groups, except for body mass index, which was higher in COVID-19 patients. NCBP patients had a higher SAPS II score compared to COVID-19 patients (P < 0.0001), but SOFA score was not different between groups (P = 0.51). Global hemodynamic and peripheral tissue perfusion parameters were not different between groups. COVID-19 patients had significantly lower skin microvascular basal blood flow than NCBP patients (P = 0.02). In addition, endothelium-dependent microvascular reactivity was threefold lower in COVID-19 patients than NCBP patients (P = 0.008). Conclusions Both baseline skin microvascular blood flow and skin endothelial-dependent microvascular reactivity were impaired in critically ill COVID-19 patients compared to NCBP patients, despite a lower disease severity score supporting a specific pathogenic role of SARS-CoV-2 on the endothelium. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01027-3.
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Affiliation(s)
- Lisa Raia
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Tomas Urbina
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Paul Gabarre
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Vincent Bonny
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Geoffroy Hariri
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Sebastien Ehrminger
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Naïke Bigé
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Jean-Luc Baudel
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Bertrand Guidet
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France.,Pierre Louis Institute of Epidemiology and Public Health, Sorbonne University, Inserm U1136, Paris, France
| | - Eric Maury
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France.,Pierre Louis Institute of Epidemiology and Public Health, Sorbonne University, Inserm U1136, Paris, France.,Centre de Recherche Saint-Antoine, Sorbonne University, Inserm U938, 75012, Paris, France
| | - Jeremie Joffre
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France.,Centre de Recherche Saint-Antoine, Sorbonne University, Inserm U938, 75012, Paris, France
| | - Hafid Ait-Oufella
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France. .,Paris Cardiovascular Research Center, Paris University, Inserm U970, Paris, France.
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16
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Raia L, Zafrani L. Endothelial Activation and Microcirculatory Disorders in Sepsis. Front Med (Lausanne) 2022; 9:907992. [PMID: 35721048 PMCID: PMC9204048 DOI: 10.3389/fmed.2022.907992] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/16/2022] [Indexed: 11/19/2022] Open
Abstract
The vascular endothelium is crucial for the maintenance of vascular homeostasis. Moreover, in sepsis, endothelial cells can acquire new properties and actively participate in the host's response. If endothelial activation is mostly necessary and efficient in eliminating a pathogen, an exaggerated and maladaptive reaction leads to severe microcirculatory damage. The microcirculatory disorders in sepsis are well known to be associated with poor outcome. Better recognition of microcirculatory alteration is therefore essential to identify patients with the worse outcomes and to guide therapeutic interventions. In this review, we will discuss the main features of endothelial activation and dysfunction in sepsis, its assessment at the bedside, and the main advances in microcirculatory resuscitation.
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Affiliation(s)
- Lisa Raia
- Medical Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Lara Zafrani
- Medical Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique des Hôpitaux de Paris, Paris, France
- INSERM UMR 976, University of Paris Cité, Paris, France
- *Correspondence: Lara Zafrani
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17
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Silva PL, Ball L, Rocco PRM, Pelosi P. Physiological and Pathophysiological Consequences of Mechanical Ventilation. Semin Respir Crit Care Med 2022; 43:321-334. [PMID: 35439832 DOI: 10.1055/s-0042-1744447] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Mechanical ventilation is a life-support system used to ensure blood gas exchange and to assist the respiratory muscles in ventilating the lung during the acute phase of lung disease or following surgery. Positive-pressure mechanical ventilation differs considerably from normal physiologic breathing. This may lead to several negative physiological consequences, both on the lungs and on peripheral organs. First, hemodynamic changes can affect cardiovascular performance, cerebral perfusion pressure (CPP), and drainage of renal veins. Second, the negative effect of mechanical ventilation (compression stress) on the alveolar-capillary membrane and extracellular matrix may cause local and systemic inflammation, promoting lung and peripheral-organ injury. Third, intra-abdominal hypertension may further impair lung and peripheral-organ function during controlled and assisted ventilation. Mechanical ventilation should be optimized and personalized in each patient according to individual clinical needs. Multiple parameters must be adjusted appropriately to minimize ventilator-induced lung injury (VILI), including: inspiratory stress (the respiratory system inspiratory plateau pressure); dynamic strain (the ratio between tidal volume and the end-expiratory lung volume, or inspiratory capacity); static strain (the end-expiratory lung volume determined by positive end-expiratory pressure [PEEP]); driving pressure (the difference between the respiratory system inspiratory plateau pressure and PEEP); and mechanical power (the amount of mechanical energy imparted as a function of respiratory rate). More recently, patient self-inflicted lung injury (P-SILI) has been proposed as a potential mechanism promoting VILI. In the present chapter, we will discuss the physiological and pathophysiological consequences of mechanical ventilation and how to personalize mechanical ventilation parameters.
