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Magnin M, Gavet M, Ngo TT, Louzier V, Victoni T, Ayoub JY, Allaouchiche B, Bonnet-Garin JM, Junot S. A multimodal tissue perfusion measurement approach for the evaluation of the effect of pimobendan, an inodilator, in a porcine sepsis model. Microvasc Res 2024; 154:104687. [PMID: 38614155 DOI: 10.1016/j.mvr.2024.104687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/03/2024] [Accepted: 04/10/2024] [Indexed: 04/15/2024]
Abstract
Sepsis is associated with hypoperfusion and organ failure. The aims of the study were: 1) to assess the effect of pimobendan on macrocirculation and perfusion and 2) to describe a multimodal approach to the assessment of perfusion in sepsis and compare the evolution of the perfusion parameters. Eighteen anaesthetized female piglets were equipped for macrocirculation monitoring. Sepsis was induced by an infusion of Pseudomonas aeruginosa. After the occurrence of hypotension, animals were resuscitated. Nine pigs received pimobendan at the start of resuscitation maneuvers, the others received saline. Tissue perfusion was assessed using temperature gradients measured with infrared thermography (TG = core temperature - tarsus temperature), urethral perfusion index (uPI) derived from photoplethysmography and sublingual microcirculation (Sidestream dark field imaging device): De Backer score (DBs), proportion of perfused vessels (PPV), microvascular flow index (MFI) and heterogeneity index (HI). Arterial lactate and ScvO2 were also measured. Pimobendan did not improve tissue perfusion nor macrocirculation. It did not allow a reduction in the amount of noradrenaline and fluids administered. Sepsis was associated with tissue perfusion disorders: there were a significant decrease in uPI, PPV and ScvO2 and a significant rise in TG. TG could significantly predict an increase in lactate. Resuscitation was associated with a significant increase in uPI, DBs, MFI, lactate and ScvO2. There were fair correlations between the different perfusion parameters. In this model, pimobendan did not show any benefit. The multimodal approach allowed the detection of tissue perfusion alteration but only temperature gradients predicted the increase in lactatemia.
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Affiliation(s)
- Mathieu Magnin
- Université de Lyon, UR APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, Vetagro Sup, Unité de Physiologie, Pharmacodynamie et Thérapeutique, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France.
| | - Morgane Gavet
- Université de Lyon, VetAgro Sup, Service d'Anesthésie, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France.
| | - Thien-Tam Ngo
- Université de Lyon, UR APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, Vetagro Sup, Unité de Physiologie, Pharmacodynamie et Thérapeutique, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France
| | - Vanessa Louzier
- Université de Lyon, UR APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, Vetagro Sup, Unité de Physiologie, Pharmacodynamie et Thérapeutique, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France.
| | - Tatiana Victoni
- Université de Lyon, UR APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, Vetagro Sup, Unité de Physiologie, Pharmacodynamie et Thérapeutique, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France.
| | - Jean Yves Ayoub
- Université de Lyon, UR APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, Vetagro Sup, Unité de Physiologie, Pharmacodynamie et Thérapeutique, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France.
| | - Bernard Allaouchiche
- Université de Lyon, UR APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Réanimation Médicale, 165 Chemin du Grand Revoyet, F-69310 Pierre-Bénite, France
| | - Jeanne-Marie Bonnet-Garin
- Université de Lyon, UR APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, Vetagro Sup, Unité de Physiologie, Pharmacodynamie et Thérapeutique, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France.
| | - Stéphane Junot
- Université de Lyon, UR APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, Vetagro Sup, Unité de Physiologie, Pharmacodynamie et Thérapeutique, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, VetAgro Sup, Service d'Anesthésie, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France.
