Direct assessment of microcirculation in shock: a randomized-controlled multicenter study.

Humans Microcirculation Prospective Studies Shock, Septic / drug therapy Resuscitation / methods Intensive Care Units
Intensive care Intravital microscopy Microcirculation Shock Sidestream-dark field video microscope

Journal

Intensive care medicine
ISSN: 1432-1238
Titre abrégé: Intensive Care Med
Pays: United States
ID NLM: 7704851

Informations de publication

Date de publication:
06 2023
Historique:
received: 16 02 2023
accepted: 08 05 2023
medline: 26 6 2023
pubmed: 6 6 2023
entrez: 6 6 2023
Statut: ppublish

Résumé

Shock is a life-threatening condition characterized by substantial alterations in the microcirculation. This study tests the hypothesis that considering sublingual microcirculatory perfusion variables in the therapeutic management reduces 30-day mortality in patients admitted to the intensive care unit (ICU) with shock. This randomized, prospective clinical multicenter trial-recruited patients with an arterial lactate value above two mmol/L, requiring vasopressors despite adequate fluid resuscitation, regardless of the cause of shock. All patients received sequential sublingual measurements using a sidestream-dark field (SDF) video microscope at admission to the intensive care unit (± 4 h) and 24 (± 4) hours later that was performed blindly to the treatment team. Patients were randomized to usual routine or to integrating sublingual microcirculatory perfusion variables in the therapy plan. The primary endpoint was 30-day mortality, secondary endpoints were length of stay on the ICU and the hospital, and 6-months mortality. Overall, we included 141 patients with cardiogenic (n = 77), post cardiac surgery (n = 27), or septic shock (n = 22). 69 patients were randomized to the intervention and 72 to routine care. No serious adverse events (SAEs) occurred. In the interventional group, significantly more patients received an adjustment (increase or decrease) in vasoactive drugs or fluids (66.7% vs. 41.8%, p = 0.009) within the next hour. Microcirculatory values 24 h after admission and 30-day mortality did not differ [crude: 32 (47.1%) patients versus 25 (34.7%), relative risk (RR) 1.39 (0.91-1.97); Cox-regression: hazard ratio (HR) 1.54 (95% confidence interval (CI) 0.90-2.66, p = 0.118)]. Integrating sublingual microcirculatory perfusion variables in the therapy plan resulted in treatment changes that do not improve survival at all.

Identifiants

DOI: 10.1007/s00134-023-07098-5 PMID: 37278760 PMC: PMC10242221
pubmed: 37278760
doi: 10.1007/s00134-023-07098-5
pii: 10.1007/s00134-023-07098-5
pmc: PMC10242221
doi:

Banques de données

ClinicalTrials.gov
['NCT04173221']

Types de publication

Randomized Controlled Trial Multicenter Study Journal Article

Langues

eng

Sous-ensembles de citation

IM

Pagination

645-655

Commentaires et corrections

Type : ErratumIn

Informations de copyright

© 2023. The Author(s).