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Affiliation(s)
- Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Department of Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Department of Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
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18
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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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19
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Gupta R, Ray S. Advances in Microcirculatory Assessment: A Game Changer in Sepsis Management or the Latest Fad?! Indian J Crit Care Med 2022; 26:261-263. [PMID: 35519922 PMCID: PMC9015941 DOI: 10.5005/jp-journals-10071-24162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Gupta R, Ray S. Advances in Microcirculatory Assessment: A Game Changer in Sepsis Management or the Latest Fad? Indian J Crit Care Med 2022;26(3):261–263.
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Affiliation(s)
- Ruchi Gupta
- Department of Critical Care Medicine, Holy Family Hospital, New Delhi, India
| | - Sumit Ray
- Department of Critical Care Medicine, Holy Family Hospital, New Delhi, India
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20
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Lavillegrand JR, Raia L, Urbina T, Hariri G, Gabarre P, Bonny V, Bigé N, Baudel JL, Bruneel A, Dupre T, Guidet B, Maury E, Ait-Oufella H. Vitamin C improves microvascular reactivity and peripheral tissue perfusion in septic shock patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2022; 26:25. [PMID: 35062987 PMCID: PMC8781452 DOI: 10.1186/s13054-022-03891-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/08/2022] [Indexed: 12/29/2022]
Abstract
Background Vitamin C has potential protective effects through antioxidant and anti-inflammatory properties. However, the effect of vitamin C supplementation on microvascular function and peripheral tissue perfusion in human sepsis remains unknown. We aimed to determine vitamin C effect on microvascular endothelial dysfunction and peripheral tissue perfusion in septic shock patients. Methods Patients with septic shock were prospectively included after initial resuscitation. Bedside peripheral tissue perfusion and skin microvascular reactivity in response to acetylcholine iontophoresis in the forearm area were measured before and 1 h after intravenous vitamin C supplementation (40 mg/kg). Norepinephrine dose was not modified during the studied period. Results We included 30 patients with septic shock. SOFA score was 11 [8–14], SAPS II was 66 [54–79], and in-hospital mortality was 33%. Half of these patients had vitamin C deficiency at inclusion. Vitamin C supplementation strongly improved microvascular reactivity (AUC 2263 [430–4246] vs 5362 [1744–10585] UI, p = 0.0004). In addition, vitamin C supplementation improved mottling score (p = 0.06), finger-tip (p = 0.0003) and knee capillary refill time (3.7 [2.6–5.5] vs 2.9 [1.9–4.7] s, p < 0.0001), as well as and central-to-periphery temperature gradient (6.1 [4.9–7.4] vs 4.6 [3.4–7.0] °C, p < 0.0001). The beneficial effects of vitamin C were observed both in patients with or without vitamin C deficiency. Conclusion In septic shock patients being resuscitated, vitamin C supplementation improved peripheral tissue perfusion and microvascular reactivity whatever plasma levels of vitamin C. ClinicalTrials.gov Identifier: NCT04778605 registered 26 January 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03891-8.