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Brouwer F, Ince C, Pols J, Uz Z, Hilty MP, Arbous MS. The microcirculation in the first days of ICU admission in critically ill COVID-19 patients is influenced by severity of disease. Sci Rep 2024; 14:6454. [PMID: 38499589 PMCID: PMC10948764 DOI: 10.1038/s41598-024-56245-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 03/04/2024] [Indexed: 03/20/2024] Open
Abstract
The objective of this study was to investigate the relationship between sublingual microcirculatory parameters and the severity of the disease in critically ill coronavirus disease 2019 (COVID-19) patients in the initial period of Intensive Care Unit (ICU) admission in a phase of the COVID-19 pandemic where patients were being treated with anti-inflammatory medication. In total, 35 critically ill COVID-19 patients were included. Twenty-one critically ill COVID-19 patients with a Sequential Organ Failure Assessment (SOFA) score below or equal to 7 were compared to 14 critically ill COVID-19 patients with a SOFA score exceeding 7. All patients received dexamethasone and tocilizumab at ICU admission. Microcirculatory measurements were performed within the first five days of ICU admission, preferably as soon as possible after admission. An increase in diffusive capacity of the microcirculation (total vessel density, functional capillary density, capillary hematocrit) and increased perfusion of the tissues by red blood cells was found in the critically ill COVID-19 patients with a SOFA score of 7-9 compared to the critically ill COVID-19 patients with a SOFA score ≤ 7. No such effects were found in the convective component of the microcirculation. These effects occurred in the presence of administration of anti-inflammatory medication.
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Affiliation(s)
- Fleur Brouwer
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Jiska Pols
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Zühre Uz
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Matthias Peter Hilty
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Mendi Sesmu Arbous
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands.
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Knobel D, Scheuzger J, Buser A, Hollinger A, Gebhard CE, Achermann R, Zaiser A, Bovey Y, Nuciforo C, Netzer JN, Räber A, Singh J, Siegemund M. Does the age of packed red blood cells, donor sex or sex mismatch affect the sublingual microcirculation in critically ill intensive care unit patients? A secondary interpretation of a retrospective analysis. J Clin Monit Comput 2023; 37:179-88. [PMID: 35665876 DOI: 10.1007/s10877-022-00877-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 05/05/2022] [Indexed: 01/24/2023]
Abstract
In vitro studies have thoroughly documented age-dependent impact of storage lesions in packed red blood cells (pRBC) on erythrocyte oxygen carrying capacity. While studies have examined the effect of pRBC age on patient outcome only few data exist on the microcirculation as their primary site of action. In this secondary analysis we examined the relationship between age of pRBC and changes of microcirculatory flow (MCF) in 54 patients based on data from the Basel Bedside assessment Microcirculation Transfusion Limit study (Ba2MiTraL) on effects of pRBC on sublingual MCF. Mean change from pre- to post-transfusion proportion of perfused vessels (∆PPV) was + 8.8% (IQR - 0.5 to 22.5), 5.5% (IQR 0.1 to 10.1), and + 4.7% (IQR - 2.1 to 6.5) after transfusion of fresh (≤ 14 days old), medium (15 to 34 days old), and old (≥ 35 days old) pRBC, respectively. Values for the microcirculatory flow index (MFI) were + 0.22 (IQR - 0.1 to 0.6), + 0.22 (IQR 0.0 to 0.3), and + 0.06 (IQR - 0.1 to 0.3) for the fresh, medium, and old pRBC age groups, respectively. Lower ∆PPV and transfusion of older blood correlated with a higher Sequential Organ Failure Assessment (SOFA) score of patients upon admission to the intensive care unit (ICU) (p = 0.01). However, regression models showed no overall significant correlation between pRBC age and ∆PPV (p = 0.2). Donor or recipient sex had no influence. We detected no significant effect of pRBC on microcirculation. Patients with a higher SOFA score upon ICU admission might experience a negative effect on the ∆PPV after transfusion of older blood.