Références

Standl T et al (2018) The nomenclature, definition and distinction of types of shock. Dtsch Arztebl Int 115(45):757–768
pubmed: 30573009 pmcid: 6323133
Dilken O, Ergin B, Ince C (2020) Assessment of sublingual microcirculation in critically ill patients: consensus and debate. Ann Transl Med 8(12):793
pubmed: 32647718 pmcid: 7333125 doi: 10.21037/atm.2020.03.222
Guven G, Hilty MP, Ince C (2020) Microcirculation: physiology, pathophysiology, and clinical application. Blood Purif 49(1–2):143–150
pubmed: 31851980 doi: 10.1159/000503775
Jung C, Kelm M (2015) Evaluation of the microcirculation in critically ill patients. Clin Hemorheol Microcirc 61(2):213–224
pubmed: 26410873 doi: 10.3233/CH-151994
Arnold RC et al (2012) Discordance between microcirculatory alterations and arterial pressure in patients with hemodynamic instability. J Crit Care 27(5):531 e1-537
pubmed: 22591569 doi: 10.1016/j.jcrc.2012.02.007
Singer M et al (2016) The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA 315(8):801–810
pubmed: 26903338 pmcid: 4968574 doi: 10.1001/jama.2016.0287
Hernandez G et al (2019) Effect of a resuscitation strategy targeting peripheral perfusion status vs serum lactate levels on 28-day mortality among patients with septic shock: the andromeda-shock randomized clinical trial. JAMA 321(7):654–664
pubmed: 30772908 pmcid: 6439620 doi: 10.1001/jama.2019.0071
Ait-Oufella H et al (2011) Mottling score predicts survival in septic shock. Intensive Care Med 37(5):801–807
pubmed: 21373821 doi: 10.1007/s00134-011-2163-y
Bakker J et al (2022) Current practice and evolving concepts in septic shock resuscitation. Intensive Care Med 48(2):148–163
pubmed: 34910228 doi: 10.1007/s00134-021-06595-9
De Backer D et al (2002) Microvascular blood flow is altered in patients with sepsis. Am J Respir Crit Care Med 166(1):98–104
pubmed: 12091178 doi: 10.1164/rccm.200109-016OC
Spronk PE, Zandstra DF, Ince C (2004) Bench-to-bedside review: sepsis is a disease of the microcirculation. Crit Care 8(6):462–468
pubmed: 15566617 pmcid: 1065042 doi: 10.1186/cc2894
Massey MJ et al (2018) Microcirculatory perfusion disturbances in septic shock: results from the ProCESS trial. Crit Care 22(1):308
pubmed: 30458880 pmcid: 6245723 doi: 10.1186/s13054-018-2240-5
Ince C (2005) The microcirculation is the motor of sepsis. Crit Care 9(4):S13–S19
pubmed: 16168069 pmcid: 3226164 doi: 10.1186/cc3753
Jung C et al (2015) Intraaortic balloon counterpulsation and microcirculation in cardiogenic shock complicating myocardial infarction: an IABP-SHOCK II substudy. Clin Res Cardiol 104(8):679–687
pubmed: 25720332 doi: 10.1007/s00392-015-0833-4
Verdant CL et al (2009) Evaluation of sublingual and gut mucosal microcirculation in sepsis: a quantitative analysis. Crit Care Med 37(11):2875–2881
pubmed: 19770750 doi: 10.1097/CCM.0b013e3181b029c1
Qian J et al (2014) Post-resuscitation intestinal microcirculation: its relationship with sublingual microcirculation and the severity of post-resuscitation syndrome. Resuscitation 85(6):833–839
pubmed: 24594091 doi: 10.1016/j.resuscitation.2014.02.019
Bruno RR et al (2020) Evaluation of a shorter algorithm in an automated analysis of sublingual microcirculation. Clin Hemorheol Microcirc 76(2):287–297
pubmed: 32925005 doi: 10.3233/CH-209201
Bruno RR et al (2020) Sublingual microcirculation in prehospital critical care medicine: a proof-of-concept study. Microcirculation 27(5):e12614
pubmed: 32065682 doi: 10.1111/micc.12614
Massey MJ et al (2013) The microcirculation image quality score: development and preliminary evaluation of a proposed approach to grading quality of image acquisition for bedside videomicroscopy. J Crit Care 28(6):913–917
pubmed: 23972316 doi: 10.1016/j.jcrc.2013.06.015
De Backer D et al (2007) How to evaluate the microcirculation: report of a round table conference. Crit Care 11(5):R101
pubmed: 17845716 pmcid: 2556744 doi: 10.1186/cc6118
Vellinga NA et al (2015) International study on microcirculatory shock occurrence in acutely ill patients. Crit Care Med 43(1):48–56
pubmed: 25126880 doi: 10.1097/CCM.0000000000000553
Spanos A et al (2010) Early microvascular changes in sepsis and severe sepsis. Shock 33(4):387–391
pubmed: 19851124 doi: 10.1097/SHK.0b013e3181c6be04
