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Jávor P, Donka T, Horváth T, Sándor L, Török L, Szabó A, Hartmann P. Impairment of Mesenteric Perfusion as a Marker of Major Bleeding in Trauma Patients. J Clin Med 2023; 12:jcm12103571. [PMID: 37240677 DOI: 10.3390/jcm12103571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 05/28/2023] Open
Abstract
The majority of potentially preventable mortality in trauma patients is related to bleeding; therefore, early recognition and effective treatment of hemorrhagic shock impose a cardinal challenge for trauma teams worldwide. The reduction in mesenteric perfusion (MP) is among the first compensatory responses to blood loss; however, there is no adequate tool for splanchnic hemodynamic monitoring in emergency patient care. In this narrative review, (i) methods based on flowmetry, CT imaging, video microscopy (VM), measurement of laboratory markers, spectroscopy, and tissue capnometry were critically analyzed with respect to their accessibility, and applicability, sensitivity, and specificity. (ii) Then, we demonstrated that derangement of MP is a promising diagnostic indicator of blood loss. (iii) Finally, we discussed a new diagnostic method for the evaluation of hemorrhage based on exhaled methane (CH4) measurement. Conclusions: Monitoring the MP is a feasible option for the evaluation of blood loss. There are a wide range of experimentally used methodologies; however, due to their practical limitations, only a fraction of them could be integrated into routine emergency trauma care. According to our comprehensive review, breath analysis, including exhaled CH4 measurement, would provide the possibility for continuous, non-invasive monitoring of blood loss.
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Affiliation(s)
- Péter Jávor
- Department of Traumatology, University of Szeged, H-6725 Szeged, Hungary
| | - Tibor Donka
- Department of Traumatology, University of Szeged, H-6725 Szeged, Hungary
| | - Tamara Horváth
- Institute of Surgical Research, University of Szeged, H-6724 Szeged, Hungary
| | - Lilla Sándor
- Department of Traumatology, University of Szeged, H-6725 Szeged, Hungary
| | - László Török
- Department of Traumatology, University of Szeged, H-6725 Szeged, Hungary
- Department of Sports Medicine, University of Szeged, H-6725 Szeged, Hungary
| | - Andrea Szabó
- Institute of Surgical Research, University of Szeged, H-6724 Szeged, Hungary
| | - Petra Hartmann
- Department of Traumatology, University of Szeged, H-6725 Szeged, Hungary
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Shin MH, Hsu HS, Chien JY, Huang CK, Kuo LC, Shun TM, Lin YT, Yeh YC. Association between microcirculation in spontaneous breathing trial and extubation success. Microvasc Res 2023; 148:104552. [PMID: 37207721 DOI: 10.1016/j.mvr.2023.104552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/03/2023] [Accepted: 05/16/2023] [Indexed: 05/21/2023]
Abstract
PURPOSE This study assessed the association between changes in sublingual microcirculation after a spontaneous breathing trial (SBT) and successful extubation. MATERIALS AND METHODS Sublingual microcirculation was assessed using an incident dark-field video microscope before and after each SBT and before extubation. Microcirculatory parameters before the SBT, at the end of the SBT, and before extubation were compared between the successful and failed extubation groups. RESULTS Forty-seven patients were enrolled and analysed in this study (34 patients in the successful extubation group and 13 patients in the failed extubation group). At the end of the SBT, the weaning parameters did not differ between the two groups. However, the total small vessel density (21.2 [20.4-23.7] versus 24.9 [22.6-26.5] mm/mm2), perfused small vessel density (20.6 [18.5-21.8] versus 23.1 [20.9-25] mm/mm2), proportion of perfused small vessels (91 [87-96] versus 95 [93-98] %), and microvascular flow index (2.8 [2.7-2.9] versus 2.9 [2.9-3]) were significantly lower in the failed extubation group than in the successful extubation group. The weaning and microcirculatory parameters did not differ significantly between the two groups before the SBT. CONCLUSIONS More patients are required to investigate the difference between baseline microcirculation before a successful SBT and the change in microcirculation at the end of the SBT between the successful and failed extubation groups. Better sublingual microcirculatory parameters at the end of SBT and before extubation are associated with successful extubation.
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Affiliation(s)
- Ming-Hann Shin
- Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Beitou Dist., Taipei 112304, Taiwan; Division of Respiratory Therapy, Department of Integrated Diagnostic and Therapeutics, National Taiwan University Hospital, No. 7, Chung Shan S. Rd., Taipei 10002, Taiwan.
| | - Han-Shui Hsu
- Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Beitou Dist., Taipei 112304, Taiwan; Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei 11217, Taiwan.
| | - Jung-Yien Chien
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung Shan S. Rd., Taipei, Taiwan.
| | - Chun-Kai Huang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung Shan S. Rd., Taipei, Taiwan
| | - Lu-Cheng Kuo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung Shan S. Rd., Taipei, Taiwan.
| | - Tien-Mei Shun
- Division of Respiratory Therapy, Department of Integrated Diagnostic and Therapeutics, National Taiwan University Hospital, No. 7, Chung Shan S. Rd., Taipei 10002, Taiwan
| | - Yi-Tsung Lin
- Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Beitou Dist., Taipei 112304, Taiwan; Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei 11217, Taiwan.
| | - Yu-Chang Yeh
- Department of Anesthesiology, National Taiwan University Hospital, No. 7, Chung Shan S. Rd., Taipei 10002, Taiwan.
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den Os MM, van den Brom CE, van Leeuwen ALI, Dekker NAM. Microcirculatory perfusion disturbances following cardiopulmonary bypass: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:218. [PMID: 32404120 PMCID: PMC7222340 DOI: 10.1186/s13054-020-02948-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 05/05/2020] [Indexed: 12/11/2022]
Abstract
Background Microcirculatory perfusion disturbances are associated with increased morbidity and mortality in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Technological advancements made it possible to monitor sublingual microcirculatory perfusion over time. The goal of this review is to provide an overview of the course of alterations in sublingual microcirculatory perfusion following CPB. The secondary goal is to identify which parameter of sublingual microcirculatory perfusion is most profoundly affected by CPB. Methods PubMed and Embase databases were systematically searched according to PRISMA guidelines and as registered in PROSPERO. Studies that reported sublingual microcirculatory perfusion measurements before and after onset of CPB in adult patients undergoing cardiac surgery were included. The primary outcome was sublingual microcirculatory perfusion, represented by functional capillary density (FCD), perfused vessel density (PVD), total vessel density (TVD), proportion of perfused vessels (PPV), and microvascular flow index (MFI). Results The search identified 277 studies, of which 19 fulfilled all eligibility criteria. Initiation of CPB had a profound effect on FCD, PVD, or PPV. Seventeen studies (89%) reported one or more of these parameters, and in 11 of those studies (65%), there was a significant decrease in these parameters during cardiac surgery; the other 6 studies (35%) reported no effect. In 29% of the studies, FCD, PVD, or PPV normalized by the end of cardiac surgery, and in 24% percent of the studies, this effect lasted at least 24 h. There was no clear effect of CPB on TVD and a mixed effect on MFI. Conclusion CPB during cardiac surgery impaired sublingual microcirculatory perfusion as reflected by reduced FCD, PVD, and PPV. Four studies reported this effect at least 24 h after surgery. Further research is warranted to conclude on the duration of CPB-induced microcirculatory perfusion disturbances and the relationship with clinical outcome. Trial registration PROSPERO, CRD42019127798
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Affiliation(s)
- Matthijs M den Os
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Charissa E van den Brom
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Department of Physiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Anoek L I van Leeuwen
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Department of Physiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Cardiothoracic surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Nicole A M Dekker
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands. .,Department of Physiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
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Abstract
Tissue hypoperfusion is a major cause of morbidity and mortality in critically ill patients but cannot always be detected by measuring standard whole-body hemodynamic and oxygen-related parameters (e.g., blood pressure, cardiac output, and central venous oxygen saturation). Preclinical and clinical studies have demonstrated that low-flow states are consistently associated with large increases in venous and tissue PCO2. Monitoring regional PCO2 with gastric tonometry (PgCO2) is known to have independent prognostic value for predicting postoperative complications and mortality. The PgCO2 gap might also be of value as a treatment target (endpoint) in critically ill patients. However, this tool has several limitations and has not yet been developed commercially, thus restricting its use. Regional capnography with sublingual and transcutaneous sensors might be an alternative noninvasive option for evaluating the adequacy of tissue perfusion in critically ill patients. However, further studies are needed to determine whether or not this monitoring technique is of value-particularly as an endpoint for guiding resuscitation. Bladder PCO2, has only been evaluated in animal studies, and so remains to be validated in patients.
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Affiliation(s)
- Stéphane Bar
- Anesthesiology and Critical Care Department, Amiens University Hospital, Amiens, France
| | - Marc-Olivier Fischer
- Normandie Univ, UNICAEN, CHU de Caen Normandie, Service d'Anesthésie Réanimation, Caen, France
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Lucas A, Williams AT, Cabrales P. Prediction of Recovery From Severe Hemorrhagic Shock Using Logistic Regression. IEEE JOURNAL OF TRANSLATIONAL ENGINEERING IN HEALTH AND MEDICINE 2019; 7:1900509. [PMID: 31367491 PMCID: PMC6661015 DOI: 10.1109/jtehm.2019.2924011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 06/13/2019] [Accepted: 06/16/2019] [Indexed: 11/09/2022]
Abstract
This paper implements logistic regression models (LRMs) and feature selection for creating a predictive model for recovery form hemorrhagic shock (HS) with resuscitation using blood in the multiple experimental rat animal protocols. A total of 61 animals were studied across multiple HS experiments, which encompassed two different HS protocols and two resuscitation protocols using blood stored for short periods using five different techniques. Twenty-seven different systemic hemodynamics, cardiac function, and blood gas parameters were measured in each experiment, of which feature selection deemed only 25% of the them as relevant. The reduced feature set was used to train a final logistic regression model. A final test set accuracy is 84% compared to 74% for a baseline classifier using only MAP and HR measurements. Receiver operating characteristics (ROC) curve analysis and Cohens kappa statistics were also used as measures of performance, with the final reduced model outperforming the model, including all parameters. Our results suggest that LRMs trained with a combination of systemic hemodynamics, cardiac function, and blood gas parameters measured at multiple timepoints during HS can successfully classify HS recovery groups. Our results show the predictive ability of traditional and novel hemodynamic and cardiac function features and their combinations, many of which had not previously been taken into consideration, for monitoring HS. Furthermore, we have devised an effective methodology for feature selection and shown ways in which the performance of such predictive models should be assessed in future studies.
