Could resuscitation be based on microcirculation data? No

Naumann, David N; Lima, Alexandre

doi:10.1007/s00134-018-5095-y

Cited by 12 publications

(10 citation statements)

References 17 publications

(19 reference statements)

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“…necessary point of contact with the tissue) and time-consuming semi-manual evaluation 11,12 . However, information about microcirculatory perfusion would be of great interest in intensive care to predict outcome and potentially guide therapy 13,14 .…”

mentioning

confidence: 99%

Optical coherence tomography angiography as a novel approach to contactless evaluation of sublingual microcirculation: A proof of principle study

Heßler

Nelis

Ertmer

et al. 2020

Sci Rep

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Microcirculatory disorders are crucial in pathophysiology of organ dysfunction in critical illness. Evaluation of sublingual microcirculation is not routinely conducted in daily practice due to timeconsuming analysis and susceptibility to artifacts. We investigated the suitability of optical coherence tomography angiography (octA) for contactless evaluation of sublingual microcirculation. Sublingual microcirculation was imaged in 10 healthy volunteers, using an OCTA device and an incident dark field (IDF) illumination microscopy (current gold standard). OCTA images were analyzed with regard to flow density and perfused vessel density (PVD byoctA). IDF videos were analyzed following current recommendations. Flow density was automatically extracted from OCTA images (whole en face 48.9% [43.2; 54.5]; central ring 52.6% [43.6; 60.6]). PVD byoctA did not differ from the PVD calculated from IDF videos (PVD byoctA 18.6 mm/mm² [18.0; 21.7]) vs. PVD byIDF 21.0 mm/mm² [17.5; 22.9]; p = 0.430). Analysis according to Bland-Altman revealed a mean bias of 0.95 mm/mm² (95% Confidence interval −1.34 to 3.25) between PVD byoctA and PVD byIDF with limits of agreement of −5.34 to 7.24 mm/mm². This study is the first to demonstrate the suitability of OCTA for evaluating sublingual microcirculation. comparison of the perfused vessel density between methods showed a plausible level of agreement. In recent years, research has highlighted the importance of the microcirculation (vessels smaller than 100 μm) in the pathophysiology of diseases and organ dysfunction in critical illness. It is known that blood flow in the microcirculation is often impaired in critically ill patients and altered blood flow in the microcirculation is associated with outcome 1-6. A decoupling of macro-and microcirculation ("loss of hemodynamic coherence"), as can occur, for example, in advanced stages of septic shock is of particular interest here 7. In such conditions, macrohemodynamic parameters such as cardiac output and perfusion pressure are no longer indicative of perfusion in the microcirculation. The aim of hemodynamic therapy should therefore be restoration not only of the macrocirculation but also the microcirculation 7. Hence the demand for bedside methods to monitor the microcirculation. Bedside analysis of the microcirculation became possible with the introduction of modern handheld video microscopes using sidestream dark field (SDF) imaging or incident dark field (IDF) illumination technology 8-10. Unfortunately, the analysis of the microcirculation has not yet become established in routine clinical practice, as video microscopy of capillary blood flow has so far been limited by artifacts (e.g.

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mentioning

confidence: 99%

Optical coherence tomography angiography as a novel approach to contactless evaluation of sublingual microcirculation: A proof of principle study

Heßler

Nelis

Ertmer

et al. 2020

Sci Rep

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“…One, by Boerma et al ( 27 ), found no outcome benefit from targeting the sublingual microcirculation with nitroglycerin. Whether such an approach may provide a “ magic bullet ” to improve survival after circulatory shock has generated conflicting views ( 9 , 11 , 12 ). This is in part due to the ongoing lack of readily accessible data from bedside techniques that assess the microcirculation, notwithstanding the conclusions of a recent consensus conference ( 28 ).…”

Section: Does “Microvascular Resuscitation” Help?mentioning

confidence: 99%

“…Nevertheless, it remains a matter of debate as to whether this is an epiphenomenon or a causal relationship, in other words, whether “ recruiting the microcirculation ” ( 9 ) or “ microvascular resuscitation ” ( 10 ) is the “ magic bullet ” that will improve survival after circulatory shock. This question still raises fairly equivocal viewpoints ( 9 , 11 , 12 ). Trezciak et al ( 13 ) failed to demonstrate any relationship between changes in microcirculatory markers and the severity of organ failure.…”