Kanoore Edul VS et al (2015) The effects of arterial hypertension and age on the sublingual microcirculation of healthy volunteers and outpatients with cardiovascular risk factors. Microcirculation 22(6):485–492
pubmed: 26177979 doi: 10.1111/micc.12219
Donadello K et al (2011) Sublingual and muscular microcirculatory alterations after cardiac arrest: a pilot study. Resuscitation 82(6):690–695
pubmed: 21414710 doi: 10.1016/j.resuscitation.2011.02.018
Pranskunas A et al (2015) Effects of whole body heat stress on sublingual microcirculation in healthy humans. Eur J Appl Physiol 115(1):157–165
pubmed: 25256945 doi: 10.1007/s00421-014-2999-2
Favory R et al (2010) Can normal be more normal than normal? Crit Care Med 38(2):737–738
pubmed: 20083957 doi: 10.1097/CCM.0b013e3181c8fd30
Guidet B et al (2018) Withholding or withdrawing of life-sustaining therapy in older adults (≥ 80 years) admitted to the intensive care unit. Intensive Care Med 44(7):1027–1038
pubmed: 29774388 doi: 10.1007/s00134-018-5196-7
Jochberger S et al (2009) The vasopressin and copeptin response in patients with vasodilatory shock after cardiac surgery: a prospective, controlled study. Intensive Care Med 35(3):489–497
pubmed: 18825368 doi: 10.1007/s00134-008-1279-1
Egi M et al (2007) Selecting a vasopressor drug for vasoplegic shock after adult cardiac surgery: a systematic literature review. Ann Thorac Surg 83(2):715–723
pubmed: 17258030 doi: 10.1016/j.athoracsur.2006.08.041
Hajjar LA et al (2017) Vasopressin versus norepinephrine in patients with vasoplegic shock after cardiac surgery: the VANCS randomized controlled trial. Anesthesiology 126(1):85–93
pubmed: 27841822 doi: 10.1097/ALN.0000000000001434
Vallabhajosyula S et al (2019) Trends, predictors, and outcomes of temporary mechanical circulatory support for postcardiac surgery cardiogenic shock. Am J Cardiol 123(3):489–497
pubmed: 30473325 doi: 10.1016/j.amjcard.2018.10.029
O’Brien PC, Fleming TR (1979) A multiple testing procedure for clinical trials. Biometrics 35(3):549–556
pubmed: 497341 doi: 10.2307/2530245
Schuler S, Kieser M, Rauch G (2017) Choice of futility boundaries for group sequential designs with two endpoints. BMC Med Res Methodol 17(1):119
pubmed: 28789615 pmcid: 5549398 doi: 10.1186/s12874-017-0387-4
Vasey MW, Thayer JF (1987) The continuing problem of false positives in repeated measures ANOVA in psychophysiology: a multivariate solution. Psychophysiology 24(4):479–486
pubmed: 3615759 doi: 10.1111/j.1469-8986.1987.tb00324.x
Lakens D (2013) Calculating and reporting effect sizes to facilitate cumulative science: a practical primer for t-tests and ANOVAs. Front Psychol 4:863
pubmed: 24324449 pmcid: 3840331 doi: 10.3389/fpsyg.2013.00863
De Backer D et al (2004) Microvascular alterations in patients with acute severe heart failure and cardiogenic shock. Am Heart J 147(1):91–99
pubmed: 14691425 doi: 10.1016/j.ahj.2003.07.006
Sakr Y et al (2004) Persistent microcirculatory alterations are associated with organ failure and death in patients with septic shock. Crit Care Med 32(9):1825–1831
pubmed: 15343008 doi: 10.1097/01.CCM.0000138558.16257.3F
Bruno RR et al (2020) Sublingual microcirculation detects impaired perfusion in dehydrated older patients. Clin Hemorheol Microcirc 75(4):475–487
pubmed: 32417766 doi: 10.3233/CH-200859
Chommeloux J et al (2020) Microcirculation evolution in patients on venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock. Crit Care Med 48(1):e9–e17
pubmed: 31634235 doi: 10.1097/CCM.0000000000004072
Evans L et al (2021) Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 47(11):1181–1247
pubmed: 34599691 pmcid: 8486643 doi: 10.1007/s00134-021-06506-y
Gutierrez G, Williams JD (2009) The riddle of hyperlactatemia. Crit Care 13(4):176
pubmed: 19691816 pmcid: 2750179 doi: 10.1186/cc7982
Casserly B et al (2015) Lactate measurements in sepsis-induced tissue hypoperfusion: results from the surviving sepsis campaign database. Crit Care Med 43(3):567–573
pubmed: 25479113 doi: 10.1097/CCM.0000000000000742
Nichol A et al (2011) Dynamic lactate indices as predictors of outcome in critically ill patients. Crit Care 15(5):R242
pubmed: 22014216 pmcid: 3334793 doi: 10.1186/cc10497
Vincent JL et al (2016) The value of blood lactate kinetics in critically ill patients: a systematic review. Crit Care 20(1):257
