Clinical relevance of early sublingual microcirculation monitoring in septic shock patients

On Admission, Microcirculation Abnormality is an Independent Predictor of Sepsis and Sepsis-related Mortality: A Hospital-based Study

Background

Microcirculatory derangement is the primary cause of organ dysfunction in patients with sepsis. Assessment of the microcirculation is usually done by means of indirect parameters (SvO₂ transcutaneous PO₂ serum lactate.) The aim of our study is to understand microcirculatory abnormalities in patients with sepsis by directly visualizing the tiny vessels using hand-held video microscopes (HVMs) and determining the role of this modality in the prediction of sepsis-related mortality.

Methods

A longitudinal prospective hospital-based study was carried out in medical ward and ICU of a tertiary care hospital. Patients admitted with the presumed infectious disease were included. Evaluation of sublingual microcirculation was done in these patients from Day 1 to Day 5 Clinical and laboratory variables and microcirculation variables were compared between patients with or without sepsis and between survivors and non-survivors of sepsis. Chi-square test for categorical and Student's t-test or Wilcoxon rank-sum test for continuous variables were applied. Univariate and multivariate regression analyses were performed using the Cox-proportional hazard model.

Results and discussion

On admission, microcirculation assessment measure, PPV (small), was significantly reduced in those with sepsis, as compared to those without sepsis. Multivariable models indicate the inverse relationship of PPV small with mortality.

How to cite this article

Panda A, Revadi G, Sharma JP, Pakhare A, Singhai A, Joshi R, et al. On Admission, Microcirculation Abnormality is an Independent Predictor of Sepsis and Sepsis-related Mortality: A Hospital-based Study. Indian J Crit Care Med 2022;26(3):294–301.

Evaluation of a shorter algorithm in an automated analysis of sublingual microcirculation

OBJECTIVE

Diagnostic and risk stratification in intensive and emergency medicine must be fast, accurate, and reliable. The assessment of sublingual microcirculation is a promising tool for this purpose. However, its value is limited because the measurement is time-consuming in unstable patients. This proof-of-concept validation study examines the non-inferiority of a reduced frame rate in image acquisition regarding quality, measurement results, and time.

METHODS

This prospective observational study included healthy volunteers. Sublingual measurement of microcirculation was performed using a sidestream dark field camera (SDF, MicroVision Medical®). Video-quality was evaluated with a modified MIQS (microcirculation image quality score). AVA 4.3C software calculated microcirculatory parameters.

RESULTS

Thirty-one volunteers were included. There was no impact of the frame rate on the time needed by the software algorithm to measure one video (4.5 ± 0.5 minutes) for AVA 4.3C. 86 frames per video provided non inferior video quality (MIQS 1.8 ± 0.7 for 86 frames versus MIQS 2.2 ± 0.6 for 215 frames, p < 0.05), equal results for all microcirculatory parameters, but did not result in an advantage in terms of speed. No complications occurred.

CONCLUSION

Video captures with 86 frames offer equal video quality and results for consensus parameters compared to 215 frames. However, there was no advantage regarding the time needed for the overall measurement procedure.

Sublingual microcirculation detects impaired perfusion in dehydrated older patients

BACKGROUND: Dehydration occurs frequently in older patients and constitutes a significant clinical problem. OBJECTIVE: This proof-of-concept study examines whether 1) sublingual measurement in dehydrated old patients is feasible, 2) frailty and incompliance in old, awake patients affects video-quality, 3) dehydration impacts microcirculation METHODS: This prospective observational study included clinically dehydrated patients aged ≥65 years immediately after admission. Dehydration was assessed clinically. A sidestream dark field camera (SDF) was used for measurement. Video-quality was evaluated with MIQS (microcirculation image quality score). Both AVA 4.3C- and AVA POEM-software analyzed the videos. Seventeen patients ≥65 years not showing dehydration served as control. RESULTS: Thirteen patients (8 female) were included. The average age was 83±8 years. The mini-mental test was 17±15 points, the Clinical Frailty Scale 4±3, the Barthel-Index 59±39. None of these parameters correlated with MIQS (3.4±4.2 SD (“acceptable”)). Dehydrated patients had a slightly impaired microcirculation, with a significantly lower percentage of perfused small vessels compared to control (83.1±7.7% versus 88.0±6.0%, P < 0.05). After rehydration, there was acute improvement in the microcirculation. CONCLUSIONS: Sublingual microcirculatory SDF-measurement is both, safe and valid for dehydrated old patients - regardless of frailty, age or cognitive performance. Dehydration leads to an impaired microcirculation.

Microcirculation-guided protection strategy in hemodynamic therapy

Microcirculatory shock is a condition defined by the presence of tissue hypoperfusion despite the normalization of systemic and regional blood flow. Currently, more evidence shows that intrinsic septic shock is microcirculatory shock, which results in septic shock that is difficult to resuscitate. At present, treatments are aimed at recovering macro-circulation functions and include fluid resuscitation, vasoactive drugs, positive inotropic drugs, de-obstruction, and even mechanical assistance to improve oxygen delivery. However, the application of these treatments to more accurately improve microcirculation or avoid further microcirculatory damage is more important in clinics. In this article, we discuss the need for microcirculation protection and microcirculation-guided protection strategies in hemodynamic therapies.