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Liu B, He H, Feng X, Yuan S, Long Y, Akin Ş, Ince C. Sublingual microcirculation: comparison between the 415 nm blue light and 520 nm green light of sidestream dark field videomicroscopes. J Clin Monit Comput 2023; 37:297-302. [PMID: 35838871 DOI: 10.1007/s10877-022-00891-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 06/28/2022] [Indexed: 01/24/2023]
Abstract
Green light with a wavelength of 520 nm is commonly used in sidestream dark field (SDF) video microscopes for sublingual microcirculation assessment in clinical practice. However, blue light could obtain a clearer microcirculatory image due to a higher light absorption coefficient of hemoglobin. The aim of this study was to compare the sublingual microcirculatory image quality acquisition and related microcirculatory parameters between 520 nm green light and 415 nm blue light probes in the SDF device named MicroSee V100. Sublingual microcirculation films from twenty-one healthy volunteers were prospectively collected by blue light and green light probes, and only one video of each wavelength was recorded and analyzed in each volunteer. Moreover, 200 sublingual microcirculation films (100 by blue light probe and 100 by green light probe) of ICU patients were retrospectively scored for microcirculation image quality. Compared to green light, an increase in the perfused vessel density (paired t test, increased by 4.6 ± 4.7 mm/mm2, P < 0.0001) and total vessel density (paired t test, increased by 5.1 ± 4.6 mm/mm2, P < 0.0001) was observed by blue light in the healthy volunteers. The blue light probe had a significantly lower rate of unacceptable films than the green light probe in the 200 films of ICU patients (10/100 vs. 39/100, P < 0.0001). Blue light provides a higher microcirculatory vessel density and image quality than the existing SDF probe using green light.
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Affiliation(s)
- Bo Liu
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
- Department of Critical Care Medicine, affiliated hospital of Ji Ning Medical University, Jining, China
| | - Huaiwu He
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China.
- Department of Intensive Care, Erasmus MC University Hospital Rotterdam, Rotterdam, Netherlands.
| | - Xiaokai Feng
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
- ICU, Hebi People's Hospital of Henan Province, Zhengzhou, China
| | - Siyi Yuan
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Şakir Akin
- Department of Intensive Care, Erasmus MC University Hospital Rotterdam, Rotterdam, Netherlands
- Department of Intensive Care, Haga Teaching Hospital, The Hague, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus MC University Hospital Rotterdam, Rotterdam, Netherlands
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Li Q, Liu X, Jia M, Sun F, Li Y, Zhang H, Liu X, He H, Zhao Z, Yan Z, Zhu Z. Assessment of sublingual microcirculation for the screening of diabetic nephropathy. Diabetol Metab Syndr 2022; 14:90. [PMID: 35794676 PMCID: PMC9258215 DOI: 10.1186/s13098-022-00864-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/14/2022] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To investigate the potential of employing sublingual microcirculation as an early noninvasive screening technique for diabetic nephropathy (DN). RESEARCH DESIGN AND METHODS We recruited 89 patients with type 2 diabetes mellitus (T2DM) and 41 healthy subjects in this cross-sectional observational study. All participants underwent fluorescein fundus angiography, vibration perception testing, 10 g (Semmes-Weinstein) monofilament examination, nerve conduction velocity, and 24-h urine microalbumin determination. HbA1c, fasting plasma glucose, blood lipid, and estimated glomerular filtration rate(eGFR) were measured. Sublingual microcirculatory images were captured using side-stream dark-field (SDF) microcirculation microscopy, and total and perfused vascular density (TVD and PVD) were calculated. RESULTS The sublingual microcirculatory parameters denoting microvascular density and perfusion were negatively correlated with both fasting plasma glucose (TVD, r = - 0.316, P < 0.001; PVD, r = - 0.350, P < 0.001; PPV, r = - 0.279, P = 0.001) and HbA1c (TVD, r = - 0.367, P < 0.001; PVD, r = - 0.423, P < 0.001; PPV, r = - 0.399, P < 0.001). Diabetes patients already had a reduction in sublingual microcirculation compared with healthy control, and more severe reductions in TVD (7.07 ± 1.64 vs. 9.67 ± 1.94 mm/mm2, P < 0.001) and PVD (5.88 ± 1.82 vs. 8.64 ± 2.46 mm/mm2, P < 0.001) were found in those diabetes patients developed microvascular complications. Sublingual microcirculation impairment was accompanied with higher urinary albumin creatinine ratio (UACR). Receiver operating characteristic (ROC) analysis showed that TVD (area under the curve, AUC = 0.890 [0.836 0.944], P < 0.001) and PVD (AUC = 0.883 [0.826, 0.940], P < 0.001) could be indicators for DN screening. We derived a combined predictor index (CPI) considering both TVD and PVD for screening DN, and both the AUC (0.892, [0.838 0.945], P < 0.001) and cutoff point of 11.30 mm/mm2 showed great improvement (sensitivity: 95.5%, specificity: 67.4%). CONCLUSIONS Diabetes patients experienced impaired sublingual microcirculation, which was closely correlated with UACR. Sublingual microcirculation monitoring could be used for the noninvasive early detection of DN.