pubmed: 27520452 pmcid: 4983759 doi: 10.1186/s13054-016-1403-5
Levy B (2006) Lactate and shock state: the metabolic view. Curr Opin Crit Care 12(4):315–321
pubmed: 16810041 doi: 10.1097/01.ccx.0000235208.77450.15
Ospina-Tascon G et al (2010) Effects of fluids on microvascular perfusion in patients with severe sepsis. Intensive Care Med 36(6):949–955
pubmed: 20221744 doi: 10.1007/s00134-010-1843-3
Hernandez G et al (2014) When to stop septic shock resuscitation: clues from a dynamic perfusion monitoring. Ann Intensive Care 4:30
pubmed: 25593746 pmcid: 4273696 doi: 10.1186/s13613-014-0030-z
Potter EK et al (2019) Manipulating the microcirculation in sepsis - the impact of vasoactive medications on microcirculatory blood flow: a systematic review. Shock 52(1):5–12
pubmed: 30102639 doi: 10.1097/SHK.0000000000001239
Dubin A et al (2009) Increasing arterial blood pressure with norepinephrine does not improve microcirculatory blood flow: a prospective study. Crit Care 13(3):R92
pubmed: 19534818 pmcid: 2717464 doi: 10.1186/cc7922
Segal SS (2005) Regulation of blood flow in the microcirculation. Microcirculation 12(1):33–45
pubmed: 15804972 doi: 10.1080/10739680590895028
Thooft A et al (2011) Effects of changes in arterial pressure on organ perfusion during septic shock. Crit Care 15(5):R222
pubmed: 21936903 pmcid: 3334768 doi: 10.1186/cc10462
Marik PE, Weinmann M (2019) Optimizing fluid therapy in shock. Curr Opin Crit Care 25(3):246–251
pubmed: 31022087 doi: 10.1097/MCC.0000000000000604
Scorcella C et al (2018) MicroDAIMON study: microcirculatory DAIly MONitoring in critically ill patients: a prospective observational study. Ann Intensive Care 8(1):64
pubmed: 29766322 pmcid: 5953911 doi: 10.1186/s13613-018-0411-9
De Backer D et al (2013) Microcirculatory alterations in patients with severe sepsis: impact of time of assessment and relationship with outcome. Crit Care Med 41(3):791–799
pubmed: 23318492 doi: 10.1097/CCM.0b013e3182742e8b
Boerma EC et al (2005) Quantifying bedside-derived imaging of microcirculatory abnormalities in septic patients: a prospective validation study. Crit Care 9(6):R601–R606
pubmed: 16280059 pmcid: 1414044 doi: 10.1186/cc3809
Akin S et al (2017) Functional evaluation of sublingual microcirculation indicates successful weaning from VA-ECMO in cardiogenic shock. Crit Care 21(1):265
pubmed: 29073930 pmcid: 5658964 doi: 10.1186/s13054-017-1855-2
Wijntjens GW et al (2020) Prognostic implications of microcirculatory perfusion versus macrocirculatory perfusion in cardiogenic shock: a CULPRIT-SHOCK substudy. Eur Heart J Acute Cardiovasc Care 9(2):108–119
pubmed: 31517505 doi: 10.1177/2048872619870035
Merdji H et al (2022) Performance of early capillary refill time measurement on outcomes in cardiogenic shock: an observational, prospective multicentric study. Am J Respir Crit Care Med 206(10):1230–1238
pubmed: 35849736 doi: 10.1164/rccm.202204-0687OC
Pranskunas A et al (2013) Microcirculatory blood flow as a tool to select ICU patients eligible for fluid therapy. Intensive Care Med 39(4):612–619
pubmed: 23263029 doi: 10.1007/s00134-012-2793-8
Naumann DN et al (2016) Real-time point of care microcirculatory assessment of shock: design, rationale and application of the point of care microcirculation (POEM) tool. Crit Care 20(1):310
pubmed: 27716373 pmcid: 5045597 doi: 10.1186/s13054-016-1492-1
Hubble SM et al (2009) Variability in sublingual microvessel density and flow measurements in healthy volunteers. Microcirculation 16(2):183–191
pubmed: 19206003 doi: 10.1080/10739680802461935
Damiani E et al (2017) Impact of microcirculatory video quality on the evaluation of sublingual microcirculation in critically ill patients. J Clin Monit Comput 31(5):981–988
pubmed: 27539312 doi: 10.1007/s10877-016-9924-7
Flaatten H et al (2022) The importance of revealing data on limitation of life sustaining therapy in critical ill elderly Covid-19 patients. J Crit Care 67:147–148
pubmed: 34781100 doi: 10.1016/j.jcrc.2021.10.024
Ospina-Tascon GA, Buchele GL, Vincent JL (2008) Multicenter, randomized, controlled trials evaluating mortality in intensive care: doomed to fail? Crit Care Med 36(4):1311–1322
pubmed: 18379260 doi: 10.1097/CCM.0b013e318168ea3e