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Affiliation(s)
- Alfredo Lucas
- Department of BioengineeringUniversity of California at San DiegoLa JollaCA92092USA
| | | | - Pedro Cabrales
- Department of BioengineeringUniversity of California at San DiegoLa JollaCA92092USA
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Tafner PFDA, Chen FK, Rabello R, Corrêa TD, Chaves RCDF, Serpa A. Recent advances in bedside microcirculation assessment in critically ill patients. Rev Bras Ter Intensiva 2018; 29:238-247. [PMID: 28977264 PMCID: PMC5496759 DOI: 10.5935/0103-507x.20170033] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 09/18/2016] [Indexed: 12/22/2022] Open
Abstract
Parameters related to macrocirculation, such as the mean arterial pressure, central venous pressure, cardiac output, mixed venous saturation and central oxygen saturation, are commonly used in the hemodynamic assessment of critically ill patients. However, several studies have shown that there is a dissociation between these parameters and the state of microcirculation in this group of patients. Techniques that allow direct viewing of the microcirculation are not completely disseminated, nor are they incorporated into the clinical management of patients in shock. The numerous techniques developed for microcirculation assessment include clinical assessment (e.g., peripheral perfusion index and temperature gradient), laser Doppler flowmetry, tissue oxygen assessment electrodes, videomicroscopy (orthogonal polarization spectral imaging, sidestream dark field imaging or incident dark field illumination) and near infrared spectroscopy. In the near future, the monitoring and optimization of tissue perfusion by direct viewing and microcirculation assessment may become a goal to be achieved in the hemodynamic resuscitation of critically ill patients.
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Affiliation(s)
| | | | - Roberto Rabello
- Unidade de Terapia Intensiva Adulto, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Thiago Domingos Corrêa
- Unidade de Terapia Intensiva Adulto, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | | | - Ary Serpa
- Unidade de Terapia Intensiva Adulto, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
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7
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Abstract
Background Fluid resuscitation is not only used to prevent acute kidney injury (AKI) but fluid management is also a cornerstone of treatment for patients with established AKI and renal failure. Ultrafiltration removes volume initially from the intravascular compartment inducing a relative degree of hypovolemia. Normal reflex mechanisms attempt to sustain blood pressure constant despite marked changes in blood volume and cardiac output. Thus, compensated shock with a normal blood pressure is a major cause of AKI or exacerbations of AKI during ultrafiltration. Methods We undertook a systematic review of the literature using MEDLINE, Google Scholar and PubMed searches. We determined a list of key questions and convened a 2-day consensus conference to develop summary statements via a series of alternating breakout and plenary sessions. In these sessions, we identified supporting evidence and generated clinical practice recommendations and/or directions for future research. Results We defined three aspects of fluid monitoring: i) normal and pathophysiological cardiovascular mechanisms; ii) measures of volume responsiveness and impending cardiovascular collapse during volume removal, and; iii) measured indices of each using non-invasive and minimally invasive continuous and intermittent monitoring techniques. The evidence documents that AKI can occur in the setting of normotensive hypovolemia and that under-resuscitation represents a major cause of both AKI and mortality ion critically ill patients. Traditional measures of intravascular volume and ventricular filling do not predict volume responsiveness whereas dynamic functional hemodynamic markers, such as pulse pressure or stroke volume variation during positive pressure breathing or mean flow changes with passive leg raising are highly predictive of volume responsiveness. Numerous commercially-available devices exist that can acquire these signals. Conclusions Prospective clinical trials using functional hemodynamic markers in the diagnosis and management of AKI and volume status during ultrafiltration need to be performed. More traditional measure of preload be abandoned as marked of volume responsiveness though still useful to assess overall volume status.
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Affiliation(s)
- M.R. Pinsky
- Bioengineering, Cardiovascular Diseases and Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA - USA
| | - P. Brophy
- Division of Pediatric Nephrology, Hypertension, Dialysis and Transplantation, University of Iowa, Children's Hospital, Iowa City, Iowa - USA
| | - J. Padilla
- Universidad de Iberoamerica, San Jose - Costa Rica
| | - E. Paganini
- Division of Nephrology, Cleveland Clinic Foundation, Cleveland, OH - USA
| | - N. Pannu
- Division of Nephrology and CCM, University of Alberta, Edmonton, Alberta - Canada
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Hopster K, Neudeck S, Wittenberg-Voges L, Kästner SB. The relationship between intestinal and oral mucosa microcirculation in anaesthetized horses. Vet Anaesth Analg 2017; 45:78-81. [PMID: 29223560 DOI: 10.1016/j.vaa.2017.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 06/22/2017] [Accepted: 07/03/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To compare alteration in intestinal blood flow in anaesthetized horses with changes in oral mucosa blood flow. STUDY DESIGN Prospective, randomized clinical study. ANIMALS Eight warmblood horses. METHODS After induction with guaifenesin and ketamine, anaesthesia was maintained with isoflurane at 1.5 vol% in oxygen. The tissue blood flow was measured using laser Doppler flowmetry at the jejunum, colon, rectal mucosa, oesophageal mucosa and the oral mucosa. After three baseline measurements, blood flow was first increased by dobutamine infusion and thereafter decreased by increasing isoflurane concentration and all measurements repeated twice. anova was used for comparing the measured parameters to baseline and correlation between the different measurement localizations was examined using Pearson correlation (p < 0.05). RESULTS Microperfusion at all measurement sites increased significantly during dobutamine infusion and decreased significantly during high isoflurane concentration. There was a significant correlation between flow at the oral mucosa and flow at the jejunum (r2 = 0.77, p = 0.002), colon (r2 = 0.76, p < 0.001), rectal mucosa (r2 = 0.88, p < 0.001) and oesophageal mucosa (r2 = 0.83, p <0.001). CONCLUSIONS AND CLINICAL RELEVANCE Oral mucosa blood flow can be used in isoflurane anaesthetized horses to reflect changes of intestinal microcirculation.
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Affiliation(s)
- Klaus Hopster
- Clinic for Horses, University of Veterinary Medicine Hannover, Foundation, Hannover, Germany.
| | - Stephan Neudeck
- Clinic for Horses, University of Veterinary Medicine Hannover, Foundation, Hannover, Germany
| | - Liza Wittenberg-Voges
- Clinic for Horses, University of Veterinary Medicine Hannover, Foundation, Hannover, Germany
| | - Sabine Br Kästner
- Clinic for Horses, University of Veterinary Medicine Hannover, Foundation, Hannover, Germany
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Palágyi P, Barna S, Csábi P, Lorencz P, László I, Molnár Z. Recent Advances of Mucosal Capnometry and the Perspectives of Gastrointestinal Monitoring in the Critically Ill. A Pilot Study. J Crit Care Med (Targu Mures) 2016; 2:30-37. [PMID: 29967834 DOI: 10.1515/jccm-2016-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 12/05/2015] [Indexed: 11/15/2022] Open
Abstract
Mucosal capnometry involves the monitoring of partial pressure of carbon dioxide (PCO2) in mucous membranes. Different techniques have been developed and applied for this purpose, including sublingual or buccal sensors, or special gastrointestinal tonometric devices. The primary use of these procedures is to detect compensated shock in critically ill patients or patients undergoing major surgery. Compensatory mechanisms, in the early phases of shock, lead to the redistribution of blood flow towards the vital organs, within ostensibly typical macro-haemodynamic parameters. Unfortunately, this may result in microcirculatory disturbances, which can play a pivotal role in the development of organ failure. In such circumstances mucosal capnometry monitoring, at different gastrointestinal sites, can provide a sensitive method for the early diagnosis of shock. The special PCO2 monitoring methods assess the severity of ischaemia and help to define the necessary therapeutic interventions and testing of these monitors have justified their prognostic value. Gastrointestinal mucosal capnometry monitoring also helps in determining the severity of ischaemia and is a useful adjunctive in the diagnosis of occlusive splanchnic arterial diseases. The supplementary functional information increases the diagnostic accuracy of radiological techniques, assists in creating individualized treatment plans, and helps in follow-up the results of interventions. The results of a pilot study focusing on the interrelation of splanchnic perfusion and gastrointestinal function are given and discussed concerning recent advances in mucosal capnometry.
