Background:Severe burns induce volume shifts via capillary leaks,eventually requiring massive fluid resuscitation and promoting tissue edema.Albumin may help to mitigate the edema,thereby improving perfusion.This stud...Background:Severe burns induce volume shifts via capillary leaks,eventually requiring massive fluid resuscitation and promoting tissue edema.Albumin may help to mitigate the edema,thereby improving perfusion.This study shows that sublingual microcirculation measurements can quantify both tissue perfusion and edema.Methods:This prospective observational study was conducted between November 2018 and December 2019 in the intensive care unit of Maasstad Hospital Burn Center,Rotterdam,The Netherlands.Patients with severe burns affecting>15%of the total body surface area were included.Fluid management was conducted in accordance with the Parkland formula.Albumin(20%)was administered at a rate of 0.5 mL/(kg·h),starting 12 h after the burn incident.Alterations in the sublingual microcirculation,including capillary perfusion and density,were measured at admission(T0)and 4 h(T4)and 12 h(T12)after admission.Sublingual depth of focus(DOF)of the microcirculation was used to quantify the tissue edema.Results:Nine patients were recruited with a mean total body surface area of 36%±23%.By T12,a median of 4085 mL(interquartile range[IQR]:3714-6756 mL)of crystalloids and 446 mL(IQR:176-700 mL)of 20%albumin were administered.The DOF increased significantly after crystalloid administration(T4 vs.T0,mean difference[MD]=27.4μm,95%confidence interval[CI]:3.4 to 50.9,P=0.040).Following albumin administration,DOF significantly decreased(T12 vs.T4,MD=-76.4μm,95%CI:-116.6 to-36.1,P=0.002).Total vessel density decreased significantly with crystalloid administration(T4 vs.T0,MD=-3.5 mm/mm2,95%CI:-5.7 to-1.4,P=0.004)but increased after albumin administration(T12 vs.T4,MD=6.2 mm/mm2,95%CI:3.2 to 9.3,P=0.001).Conclusion:Sublingual microcirculation measurement of DOF and other parameters provide a valuable tool for the assessment of tissue perfusion and edema in patients with severe burns.Further investigation is required to evaluate the role of albumin in increasing microcirculatory convection and reducing tissue edema.展开更多
Objective:Poor tissue perfusion/cellular hypoxia may persist despite restoration of the macrocirculation(Macro).This article reviewed the literatures of coherence between hemodynamics and tissue perfusion in circulato...Objective:Poor tissue perfusion/cellular hypoxia may persist despite restoration of the macrocirculation(Macro).This article reviewed the literatures of coherence between hemodynamics and tissue perfusion in circulatory shock.Data sources:We retrieved information from the PubMed database up to January 2018 using various search terms or/and their combinations,including resuscitation,circulatory shock,septic shock,tissue perfusion,hemodynamic coherence,and microcirculation(Micro).Study selection:The data from peer-reviewed journals printed in English on the relationships of tissue perfusion,shock,and resuscitation were included.Results:A binary(coherence/incoherence,coupled/uncoupled,or associated/disassociated)mode is used to describe resuscitation coherence.The phenomenon of resuscitation incoherence(RI)has gained great attention.However,the RI concept requires a more practical,systematic,and comprehensive framework for use in clinical practice.Moreover,we introduce a conceptual framework of RI to evaluate the interrelationship of the Macro,Micro,and cell.The RI is divided into four types(Type 1:Macro-Micro incoherence+impaired cell;Type 2:Macro-Micro incoherence+normal cell;Type 3:Micro-Cell incoherence+normal Micro;and Type 4:both Macro-Micro and Micro-cell incoherence).Furthermore,we propose the concept of dynamic circulation-perfusion coupling to evaluate the relationship of circulation and tissue perfusion during circulatory shock.Conclusions:The concept of RI and dynamic circulation-perfusion coupling should be considered in the management of circulatory shock.Moreover,these concepts require further studies in clinical practice.展开更多