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Affiliation(s)
- Qiang Li
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - XiaoXiao Liu
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Mengxiao Jia
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Fang Sun
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Yingsha Li
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Hexuan Zhang
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Xiaoli Liu
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Hongbo He
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Zhigang Zhao
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Zhencheng Yan
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Zhiming Zhu
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Army Medical University, Chongqing, 400042, China.
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Jiang S, Li P, Shen Y, Yan M, Zhang J, Liu M, Ning G, Cai G. An adaptive fractal model for sublingual microcirculation. Microvasc Res 2021; 134:104101. [PMID: 33166577 DOI: 10.1016/j.mvr.2020.104101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/02/2020] [Accepted: 11/03/2020] [Indexed: 12/16/2022]
Abstract
The hemodynamic conditions and partial pressure of oxygen in microcirculation generally indicate the status of tissue perfusion, which provides essential information for the assessment and treatment of critical diseases such as sepsis. The human tongue is known to have abundant microcirculation and is an ideal window to observe the microcirculation. At present, the monitoring of sublingual microcirculation is mostly achieved using handheld vital microscopy (HVM). Microcirculation is organized and works as a network. However, HVM can obtain only limited view of few vessels and is not able to acquire information regarding the entire network. In this work, we proposed a method to construct a mathematical network model of sublingual microcirculation to solve the problems. The proposed method is based on fractal analysis to model and simulate the hemodynamic and functional activities of sublingual microcirculation. Specifically, the HVM technology is used to obtain the partial morphological and hemodynamic data of sublingual microcirculation, and fractal analysis is applied thereafter to establish the hemodynamic model of the network based on the data from few vessels. Further, the adaptive regulation mechanism of microcirculation is introduced to enhance the performance of the model. The model was validated by the experimental data and the results are consistent with the characteristics of microcirculation. The work demonstrates the potential of the proposed method in sublingual microcirculation research and for the further assessment of tissue perfusion.
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Abstract
Several autopsy studies showed microthrombi in pulmonary circulation of severe COVID-19 patients. The major limitation of these investigations is that the autopsy provided static information. Some of these alterations could be secondary to the disseminated intravascular coagulation (DIC) observed as the final standard route to the multisystem organ failure exhibited in critically ill patients. We report preliminary results of an in vivo evaluation of sublingual microcirculation in thirteen patients with severe COVID-19 requiring mechanical ventilation. We observed multiple filling defects moving within the microvessels indicative of thrombi in most of the cases 11/13 (85%). This is the first imaging documentation of microvascular thrombosis in living severe COVID-19 patients since the beginning of the hospitalization. The clinical relevance of microvascular thrombosis in this disease requires further research.
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Affiliation(s)
- Douglas Alexandre do Espírito Santo
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Rua Bernardino de Campos, 1000, Ribeirão Preto, SP, 14020-670, Brazil
| | - Anna Cristina Bertoldi Lemos
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Rua Bernardino de Campos, 1000, Ribeirão Preto, SP, 14020-670, Brazil
| | - Carlos Henrique Miranda
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Rua Bernardino de Campos, 1000, Ribeirão Preto, SP, 14020-670, Brazil.