Auteurs

Raphael Romano Bruno (RR)

Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany.

Jakob Wollborn (J)

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA.

Karl Fengler (K)

Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany.

Moritz Flick (M)

Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Christian Wunder (C)

Department of Anesthesiology and Intensive Care Medicine, Robert-Bosch-Krankenhaus, Stuttgart, Germany.

Sebastian Allgäuer (S)

Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany.

Holger Thiele (H)

Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany.

Mara Schemmelmann (M)

Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany.

Johanna Hornemann (J)

Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany.

Helene Mathilde Emilie Moecke (HME)

Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany.

Filiz Demirtas (F)

Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany.

Lina Palici (L)

Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany.

Marcus Franz (M)

Department of Internal Medicine I, University Hospital Jena, Jena, Germany.

Bernd Saugel (B)

Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Eduardo Kattan (E)

Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.

Daniel De Backer (D)

Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium.

Jan Bakker (J)

NYU Langone Health and Columbia University Irving Medical Center, New York, USA.
Erasmus MC University Medical Center, Rotterdam, The Netherlands.

Glenn Hernandez (G)

Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.

Malte Kelm (M)

Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany.
CARID (Cardiovascular Research Institute Düsseldorf), Düsseldorf, Germany.

Christian Jung (C)

Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany. christian.jung@med.uni-duesseldorf.de.
ORCID: 0000-0001-8325-250X

Articles similaires

[Redispensing of expensive oral anticancer medicines: a practical application].

Lisanne N van Merendonk, Kübra Akgöl, Bastiaan Nuijen
1.00
Humans Antineoplastic Agents Administration, Oral Drug Costs Counterfeit Drugs

Smoking Cessation and Incident Cardiovascular Disease.

Jun Hwan Cho, Seung Yong Shin, Hoseob Kim et al.
1.00
Humans Male Smoking Cessation Cardiovascular Diseases Female

Evaluation of Low-Value Services Across Major Medicare Advantage Insurers and Traditional Medicare.

Ciara Duggan, Adam L Beckman, Ishani Ganguli et al.
1.00
Humans United States Aged Cross-Sectional Studies Medicare Part C

Effectiveness of Virtual Yoga for Chronic Low Back Pain: A Randomized Clinical Trial.

Hallie Tankha, Devyn Gaskins, Amanda Shallcross et al.
1.00
Humans Yoga Low Back Pain Female Male

Classifications MeSH

questionsmedicales.fr › Eucaryotes › Animaux › Chordés › Vertébrés › Mammifères › Eutheria › Primates › Haplorhini › Catarrhini › Hominidae › Humains › Direct assessment of microcirculation in...
questionsmedicales.fr › Phénomènes physiologiques respiratoires et circulatoires › Phénomènes physiologiques cardiovasculaires › Circulation sanguine › Microcirculation › Direct assessment of microcirculation in...
questionsmedicales.fr › Environnement et santé publique › Santé publique › Méthodes épidémiologiques › Caractéristiques des études épidémiologiques › Études épidémiologiques › Études de cohortes › Études prospectives › Direct assessment of microcirculation in...
questionsmedicales.fr › États, signes et symptômes pathologiques › Processus pathologiques › Choc › Syndrome de réponse inflammatoire généralisée › Choc septique › Direct assessment of microcirculation in...
questionsmedicales.fr › Thérapeutique › Traitement d'urgence › Réanimation › Direct assessment of microcirculation in...
questionsmedicales.fr › Établissements, main d'oeuvre et services de soins de santé › Établissements de santé › Unités hospitalières › Unités de soins intensifs › Direct assessment of microcirculation in...