Background:Vascular inflow occlusion(VIO)during liver resections(Pringle manoeuvre)can be applied to reduce blood loss,however may at the same time,give rise to ischemia-reperfusion injury(IRI).The aim of this study w...Background:Vascular inflow occlusion(VIO)during liver resections(Pringle manoeuvre)can be applied to reduce blood loss,however may at the same time,give rise to ischemia-reperfusion injury(IRI).The aim of this study was to assess the characteristics of hepatic microvascular perfusion during VIO in patients undergoing major liver resection.Methods:Assessment of hepatic microcirculation was performed using a handheld vital microscope(HVM)at the beginning of surgery,end of VIO(20 minutes)and during reperfusion after the termination of VIO.The microcirculatory parameters assessed were:functional capillary density(FCD),microvascular flow index(MFI)and sinusoidal diameter(SinD).Results:A total of 15 patients underwent VIO;8 patients showed hepatic microvascular perfusion despite VIO(partial responders)and 7 patients showed complete cessation of hepatic microvascular perfusion(full responders).Functional microvascular parameters and blood flow levels were significantly higher in the partial responders when compared to the full responders during VIO(FCD:0.84±0.88 vs.0.00±0.00 mm/mm2,P<0.03,respectively,and MFI:0.69–0.22 vs.0.00±0.00,P<0.01,respectively).Conclusions:An interpatient heterogeneous response in hepatic microvascular blood flow was observed upon VIO.This may explain why clinical strategies to protect the liver against IRI lacked consistency.展开更多
Background:Accurate risk stratification of critically ill patients with coronavirus disease 2019(COVID-19)is essential for optimizing resource allocation,delivering targeted interventions,and maximizing patient surviv...Background:Accurate risk stratification of critically ill patients with coronavirus disease 2019(COVID-19)is essential for optimizing resource allocation,delivering targeted interventions,and maximizing patient survival probability.Machine learning(ML)techniques are attracting increased interest for the development of prediction models as they excel in the analysis of complex signals in data-rich environments such as critical care.Methods:We retrieved data on patients with COVID-19 admitted to an intensive care unit(ICU)between March and October 2020 from the RIsk Stratification in COVID-19 patients in the Intensive Care Unit(RISC-19-ICU)registry.We applied the Extreme Gradient Boosting(XGBoost)algorithm to the data to predict as a binary out-come the increase or decrease in patients’Sequential Organ Failure Assessment(SOFA)score on day 5 after ICU admission.The model was iteratively cross-validated in different subsets of the study cohort.Results:The final study population consisted of 675 patients.The XGBoost model correctly predicted a decrease in SOFA score in 320/385(83%)critically ill COVID-19 patients,and an increase in the score in 210/290(72%)patients.The area under the mean receiver operating characteristic curve for XGBoost was significantly higher than that for the logistic regression model(0.86 vs.0.69,P<0.01[paired t-test with 95%confidence interval]).Conclusions:The XGBoost model predicted the change in SOFA score in critically ill COVID-19 patients admitted to the ICU and can guide clinical decision support systems(CDSSs)aimed at optimizing available resources.展开更多
Background:In clinical practice,blood pressure is used as a resuscitation goal on a daily basis,with the aim of maintaining adequate perfusion and oxygen delivery to target organs.Compromised perfusion is often indica...Background:In clinical practice,blood pressure is used as a resuscitation goal on a daily basis,with the aim of maintaining adequate perfusion and oxygen delivery to target organs.Compromised perfusion is often indicated as a key factor in the pathophysiology of anastomotic leakage.This study was aimed at assessing the extent to which the microcirculation of the bowel coheres with blood pressure during abdominal surgery.Methods:We performed a prospective and observational cohort study.In patients undergoing abdominal surgery,the serosal microcirculation of either the small intestine or the colon was visualized using handheld vital mi-croscopy(HVM).From the acquired HVM image sequences,red blood cell velocity(RBCv)and total vessel density(TVD)were calculated using MicroTools and AVA software,respectively.The association between microcircula-tory parameters and blood pressure was assessed using Pearson’s correlation analysis.We considered a two-sided P-value of<0.050 to be significant.Results:In 28 patients undergoing abdominal surgery,a total of 76 HVM images were analyzed.The RBCv was 335±96μm/s and the TVD was 13.7±3.4 mm/mm ^(2).Mean arterial pressure(MAP)was 71±12 mm Hg during microcirculatory imaging.MAP was not correlated with RBCv(Pearson’s r=−0.049,P=0.800)or TVD(Pearson’s r=0.310,P=0.110).Conclusion:In 28 patients undergoing abdominal surgery,we found no association between serosal intestinal microcirculatory parameters and blood pressure.展开更多
基金project is co-funded by the PPP allowance to stimulate public-private partnership made available by Health~Holland,Top Sector Life Sciences&Health,as well as by a contribution from the Dutch Burns Foundation(grant number:nr LSHM 17077-SGF)www.health-holland.com.