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Scheuzger J, Zehnder A, Meier V, Yeginsoy D, Flükiger J, Siegemund M. Sublingual microcirculation does not reflect red blood cell transfusion thresholds in the intensive care unit-a prospective observational study in the intensive care unit. Crit Care 2020; 24:18. [PMID: 31952555 DOI: 10.1186/s13054-020-2728-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 01/01/2020] [Indexed: 01/28/2023]
Abstract
Purpose Hemoglobin (Hb) transfusion thresholds are established in intensive care units. A restrictive transfusion threshold (Hb 70–75 g/l) is recommended in septic patients, and a liberal transfusion threshold (Hb 90 g/l) for cardiogenic shock. It is unclear whether these historically adopted transfusion thresholds meet the challenges of individual patients. Methods We evaluated microvascular flow index (MFI) and proportion of perfused vessels (PPV) in the sublingual microcirculation with CytoCam-IDF microscopy and near-infrared spectroscopy (NIRS). A study team-independent, treating intensivist assigned a total of 64 patients to 1 of 2 two transfusion thresholds, 43 patients to the Hb 75 g/l threshold and 21 patients to the Hb 90 g/l threshold, at a surgical intensive care unit. We performed microcirculatory measurements 1 h before and 1 h after transfusion of 1 unit of red blood cells. Results Microcirculatory flow variables correlated negatively with pre-transfusion flow variables (ΔMFI: ρ = − 0.821, p < 0.001; ΔPPV: ρ = − 0.778, p < 0.001). Patients with good initial microcirculation (cutoffs: MFI > 2.84, PPV > 88%) showed a deteriorated microcirculation after red blood cell transfusion. An impaired microcirculation improved after transfusion. At both transfusion thresholds, approximately one third of the patients showed an initially impaired microcirculation. In contrast, one third in every group had good microcirculation above the cutoff variables and did not profit from the transfusion. Conclusion The data suggest that the established transfusion thresholds and other hemodynamic variables do not reflect microcirculatory perfusion of patients. Blood transfusion at both thresholds 75 g/l and 90 g/l hemoglobin can either improve or harm the microcirculatory blood flow, questioning the concept of arbitrary transfusion thresholds.
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Uz Z, Aykut G, Massey M, Ince Y, Ergin B, Shen L, Toraman F, van Gulik TM, Ince C. Leukocyte-Endothelium Interaction in the Sublingual Microcirculation of Coronary Artery Bypass Grafting Patients. J Vasc Res 2019; 57:8-15. [PMID: 31505501 DOI: 10.1159/000501826] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 07/01/2019] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE The aim of this study was to apply an innovative methodology to incident dark-field (IDF) imaging in coronary artery bypass grafting (CABG) patients for the identification and quantification of rolling leukocytes along the sublingual microcirculatory endothelium. METHODS This study was a post hoc analysis of a prospective study that evaluated the perioperative course of the sublingual microcirculation in CABG patients. Video images were captured using IDF imaging following the induction of anesthesia (T0) and cardiopulmonary bypass (CPB) (T1) in 10 patients. Rolling leukocytes were identified and quantified using frame averaging, which is a technique that was developed for correctly identifying leukocytes. RESULTS The number of rolling leukocytes increased significantly from T0 (7.5 [6.4-9.1] leukocytes/capillary-postcapillary venule/4 s) to T1 (14.8 [13.2-15.5] leukocytes/capillary-postcapillary venule/4 s) (p < 0.0001). A significant increase in systemic leukocyte count was also detected from 7.4 ± 0.9 × 109/L (preoperative) to 12.4 ± 4.4 × 109/L (postoperative) (p < 0.01). CONCLUSION The ability to directly visualize leukocyte-endothelium interaction using IDF imaging facilitates the diagnosis of a systemic inflammatory response after CPB via the identification of rolling leukocytes. Integration of the frame averaging algorithm into the software of handheld vital microscopes may enable the use of microcirculatory leukocyte count as a real-time parameter at the bedside.
