Evaluation of sublingual microcirculation in a paediatric intensive care unit: prospective observational study about its feasibility and utility

Abstract

BackgroundEvaluation of the microcirculation in critically ill patients is usually done by means of indirect parameters. The aim of our study was to evaluate the functional state of the microcirculation by direct visualization of sublingual microcirculation using Sidestream Dark Field Imaging, to determine the correlation between these findings and other parameters that are commonly used in the clinical practice and to assess the applicability of the systematic use of this technique in critically ill children.MethodsA prospective observational study was carried out in a Pediatric Intensive Care Unit (PICU) of a tertiary referral hospital. All patients admitted to the PICU during a three-month period were included in the study after obtaining the informed consent from the patient. Systematic evaluation of sublingual microcirculation was done in these patients (Total Vessel Density, Proportion of Perfused Vessels, Perfused Vessel Density, De Backer Score, Microvascular Flow Index, Heterogeneity Index) within the first day of admission (T1) and between the second and third day of admission (T2). Other clinical, hemodynamic, and biochemical parameters were measured and registered simultaneously. When the evaluation of the microcirculation was not feasible, the reason was registered. Descriptive analysis of our findings are expressed as means, medians, standard deviations and interquartile ranges. Mann–Whitney-Wilcoxon and Fisher tests were used to compare variables between patients with and without evaluation of the microcirculation. Pearson Correlation Coefficient (ρ) was used to evaluate the correlation between microcirculatory parameters and other clinical parameters.ResultsOne hundred fine patients were included during the study period. Evaluation of the microcirculation was feasible in 18 patients (17.1%). 95.2% of them were intubated. The main reason for not evaluating microcirculation was the presence of respiratory difficulty or the absence of collaboration (95.1% on T1 and 68.9% on T2). Evaluated patients had a higher prevalence of intubation and ECMO at admission (72.2% vs. 14.9% and 16.6% vs. 1.1%, respectively), and longer median duration of mechanical ventilation (0 vs. 6.5 days), vasoactive drugs (0 vs. 3.5 days) and length of stay (3 vs. 16.5 days) than non-evaluated patients. There was a moderate correlation between microcirculatory parameters and systolic arterial pressure, central venous pressure, serum lactate and other biochemical parameters used for motoring critically ill children.ConclusionsSystematic evaluation of microcirculation in critically ill children is not feasible in the unstable critically ill patient, but it is feasible in stable critically ill children. Microcirculatory parameters show a moderate correlation with other parameters that are usually monitored in critically ill children.Electronic supplementary materialThe online version of this article (doi:10.1186/s12887-017-0837-5) contains supplementary material, which is available to authorized users.

Assessing the Microcirculation With Handheld Vital Microscopy in Critically Ill Neonates and Children: Evolution of the Technique and Its Potential for Critical Care

“…Although its use is validated in children and neonates, the acquisition is complicated as children need to be sufficiently sedated or fully cooperative to attain good quality imaging (13, 35, 36). Gonzalez et al performed an observational study in the pediatric ICU, where sublingual microcirculatory monitoring was only possible in 17% of the admitted patients in the study period (37). These patients were sedated and/or more severely ill. As for microcirculatory measurements of the skin, these are performed in the first few weeks of life in both preterm and term neonates.…”

The Sublingual Microcirculation Throughout Neonatal and Pediatric Extracorporeal Membrane Oxygenation Treatment: Is It Altered by Systemic Extracorporeal Support?

“…These challenges are not unique to our study. Gonzalez et al showed that in a general pediatric ICU population, microcirculatory assessment was only possible in 17% of the patients (32). These were mostly sedated and stable critically ill children.…”

Recommendations for hemodynamic Monitoring for Critically Ill Children – Expert Consensus Statement issued by the Cardiovascular Dynamics Section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

“…No studies have de ned the normal values of microcirculation in children outside the neonatal period but do report that vascular density seems to decrease with age [72]. So far, published studies have not de ned target values of microcirculatory parameters in critically ill children [72][73][74][75][76][77]. At this point in time, the committee recommends its use only for research purposes.…”