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Wollborn J, Hassenzahl LO, Reker D, Staehle HF, Omlor AM, Baar W, Kaufmann KB, Ulbrich F, Wunder C, Utzolino S, Buerkle H, Kalbhenn J, Heinrich S, Goebel U. Diagnosing capillary leak in critically ill patients: development of an innovative scoring instrument for non-invasive detection. Ann Intensive Care 2021; 11:175. [PMID: 34910264 PMCID: PMC8674404 DOI: 10.1186/s13613-021-00965-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 12/02/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The concomitant occurrence of the symptoms intravascular hypovolemia, peripheral edema and hemodynamic instability is typically named Capillary Leak Syndrome (CLS) and often occurs in surgical critical ill patients. However, neither a unitary definition nor standardized diagnostic criteria exist so far. We aimed to investigate common characteristics of this phenomenon with a subsequent scoring system, determining whether CLS contributes to mortality. METHODS We conducted this single-center, observational, multidisciplinary, prospective trial in two separately run surgical ICUs of a tertiary academic medical center. 200 surgical patients admitted to the ICU and 30 healthy volunteers were included. Patients were clinically diagnosed as CLS or No-CLS group (each N = 100) according to the grade of edema, intravascular hypovolemia, hemodynamic instability, and positive fluid balance by two independent attending physicians with > 10 years of experience in ICU. We performed daily measurements with non-invasive body impedance electrical analysis, ultrasound and analysis of serum biomarkers to generate objective diagnostic criteria. Receiver operating characteristics were used, while we developed machine learning models to increase diagnostic specifications for our scoring model. RESULTS The 30-day mortility was increased among CLS patients (12 vs. 1%, P = 0.002), while showing higher SOFA-scores. Extracellular water was increased in patients with CLS with higher echogenicity of subcutaneous tissue [29(24-31) vs. 19(16-21), P < 0.001]. Biomarkers showed characteristic alterations, especially with an increased angiopoietin-2 concentration in CLS [9.9(6.2-17.3) vs. 3.7(2.6-5.6)ng/mL, P < 0.001]. We developed a score using seven parameters (echogenicity, SOFA-score, angiopoietin-2, syndecan-1, ICAM-1, lactate and interleukin-6). A Random Forest prediction model boosted its diagnostic characteristics (AUC 0.963, P < 0.001), while a two-parameter decision tree model showed good specifications (AUC 0.865). CONCLUSIONS Diagnosis of CLS in critically ill patients is feasible by objective, non-invasive parameters using the CLS-Score. A simplified two-parameter diagnostic approach can enhance clinical utility. CLS contributes to mortality and should, therefore, classified as an independent entity. TRIAL REGISTRATION German Clinical Trials Registry (DRKS No. 00012713), Date of registration 10/05/2017, www.drks.de.
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Affiliation(s)
- Jakob Wollborn
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany. .,Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA. .,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.
| | - Lars O Hassenzahl
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Daniel Reker
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Hans Felix Staehle
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Anne Marie Omlor
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Wolfgang Baar
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Kai B Kaufmann
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Felix Ulbrich
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Christian Wunder
- Department of Anesthesiology and Critical Care, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Stefan Utzolino
- Department of General and Visceral Surgery, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Hartmut Buerkle
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Johannes Kalbhenn
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Sebastian Heinrich
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Ulrich Goebel
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.,Department of Anesthesiology and Critical Care, St. Franziskus-Hospital, Muenster, Germany
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Zhuravleva K, Goertz O, Wölkart G, Guillemot L, Petzelbauer P, Lehnhardt M, Schmidt K, Citi S, Schossleitner K. The tight junction protein cingulin regulates the vascular response to burn injury in a mouse model. Microvasc Res 2020; 132:104067. [PMID: 32877697 DOI: 10.1016/j.mvr.2020.104067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/25/2020] [Accepted: 08/27/2020] [Indexed: 02/04/2023]
Abstract