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Affiliation(s)
- Zühre Uz
- Department of Translational Physiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands, .,Department of Experimental Surgery and Translational Physiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands,
| | - Güçlü Aykut
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Michael Massey
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Yasin Ince
- Department of Translational Physiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bülent Ergin
- Department of Translational Physiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Lucinda Shen
- Department of Translational Physiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Fevzi Toraman
- Department of Anesthesiology and Reanimation, Acıbadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Turkey
| | - Thomas M van Gulik
- Department of Experimental Surgery and Translational Physiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Can Ince
- Department of Translational Physiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Zuccari S, Damiani E, Domizi R, Scorcella C, D'Arezzo M, Carsetti A, Pantanetti S, Vannicola S, Casarotta E, Ranghino A, Donati A, Adrario E. Changes in Cytokines, Haemodynamics and Microcirculation in Patients with Sepsis/Septic Shock Undergoing Continuous Renal Replacement Therapy and Blood Purification with CytoSorb. Blood Purif 2019; 49:107-113. [PMID: 31434083 DOI: 10.1159/000502540] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 08/04/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Extracorporeal blood purification therapies have been proposed as a strategy to remove inflammatory mediators during sepsis, thus improving outcome. OBJECTIVES We aimed to evaluate changes in cytokines, haemodynamics and microcirculation during blood purification with Cytosorb adsorber in septic patients. METHODS Prospective observational study on critically ill adult patients with sepsis/septic shock underwent renal replacement therapy (RRT) for acute renal failure and haemoadsorption with Cytosorb as adjunctive therapy for 24 h. Measurements were taken at baseline, after 6 and 24 h: haemodynamic parameters, arterial and central venous blood gases, plasma levels of tumour necrosis factor alpha, interleukin (IL) 1-beta, IL-6, IL-8 and IL-10. The sublingual microcirculation was assessed with sidestream dark field videomicroscopy to evaluate the perfused vessel density (PVD) and microvascular flow quality. Tissue oxygenation and microvascular reactivity were assessed with thenar near infrared spectroscopy (NIRS) with a vascular occlusion test. RESULTS Nine patients; plasma levels of IL-8 decreased at 24 h (p < 0.05 versus 6 h); no significant variation was found for other cytokines. Haemodynamic remained stable throughout the observation. Microvascular perfusion improved over time, with an increase in PVDs at 6 and 24 h (from 13.9 [13.3-16.4] to 15.7 [15-17.3] and 17 [14.8-18.6] mm/mm2 respectively, p = 0.003) and total vessel densities at 24 h (14.9 [13.9-16.9] vs. 17.9 [15.3-20], p = 0.0015). No significant variation was detected in NIRS-derived parameters. The Sequential Organ Failure Assessment score decreased from 12 ± 3 to 10 ± 1 at 24 h (p = 0.039). CONCLUSIONS In septic patients undergoing RRT, haemoadsorption with Cytosorb seems to determine a decreasing in plasma levels of IL-8, although levels of other cytokines did not vary significantly, and an improvement of microcirculation despite no significant variation in macro-haemodynamics.
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Affiliation(s)
- Samuele Zuccari
- Anaesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Elisa Damiani
- Anaesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Roberta Domizi
- Anaesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Claudia Scorcella
- Anaesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Mario D'Arezzo
- Nephrology, Dialysis and Renal Transplantation Unit, Azienda Ospedaliera Universitaria Ospedali Riuniti Umberto I, Lancisi, Salesi of Ancona, Ancona, Italy
| | - Andrea Carsetti
- Anaesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Simona Pantanetti
- Anaesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Sara Vannicola
- Anaesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Erika Casarotta
- Anaesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Andrea Ranghino
- Nephrology, Dialysis and Renal Transplantation Unit, Azienda Ospedaliera Universitaria Ospedali Riuniti Umberto I, Lancisi, Salesi of Ancona, Ancona, Italy
| | - Abele Donati
- Anaesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy,
| | - Erica Adrario
- Anaesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
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Uz Z, Ince C, Guerci P, Ince Y, P Araujo R, Ergin B, Hilty MP, van Gulik TM, de Mol BA. Recruitment of sublingual microcirculation using handheld incident dark field imaging as a routine measurement tool during the postoperative de-escalation phase-a pilot study in post ICU cardiac surgery patients. Perioper Med (Lond) 2018; 7:18. [PMID: 30116524 PMCID: PMC6083575 DOI: 10.1186/s13741-018-0091-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 04/30/2018] [Indexed: 02/07/2023] Open
Abstract