文摘Background:Severe burns induce volume shifts via capillary leaks,eventually requiring massive fluid resuscitation and promoting tissue edema.Albumin may help to mitigate the edema,thereby improving perfusion.This study shows that sublingual microcirculation measurements can quantify both tissue perfusion and edema.Methods:This prospective observational study was conducted between November 2018 and December 2019 in the intensive care unit of Maasstad Hospital Burn Center,Rotterdam,The Netherlands.Patients with severe burns affecting>15%of the total body surface area were included.Fluid management was conducted in accordance with the Parkland formula.Albumin(20%)was administered at a rate of 0.5 mL/(kg·h),starting 12 h after the burn incident.Alterations in the sublingual microcirculation,including capillary perfusion and density,were measured at admission(T0)and 4 h(T4)and 12 h(T12)after admission.Sublingual depth of focus(DOF)of the microcirculation was used to quantify the tissue edema.Results:Nine patients were recruited with a mean total body surface area of 36%±23%.By T12,a median of 4085 mL(interquartile range[IQR]:3714-6756 mL)of crystalloids and 446 mL(IQR:176-700 mL)of 20%albumin were administered.The DOF increased significantly after crystalloid administration(T4 vs.T0,mean difference[MD]=27.4μm,95%confidence interval[CI]:3.4 to 50.9,P=0.040).Following albumin administration,DOF significantly decreased(T12 vs.T4,MD=-76.4μm,95%CI:-116.6 to-36.1,P=0.002).Total vessel density decreased significantly with crystalloid administration(T4 vs.T0,MD=-3.5 mm/mm2,95%CI:-5.7 to-1.4,P=0.004)but increased after albumin administration(T12 vs.T4,MD=6.2 mm/mm2,95%CI:3.2 to 9.3,P=0.001).Conclusion:Sublingual microcirculation measurement of DOF and other parameters provide a valuable tool for the assessment of tissue perfusion and edema in patients with severe burns.Further investigation is required to evaluate the role of albumin in increasing microcirculatory convection and reducing tissue edema.
基金supported by a grant from the Fundamental Research Funds for the Central Universities(No.3332018010).
文摘Objective:Poor tissue perfusion/cellular hypoxia may persist despite restoration of the macrocirculation(Macro).This article reviewed the literatures of coherence between hemodynamics and tissue perfusion in circulatory shock.Data sources:We retrieved information from the PubMed database up to January 2018 using various search terms or/and their combinations,including resuscitation,circulatory shock,septic shock,tissue perfusion,hemodynamic coherence,and microcirculation(Micro).Study selection:The data from peer-reviewed journals printed in English on the relationships of tissue perfusion,shock,and resuscitation were included.Results:A binary(coherence/incoherence,coupled/uncoupled,or associated/disassociated)mode is used to describe resuscitation coherence.The phenomenon of resuscitation incoherence(RI)has gained great attention.However,the RI concept requires a more practical,systematic,and comprehensive framework for use in clinical practice.Moreover,we introduce a conceptual framework of RI to evaluate the interrelationship of the Macro,Micro,and cell.The RI is divided into four types(Type 1:Macro-Micro incoherence+impaired cell;Type 2:Macro-Micro incoherence+normal cell;Type 3:Micro-Cell incoherence+normal Micro;and Type 4:both Macro-Micro and Micro-cell incoherence).Furthermore,we propose the concept of dynamic circulation-perfusion coupling to evaluate the relationship of circulation and tissue perfusion during circulatory shock.Conclusions:The concept of RI and dynamic circulation-perfusion coupling should be considered in the management of circulatory shock.Moreover,these concepts require further studies in clinical practice.