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21
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Mendelson AA, Rajaram A, Bainbridge D, Lawrence KS, Bentall T, Sharpe M, Diop M, Ellis CG. Dynamic tracking of microvascular hemoglobin content for continuous perfusion monitoring in the intensive care unit: pilot feasibility study. J Clin Monit Comput 2021; 35:1453-1465. [PMID: 33104968 PMCID: PMC7586414 DOI: 10.1007/s10877-020-00611-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/20/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE There is a need for bedside methods to monitor oxygen delivery in the microcirculation. Near-infrared spectroscopy commonly measures tissue oxygen saturation, but does not reflect the time-dependent variability of microvascular hemoglobin content (MHC) that attempts to match oxygen supply with demand. The objective of this study is to determine the feasibility of MHC monitoring in critically ill patients using high-resolution near-infrared spectroscopy to assess perfusion in the peripheral microcirculation. METHODS Prospective observational cohort of 36 patients admitted within 48 h at a tertiary intensive care unit. Perfusion was measured on the quadriceps, biceps, and/or deltoid, using the temporal change in optical density at the isosbestic wavelength of hemoglobin (798 nm). Continuous wavelet transform was applied to the hemoglobin signal to delineate frequency ranges corresponding to physiological oscillations in the cardiovascular system. RESULTS 31/36 patients had adequate signal quality for analysis, most commonly affected by motion artifacts. MHC signal demonstrates inter-subject heterogeneity in the cohort, indicated by different patterns of variability and frequency composition. Signal characteristics were concordant between muscle groups in the same patient, and correlated with systemic hemoglobin levels and oxygen saturation. Signal power was lower for patients receiving vasopressors, but not correlated with mean arterial pressure. Mechanical ventilation directly impacts MHC in peripheral tissue. CONCLUSION MHC can be measured continuously in the ICU with high-resolution near-infrared spectroscopy, and reflects the dynamic variability of hemoglobin distribution in the microcirculation. Results suggest this novel hemodynamic metric should be further evaluated for diagnosing microvascular dysfunction and monitoring peripheral perfusion.
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Affiliation(s)
- Asher A Mendelson
- Department of Medical Biophysics, Western University, London, ON, Canada
- Centre for Critical Illness Research, Lawson Health Research Institute, London, ON, Canada
| | - Ajay Rajaram
- Department of Medical Biophysics, Western University, London, ON, Canada
- Imaging Program, Lawson Health Research Institute, London, ON, Canada
| | - Daniel Bainbridge
- Department of Anesthesia and Peri-operative Medicine, Western University, London, ON, Canada
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
| | - Keith St Lawrence
- Department of Medical Biophysics, Western University, London, ON, Canada
- Imaging Program, Lawson Health Research Institute, London, ON, Canada
| | - Tracey Bentall
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
| | - Michael Sharpe
- Department of Anesthesia and Peri-operative Medicine, Western University, London, ON, Canada
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
| | - Mamadou Diop
- Department of Medical Biophysics, Western University, London, ON, Canada
- Imaging Program, Lawson Health Research Institute, London, ON, Canada
| | - Christopher G Ellis
- Department of Medical Biophysics, Western University, London, ON, Canada.
- Centre for Critical Illness Research, Lawson Health Research Institute, London, ON, Canada.
- Robarts Research Institute, Rm 3205, London, ON, N6A 5B7, Canada.
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22
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Beneyto-Ripoll C, Palazón-Bru A, Llópez-Espinós P, Martínez-Díaz AM, Gil-Guillén VF, de Los Ángeles Carbonell-Torregrosa M. A critical appraisal of the prognostic predictive models for patients with sepsis: Which model can be applied in clinical practice? Int J Clin Pract 2021; 75:e14044. [PMID: 33492724 DOI: 10.1111/ijcp.14044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 01/19/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Sepsis is associated with high mortality and predictive models can help in clinical decision-making. The objective of this study was to carry out a systematic review of these models. METHODS In 2019, we conducted a systematic review in MEDLINE and EMBASE (CDR42018111121:PROSPERO) of articles that developed predictive models for mortality in septic patients (inclusion criteria). We followed the CHARMS recommendations (Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies), extracting the information from its 11 domains (Source of data, Participants, etc). We determined the risk of bias and applicability (participants, outcome, predictors and analysis) through PROBAST (Prediction model Risk Of Bias ASsessment Tool). RESULTS A total of 14 studies were included. In the CHARMS extraction, the models found showed great variability in its 11 domains. Regarding the PROBAST checklist, only one article had an unclear risk of bias as it did not indicate how missing data were handled while the others all had a high risk of bias. This was mainly due to the statistical analysis (inadequate sample size, handling of continuous predictors, missing data and selection of predictors), since 13 studies had a high risk of bias. Applicability was satisfactory in six articles. Most of the models integrate predictors from routine clinical practice. Discrimination and calibration were assessed for almost all the models, with the area under the ROC curve ranging from 0.59 to 0.955 and no lack of calibration. Only three models were externally validated and their maximum discrimination values in the derivation were from 0.712 and 0.84. One of them (Osborn) had undergone multiple validation studies. DISCUSSION Despite most of the studies showing a high risk of bias, we very cautiously recommend applying the Osborn model, as this has been externally validated various times.
