Microcirculatory perfusion disturbances in septic shock: results from the ProCESS trial

Abstract

BackgroundWe sought to determine the effects of alternative resuscitation strategies on microcirculatory perfusion and examine any association between microcirculatory perfusion and mortality in sepsis.MethodsThis was a prospective, formally designed substudy of participants in the Protocolized Care in Early Septic Shock (ProCESS) trial. We recruited from six sites with the equipment and training to perform these study procedures. All subjects were adults with septic shock, and each was assigned to alternative resuscitation strategies. The two main analyses assessed (1) the impact of resuscitation strategies on microcirculatory perfusion parameters and (2) the association of microcirculatory perfusion with 60-day in-hospital mortality. We measured sublingual microcirculatory perfusion using sidestream dark field in vivo video microscopy at the completion of the 6-h ProCESS resuscitation protocol and then again at 24 and 72 h.ResultsWe enrolled 207 subjects (demographics were similar to the overall ProCESS cohort) and observed 40 (19.3%) deaths. There were no differences in average perfusion characteristics between treatment arms. Analyzing the relationship between microcirculatory perfusion and mortality, we found an association between vascular density parameters and mortality. Total vascular density (beta = 0.006, p < 0.003), perfused vascular density (beta = 0.005, p < 0.04), and De Backer score (beta = 0.009, p < 0.01) were higher overall in survivors in a generalized estimating equation model, and this association was significant at the 72-h time point (p < 0.05 for each parameter).ConclusionsMicrocirculatory perfusion did not differ between three early septic shock treatment arms. We found an association between microcirculatory perfusion parameters of vascular density at 72 h and mortality.Trial registrationClinicalTrials.gov, NCT00510835. Registered on August 2, 2007.Electronic supplementary materialThe online version of this article (10.1186/s13054-018-2240-5) contains supplementary material, which is available to authorized users.

Association of sublingual microcirculation parameters and endothelial glycocalyx dimensions in resuscitated sepsis

“…Consistent with this notion, De Backer et al reported that microcirculatory alterations are less severe in the later phase of sepsis than in the earlier phase [28]. Microcirculatory and PBR derangements in our resuscitated sepsis cohort (only 10% in shock) were comparable to values in ICU patients with moderate disease severity reported by other groups [19,21,27,49]. Data regarding the regeneration of the eGC in both human and murine sepsis are missing.…”

“…Analysis of the sublingual microcirculation by sidestream dark field (SDF) imaging and incident dark field (IDF) illumination imaging has already been recognized as an interesting tool to improve risk stratification and prognostication and possibly to guide individual therapy in the future [22][23][24][25][26][27]. For example, De Backer et al [28] found that the proportion of perfused small sublingual vessels outperformed global hemodynamic variables in the prediction of ICU mortality in patients with severe sepsis.…”

Microcirculatory perfusion disturbances following cardiopulmonary bypass: a systematic review

“…However, ample literature exists on the correlation between microcirculatory perfusion disturbances and outcome in other settings such as sepsis and hemorrhagic shock [37,38]. It was shown that reduced microvascular density at 72 h was independently associated with mortality in septic shock patients [43], whereas early improvement of microcirculatory perfusion parameters was seen in survivors [37]. Interestingly, also early goal-directed therapy may improve microcirculatory perfusion parameters irrespective of global hemodynamics and was found to be associated with reduced multi-organ failure [44].…”

The compelling arguments for the need of microvascular investigation in COVID-19 critical patients

“…The clinical significance of sublingual microcirculation in representing the microcirculatory in other organ microcirculatory districts has been demonstrated in several studies [43][44][45][46]. Moreover, the HVM has proved how sublingual microcirculation is much more sensitive and specific than macro haemodynamic variables, in predicting patient morbidity and mortality [47][48][49][50][51][52][53]. The relevance of HVM has been highlighted in an international consensus paper on the measurement of sublingual microcirculation in critically ill patients by the European Society for Intensive Care Medicine [54].…”