Background Management of tissue perfusion following cardiac surgery is a challenging task where common clinical parameters do not reflect microcirculatory dysfunction. Heterogeneity in blood flow perfusion and abnormalities in capillary density characterize microcirculatory dysfunction. The restoration of a normal microcirculation may become a novel target for therapy in the future in addition to macrocirculatory parameters. The aim of this study is to determine how the sublingual microcirculatory parameters vary at the bedside in post-cardiac surgery patients which underwent diuretic therapy to correct fluid overload. Methods In this prospective observational pilot study, video clips of sublingual microcirculation in post-cardiac surgery patients receiving furosemide and/or spironolactone to achieve normal fluid balance were recorded using Cytocam-IDF imaging. Data was obtained on the first (T0), second (T1), and third (T2) day after the patients left the intensive care unit (ICU). Measurements were analyzed off-line to obtain the following microcirculatory parameters: total vessel density (TVD), microcirculatory flow index (MFI), proportion of perfused vessel (PPV), and perfused vessel density (PVD). Macrocirculatory parameters and body weight were also collected at these time points. Results Ninety measurements were performed in ten post ICU cardiac surgery patients. Thirteen measurements were excluded due to quality reasons; these excluded measurements were spread across the patients and time points, and there was no loss of patients or time points. An increase in TVD was observed from T0 to T1 (20 ± 2.7 to 24 ± 3.2 mm/mm2; p = 0.0410) and from T0 to T2 (20 ± 2.7 to 26 ± 3.3 mm/mm2; p = 0.0005). An increase in PVD was present from T0 to T1 (19 ± 2.3 to 24 ± 3.5 mm/mm2; p = 0.0072) and from T0 to T2 (19 ± 2.3 to 26 ± 3.4 mm/mm2, p = 0.0008). Fluid overload was assessed through a positive cumulative fluid balance on the day of ICU discharge. Conclusions Cytocam-IDF imaging to monitor microcirculation as a daily parameter is feasible and could become a valuable tool to non-invasively assess the tissue oxygenation at the bedside. An increase in TVD and PVD (functional capillary density) indicated the recruitment of the sublingual microcirculation in patients with diuretic therapy. Future research is needed to prove the correlation between the recruitment of the sublingual microcirculation and the de-escalation phase of the fluid management.
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Affiliation(s)
- Zühre Uz
- 1Department of Experimental Surgery and Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Can Ince
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Philippe Guerci
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Yasin Ince
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Renata P Araujo
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Bulent Ergin
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Matthias P Hilty
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Thomas M van Gulik
- 1Department of Experimental Surgery and Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Bas A de Mol
- 3Department of Cardio-Thoracic Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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12
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Sharawy N, Mukhtar A, Islam S, Mahrous R, Mohamed H, Ali M, Hakeem AA, Hossny O, Refaa A, Saka A, Cerny V, Whynot S, George RB, Lehmann C. Preliminary clinical evaluation of automated analysis of the sublingual microcirculation in the assessment of patients with septic shock: Comparison of automated versus semi-automated software. Clin Hemorheol Microcirc 2018; 67:489-498. [PMID: 28922146 DOI: 10.3233/ch-179232] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The outcome of patients in septic shock has been shown to be related to changes within the microcirculation. Modern imaging technologies are available to generate high resolution video recordings of the microcirculation in humans. However, evaluation of the microcirculation is not yet implemented in the routine clinical monitoring of critically ill patients. This is mainly due to large amount of time and user interaction required by the current video analysis software. The aim of this study was to validate a newly developed automated method (CCTools®) for microcirculatory analysis of sublingual capillary perfusion in septic patients in comparison to standard semi-automated software (AVA3®). METHODS 204 videos from 47 patients were recorded using incident dark field (IDF) imaging. Total vessel density (TVD), proportion of perfused vessels (PPV), perfused vessel density (PVD), microvascular flow index (MFI) and heterogeneity index (HI) were measured using AVA3® and CCTools®. RESULTS Significant differences between the numeric results obtained by the two different software packages were observed. The values for TVD, PVD and MFI were statistically related though. CONCLUSION The automated software technique successes to show septic shock induced microcirculation alterations in near real time. However, we found wide degrees of agreement between AVA3® and CCTools® values due to several technical factors that should be considered in the future studies.