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Affiliation(s)
| | - Antonio Palazón-Bru
- Department of Clinical Medicine, Miguel Hernández University, San Juan de Alicante, Alicante, Spain
| | | | | | | | - María de Los Ángeles Carbonell-Torregrosa
- Department of Clinical Medicine, Miguel Hernández University, San Juan de Alicante, Alicante, Spain
- Emergency Services, General University Hospital of Elda, Elda, Alicante, Spain
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23
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Hu KM, Brown RM. Resuscitation of the Critically Ill Older Adult. Emerg Med Clin North Am 2021; 39:273-286. [PMID: 33863459 DOI: 10.1016/j.emc.2020.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In 30 years, adults 65 and older will represent 20% of the US population, with increased medical comorbidities leading to higher rates of critical illness and mortality. Despite significant acute illness, presenting symptoms and vital sign abnormalities may be subtle. Resuscitative guidelines are a helpful starting point but appropriate diagnostics, bedside ultrasound, and frequent reassessments are needed to avoid procrustean care that may worsen outcomes. Baseline functional status is as important as underlying comorbid conditions when prognosticating, and the patient's personal wishes should be sought early and throughout care with clear communication regarding prospects for immediate survival and overall recovery.
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Affiliation(s)
- Kami M Hu
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA; Department of Internal Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Robert M Brown
- Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, Carilion Roanoke Memorial Hospital, 1906 Belleview Ave SE, Roanoke, VA 24014, USA
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24
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Virág M, Leiner T, Rottler M, Ocskay K, Molnar Z. Individualized Hemodynamic Management in Sepsis. J Pers Med 2021; 11:157. [PMID: 33672267 PMCID: PMC7926902 DOI: 10.3390/jpm11020157] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/13/2021] [Accepted: 02/18/2021] [Indexed: 02/06/2023] Open
Abstract
Hemodynamic optimization remains the cornerstone of resuscitation in the treatment of sepsis and septic shock. Delay or inadequate management will inevitably lead to hypoperfusion, tissue hypoxia or edema, and fluid overload, leading eventually to multiple organ failure, seriously affecting outcomes. According to a large international survey (FENICE study), physicians frequently use inadequate indices to guide fluid management in intensive care units. Goal-directed and "restrictive" infusion strategies have been recommended by guidelines over "liberal" approaches for several years. Unfortunately, these "fixed regimen" treatment protocols neglect the patient's individual needs, and what is shown to be beneficial for a given population may not be so for the individual patient. However, applying multimodal, contextualized, and personalized management could potentially overcome this problem. The aim of this review was to give an insight into the pathophysiological rationale and clinical application of this relatively new approach in the hemodynamic management of septic patients.
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Affiliation(s)
- Marcell Virág
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (T.L.); (M.R.); (K.O.)
- Szent György University Teaching Hospital of Fejér County, 8000 Székesfehérvár, Hungary
| | - Tamas Leiner
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (T.L.); (M.R.); (K.O.)
- Anaesthetic Department, North West Anglia NHS Foundation Trust, Hinchingbrooke Hospital, Huntingdon PE29 6NT, UK
| | - Mate Rottler
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (T.L.); (M.R.); (K.O.)
- Szent György University Teaching Hospital of Fejér County, 8000 Székesfehérvár, Hungary
| | - Klementina Ocskay
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (T.L.); (M.R.); (K.O.)
| | - Zsolt Molnar
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (T.L.); (M.R.); (K.O.)