文摘Background:Vascular inflow occlusion(VIO)during liver resections(Pringle manoeuvre)can be applied to reduce blood loss,however may at the same time,give rise to ischemia-reperfusion injury(IRI).The aim of this study was to assess the characteristics of hepatic microvascular perfusion during VIO in patients undergoing major liver resection.Methods:Assessment of hepatic microcirculation was performed using a handheld vital microscope(HVM)at the beginning of surgery,end of VIO(20 minutes)and during reperfusion after the termination of VIO.The microcirculatory parameters assessed were:functional capillary density(FCD),microvascular flow index(MFI)and sinusoidal diameter(SinD).Results:A total of 15 patients underwent VIO;8 patients showed hepatic microvascular perfusion despite VIO(partial responders)and 7 patients showed complete cessation of hepatic microvascular perfusion(full responders).Functional microvascular parameters and blood flow levels were significantly higher in the partial responders when compared to the full responders during VIO(FCD:0.84±0.88 vs.0.00±0.00 mm/mm2,P<0.03,respectively,and MFI:0.69–0.22 vs.0.00±0.00,P<0.01,respectively).Conclusions:An interpatient heterogeneous response in hepatic microvascular blood flow was observed upon VIO.This may explain why clinical strategies to protect the liver against IRI lacked consistency.
基金supported by the“Microsoft Grant Award:AI for Health COVID-19″The RISC-19-ICU reg-istry is supported by the Swiss Society of Intensive Care Medicine and funded by internal resources of the Institute of Intensive Care Medicine,of the University Hospital Zurich and by unrestricted grants from CytoSorbents Europe GmbH(Berlin,Germany)+1 种基金Union Bancaire Privée(Zurich,Switzerland)The sponsors had no role in the design of the study,the collection and analysis of the data,or the preparation of the manuscript.
文摘Background:Accurate risk stratification of critically ill patients with coronavirus disease 2019(COVID-19)is essential for optimizing resource allocation,delivering targeted interventions,and maximizing patient survival probability.Machine learning(ML)techniques are attracting increased interest for the development of prediction models as they excel in the analysis of complex signals in data-rich environments such as critical care.Methods:We retrieved data on patients with COVID-19 admitted to an intensive care unit(ICU)between March and October 2020 from the RIsk Stratification in COVID-19 patients in the Intensive Care Unit(RISC-19-ICU)registry.We applied the Extreme Gradient Boosting(XGBoost)algorithm to the data to predict as a binary out-come the increase or decrease in patients’Sequential Organ Failure Assessment(SOFA)score on day 5 after ICU admission.The model was iteratively cross-validated in different subsets of the study cohort.Results:The final study population consisted of 675 patients.The XGBoost model correctly predicted a decrease in SOFA score in 320/385(83%)critically ill COVID-19 patients,and an increase in the score in 210/290(72%)patients.The area under the mean receiver operating characteristic curve for XGBoost was significantly higher than that for the logistic regression model(0.86 vs.0.69,P<0.01[paired t-test with 95%confidence interval]).Conclusions:The XGBoost model predicted the change in SOFA score in critically ill COVID-19 patients admitted to the ICU and can guide clinical decision support systems(CDSSs)aimed at optimizing available resources.
文摘Background:In clinical practice,blood pressure is used as a resuscitation goal on a daily basis,with the aim of maintaining adequate perfusion and oxygen delivery to target organs.Compromised perfusion is often indicated as a key factor in the pathophysiology of anastomotic leakage.This study was aimed at assessing the extent to which the microcirculation of the bowel coheres with blood pressure during abdominal surgery.Methods:We performed a prospective and observational cohort study.In patients undergoing abdominal surgery,the serosal microcirculation of either the small intestine or the colon was visualized using handheld vital mi-croscopy(HVM).From the acquired HVM image sequences,red blood cell velocity(RBCv)and total vessel density(TVD)were calculated using MicroTools and AVA software,respectively.The association between microcircula-tory parameters and blood pressure was assessed using Pearson’s correlation analysis.We considered a two-sided P-value of<0.050 to be significant.Results:In 28 patients undergoing abdominal surgery,a total of 76 HVM images were analyzed.The RBCv was 335±96μm/s and the TVD was 13.7±3.4 mm/mm ^(2).Mean arterial pressure(MAP)was 71±12 mm Hg during microcirculatory imaging.MAP was not correlated with RBCv(Pearson’s r=−0.049,P=0.800)or TVD(Pearson’s r=0.310,P=0.110).Conclusion:In 28 patients undergoing abdominal surgery,we found no association between serosal intestinal microcirculatory parameters and blood pressure.