Edema formation due to the collapse of physiological barriers and the associated delayed healing process is still a central problem in the treatment of burn injuries. In healthy individuals, tight junctions form a barrier to fluid and small molecules. Cingulin is a cytoplasmic component of tight junctions and is involved in the regulation of the paracellular barrier. Endothelial specific cingulin knock-out mice provide new insight into the influence of tight junction proteins on edema formation and angiogenesis during wound healing. Knock-out mice lacking the head domain of cingulin in endothelial cells (CgnΔEC) were created by breeding Cgnfl/fl mice with Tie1-cre mice. Using a no-touch hot air jet a burn trauma was induced on the ear of the mouse. Over a period of 12 days microcirculatory parameters such as edema formation, angiogenesis and leukocyte-endothelial interactions were visualized using intravital fluorescence microscopy. At baseline, CgnΔEC mice surprisingly showed significantly less tracer extravasation compared to Cgnfl/fl littermates, whereas, after burn injury, edema was consistently higher in CgnΔEC mice. Non-perfused area after wounding was increased, but there was no difference in vessel diameters, contraction or dilation of arteries in CgnΔEC mice. Moreover, cingulin knock-out did not cause a difference in leukocyte adhesion after burn injury. In summary, cingulin limits non-perfused area after burn injury and maintains the paracellular barrier of blood vessels. Since edema formation with serious systemic effects is a central problem of burn wounds, understanding the importance of tight junction proteins might help to find new treatment strategies for burn wounds.
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Affiliation(s)
- Kristina Zhuravleva
- Department of Plastic and Hand Surgery, Burn Center, BG-University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany; Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Martin-Luther Hospital, Berlin, Germany
| | - Ole Goertz
- Department of Plastic and Hand Surgery, Burn Center, BG-University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany; Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Martin-Luther Hospital, Berlin, Germany
| | - Gerald Wölkart
- Department of Pharmacology and Toxicology, Institute of Pharmaceutical Sciences, Karl-Franzens-Universität Graz, Graz, Austria
| | - Laurent Guillemot
- Department of Cell Biology, Faculty of Sciences, and Institute of Genetics and Genomics of Geneva, University of Geneva, Switzerland
| | - Peter Petzelbauer
- Skin and Endothelium Research Division, Department of Dermatology, Medical University Vienna, Vienna, Austria
| | - Marcus Lehnhardt
- Department of Plastic and Hand Surgery, Burn Center, BG-University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Kurt Schmidt
- Department of Pharmacology and Toxicology, Institute of Pharmaceutical Sciences, Karl-Franzens-Universität Graz, Graz, Austria
| | - Sandra Citi
- Department of Cell Biology, Faculty of Sciences, and Institute of Genetics and Genomics of Geneva, University of Geneva, Switzerland
| | - Klaudia Schossleitner
- Skin and Endothelium Research Division, Department of Dermatology, Medical University Vienna, Vienna, Austria.
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Wollborn J, Schlegel N, Schick MA. [Phosphodiesterase 4 inhibition for treatment of endothelial barrier and microcirculation disorders in sepsis]. Anaesthesist 2018; 66:347-352. [PMID: 28429038 DOI: 10.1007/s00101-017-0305-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Sepsis is commonly associated with loss of microvascular endothelial barrier function (capillary leak) and dysfunctional microcirculation, which both promote organ failure. The development of a distinct therapy of impaired endothelial barrier function and disturbed microcirculation is highly relevant because both of these phenomena constitute crucial processes which critically influence the prognosis of patients. Numerous in vivo and in vitro trials over the past years have fostered a better understanding of the pathophysiology of capillary leak. Furthermore, promising data in animal models show that therapeutic modulation of endothelial barrier function and microcirculation can be achieved by stabilizing endothelial cAMP (cyclic adenosine monophosphate) levels followed by activation of Rho-GTPase Rac1, e. g. by phosphodiesterase 4 inhibitors. This review summarizes and discusses recent findings of cellular mechanisms and in vivo trials.
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Affiliation(s)
- J Wollborn
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Hugstetter Str. 55, 79106, Freiburg, Deutschland
| | - N Schlegel
- Klinik und Poliklinik für Allgemein-, Viszeral-, Gefäß- und Kinderchirurgie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - M A Schick
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Hugstetter Str. 55, 79106, Freiburg, Deutschland.
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