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

Alexandros Rovas, Laura Mareen Seidel, Hans Vink, Timo Pohlkötter, Hermann Pavenstädt, Christian Ertmer, Michael Hessler, Philipp Kümpers, Alexandros Rovas, Laura Mareen Seidel, Hans Vink, Timo Pohlkötter, Hermann Pavenstädt, Christian Ertmer, Michael Hessler, Philipp Kümpers

Abstract

Background: The endothelial glycocalyx (eGC) covers the luminal surface of the vascular endothelium and plays an important protective role in systemic inflammatory states and particularly in sepsis. Its breakdown leads to capillary leak and organ dysfunction. Moreover, sepsis-induced alterations of sublingual microcirculation are associated with a worse clinical outcome. The present study was performed to investigate the associations between eGC dimensions and established parameters of microcirculation dysfunction in sepsis.

Methods: This observational, prospective, cross-sectional study included 40 participants, of which 30 critically ill septic patients were recruited from intensive care units of a university hospital and 10 healthy volunteers served as controls. The established microcirculation parameters were obtained sublingually and analyzed according to the current recommendations. In addition, the perfused boundary region (PBR), an inverse parameter of the eGC dimensions, was measured sublingually, using novel data acquisition and analysis software (GlycoCheck™). Moreover, we exposed living endothelial cells to 5% serum from a subgroup of study participants, and the delta eGC breakdown, measured with atomic force microscopy (AFM), was correlated with the paired PBR values.

Results: In septic patients, sublingual microcirculation was impaired, as indicated by a reduced microvascular flow index (MFI) and a reduced proportion of perfused vessels (PPV) compared to those in healthy controls (MFI, 2.93 vs 2.74, p = 0.002; PPV, 98.53 vs 92.58, p = 0.0004). PBR values were significantly higher in septic patients compared to those in healthy controls, indicating damage of the eGC (2.04 vs 2.34, p < 0.0001). The in vitro AFM data correlated exceptionally well with paired PBR values obtained at the bedside (rs = - 0.94, p = 0.02). Both PBR values and microcirculation parameters correlated well with the markers of critical illness. Interestingly, no association was observed between the PBR values and established microcirculation parameters.

Conclusion: Our findings suggest that eGC damage can occur independently of microcirculatory impairment as measured by classical consensus parameters. Further studies in critically ill patients are needed to unravel the relationship of glycocalyx damage and microvascular impairment, as well as their prognostic and therapeutic importance in sepsis.

Trial registration: Retrospectively registered: Clinicaltrials.gov, NCT03960307.

Keywords: Endothelial glycocalyx; Glycosaminoglycans; Incident dark field illumination imaging; Intensive care unit; Intravital microscopy; Microcirculation; PBR; Perfused boundary region; Sepsis; Sidestream dark field microscopy.

Conflict of interest statement

AR, LMS, TP, HP, CE, MH, and PK declare that they have no competing interests. HV is a Chief Science Officer of GlycoCheck BV, The Netherlands.

Figures

Fig. 1
Fig. 1
Endothelial glycocalyx dimensions measured in vivo and in vitro. a Boxplots of PBR values of healthy controls (white) and septic patients (grey) based on the different microvascular diameter ranges. b Correlation of sublingually measured PBR and paired syndecan-1 values. c A subpopulation from a was randomly selected, and ECs were incubated with 5% sterile-filtered human serum from three septic patients (black circles) and three apparently healthy individuals (white circles), respectively. Scatter plot showing the association between AFM-derived eGC decline (in vitro) and corresponding PBR values (in vivo). Each circle represents the mean of three independent experiments (consisting of ≥ 5 indentation curves in each of ≥ 10 cells) for each individual serum. Incubation without human serum served as control. Data are presented as mean ± SEM. AFM, atomic force microscopy; eGC, endothelial glycocalyx; ICU, intensive care unit; PBR, perfused boundary region; SEM, standard error of mean
Fig. 2
Fig. 2
Boxplots of microcirculation parameters in healthy controls and septic patients. a MFI and b PPV values revealed a damaged microcirculation in the ICU septic population. c The measured PVD tended to be lower in septic patients compared to the healthy controls. ICU, intensive care unit; MFI, microvascular flow index; PPV, proportion of perfused vessels; PVD, perfused vessel density
Fig. 3
Fig. 3
Association of microcirculation and endothelial glycocalyx parameters. a–c Boxplots of PVD, PPV, and MFI values after dichotomizing the sepsis group by the median PBR values. d–f Boxplots of septic patients classified on the basis of their microcirculation parameters into the following groups: “intact” (PPV > 90% and MFI > 2.9), “at risk” (PPV ≤ 90% or MFI ≤ 2.9), and “impaired” (PPV ≤ 90% and MFI ≤ 2.9). No difference was observed between the groups regarding PBR, syn-1 levels, or MAP. ICU, intensive care unit; MAP, mean arterial pressure; MFI, microvascular flow index; PBR, perfused boundary region; PPV, proportion of perfused vessels; PVD, perfused vessel density; syn-1, syndecan-1

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