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Affiliation(s)
- Nivin Sharawy
- Surgical Intensive Care Trauma Center, Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt.,Department of Physiology, Faculty of Medicine, Cairo University, Cairo, Egypt.,Department of Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ahmed Mukhtar
- Surgical Intensive Care Trauma Center, Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sufia Islam
- Department of Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Reham Mahrous
- Surgical Intensive Care Trauma Center, Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hassan Mohamed
- Surgical Intensive Care Trauma Center, Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Ali
- Surgical Intensive Care Trauma Center, Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amr A Hakeem
- Surgical Intensive Care Trauma Center, Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Osama Hossny
- Surgical Intensive Care Trauma Center, Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amera Refaa
- Surgical Intensive Care Trauma Center, Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Saka
- Surgical Intensive Care Trauma Center, Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Vladimir Cerny
- Department of Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sara Whynot
- Department of Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ronald B George
- Department of Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Christian Lehmann
- Department of Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Pharmacology, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Microbiology and Immunology, Dalhousie University, Halifax, Nova Scotia, Canada
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13
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Maddison L, Karjagin J, Buldakov M, Mäll M, Kruusat R, Lillemäe K, Kirsimägi U, Starkopf J. Sublingual microcirculation in patients with intra-abdominal hypertension: a pilot study in 15 critically ill patients. J Crit Care 2013; 29:183.e1-6. [PMID: 24125769 DOI: 10.1016/j.jcrc.2013.08.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 08/07/2013] [Accepted: 08/27/2013] [Indexed: 01/18/2023]
Abstract
PURPOSE The purpose of the study is to clarify whether increased intra-abdominal pressure (IAP) is associated with sublingual microcirculatory alterations in intensive care patients. METHODS Fifteen adult, mechanically ventilated patients were included if their IAP was at least 12 mm Hg for at least 12 hours within the first 3 days after admission to the intensive care unit. Sublingual sidestream dark field (SDF) images were recorded twice a day for 7 days. RESULTS Median (interquartile range) IAP at inclusion was 14.5 (12.5-16.0) mm Hg. The total vascular density of small vessels at the sublingual area was 13.1 (10.6-14.3) per square millimeter at baseline; the proportion of perfused vessels, 78.9% (69.6%-86.2%); and perfused vessels density, 12.4 (10.8-13.8) per square millimeter. The calculated indices suggested relatively good blood flow in the capillaries, with a De Backer score of 9.0 (8.3-10.2) and a microvascular blood flow of 3.0 (2.9-3.0). Blood flow heterogeneity index was 0.3 (0.1-0.5) at study entry. Despite that IAP, vasopressors dose, and arterial lactate decreased significantly over time, no significant changes were observed in sublingual microvascular density or blood flow. Weak correlations of microvascular blood flow (positive) and heterogeneity index (negative) were detected with both mean arterial pressure and abdominal perfusion pressure. CONCLUSIONS Neither grade I or II intra-abdominal hypertension (IAP from 12 to 18 mm Hg) is associated with significant changes of sublingual microcirculation in intensive care patients. Correlation analysis indicates better microvascular blood flow at higher mean arterial pressure and abdominal perfusion pressure levels.
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Affiliation(s)
- Liivi Maddison
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu University Hospital, Puusepa 8, 51014 Tartu, Estonia.
| | - Juri Karjagin
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu University Hospital, Puusepa 8, 51014 Tartu, Estonia
| | - Maksim Buldakov
- University of Tartu, Medical Faculty, Ravila 19, Tartu, Estonia
| | - Merilin Mäll
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu University Hospital, Puusepa 8, 51014 Tartu, Estonia
| | - Rein Kruusat
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu University Hospital, Puusepa 8, 51014 Tartu, Estonia
| | - Kadri Lillemäe
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu University Hospital, Puusepa 8, 51014 Tartu, Estonia
| | - Ulle Kirsimägi
- Department of Surgery, University of Tartu, Tartu University Hospital, Puusepa 8, 51014 Tartu, Estonia
| | - Joel Starkopf
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu University Hospital, Puusepa 8, 51014 Tartu, Estonia
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