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Affiliation(s)
- Péter Palágyi
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Sándor Barna
- Department of Anaesthesiology and Intensive Therapy, Bács-Kiskun County Hospital, Teaching Hospital of the University of Szeged, Szeged, Hungary
| | - Péter Csábi
- Department of Anaesthesia and Intensive Care, Wexham Park Hospital, Wexham Park, United Kingdom
| | - Péter Lorencz
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Ildikó László
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Zsolt Molnár
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
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Lee YLL, Simmons JD, Gillespie MN, Alvarez DF, Gonzalez RP, Brevard SB, Frotan MA, Schneider AM, Richards WO. Evaluation of Microvascular Perfusion and Resuscitation after Severe Injury. Am Surg 2015. [DOI: 10.1177/000313481508101231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Achieving adequate perfusion is a key goal of treatment in severe trauma; however, tissue perfusion has classically been measured by indirect means. Direct visualization of capillary flow has been applied in sepsis, but application of this technology to the trauma population has been limited. The purpose of this investigation was to compare the efficacy of standard indirect measures of perfusion to direct imaging of the sublingual microcirculatory flow during trauma resuscitation. Patients with injury severity scores >15 were serially examined using a handheld sidestream dark-field video microscope. In addition, measurements were also made from healthy volunteers. The De Backer score, a morphometric capillary density score, and total vessel density (TVD) as cumulative vessel area within the image, were calculated using Automated Vascular Analysis (AVA3.0) software. These indices were compared against clinical and laboratory parameters of organ function and systemic metabolic status as well as mortality. Twenty severely injured patients had lower TVD (X = 14.6 ± 0.22 vs 17.66 ± 0.51) and De Backer scores (X = 9.62 ± 0.16 vs 11.55 ± 0.37) compared with healthy controls. These scores best correlated with serum lactate (TVD R2 = 0.525, De Backer R2 = 0.576, P < 0.05). Mean arterial pressure, heart rate, oxygen saturation, pH, bicarbonate, base deficit, hematocrit, and coagulation parameters correlated poorly with both TVD and De Backer score. Direct measurement of sublingual microvascular perfusion is technically feasible in trauma patients, and seems to provide real-time assessment of micro-circulatory perfusion. This study suggests that in severe trauma, many indirect measurements of perfusion do not correlate with microvascular perfusion. However, visualized perfusion deficiencies do reflect a shift toward anaerobic metabolism.
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Affiliation(s)
- Yann-Leei L. Lee
- Departments of Surgery, University of South Alabama, Mobile, Alabama
- Departments of Pharmacology, University of South Alabama, Mobile, Alabama
| | - Jon D. Simmons
- Departments of Surgery, University of South Alabama, Mobile, Alabama
| | - Mark N. Gillespie
- Departments of Pharmacology, University of South Alabama, Mobile, Alabama
| | - Diego F. Alvarez
- Departments of Pharmacology, University of South Alabama, Mobile, Alabama
| | | | - Sidney B. Brevard
- Departments of Surgery, University of South Alabama, Mobile, Alabama
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Monitoring Microcirculatory Blood Flow with a New Sublingual Tonometer in a Porcine Model of Hemorrhagic Shock. BIOMED RESEARCH INTERNATIONAL 2015; 2015:847152. [PMID: 26504837 PMCID: PMC4609384 DOI: 10.1155/2015/847152] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 03/23/2015] [Accepted: 03/24/2015] [Indexed: 12/27/2022]
Abstract
Tissue capnometry may be suitable for the indirect evaluation of regional hypoperfusion. We tested the performance of a new sublingual capillary tonometer in experimental hemorrhage. Thirty-six anesthetized, ventilated mini pigs were divided into sham-operated (n = 9) and shock groups (n = 27). Hemorrhagic shock was induced by reducing mean arterial pressure (MAP) to 40 mmHg for 60 min, after which fluid resuscitation started aiming to increase MAP to 75% of the baseline value (60-180 min). Sublingual carbon-dioxide partial pressure was measured by tonometry, using a specially coiled silicone rubber tube. Mucosal red blood cell velocity (RBCV) and capillary perfusion rate (CPR) were assessed by orthogonal polarization spectral (OPS) imaging. In the 60 min shock phase a significant drop in cardiac index was accompanied by reduction in sublingual RBCV and CPR and significant increase in the sublingual mucosal-to-arterial PCO2 gap (PSLCO2 gap), which significantly improved during the 120 min resuscitation phase. There was significant correlation between PSLCO2 gap and sublingual RBCV (r = -0.65, p < 0.0001), CPR (r = -0.64, p < 0.0001), central venous oxygen saturation (r = -0.50, p < 0.0001), and central venous-to-arterial PCO2 difference (r = 0.62, p < 0.0001). This new sublingual tonometer may be an appropriate tool for the indirect evaluation of circulatory changes in shock.
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12
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A Newly Developed Sublingual Tonometric Method for the Evaluation of Tissue Perfusion and Its Validation In Vitro and in Healthy Persons In Vivo and the Results of the Measurements in COPD Patients. Crit Care Res Pract 2015; 2014:534130. [PMID: 25580290 PMCID: PMC4280804 DOI: 10.1155/2014/534130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Revised: 10/24/2014] [Accepted: 11/27/2014] [Indexed: 11/17/2022] Open
Abstract
Introduction. Since its first publication in the medical literature, an extremely large number of references have demonstrated that the tonometric measurement of tissue perfusion is a reliable indicator of the actual condition of critically ill patients. Later a new method was developed by the introduction of sublingual tonometry for the determination of tissue perfusion. In comparison with gastric tonometry, the new method was simpler and could even be used in awake patients. Unfortunately, at present, because of severe failures of manufacturing, the device is withdrawn from commerce. Materials and Methods. In this study, we present a new method using a newly developed tool for the PslCO2 measurement in sublingual tonometry as well as the data for its validation in vitro and in vivo and the results of 25 volunteers and 54 COPD patients belonging to different GOLD groups at their hospitalization due to the acute exacerbation of the disease but already in a stable condition at the time of the examination. Results and Conclusion. The results of the performed examinations showed that the method is suitable for monitoring the actual condition of the patients by mucosal perfusion tonometry in the sublingual region.
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13
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Abstract
The primary end point when treating acute shock is to restore blood circulation, mainly by reaching macrocirculatory parameters. However, even if global haemodynamic goals can be achieved, microcirculatory perfusion may remain impaired, leading to cellular hypoxia and organ damage. Interestingly, few methods are currently available to measure the adequacy of organ blood flow and tissue oxygenation. The rise in tissue partial pressure of carbon dioxide (CO2) has been observed when tissue perfusion is decreased. In this regard, tissue partial pressure of CO2 has been proposed as an early and reliable marker of tissue hypoxia even if the mechanisms of tissue partial pressure in CO2 rise during hypoperfusion remain unclear. Several technologies allow the estimation of CO2 content from different body sites: vascular, tissular (in hollow organs, mucosal or cutaneous), and airway. These tools remain poorly evaluated, and some are used but are not widely used in clinical practice. The present review clarifies the physiology of increasing tissue CO2 during hypoperfusion and underlines the specificities of the different technologies that allow bedside estimation of tissue CO2 content.
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Yeh YC, Wang MJ, Chao A, Ko WJ, Chan WS, Fan SZ, Tsai JC, Sun WZ. Correlation between early sublingual small vessel density and late blood lactate level in critically ill surgical patients. J Surg Res 2012; 180:317-21. [PMID: 22658494 DOI: 10.1016/j.jss.2012.05.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 04/16/2012] [Accepted: 05/02/2012] [Indexed: 01/18/2023]
Abstract
BACKGROUND Surgical stress may cause excessive inflammation and lead to microcirculatory dysfunction. The hypothesis of this study was that early microcirculatory dysfunction may result in anaerobic glycolysis and lead to elevated blood lactate levels in patients admitted to surgical intensive care units. METHODS This prospective observational study enrolled adult patients admitted to surgical intensive care units after general surgery or thoracic surgery. We measured blood lactate levels before the operation and at 1 h and 24 h after the operation. We obtained images of sublingual microcirculation using a sidestream dark field video microscope and analyzed them employing automated analysis software. RESULTS A total of 31 patients completed the study. Perioperative total and perfused small vessel densities were lower in patients with a blood lactate level ≥3 mmol/L. We observed a significant correlation between the total small vessel density at 1 h and the blood lactate level at 24 h (r = -0.573; P = 0.001). In addition, we saw a significant correlation between the perfused small vessel density at 1 h and the blood lactate level at 24 h (r = -0.476; P = 0.008). CONCLUSIONS Early total and perfused small vessel density may be used as an early predictor or therapeutic goal for critically ill surgical patients in further studies.
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Affiliation(s)
- Yu-Chang Yeh
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
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Holley A, Lukin W, Paratz J, Hawkins T, Boots R, Lipman J. Review article: Part two: Goal-directed resuscitation--which goals? Perfusion targets. Emerg Med Australas 2012; 24:127-35. [PMID: 22487661 DOI: 10.1111/j.1742-6723.2011.01515.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Haemodynamic targets, such as cardiac output, mean arterial blood pressure and central venous oxygen saturations, remain crude predictors of tissue perfusion and oxygen supply at a cellular level. Shocked patients may appear adequately resuscitated based on normalization of global vital signs, yet they are still experiencing occult hypoperfusion. If targeted resuscitation is employed, appropriate use of end-points is critical. In this review, we consider the value of directing resuscitation at the microcirculation or cellular level. Current technologies available include sublingual capnometry, video microscopy of the microcirculation and near-infrared spectroscopy providing a measure of tissue oxygenation, whereas base deficit and lactate potentially provide a surrogate measure of the adequacy of global perfusion. The methodology and evidence for these technologies guiding resuscitation are considered in this narrative review.
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Affiliation(s)
- Anthony Holley
- Departments of Intensive Care Medicine Emergency Medicine, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD 4029, Australia.
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Abstract
BACKGROUND For decades we have been testing blood either ex vivo or else placing monitors directly in the bloodstream to "see" what might be going on in tissues. In the last 20 yrs, conceptual and practical advances in interstitial monitoring have begun to challenge traditional approaches. In this review we explore how interstitial monitoring might be used as a platform for future diagnostics and therapy in critical illness. RESULTS From a diagnostic perspective, interstitial analysis has been instructive about the pathophysiology of critical illness. Valuable insights have been gained into the pathophysiology of critical illness. To this end, examples from the areas of interstitial oxygenation and acid base, endocrine pathophysiology, and head injury monitoring have been used. From a therapeutic perspective, the main focus has been on antibiotic therapy and an improved understanding of pharmacokinetics and pharmacodynamics in critical illness. CONCLUSIONS Monitoring of the interstitium is feasible and can be achieved through minimally invasive techniques. It has improved the understanding of the pathophysiology of critical illness, holds potential in the diagnosis and management of sepsis, may allow early prediction of organ deterioration, and finally offers the possibility of reduction of blood testing and minimizing blood loss. While all of these hold promise, randomized trials will need to be conducted based on interstitial end points rather than plasma end points. This will pave the way for a more rational approach to the therapy of critically ill patients.
