Microcirculation-guided resuscitation in sepsis: the next frontier?

Abstract

Microcirculatory dysfunction plays a key role in the pathogenesis of tissue dysoxia and organ failure in sepsis. Sublingual videomicroscopy techniques enable the real-time non-invasive assessment of microvascular blood flow. Alterations in sublingual microvascular perfusion were detected during sepsis and are associated with poor outcome. More importantly, sublingual videomicroscopy allowed to explore the effects of commonly applied resuscitative treatments in septic shock, such as fluids, vasopressors and inotropes, and showed that the optimization of macro-hemodynamic parameters may not be accompanied by an improvement in microvascular perfusion. This loss of “hemodynamic coherence,” i.e., the concordance between the response of the macrocirculation and the microcirculation, advocates for the integration of microvascular monitoring in the management of septic patients. Nonetheless, important barriers remain for a widespread use of sublingual videomicroscopy in the clinical practice. In this review, we discuss the actual limitations of this technique and future developments that may allow an easier and faster evaluation of the microcirculation at the bedside, and propose a role for sublingual microvascular monitoring in guiding and titrating resuscitative therapies in sepsis.

Potential of acetaminophen on the sublingual microcirculation and peripheral tissue perfusion of febrile septic patients: prospective observational study

“…“Resuscitating” the microcirculation is a target of therapy for those patients, but unfortunately few options are currently available to normalize microvascular flow [ 31 ]. Given the high heterogeneity of sepsis a personalized approach is needed and based on the results of this study we encourage further investigation about the effects of ACT on the microcirculation and tissue perfusion of septic patients.…”

“…Independently from cell-free Hb levels, a potential role of the vasculature as a target of the anti-inflammatory effects of ACT has been evaluated in the cerebral microcirculation, where it was demonstrated that ACT protects cultured brain endothelial cells from oxidative stress and oxidative-induced cell death and regulates/reduces cytokine and chemokines secretion from cultured brain [28][29][30][31].…”

Microcirculation and Mitochondria: The Critical Unit

“…Consequently, we integrated microcirculation and mitochondria into a concept called the "critical unit", which we propose is the key link in the occurrence and development of critical illness. On the basis of this understanding, the treatment of critical illness has gradually stepped onto the stage of microcirculation-guided resuscitation and even mitochondria-guided resuscitation; that is, we have arrived at the era of critical unit-guided treatment [3].…”