- Department of Anesthesiology and Intensive Therapy, Poznan University of Medical Sciences, 61-701 Poznan, Poland
- Department of Anesthesiology and Intensive Therapy, Markusovszky Teaching Hospital, 9700 Szombathely, Hungary
- Multidisciplinary Doctoral School, University of Szeged, 6720 Szeged, Hungary
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25
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Mok G, Hendin A, Reardon P, Hickey M, Gray S, Yadav K. Macrocirculatory and Microcirculatory Endpoints in Sepsis Resuscitation. J Intensive Care Med 2020; 36:1385-1391. [PMID: 33375916 DOI: 10.1177/0885066620982585] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Sepsis is a common disease process encountered by physicians. Sepsis can lead to septic shock, which carries a hospital mortality rate in excess of 40%. Although the Surviving Sepsis Guidelines recommend targeting a mean arterial pressure (MAP) of 65 mmHg and normalization of lactate, these endpoints do not necessarily result in tissue perfusion in states of shock. While MAP and lactate are commonly used markers in resuscitation, clinicians may be able to improve their resuscitation by broadening their assessment of the microcirculation, which more adequately reflects tissue perfusion. As such, in order to achieve a successful resuscitation, clinicians must optimize both macrocirculatory (MAP, cardiac output) and microcirculatory (proportion of perfused vessels, lactate, mottling, capillary refill time) endpoints. This review will summarize various macrocirculatory and microcirculatory markers of perfusion that can be used to guide the initial resuscitation of patients with sepsis.
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Affiliation(s)
- Garrick Mok
- Department of Emergency Medicine, The Ottawa Hospital, 6363University of Ottawa, Ottawa, Ontario, Canada
| | - Ariel Hendin
- Department of Emergency Medicine, The Ottawa Hospital, 6363University of Ottawa, Ottawa, Ontario, Canada.,Department of Critical Care Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Reardon
- Department of Emergency Medicine, The Ottawa Hospital, 6363University of Ottawa, Ottawa, Ontario, Canada.,Department of Critical Care Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael Hickey
- Department of Medicine, Division of Critical Care, St. Joseph's Health Centre, University of Toronto, Toronto, Canada
| | - Sara Gray
- Division of Emergency Medicine and the Interdepartmental Division of Critical Care, 7938University of Toronto, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, The Ottawa Hospital, 6363University of Ottawa, Ottawa, Ontario, Canada
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26
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Amson H, Vacheron CH, Thiolliere F, Piriou V, Magnin M, Allaouchiche B. Core-to-skin temperature gradient measured by thermography predicts day-8 mortality in septic shock: A prospective observational study. J Crit Care 2020; 60:294-299. [DOI: 10.1016/j.jcrc.2020.08.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/15/2020] [Accepted: 08/22/2020] [Indexed: 10/23/2022]
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27
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Abstract
PURPOSE OF REVIEW To appraise the basic and more advanced methods available for hemodynamic monitoring, and describe the definitions and criteria for the use of hemodynamic variables. RECENT FINDINGS The hemodynamic assessment in critically ill patients suspected of circulatory shock follows a step-by-step algorithm to help determine diagnosis and prognosis. Determination of accurate diagnosis and prognosis in turn is crucial for clinical decision-making. Basic monitoring involving clinical examination in combination with hemodynamic variables obtained with an arterial catheter and a central venous catheter may be sufficient for the majority of patients with circulatory shock. In case of uncertainty of the underlying cause or to guide treatment in severe shock may require additional advanced hemodynamic technologies, and each is utilized for different indications and has specific limitations. Future developments include refining the clinical examination and performing studies that demonstrate better patient outcomes by targeting hemodynamic variables using advanced hemodynamic monitoring. SUMMARY Determination of accurate diagnosis and prognosis for patients suspected of circulatory shock is essential for optimal decision-making. Numerous techniques are available, and each has its specific indications and value.
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28
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Storz MA, Seidlitz F. Severe skin mottling in fatal sepsis. Postgrad Med J 2020; 98:e7. [PMID: 37066557 DOI: 10.1136/postgradmedj-2020-139119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/08/2020] [Accepted: 10/13/2020] [Indexed: 11/03/2022]
Affiliation(s)
| | - Florian Seidlitz
- Department of Intensive Care Medicine, Die Filderklinik gGmbH, Bonlanden, Germany
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29
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Wollborn J, Jung C, Göbel U, Bruno RR. [Evaluation of the microcirculation in critically ill patients : Relevance, practical possibilities and scientific evidence]. Anaesthesist 2020; 69:753-757. [PMID: 32803320 PMCID: PMC7653807 DOI: 10.1007/s00101-020-00832-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Für die Aufrechterhaltung der Organdurchblutung ist eine intakte Makro- und Mikrozirkulation essentiell. Sowohl das wachsende Verständnis um die Bedeutung der Mikrozirkulation im Organversagen als auch die Möglichkeit, diese zu visualisieren, lenken die Aufmerksamkeit der Intensivmedizin auf die mikrovaskuläre Endstrombahn. Als Surrogat-Parameter sind die Rekapillarisierungszeit, der „mottling score“ und die Messung des Serum-Laktats bereits lange in der klinischen Praxis etabliert. Neuere Studien messen der Echtzeit-Darstellung der sublingualen Mikrozirkulation mittels Intravital-Videomikroskopie eine immer größere Bedeutung bei. Verschiedene Studien unterstreichen hierbei die Mikrozirkulation als prognostischen Parameter. Darüber hinaus ermöglicht die Erhebung von objektivierbaren Messwerten, diese in der Zukunft zur individuellen Therapiesteuerung weitergehend zu untersuchen.