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Abstract
The microcirculation plays an essential role in health and disease. Microvascular perfusion can be assessed directly using laser Doppler flowmetry and various imaging techniques or indirectly using regional capnometry and measurement of indicators of mismatch between oxygen delivery and oxygen consumption or indices of disturbed cellular oxygen utilization. Assessment of microvascular oxygen availability implies measurement of oxygen pressure or measurement of hemoglobin oxygen saturation. Microvascular function is assessed using other methods, including venous plethysmography. In this paper, I review current knowledge concerning assessment of the microcirculation with special emphasis on methods that could be used at the bedside.
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Affiliation(s)
- Yasser Sakr
- Department of Anesthesiology and Intensive Care, Friedrich Schiller University Hospital, Erlanger Allee 101, Jena 07743, Germany.
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Vallée F, Mateo J, Dubreuil G, Poussant T, Tachon G, Ouanounou I, Payen D. Cutaneous ear lobe Pco₂ at 37°C to evaluate microperfusion in patients with septic shock. Chest 2010; 138:1062-70. [PMID: 20472858 DOI: 10.1378/chest.09-2690] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Tissue hypercarbia is related to hypoperfusion and microcirculatory disturbances in patients with septic shock. Transcutaneous Pco₂ devices using a heated sensor to arterialize the tissue have been used as an alternative method for estimation of Paco₂. This study investigates whether a cutaneous sensor attached to an ear lobe and regulated to 37°C could be used to measure cutaneous Pco₂ (Pcco₂) and evaluate microperfusion in patients with septic shock. METHODS Fifteen stable patients in an ICU were studied as a control group. Forty-six patients with septic shock who were ventilated were enrolled as the study group. The difference of the gradients between Pcco₂ and Paco₂ (Pc-aco₂) and between Pcco₂ and end-tidal Pco₂(Pc-etco₂) were evaluated for 36 h. Variations of the Pc-aco₂ and Pc-etco₂ during fluid challenge were compared with microcirculatory skin blood flow (mBFskin) assessed by laser Doppler flowmetry. RESULTS The baseline levels for Pc-aco₂ and Pc-etco₂ were significantly higher in the patients with septic shock than in the control group (14.8 [12.6] vs 6 [2.7] mm Hg and 25 [16.3] vs 9 [3.8] mm Hg, P < .0001, respectively). During the following 36 h, the Pc-aco₂ and Pc-etco₂ for the surviving patients with septic shock decreased significantly compared with the nonsurvivors (P < .01). The evolution of macrohemodynamic parameters showed no differences between survivors and nonsurvivors. At hour 24, a Pc-aco₂ > 16 mm Hg and a Pc-etco₂ > 26 mm Hg were related to poor outcome. Pc-aco₂ and Pc-etco₂ variations during fluid challenge were inversely correlated with changes in mBFskin (r² = 0.7). CONCLUSIONS Ear lobe cutaneous Pco₂ at 37°C represents a noninvasive technique to assess tissue Pco₂ measurement. Pc-aco₂ and Pc-etco₂ were related to outcome and provide continuous information on microperfusion in patients with septic shock.
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Affiliation(s)
- Fabrice Vallée
- Département d'Anesthésie- Réanimation-SMUR, Hôpital Lariboisière, 75010, Paris, France.
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Characterization of buccal microvascular response in patients with septic shock. Eur J Anaesthesiol 2010; 27:388-94. [DOI: 10.1097/eja.0b013e3283349db3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Pinsky MR, Payen D. Probing the limits of regional tissue oxygenation measures. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13 Suppl 5:S1. [PMID: 19951381 PMCID: PMC2786103 DOI: 10.1186/cc7999] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Michael R Pinsky
- Critical Care Medicine, Bioengineering, Cardiovascular Disease and Anesthesiology, 606 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, USA
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McManus JG, Ryan KL, Morton MJ, Rickards CA, Cooke WH, Convertino VA. Limitations of End-Tidal CO2as an Early Indicator of Central Hypovolemia in Humans. PREHOSP EMERG CARE 2009; 12:199-205. [DOI: 10.1080/10903120801907182] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Abstract
We have recently demonstrated that measurement of buccal mucosal PCO2 (PBUCO2) is a reliable alternative to sublingual mucosal PCO2 for measuring the severity of hemorrhagic shock. We hypothesized that measurement of PBUCO2 would serve as a continuous and a more sensitive and specific measurement for predicting survival during hemorrhagic shock than conventional measurements and thereby better guide initial management. Four groups of five pentobarbital anesthetized Sprague-Dawley rats were randomly assigned to be bled over 30 min in amounts estimated to be 25%, 30%, 35%, or 40% of total blood volume. With an optical PCO2 sensor applied noninvasively to the mucosa of the left inner cheek, PBUCO2 was continuously measured together with arterial pressure, end-tidal PCO2, and intermittent measurement of cardiac output, arterial blood lactate, and base deficit. Surviving animals had free access to water and food but no other treatment during the 72-h interval after recovery from anesthesia. After an estimated 40% blood loss, all animals died within 1 h. In the remaining animals, arterial pressure, end-tidal carbon dioxide, cardiac index, blood lactate, and base deficit each failed to discriminate among animals with 35%, 30%, and 25% acute blood losses. This contrasted with PBUCO2, which discriminated between the magnitude of massive blood loss and untreated survival. Buccal mucosal PCO2 was predictive of outcome after rapid bleeding when compared with arterial pressure, end-tidal carbon dioxide, cardiac index, arterial blood lactate, and base deficit. This measurement is therefore likely to serve as a useful guide for the immediate management of hemorrhagic shock.
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Abstract
OBJECTIVE Epinephrine has been the primary drug for cardiopulmonary resuscitation (CPR) for more than a century. The therapeutic rationale was to restore threshold levels of myocardial and cerebral blood flows by its alpha1 (alpha1) and alpha2 (alpha2)-adrenergic agonist vasopressor actions. On the basis of coincidental observations on changes in microvascular flow in the cerebral cortex, we hypothesized that epinephrine selectively decreases microvascular flow. DESIGN Randomized prospective animal study. SETTING University-affiliated research laboratory. SUBJECTS Domestic pigs. INTERVENTIONS Four groups of five male domestic pigs weighing 40 +/- 3 kg were investigated. After induction of anesthesia, endotracheal intubation was followed by mechanical ventilation. A frontoparietal bilateral craniotomy was created. Ventricular fibrillation was induced and untreated for 3 minutes before the start of precordial compression, mechanical ventilation, and attempted defibrillation. Animals were randomized to receive central venous injections during CPR of 1) placebo, 2) epinephrine, 3) epinephrine in which both alpha1- and beta (beta)-adrenergic effects were blocked by previous administration of prazosin and propranolol, and 4) epinephrine in which both alpha2- and beta-adrenergic effects were blocked by previous administration of yohimbine and propranolol. MEASUREMENTS AND MAIN RESULTS Cerebral cortical microcirculatory blood flow (MBF) was measured with orthogonal polarization spectral imaging. Cerebral cortical carbon dioxide and oxygen tensions (Pbco2 and Pbo2) were concurrently measured using miniature tissue optical sensors. Each animal was resuscitated. No differences in the number of electrical shocks for defibrillation or in the duration of CPR preceding return of spontaneous circulation were observed. Yet when epinephrine induced increases in arterial pressure, it significantly decreased Pbo2 tension and increased Pbco2 tension. Epinephrine therefore significantly decreased MBF and increased indicators of cerebral ischemia. Reduced MBF and magnified brain tissue ischemia during and after cardiopulmonary resuscitation were traced to the alpha1-adrenergic agonist action of epinephrine. When the alpha2 effects of epinephrine were blocked, reduced MBF and tissue ischemia persisted. No differences in cardiac output, end tidal Pco2, arterial Po2 and Pco2, and brain temperature were observed before inducing cardiac arrest and following return of spontaneous circulation. CONCLUSIONS In this model, epinephrine through its alpha1-agonist action had adverse effects on cerebral microvascular blood flow such as to increase the severity of cerebral ischemia during CPR.
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Ristagno G, Tang W, Weil MH. Reply to Letter: Cerebral cortical microvascular flow during and following cardiopulmonary resuscitation after short duration of cardiac arrest. Resuscitation 2008. [DOI: 10.1016/j.resuscitation.2008.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
PURPOSE OF REVIEW To assess the recent literature on effective use of information received from hemodynamic monitoring. RECENT FINDINGS Dynamic hemodynamic measures are more effective in assessing cardiovascular status than static measures. In this review, we will focus on the application of hemodynamic monitoring to evaluate the effect of therapy. SUMMARY A systematic approach to an effective resuscitation effort can be incorporated into a protocolized cardiovascular management algorithm, which, in turn, can improve patient-centered outcomes and the cost of healthcare systems, by faster and more effective response in order to diagnose and treat hemodynamically unstable patients both inside and outside of intensive care units.