Section: Introductionmentioning

confidence: 99%

Microcirculation vs. Mitochondria—What to Target?

et al. 2020

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Circulatory shock is associated with marked disturbances of the macro- and microcirculation and flow heterogeneities. Furthermore, a lack of tissue adenosine trisphosphate (ATP) and mitochondrial dysfunction are directly associated with organ failure and poor patient outcome. While it remains unclear if microcirculation-targeted resuscitation strategies can even abolish shock-induced flow heterogeneity, mitochondrial dysfunction and subsequently diminished ATP production could still lead to organ dysfunction and failure even if microcirculatory function is restored or maintained. Preserved mitochondrial function is clearly associated with better patient outcome. This review elucidates the role of the microcirculation and mitochondria during circulatory shock and patient management and will give a viewpoint on the advantages and disadvantages of tailoring resuscitation to microvascular or mitochondrial targets.

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“…If technical development will provide these techniques more readily available for clinical use at a reasonable price, this could be a major step forward to bring microcirculatory parameters into the first line of shock assessment and guidance of therapy (68, 69). However, the additional value of these technologies in addition to thorough clinical examination has been questioned (70).…”

Section: Technical Assessment Of Microcirculationmentioning

confidence: 99%

“…The signal detected by NIRS is not directly related to blood flow within a specific vascular bed, since it reflects StO 2 based on signals from arterioles, capillaries, and venules (36). NIRS signals may be misleading in case of cold extremities (70). The clinical usefulness might be increased by a standardized test with a short term ischemia (vascular occlusion test VOT) which can help to assess the microvascular reserve and oxygen consumption in the tenar muscle (55–57).…”

Section: Technical Assessment Of Microcirculationmentioning

confidence: 99%

Assessment of Regional Perfusion and Organ Function: Less and Non-invasive Techniques

et al. 2019

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Sufficient organ perfusion essentially depends on preserved macro- and micro-circulation. The last two decades brought substantial progress in the development of less and non-invasive monitoring of macro-hemodynamics. However, several recent studies suggest a frequent incoherence of macro- and micro-circulation. Therefore, this review reports on interactions of macro- and micro-circulation as well as on specific regional and micro-circulation. Regarding global micro-circulation the last two decades brought advances in a more systematic approach of clinical examination including capillary refill time, a graded assessment of mottling of the skin and accurate measurement of body surface temperatures. As a kind of link between macro- and microcirculation, a number of biochemical markers can easily be obtained. Among those are central-venous oxygen saturation (S cv O 2 ), plasma lactate and the difference between central-venous and arterial CO 2 (cv-a-pCO 2 -gap). These inexpensive markers have become part of clinical routine and guideline recommendations. While their potential to replace parameters of macro-circulation such as cardiac output (CO) is limited, they facilitate the interpretation of the adequacy of CO and other macro-circulatory markers. Furthermore, they give additional hints on micro-circulatory impairment. In addition, a number of more sophisticated technical approaches to quantify and visualize micro-circulation including video-microscopy, laser flowmetry, near-infrared spectroscopy (NIRS), and partial oxygen pressure measurement have been introduced within the last 20 years. These technologies have been extensively used for scientific purposes. Moreover, they have been successfully used for educational purposes and to visualize micro-circulatory disturbances during sepsis and other causes of shock. Despite several studies demonstrating the association of these techniques and parameters with outcome, their practical application still is limited. However, future improvements in automated and “online” diagnosis will help to make these technologies more applicable in clinical routine. This approach is promising with regard to several studies which demonstrated the potential to guide therapy in different types of shock. Finally several organs have specific patterns of circulation related to their special anatomy (liver) or their auto-regulatory capacities (brain, kidney). Therefore, this review also discusses specific issues of monitoring liver, brain, and kidney circulation and function.

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Could resuscitation be based on microcirculation data? No

Cited by 12 publications

References 17 publications

Optical coherence tomography angiography as a novel approach to contactless evaluation of sublingual microcirculation: A proof of principle study

Optical coherence tomography angiography as a novel approach to contactless evaluation of sublingual microcirculation: A proof of principle study

Microcirculation vs. Mitochondria—What to Target?

Assessment of Regional Perfusion and Organ Function: Less and Non-invasive Techniques

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