Impact of plasma viscosity on microcirculatory flow after traumatic haemorrhagic shock: A prospective observational study

BACKGROUND

Preclinical studies report that higher plasma viscosity improves microcirculatory flow after haemorrhagic shock and resuscitation, but no clinical study has tested this hypothesis.

OBJECTIVE

We investigated the relationship between plasma viscosity and sublingual microcirculatory flow in patients during resuscitation for traumatic haemorrhagic shock (THS).

METHODS

Sublingual video-microscopy was performed for 20 trauma patients with THS as soon as feasible in hospital, and then at 24 h and 48 h. Values were obtained for total vessel density, perfused vessel density, proportion of perfused vessels, microcirculatory flow index (MFI), microcirculatory heterogeneity index (MHI), and Point of Care Microcirculation (POEM) scores. Plasma viscosity was measured using a Wells-Brookfield cone and plate micro-viscometer. Logistic regression analyses examined relationships between microcirculatory parameters and plasma viscosity, adjusting for covariates (systolic blood pressure, heart rate, haematocrit, rate and volume of fluids, and rate of noradrenaline).

RESULTS

Higher plasma viscosity was not associated with improved microcirculatory parameters. Instead, there were weakly significant associations between higher plasma viscosity and lower (poorer) MFI (p = 0.040), higher (worse) MHI (p = 0.033), and lower (worse) POEM scores (p = 0.039).

CONCLUSIONS

The current study did not confirm the hypothesis that higher plasma viscosity improves microcirculatory flow dynamics in patients with THS. Further clinical investigations are warranted to determine whether viscosity is a physical parameter of importance during resuscitation of these patients.

MicroRNA-494-3p protects rat cardiomyocytes against septic shock via PTEN

The aim of the present study was to investigate the role of microRNA (miR)-494-3p in myocardial injury in patients with septic shock and the underlying mechanism. A total of 22 patients with sepsis and 17 patients with septic shock were included in the present study. In addition, 20 healthy subjects were recruited as the control group. Peripheral blood was collected from all subjects and a rat cardiomyocyte model of myocardial injury was constructed. Reverse transcription-quantitative polymerase chain reaction was used to measure miR-494-3p expression, while cell counting kit-8 assays were performed to assess cell proliferation. Flow cytometry was performed to investigate cell cycle distribution and apoptosis. Lactate dehydrogenase (LDH) assays were performed to measure LDH levels. ELISA was also performed to measure LDH, tumor necrosis factor (TNF)-α and interleukin (IL)-6 levels in cell culture supernatants. Western blotting was employed to detect phosphatase and tensin homolog (PTEN) protein expression and dual luciferase reporter assays were performed to identify the interaction between miR-494-3p and PTEN mRNA. Reduced miR-494-3p expression was correlated with myocardial damage in patients with septic shock. Sera from patients with septic shock downregulated miR-494-3p expression in rat cardiomyocytes. miR-494-3p overexpression inhibited rat cardiomyocyte injury induced by treatment with sera from patients with septic shock. Furthermore, miR-494-3p overexpression reduced the synthesis and release of TNF-α and IL-6 from rat cardiomyocytes. PTEN knockdown alleviated rat cardiomyocyte injury following treatment with serum from patients with septic shock. PTEN was demonstrated to induce the release of TNF-α and IL-6 from rat cardiomyocytes treated with septic shock serum, while miR-494-3p was demonstrated to bind to the 3′-untranslated seed region of PTEN mRNA to regulate its expression. The results of the present study suggest that miR-494-3p is downregulated in the peripheral blood of patients with septic shock and is negatively correlated with myocardial injury. The present study also indicates that miR-494-3p regulates PTEN expression, inhibits sepsis-induced myocardial injury and protects the function of cardiomyocytes. The protective effect and mechanism of action of miR-494-3p indicate that it has potential for use in the clinical diagnosis and therapy of myocardial damage.

Analysis of human microcirculation in weightlessness: Study protocol and pre-study experiments

BACKGROUND

In weightlessness, alterations in organ systems have been reported. The microcirculation consists of a network of blood vessels with diameters of a few μm. It is considered the largest part of the circulatory system of the human body and essential for exchange of gas, nutrients and waste products. An investigation of the microcirculation in weightlessness seems warranted but has not yet been performed.

OBJECTIVE

In this paper, we outline a study in which we will investigate the possible interrelations between weightlessness and microcirculation. We will induce weightlessness in the course of parabolic flight maneuvers, which will be conducted during a parabolic flight campaign. In this study protocol also an evaluation of a possible influence of parabolic flight premedication on microcirculation will be described.

METHODS

The microcirculation will be investigated by sublingual intravital measurements applying sidestream darkfield microscopy. Parameters of macrocirculation such as heart rate, blood pressure and blood oxygenation will also be investigated.

RESULTS

In our pre-study experiments, neither dimenhydrinate nor scopolamine altered microcirculation.

CONCLUSIONS

As the application of motion sickness therapy did not alter microcirculation, it will be applied during the parabolic flight maneuvers of the campaign. Our results might deepen the understanding of microcirculation on space missions and on earth.