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Affiliation(s)
- Mehrnaz Hadian
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA
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Trzeciak S, Cinel I, Phillip Dellinger R, Shapiro NI, Arnold RC, Parrillo JE, Hollenberg SM. Resuscitating the microcirculation in sepsis: the central role of nitric oxide, emerging concepts for novel therapies, and challenges for clinical trials. Acad Emerg Med 2008; 15:399-413. [PMID: 18439194 DOI: 10.1111/j.1553-2712.2008.00109.x] [Citation(s) in RCA: 142] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Microcirculatory dysfunction is a critical element of the pathogenesis of severe sepsis and septic shock. In this Bench-to-Bedside review, we present: 1) the central role of the microcirculation in the pathophysiology of sepsis; 2) new translational research techniques of in vivo video microscopy for assessment of microcirculatory flow in human subjects; 3) clinical investigations that reported associations between microcirculatory dysfunction and outcome in septic patients; 4) the potential role of novel agents to "rescue" the microcirculation in sepsis; 5) current challenges facing this emerging field of clinical investigation; and 6) a framework for the design of future clinical trials aimed to determine the impact of novel agents on microcirculatory flow and organ failure in patients with sepsis. We specifically focus this review on the central role and vital importance of the nitric oxide (NO) molecule in maintaining microcirculatory homeostasis and patency, especially when the microcirculation sustains an insult (as with sepsis). We also present the scientific rationale for clinical trials of exogenous NO administration to treat microcirculatory dysfunction and augment microcirculatory blood flow in early sepsis therapy.
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Affiliation(s)
- Stephen Trzeciak
- Department of Emergency Medicine, Division of Critical Care Medicine, University of Medicine and Dentistry of New Jersey (UMDNJ)-Robert Wood Johnson Medical School at Camden, Cooper University Hospital, Camden, NJ, USA.
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Abstract
OBJECTIVE To test the hypothesis that persistent villi hypoperfusion explains intramucosal acidosis after endotoxemic shock resuscitation. DESIGN Controlled experimental study. SETTING University-based research laboratory. SUBJECTS A total of 14 anesthetized, mechanically ventilated sheep. INTERVENTIONS Sheep were randomly assigned to endotoxin (n = 7) or control groups (n = 7). The endotoxin group received 5 microg/kg endotoxin, followed by 4 microg x kg(-1) x hr(-1) for 150 mins. After 60 mins of shock, hydroxyethylstarch resuscitation was given to normalize oxygen transport for an additional 90 mins. MEASUREMENTS AND MAIN RESULTS Endotoxin infusion decreased mean arterial blood pressure, cardiac output, and superior mesenteric artery blood flow (96 +/- 10 vs. 51 +/- 20 mm Hg, 145 +/- 30 vs. 90 +/- 30 mL x min(-1) x kg(-1), and 643 +/- 203 vs. 317 +/- 93 mL x min(-1) x kg(-1), respectively; p < .05 vs. basal), whereas it increased intramucosal-arterial PCO2 (deltaPCO2) and arterial lactate (3 +/- 3 vs. 14 +/- 8 mm Hg, and 1.5 +/- 0.5 vs. 3.7 +/- 1.3 mmol/L; p < .05). Sublingual, and serosal and mucosal intestinal microvascular flow indexes, and the percentage of perfused ileal villi were reduced (3.0 +/- 0.1 vs. 2.3 +/- 0.4, 3.2 +/- 0.2 vs. 2.4 +/- 0.6, 3.0 +/- 0.0 vs. 2.0 +/- 0.2, and 98% +/- 3% vs. 76% +/- 10%; p < .05). Resuscitation normalized mean arterial blood pressure (92 +/- 13 mm Hg), cardiac output (165 +/- 32 mL x min(-1) x kg(-1)), superior mesenteric artery blood flow (683 +/- 192 mL x min(-1) x kg(-1)), and sublingual and serosal intestinal microvascular flow indexes (2.8 +/- 0.5 and 3.5 +/- 0.7). Nevertheless, deltaPCO2, lactate, mucosal intestinal microvascular flow indexes, and percentage of perfused ileal villi remained altered (10 +/- 6 mm Hg, 3.7 +/- 0.9 mmol/L, 2.3 +/- 0.4, and 78% +/- 11%; p < .05). CONCLUSIONS In this model of endotoxemia, fluid resuscitation corrected both serosal intestinal and sublingual microcirculation but was unable to restore intestinal mucosal perfusion. Intramucosal acidosis might be due to persistent villi hypoperfusion.
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Abstract
Hemodynamic monitoring, a cornerstone in the management of the critically ill patient, is used to identify cardiovascular insufficiency, its probable cause, and response to therapy. Still it is difficult to document the efficacy of monitoring because no device improves outcome unless coupled to a treatment that improves outcome. Several clinical trials have consistently documented that preoptimization for high-risk surgery patients treated in the operating room and early (< 12 h) goal-directed resuscitation in septic patients treated in the emergency department reduce morbidity, mortality, and resource use (costs) when the end points of resuscitation were focused on surrogate measures of adequacy of global oxygen delivery (Do2). The closer the resuscitation is to the insult, the greater the benefit. When resuscitation was started after ICU admission in high-risk surgical patients, reduced length of stay was also seen. The focus of these monitoring protocols is to establish a mean arterial pressure > 65 mm Hg and then to increase Do2 to 600 mL/min/m2 within the first few minutes to hours of presentation. To accomplish these goals, hemodynamic monitoring focuses more on measures of cardiac output and mixed venous oxygen saturation to access adequacy of resuscitation efforts than on filling pressures. Although these protocols reduce mortality and morbidity is selected high-risk patient groups, the widespread use of monitoring-driven treatment protocols has not yet happened, presumably because all studies have been single-center trials using a single, proprietary blood flow-monitoring device. Multicenter trials are needed of early goal-directed therapies for all patients presenting in shock of various etiologies and when the protocol and not the monitoring device is the primary variable.
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Affiliation(s)
- Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
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Ristagno G, Tang W, Sun S, Weil MH. Cerebral cortical microvascular flow during and following cardiopulmonary resuscitation after short duration of cardiac arrest. Resuscitation 2008; 77:229-34. [PMID: 18280632 DOI: 10.1016/j.resuscitation.2007.12.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2007] [Revised: 11/27/2007] [Accepted: 12/10/2007] [Indexed: 11/28/2022]
Abstract
AIM To examine changes in cerebral cortical macro- and microcirculation and their relationship to the severity of brain ischaemia during and following resuscitation from a short duration of cardiac arrest. METHODS Bilateral cranial windows were created in eight domestic pigs weighing 41+/-1 kg, exposing the frontoparietal cortex for orthogonal polarization spectral imaging together with estimation of cortical-tissue partial pressure of carbon dioxide, a quantitator of the severity of cerebral ischaemia. After 3 min of untreated ventricular fibrillation, cardiopulmonary resuscitation was begun and continued for 4 min before defibrillation. Aortic pressure, end-tidal and cortical-tissue partial pressure of carbon dioxide, and cortical microcirculatory blood flow in vessels of less and more than 20 microm in diameter were continuously measured. RESULTS Cerebral microcirculatory blood flow progressively decreased over the 3-min interval that followed onset of ventricular fibrillation. Chest compression restored cortical microvascular flow to approximately 40% of the pre-arrest value. Following return of spontaneous circulation, microvascular flow velocity was restored to baseline values over 3 min. Reversal of cerebral ischaemia with normalisation of cerebral cortical-tissue partial pressure of carbon dioxide occurred over 7 min after resuscitation. Cortical microcirculatory blood flow in microvessels less than 20 microm was highly correlated with flow in vessels more than 20 microm together with mean aortic pressure and end-tidal partial pressure of carbon dioxide. CONCLUSION Cerebral cortical microcirculatory flow ceased only 3 min after onset of cardiac arrest. Flow was promptly restored to 40% of its pre-arrest value after start of chest compression. After resuscitation, both macro- and microcirculatory flows were fully restored over 3 min, but cerebral ischaemia reversed more slowly.
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Affiliation(s)
- Giuseppe Ristagno
- Weil Institute of Critical Care Medicine, Rancho Mirage, CA 92270, USA
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Using Mathematical Models to Improve the Utility of Quantitative ICU Data. Intensive Care Med 2007. [DOI: 10.1007/978-0-387-49518-7_43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ristagno G, Sun S, Tang W, Castillo C, Weil MH. Effects of epinephrine and vasopressin on cerebral microcirculatory flows during and after cardiopulmonary resuscitation. Crit Care Med 2007; 35:2145-9. [PMID: 17855828 DOI: 10.1097/01.ccm.0000280427.76175.d2] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Both epinephrine and vasopressin increase aortic and carotid arterial pressure when administered during cardiopulmonary resuscitation. However, we recently demonstrated that epinephrine reduces cerebral cortical microcirculatory blood flow. Accordingly, we compared the effects of nonadrenergic vasopressin with those of epinephrine on cerebral cortical microvascular flow together with cortical tissue Po2 and Pco2 as indicators of cortical tissue ischemia. DESIGN Randomized, prospective animal study. SETTING University-affiliated research laboratory. SUBJECTS Domestic pigs. MEASUREMENTS AND MAIN RESULTS The tracheae of ten domestic male pigs, weighing 40 +/- 2 kg, were noninvasively intubated, and the animals were mechanically ventilated. A frontoparietal bilateral craniotomy was created. Microcirculatory blood flow was quantitated with orthogonal polarization spectral imaging. Blood flow velocity in pial and cortical penetrating vessels measuring <20 microm was graded from 0 (no flow) to 3 (normal). Cerebral cortical tissue carbon dioxide and oxygen tensions (Pbco2 and Pbo2) were measured concurrently using miniature optical sensors. Ventricular fibrillation, induced with an alternating current delivered to the right ventricular endocardium, was untreated for 3 mins. Animals were then randomized to receive central venous injections of equipressor doses of epinephrine (30 microg/kg) or vasopressin (0.4 units/kg) at 1 min after the start of cardiopulmonary resuscitation. After 4 mins of cardiopulmonary resuscitation, defibrillation was attempted. Spontaneous circulation was restored in each animal. However, postresuscitation microvascular flows and Pbo2 were greater and Pbco2 less after vasopressin when compared with epinephrine. We observed that a significantly greater number of cortical microvessels were perfused after vasopressin. CONCLUSIONS Cortical microcirculatory blood flow was markedly reduced after epinephrine, resulting in a greater severity of brain ischemia after the restoration of spontaneous circulation in contrast to the more benign effects of vasopressin.