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Affiliation(s)
- J Wollborn
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Hugstetter Str. 55, 79106, Freiburg, Deutschland.
| | - C Jung
- Klinik für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - U Göbel
- Klinik für Anästhesiologie und operative Intensivmedizin, St. Franziskus-Hospital Münster, Münster, Deutschland
| | - R R Bruno
- Klinik für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
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30
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Das S, Ray S. Mottling, Lactate, and the Microcirculation in Sepsis: Are We Back to Bedside Clinical Assessment after the Honeymoon with Technology? Indian J Crit Care Med 2020; 24:615-616. [PMID: 33024361 PMCID: PMC7519621 DOI: 10.5005/jp-journals-10071-23514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: Das S, Ray S. Mottling, Lactate, and the Microcirculation in Sepsis: Are We Back to Bedside Clinical Assessment after the Honeymoon with Technology? Indian J Crit Care Med 2020;24(8):615-616.
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Affiliation(s)
- Saurabh Das
- Department of Critical Care, Artemis Hospital, Gurugram, India
| | - Sumit Ray
- Department of Critical Care Medicine, Holy Family Hospital, Delhi, India
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31
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Hemodynamic and skin perfusion is associated with successful enteral nutrition therapy in septic shock patients. Clin Nutr 2020; 39:3721-3729. [PMID: 32307194 DOI: 10.1016/j.clnu.2020.03.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 03/14/2020] [Accepted: 03/24/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND & AIMS Enteral nutrition is controversial in hemodynamically unstable patients. This study aimed to evaluate the association between hemodynamic and skin perfusion parameters and enteral nutrition therapy (NT) outcomes in septic shock patients. METHODS Ventilated adults with septic shock were evaluated at bedside upon admission (H0), and at 12 h (H1), 24 h (H2) and 48 h (H3) for mean arterial pressure (MAP), heart rate, urine output, lactate levels, mottling score, capillary refill time (CRT), central-to-toe temperature gradient and norepinephrine dose. Two groups were stratified: NT success (NTS) (≥20 kcal/kg or 11 kcal/kg for obese in the first ICU week) or NT failure (NTF). A generalized linear model and generalized estimating equations were performed. RESULTS Over a 19-month period, 2167 admissions were assessed and 141 patients were analyzed (63.5 ± 15.0 years, SAPS-3 75 ± 12, 102 [72%] in the NTS vs. 39 [28%] in NTF). At 12 h, the failure group showed more severe mottling scores, higher lactate levels, norepinephrine dose and central-to-toe temperature gradient. Mottling score at 12 h was a predictor of NT failure (RR 1.28 95%CI [1.09-1.50], p = .003). Over 48 h, higher mottling scores, lactate levels and norepinephrine dosage, % of patients with central-to-toe temperature gradient and CRT ≥3 s were observed in the failure group and higher urine output and MAP values were observed in the success group. CONCLUSION Early improvement in hemodynamic and skin perfusion parameters was associated with success in nutrition therapy, and mottling score at 12 h was a risk factor for nutrition therapy failure. This data could support the recommendation to start NT after hemodynamic and perfusion goals are achieved and to proactively evaluate bedside parameters while implementing NT in critical care setting.
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32
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Ji Q, Li W. A significant p value is not equivalent to the superiority of one test index over another. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:359. [PMID: 31729998 PMCID: PMC6857245 DOI: 10.1186/s13054-019-2651-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 10/17/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Qiaoying Ji
- Department of Respiratory, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, People's Republic of China
| | - Weimin Li
- Department of Cardiology, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, People's Republic of China.