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Ristagno G, Tang W, Sun S, Weil MH. Role of buccal PCO2 in the management of fluid resuscitation during hemorrhagic shock. Crit Care Med 2007; 34:S442-6. [PMID: 17114975 DOI: 10.1097/01.ccm.0000247722.24781.d0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Arterial pressure is a widely used measurement for estimating the severity of hemorrhagic shock and to guide its management. However, this capability is reduced when very low arterial pressure values cannot be reliably measured by noninvasive methods. Moreover, hypoperfusion may be masked by compensatory hemodynamic changes, and therefore, in the presence of near normal blood pressure, tissue hypoperfusion may progress undetected. Accordingly, hypercarbia is a general phenomenon of perfusion failure, which occurs in coincidence of the onset of hypotension and is promptly reversed with restoration of normal blood flows. Increases in buccal mucosa PCO2 are highly correlated with increases in gastric wall and sublingual mucosa PCO2 and decreases in tissue blood flows during hemorrhagic shock. In both clinical and experimental settings, tissue PCO2 measured in the oral mucosa proved to be a practical and reliable measurement for the diagnosis of circulatory failure states and an indicator of its severity. In contrast to intraarterial pressure, buccal PCO2 discriminated between short- and long-term survival after large-volume blood loss. Buccal PCO2 measurement therefore emerges as a useful predictor for survival and outcome and a useful guide to manage fluid resuscitation during hemorrhagic shock.
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Affiliation(s)
- Giuseppe Ristagno
- Weil Institute of Critical Care Medicine, Rancho Mirage, California, USA
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Sakr Y, Chierego M, Piagnerelli M, Verdant C, Dubois MJ, Koch M, Creteur J, Gullo A, Vincent JL, De Backer D. Microvascular response to red blood cell transfusion in patients with severe sepsis. Crit Care Med 2007; 35:1639-44. [PMID: 17522571 DOI: 10.1097/01.ccm.0000269936.73788.32] [Citation(s) in RCA: 171] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Microvascular alterations may play a role in the development of multiple organ failure in severe sepsis. The effects of red blood cell transfusions on microvascular perfusion are not well defined. We investigated the effects of red blood cell transfusion on sublingual microvascular perfusion in patients with sepsis. DESIGN Prospective, observational study. SETTING A 31-bed, medical-surgical intensive care unit of a university hospital. PATIENTS Thirty-five patients with severe sepsis requiring red blood cell transfusions. INTERVENTIONS Transfusion of one to two units of leukocyte-reduced red blood cells. MEASUREMENTS AND MAIN RESULTS The sublingual microcirculation was assessed with an Orthogonal Polarization Spectral device before and 1 hr after red blood cell transfusion. Red blood cell transfusions increased hemoglobin concentration from 7.1 (25th-75th percentile, 6.7-7.6) to 8.1 (7.5-8.6) g/dL (p < .01), mean arterial pressure from 75 (69-89) to 82 (75-90) mm Hg (p < .01), and oxygen delivery from 349 (278-392) to 391 (273-473) mL/min.M (p < .001). Microvascular perfusion was not significantly altered by transfusion, but there was considerable interindividual variation. The change in capillary perfusion after transfusion correlated with baseline capillary perfusion (Spearman-rho = -.49; p = .003). Capillary perfusion was significantly lower at baseline in patients who increased their capillary perfusion by >8% compared with those who did not (57 [52-64] vs. 75 [70-79]; p < .01), while hemodynamic and global oxygen transport variables were similar in the two groups. Red blood cell storage time had no influence on the microvascular response to red blood cell transfusion. CONCLUSIONS The sublingual microcirculation is globally unaltered by red blood cell transfusion in septic patients; however, it can improve in patients with altered capillary perfusion at baseline.
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Affiliation(s)
- Yasser Sakr
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Brussels, Belgium
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Ward KR, Barbee RW, Reynolds PS, Torres Filho IP, Tiba MH, Torres L, Pittman RN, James T. Oxygenation monitoring of tissue vasculature by resonance Raman spectroscopy. Anal Chem 2007; 79:1514-8. [PMID: 17297949 PMCID: PMC2515598 DOI: 10.1021/ac061072x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Resonance Raman spectroscopy offers a mechanism for the noninvasive measurement of in vivo and in situ hemoglobin oxygen saturation (HbO(2)Sat) in living tissue. Clinically informative signals can be provided by resonance enhancement with deep violet excitation. It is notable that fluorescence does not significantly degrade the quality of the signals. During the controlled hemorrhage and resuscitation of rats, signal intensity ratios of oxy- vs. deoxyhemoglobin from sublingual mucosa correlated with co-oximetry values of blood withdrawn from a central venous catheter. The spectroscopic application described here has potential as a noninvasive method for the diagnosis of clinical shock and guidance of its therapy.
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Affiliation(s)
- Kevin R. Ward
- Dept of Emergency Medicine, Virginia Commonwealth University and the Virginia Commonwealth University Reanimation Engineering Shock Center (VCURES); Richmond, VA 23298 USA
- Dept of Physiology, Virginia Commonwealth University and the Virginia Commonwealth University Reanimation Engineering Shock Center (VCURES); Richmond, VA 23298 USA
| | - R. Wayne Barbee
- Dept of Emergency Medicine, Virginia Commonwealth University and the Virginia Commonwealth University Reanimation Engineering Shock Center (VCURES); Richmond, VA 23298 USA
- Dept of Physiology, Virginia Commonwealth University and the Virginia Commonwealth University Reanimation Engineering Shock Center (VCURES); Richmond, VA 23298 USA
| | - Penny S. Reynolds
- Dept of Emergency Medicine, Virginia Commonwealth University and the Virginia Commonwealth University Reanimation Engineering Shock Center (VCURES); Richmond, VA 23298 USA
| | - Ivo P. Torres Filho
- Dept of Anesthesiology, Virginia Commonwealth University and the Virginia Commonwealth University Reanimation Engineering Shock Center (VCURES); Richmond, VA 23298 USA
- Dept of Emergency Medicine, Virginia Commonwealth University and the Virginia Commonwealth University Reanimation Engineering Shock Center (VCURES); Richmond, VA 23298 USA
| | - M. Hakam Tiba
- Dept of Emergency Medicine, Virginia Commonwealth University and the Virginia Commonwealth University Reanimation Engineering Shock Center (VCURES); Richmond, VA 23298 USA
| | - Luciana Torres
- Dept of Emergency Medicine, Virginia Commonwealth University and the Virginia Commonwealth University Reanimation Engineering Shock Center (VCURES); Richmond, VA 23298 USA
- Dept of Physiology, Virginia Commonwealth University and the Virginia Commonwealth University Reanimation Engineering Shock Center (VCURES); Richmond, VA 23298 USA
| | - Roland N. Pittman
- Dept of Emergency Medicine, Virginia Commonwealth University and the Virginia Commonwealth University Reanimation Engineering Shock Center (VCURES); Richmond, VA 23298 USA
- Dept of Physiology, Virginia Commonwealth University and the Virginia Commonwealth University Reanimation Engineering Shock Center (VCURES); Richmond, VA 23298 USA
| | - Terner James
- Dept of Chemistry, Virginia Commonwealth University and the Virginia Commonwealth University Reanimation Engineering Shock Center (VCURES); Richmond, VA 23298 USA
- * Corresponding author: e-mail , tel. 804-828-7500, Dept. of Chemistry, VCU Box 842006, Richmond, VA 23284-2006
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Trzeciak S, Dellinger RP, Parrillo JE, Guglielmi M, Bajaj J, Abate NL, Arnold RC, Colilla S, Zanotti S, Hollenberg SM. Early microcirculatory perfusion derangements in patients with severe sepsis and septic shock: relationship to hemodynamics, oxygen transport, and survival. Ann Emerg Med 2006; 49:88-98, 98.e1-2. [PMID: 17095120 DOI: 10.1016/j.annemergmed.2006.08.021] [Citation(s) in RCA: 418] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2006] [Revised: 07/25/2006] [Accepted: 08/25/2006] [Indexed: 12/16/2022]
Abstract
STUDY OBJECTIVE To study early microcirculatory perfusion indices in patients with severe sepsis/septic shock, compare early microcirculatory indices in sepsis survivors versus nonsurvivors, and identify systemic hemodynamic/oxygen transport variables that correlate with early microcirculatory perfusion indices. METHODS This prospective observational study used orthogonal polarization spectral imaging to directly visualize the sublingual microcirculation in patients with severe sepsis/septic shock treated with early goal-directed therapy. We performed initial imaging within 6 hours of early goal-directed therapy initiation and late follow-up studies at 24-hour intervals until death or resolution of organ dysfunction. We imaged 5 sublingual sites and analyzed the data offline in a blinded fashion. We calculated 3 microcirculatory perfusion indices: flow velocity score, flow heterogeneity index, and capillary density. We analyzed early data to compare survivors versus nonsurvivors and examine correlations with systemic hemodynamic measurements. We used a linear mixed-effects model for longitudinal analyses. RESULTS We performed 66 orthogonal polarization spectral studies in 26 sepsis patients. Early microcirculatory indices were more markedly impaired (lower flow velocity and more heterogeneous perfusion) in nonsurvivors compared with survivors. These same early indices, flow velocity and heterogeneity, were also more markedly impaired with increasing severity of systemic cardiovascular dysfunction (lower arterial pressure or increasing vasopressor requirement). CONCLUSION Early microcirculatory perfusion indices in severe sepsis and septic shock are more markedly impaired in nonsurvivors compared with survivors and with increasing severity of global cardiovascular dysfunction.
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Affiliation(s)
- Stephen Trzeciak
- Division of Cardiovascular Disease and Critical Care Medicine, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School at Camden, Cooper University Hospital, Camden, NJ 08103, USA.
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Jones AE, Kuehne K, Steuerwald M, Kline JA. End expiratory oxygen concentrations to predict central venous oxygen saturation: an observational pilot study. BMC Emerg Med 2006; 6:9. [PMID: 16987417 PMCID: PMC1592120 DOI: 10.1186/1471-227x-6-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2006] [Accepted: 09/20/2006] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND A non-invasive surrogate measurement for central venous oxygen saturation (ScVO2) would be useful in the ED for assessing therapeutic interventions in critically ill patients. We hypothesized that either linear or nonlinear mathematical manipulation of the partial pressure of oxygen in breath at end expiration (EtO2) would accurately predict ScVO2. METHODS Prospective observational study of a convenience sample of hemodialysis patients age > 17 years with existing upper extremity central venous catheters were enrolled. Using a portable respiratory device, we collected both tidal breathing and end expiratory oxygen and carbon dioxide concentrations, volume and flow on each patient. Simultaneous ScVO2 measurements were obtained via blood samples collected from the hemodialysis catheter. Two models were used to predict ScVO2: 1) Best-fit multivariate linear regression equation incorporating all respiratory variables; 2) MathCAD to model the decay curve of EtO2 versus expiratory volume using the least squares method to estimate the pO2 that would occur at <20% of total lung capacity. RESULTS From 21 patients, the correlation between EtO2 and measured ScVO2 yielded R2 = 0.11. The best fit multivariate equation included EtCO2 and EtO2 and when solved for ScVO2, the equation yielded a mean absolute difference from the measured ScVO2 of 8 +/- 6% (range -18 to +17%). The predicted ScVO2 value was within 10% of the actual value for 57% of the patients. Modeling of the EtO2 curve did not accurately predict ScVO2 at any lung volume. CONCLUSION We found no significant correlation between EtO2 and ScVO2. A linear equation incorporating EtCO2 and EtO2 had at best modest predictive accuracy for ScVO2.
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Affiliation(s)
- Alan E Jones
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Karl Kuehne
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Michael Steuerwald
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Jeffrey A Kline
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
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Abstract
PURPOSE OF REVIEW Tissue hypoperfusion is a common pathophysiologic process leading to multiple organ dysfunction and death. Increases in tissue PCO2 can reflect an abnormal oxygen supply to the cells, so that monitoring tissue PCO2 by the use of gastric or sublingual capnometry may help identify circulatory abnormalities and guide their correction. This review provides an update on these technologies. RECENT FINDINGS Gastric tonometry aims at monitoring PCO2 in the stomach, an organ that becomes ischemic quite early when the circulatory status is jeopardized. Despite substantial initial enthusiasm, this technique has never been widely implemented due to methodological problems. The measurement of sublingual mucosal PCO2 (PslCO2) by sublingual capnometry is technically simple and noninvasive. Experimental studies have suggested that PslCO2 is a reliable marker of tissue perfusion. Clinical studies have demonstrated that high PslCO2 values are associated with impaired microcirculatory blood flow and a worse prognosis in critically ill patients. SUMMARY Gastric tonometry was proposed for regional PCO2 monitoring, but it is prone to a number of technical limitations. Sublingual capnometry could offer a valuable alternative for tissue PCO2 monitoring in clinical practice, representing a simple, noninvasive method to monitor tissue perfusion and titrate therapeutic interventions in critically ill patients.
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Affiliation(s)
- Jacques Creteur
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Belgium.
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41
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Marik PE. Sublingual capnometry: a non-invasive measure of microcirculatory dysfunction and tissue hypoxia. Physiol Meas 2006; 27:R37-47. [PMID: 16705254 DOI: 10.1088/0967-3334/27/7/r01] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
With improvement in supportive care patients rarely die from their presenting illness but rather from its sequela, namely sequential multi-organ failure. Tissue hypoxia is believed to be the causation of multi-organ dysfunction syndrome (MODS). The expedient detection and correction of tissue hypoxia may therefore limit the development of MODS. The standard oxygenation and hemodynamic variables (blood pressure, arterial oxygenation, cardiac output) which are monitored in critically ill patients are 'upstream' markers and provide little information as to the adequacy of tissue oxygenation. Global 'downstream' markers such as mixed venous oxygen saturation and blood lactate are insensitive indicators of tissue hypoxia. Sublingual PCO(2) is a regional marker of microvascular perfusion and tissue hypoxia that holds great promise for the risk stratification and end-point of goal directed resuscitation in critically ill patients. This paper reviews the technology and application of sublingual PCO(2) monitoring.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA
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Creteur J, De Backer D, Sakr Y, Koch M, Vincent JL. Sublingual capnometry tracks microcirculatory changes in septic patients. Intensive Care Med 2006; 32:516-23. [PMID: 16485092 DOI: 10.1007/s00134-006-0070-4] [Citation(s) in RCA: 156] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2005] [Accepted: 11/28/2005] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To test the hypothesis that microcirculatory blood flow is the main determinant of sublingual carbon dioxide pressure in patients with septic shock. DESIGN Prospective, open-label study. SETTING A 31-bed medico-surgical department of intensive care. PATIENTS Eighteen consecutive mechanically ventilated patients with septic shock. INTERVENTIONS A 5 microg/kg x min dobutamine infusion was used to increase blood flow. METHODS Sublingual carbon dioxide pressure was monitored using a microelectrode sensor, and sublingual microcirculation was assessed using orthogonal polarization spectral imaging. The sublingual carbon dioxide pressure gap was calculated as the difference between sublingual and arterial carbon dioxide pressures. In each patient, a nasogastric tonometry catheter was inserted for gastric mucosal carbon dioxide pressure measurement. The gastric carbon dioxide pressure gap was calculated as the difference between gastric mucosal and arterial carbon dioxide pressures. MEASUREMENTS AND RESULTS Dobutamine infusion was associated with increases cardiac index and mixed venous blood oxygen saturation. Dobutamine infusion resulted in decreases in sublingual carbon dioxide pressure gap from 40+/-15 to 17+/-8 mmHg (p<0.01). There was a significant correlation between sublingual and gastric mucosal carbon dioxide pressures (r 2=0.61, p<0.05). At baseline, sublingual carbon dioxide pressure gap correlated with the proportion of well-perfused capillaries (r 2=0.80). The decrease in sublingual carbon dioxide pressure gap paralleled the increase in the proportion of well-perfused capillaries in each patient. CONCLUSIONS Regional microcirculatory blood flow is the main determinant of sublingual carbon dioxide pressure. Sublingual capnometry could represent a simple, non-invasive method to monitor these microcirculatory alterations in septic patients.
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Affiliation(s)
- Jacques Creteur
- Department of Intensive Care, Erasme University Hospital, Route de Lennik 808, 1070, Brussels, Belgium
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Fries M, Weil MH, Sun S, Huang L, Fang X, Cammarata G, Castillo C, Tang W. Increases in tissue Pco2 during circulatory shock reflect selective decreases in capillary blood flow*. Crit Care Med 2006; 34:446-52. [PMID: 16424727 DOI: 10.1097/01.ccm.0000196205.23674.23] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Tissue Pco2 reflects metabolic alterations due to circulatory failure during circulatory shock. This study addresses simultaneous changes in gastric and buccal tissue Pco2 with changes in microcirculatory blood flow in a rat model of circulatory shock induced by cecal ligation and puncture. DESIGN Prospective controlled laboratory study. SETTING University-affiliated research laboratory. SUBJECTS Male breeder Sprague-Dawley rats. INTERVENTIONS Induction of polymicrobial, abdominal sepsis by cecal ligation and puncture. MEASUREMENTS AND MAIN RESULTS Tissue Pco2 was continuously measured with the aid of a miniature carbon dioxide electrode. Using orthogonal polarization spectral imaging, recordings of the microcirculation were taken at baseline and hourly intervals until death and compared with sham-operated animals. Gastric and buccal tissue Pco2 values progressively increased in animals after cecal ligation and puncture and terminated in death. Microcirculatory blood flow in vessels >20 microm was well preserved during progression of shock, whereas there was an early and progressive decrease in microcirculatory blood flow in vessels <20 microm, mostly representing capillaries. Tissue Pco2, the tissue Pco2-Paco2 gradient, and blood flow in vessels <20 microm were highly correlated. This contrasted with sham control animals in which no significant hemodynamic, blood gas, lactate, microcirculatory, and tissue Pco2 abnormalities were observed. CONCLUSIONS These observations suggest that microcirculatory failure in capillaries appears as an early defect in close association with anaerobic metabolism during progression of circulatory shock in an animal model of septic peritonitis.