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33
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Kazune S, Caica A, Volceka K, Suba O, Rubins U, Grabovskis A. Relationship of mottling score, skin microcirculatory perfusion indices and biomarkers of endothelial dysfunction in patients with septic shock: an observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:311. [PMID: 31511042 PMCID: PMC6739999 DOI: 10.1186/s13054-019-2589-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 08/29/2019] [Indexed: 11/17/2022]
Abstract
Background In patients with septic shock, the skin is often chosen for the evaluation of peripheral perfusion and oxygenation. Changes in skin microcirculatory vessel oxygen saturation and relative hemoglobin concentration can be described using a mottling score or captured with hyperspectral imaging. However, the effectiveness of the mottling score in assessing microcirculation remains to be shown. We hypothesize that the mottling score in patients with septic shock is related to skin microcirculatory perfusion indices quantified by hyperspectral imaging, biomarkers that reflect endothelium activation and damage, and clinical outcome. Methods Hyperspectral imaging of the knee area was performed in 95 intensive care patients with septic shock enrolled in a single-center observational study to obtain relative oxy/deoxyhemoglobin concentration values and construct anatomical maps of skin microcirculatory saturation. The blood was sampled to obtain concentrations of thrombomodulin, plasminogen activator inhibitor-1 (PAI-1), soluble intercellular adhesion molecule-1 (ICAM-1), soluble vascular cell adhesion molecule-1 (VCAM-1), angiopoietin-2, and syndecan-1. The spectrophotometrically obtained skin microvascular perfusion indices were compared to the mottling score and biomarker concentration. The association between mottling score, skin microcirculatory perfusion indices, and 28-day mortality was also analyzed. Results Microcirculatory oxygen saturation was significantly lower and total hemoglobin concentration was significantly higher in patients with a mottling score of 2 compared to those with a score of 0 (p = 0.02), with no difference between other scores. We found an association between microcirculatory oxygen saturation and PAI-1 levels (rho = − 0.3; p = 0.007). Increased mottling score and decreased microcirculatory oxygen saturation were predictive of 28-day mortality (mottling score 2 vs 0: OR 15.31, 95% CI 4.12–68.11; microcirculatory oxygen saturation: OR 0.90, 95% CI 0.85–0.95). Endothelial biomarkers did not increase the predictive value of skin microcirculatory perfusion indices. Conclusions Higher mottling scores are associated with lower microcirculatory oxygen saturation but with significant overlap between scores. Microcirculatory oxygen saturation is a quantitative measure of peripheral oxygenation and is more specific than the mottling score in predicting 28-day mortality. Electronic supplementary material The online version of this article (10.1186/s13054-019-2589-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sigita Kazune
- Department of Anesthesiology, Hospital of Traumatology and Orthopedics, 22 Duntes Street, Riga, LV-1013, Latvia. .,Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, LV-1004, Latvia.
| | - Anastasija Caica
- Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, LV-1004, Latvia.,Department of Human and Animal Physiology, Faculty of Biology, University of Latvia, 1 Jelgavas Street, Riga, LV-1004, Latvia
| | - Karina Volceka
- Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, LV-1004, Latvia.,Department of Human and Animal Physiology, Faculty of Biology, University of Latvia, 1 Jelgavas Street, Riga, LV-1004, Latvia
| | - Olegs Suba
- Clinic of Toxicology and Sepsis, Riga East University Hospital, 2 Hipokrata Street, Riga, LV-1038, Latvia
| | - Uldis Rubins
- Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, LV-1004, Latvia
| | - Andris Grabovskis
- Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, LV-1004, Latvia
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Taylor D, Wyncoll D. Mottling reduction in the early phases of profound septic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:268. [PMID: 31375126 PMCID: PMC6676589 DOI: 10.1186/s13054-019-2558-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 07/25/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Daniel Taylor
- Department of Critical Care, St Thomas' Hospital, Westminster Bridge Rd., Lambeth, London, SE1 7EH, UK.
| | - Duncan Wyncoll
- Department of Critical Care, St Thomas' Hospital, Westminster Bridge Rd., Lambeth, London, SE1 7EH, UK
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