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Affiliation(s)
- Michael Fries
- Weil Institute of Critical Care Medicine, Rancho Mirage, CA, USA
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Cammarata GAAM, Weil MH, Fries M, Tang W, Sun S, Castillo CJ. Buccal capnometry to guide management of massive blood loss. J Appl Physiol (1985) 2006; 100:304-6. [PMID: 16141375 DOI: 10.1152/japplphysiol.01247.2004] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
In both clinical and experimental settings, tissue Pco2 measured in the oral mucosa is a practical and reliable measurement of the severity of hypoperfusion. We hypothesized that a threshold level of buccal tissue Pco2 (Pco2 BU) would prognosticate the effects of volume repletion on survival. Twenty pentobarbital-anesthetized Sprague-Dawley male breeder rats, each weighing ∼0.5 kg, were randomly assigned to one of four groups. Animals were bled over an interval of 30 min in amounts estimated to be 25, 30, 35, or 40% of total blood volume. One-half hour after the completion of bleeding, each animal received an infusion of Ringer lactate solution over the ensuing 30 min in amounts equivalent to two times the volume of blood loss. Pco2 BU was measured continuously with an optical Pco2 sensor applied noninvasively to the mucosa of the left cheek. Arterial pressure and end-tidal CO2 were measured over the same interval. Neurological deficit and 72-h survival were recorded. Aortic pressures were restored to near baseline values for each of the four groups after fluid resuscitation. This contrasted with the improvement of Pco2 BU, which differentiated between animals with short and long durations of postintervention survival. After electrolyte fluid resuscitation in rats subjected to rapid bleeding, noninvasive measurement of Pco2 BU was predictive of outcomes. Neither noninvasive end-tidal Pco2 nor invasive aortic pressure measurements achieved such discrimination. Accordingly, Pco2 BU fulfills the criterion of a noninvasive and reliable measurement to guide fluid management of hemorrhagic shock.
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Affiliation(s)
- Gianluca A A M Cammarata
- Weil Institute of Critical Care Medicine, 35100 Bob Hope Dr., Rancho Mirage, California 92270, USA
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Pinsky MR, Payen D. Functional hemodynamic monitoring. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2005; 9:566-72. [PMID: 16356240 PMCID: PMC1414021 DOI: 10.1186/cc3927] [Citation(s) in RCA: 178] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Hemodynamic monitoring is a central component of intensive care. Patterns of hemodynamic variables often suggest cardiogenic, hypovolemic, obstructive, or distributive (septic) etiologies to cardiovascular insufficiency, thus defining the specific treatments required. Monitoring increases in invasiveness, as required, as the risk for cardiovascular instability-induced morbidity increases because of the need to define more accurately the diagnosis and monitor the response to therapy. Monitoring is also context specific: requirements during cardiac surgery will be different from those in the intensive care unit or emergency department. Solitary hemodynamic values are useful as threshold monitors (e.g. hypotension is always pathological, central venous pressure is only elevated in disease). Some hemodynamic values can only be interpreted relative to metabolic demand, whereas others have multiple meanings. Functional hemodynamic monitoring implies a therapeutic application, independent of diagnosis such as a therapeutic trial of fluid challenge to assess preload responsiveness. Newer methods for assessing preload responsiveness include monitoring changes in central venous pressure during spontaneous inspiration, and variations in arterial pulse pressure, systolic pressure, and aortic flow variation in response to vena caval collapse during positive pressure ventilation or passive leg raising. Defining preload responsiveness using these functional measures, coupled to treatment protocols, can improve outcome from critical illness. Potentially, as these and newer, less invasive hemodynamic measures are validated, they could be incorporated into such protocolized care in a cost-effective manner.
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Affiliation(s)
- Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
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46
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Marik PE. Monitoring therapeutic interventions in critically ill septic patients. Nutr Clin Pract 2005; 19:423-32. [PMID: 16215136 DOI: 10.1177/0115426504019005423] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Sepsis is the leading cause of admission to intensive care units in the United States. Although the treatment of sepsis is complex and multimodal, nutrition support plays an important role in the management of these patients. The diagnosis of sepsis, disease category, and severity of illness and the change in sepsis severity and organ function over time affect the delivery of nutrition support. This paper reviews the diagnostic criteria of sepsis, the use of "sepsis biomarkers," and regional and global markers of organ function in sepsis and quantitative measures of illness severity and organ dysfunction.
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Affiliation(s)
- Paul E Marik
- Department of Critical Care, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15261, USA.
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47
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Abstract
PURPOSE OF REVIEW Tissue dysoxia is now widely regarded as the major factor leading to organ dysfunction in critically ill patients. Recent data suggests that early aggressive resuscitation of critically ill patients, which limits and/or reverses tissue dysoxia may prevent progression to organ dysfunction and improve outcome. The traditional clinical and laboratory markers used to assess tissue dysoxia are, however, insensitive and have numerous limitations. Regional carbon dioxide monitoring appears to be ideally suited to monitoring the adequacy of resuscitation. This review provides an update on this evolving technology. RECENT FINDINGS Gastric intramucosal carbon dioxide as measured by gastric tonometry has proven to be useful as a prognostic marker, in evaluating the response to specific therapeutic interventions and as an end point of resuscitation. Gastric tonometry is, however, cumbersome and has a number of limitations that may have prevented its widespread adoption. The measurement of carbon dioxide in the sublingual mucosa by sublingual capnometry is technically simple, noninvasive, and provides near instantaneous information. Clinical studies have demonstrated a good correlation between gastric intramucosal carbon dioxide and sublingual mucosa carbon dioxide. Sublingual mucosa carbon dioxide responds more rapidly to therapeutic interventions than does gastric intramucosal carbon dioxide and may be a better prognostic marker. SUMMARY Sublingual capnometry may be the ideal technology for guiding early goal directed therapy. This technology may be useful for monitoring tissue oxygenation, titrating therapeutic interventions, and as an end point for resuscitation in critically ill and injured patients.
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Affiliation(s)
- Paul E Marik
- Pulmonary and Critical Care Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA.
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Lima A, Bakker J. Noninvasive monitoring of peripheral perfusion. Intensive Care Med 2005; 31:1316-26. [PMID: 16170543 DOI: 10.1007/s00134-005-2790-2] [Citation(s) in RCA: 235] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2005] [Accepted: 08/04/2005] [Indexed: 12/14/2022]
Abstract
BACKGROUND Early hemodynamic assessment of global parameters in critically ill patients fails to provide adequate information on tissue perfusion. It requires invasive monitoring and may represent a late intervention initiated mainly in the intensive care unit. Noninvasive monitoring of peripheral perfusion can be a complementary approach that allows very early application throughout the hospital. In addition, as peripheral tissues are sensitive to alterations in perfusion, monitoring of the periphery could be an early marker of tissue hypoperfusion. This review discusses noninvasive methods for monitoring perfusion in peripheral tissues based on clinical signs, body temperature gradient, optical monitoring, transcutaneous oximetry, and sublingual capnometry. DISCUSSION Clinical signs of poor peripheral perfusion consist of a cold, pale, clammy, and mottled skin, associated with an increase in capillary refill time. The temperature gradients peripheral-to-ambient, central-to-peripheral and forearm-to-fingertip skin are validated methods to estimate dynamic variations in skin blood flow. Commonly used optical methods for peripheral monitoring are perfusion index, near-infrared spectroscopy, laser Doppler flowmetry and orthogonal polarization spectroscopy. Continuous noninvasive transcutaneous measurement of oxygen and carbon dioxide tensions can be used to estimate cutaneous blood flow. Sublingual capnometry is a noninvasive alternative for gastric tonometry.
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Affiliation(s)
- Alexandre Lima
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
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Abstract
PURPOSE OF REVIEW The management of the traumatically injured patient has evolved during the past half century despite continually high morbidity and mortality rates. The management of the trauma victim requires timely intervention and damage control in an attempt to maintain normal hemodynamic parameters and adequate systemic perfusion. There is a fine balance between oxygen delivery and consumption, and when this is perturbed, oxygen debt may ensue. The presence of ongoing oxygen debt is rather deleterious, resulting in an inflammatory cascade that can lead to multisystem organ dysfunction. The rapid identification and restoration of oxygen debt are central to the resuscitation of the critically ill patient, be it the result of sepsis or trauma. RECENT FINDINGS Resuscitation end points have evolved that allow the physician to more rapidly identify a perturbation between oxygen delivery and consumption. Moreover, end points allow uniformity in gauging the adequacy of resuscitation: preventing under- and overresuscitation and serving as a basis to compare outcome measures in resuscitation trials. Recent technologic advances have allowed a greater wealth of clinical data that can be obtained via less invasive means. Examples of this include esophageal Doppler monitoring, sublingual capnography, orthogonal polarization spectral imaging, and lithium dilution cardiac output determinations. These devices can be used in concert with more traditional resuscitation end points (ie, lactate and base deficit) to maximize oxygen delivery and correct tissue dysoxia. In addition, the management of hemorrhagic shock is continuing to evolve and challenge the dogmatic practices of normotensive resuscitation. SUMMARY This review addresses (1) resuscitation end points to optimize cardiac function, (2) resuscitation end points to assess the microcirculation, (3) recent developments in the management of hypotensive hemorrhagic shock, and (4) the translation of early goal-directed therapy from septic shock to use in trauma. Past findings are reflected on and direction for future investigation and clinical practice based on recent clinical advances is provided.
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Affiliation(s)
- Robert N Bilkovski
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan 48202, USA.
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50
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Gunn SR, Fink MP, Wallace B. Equipment review: the success of early goal-directed therapy for septic shock prompts evaluation of current approaches for monitoring the adequacy of resuscitation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2005; 9:349-59. [PMID: 16137384 PMCID: PMC1269450 DOI: 10.1186/cc3725] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
A recent trial utilizing central venous oxygen saturation (SCVO2) as a resuscitation marker in patients with sepsis has resulted in its inclusion in the Surviving Sepsis Campaign guidelines. We review the evidence behind SCVO2 and its relationship to previous trials of goal-directed therapy. We compare SCVO2 to other tools for assessing the adequacy of resuscitation including physical examination, biochemical markers, pulmonary artery catheterization, esophageal Doppler, pulse contour analysis, echocardiography, pulse pressure variation, and tissue capnometry. It is unlikely that any single technology can improve outcome if isolated from an organized pattern of early recognition, algorithmic resuscitation, and frequent reassessment. This article includes a response to the journal's Health Technology Assessment questionnaire by the manufacturer of the SCVO2 catheter.
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Affiliation(s)
- Scott R Gunn
- Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mitchell P Fink
- Departments of Critical Care Medicine and Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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