Assessment of sublingual microcirculation in critically ill patients: consensus and debate

Olcay Dilken, Bulent Ergin, Can Ince, Olcay Dilken, Bulent Ergin, Can Ince

Abstract

The main concern in shock and resuscitation is whether the microcirculation can carry adequate oxygen to the tissues and remove waste. Identification of an intact coherence between macro- and microcirculation during states of shock and resuscitation shows a functioning regulatory mechanism. However, loss of hemodynamic coherence between the macro and microcirculation can be encountered frequently in sepsis, cardiogenic shock, or any hemodynamically compromised patient. This loss of hemodynamic coherence results in an improvement in macrohemodynamic parameters following resuscitation without a parallel improvement in microcirculation resulting in tissue hypoxia and tissue compromise. Hand-held vital microscopes (HVMs) can visualize the microcirculation and help to diagnose the nature of microcirculatory shock. Although treatment with the sole aim of recruiting the microcirculation is as yet not realized, interventions can be tailored to the needs of the patient while monitoring sublingual microcirculation. With the help of the newly introduced software, called MicroTools, we believe sublingual microcirculation monitoring and diagnosis will be an essential point-of-care tool in managing shock patients.

Keywords: Crit Care; coherence; microcirculation; sepsis; shock.

Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/atm.2020.03.222). The series “Hemodynamic Monitoring in Critically Ill Patients” was commissioned by the editorial office without any funding or sponsorship. CI has received a grant from CytoSorb to commence a randomized controlled trial on the effect of the adsorber on the microcirculation of critically ill patients at the department of Intensive Care of the Erasmus Medical Center Rotterdam. CI and his team provide services and training with regard to clinical microcirculation. To this purpose, he runs an internet site called https://www.microcirculationacademy.org. The internet site and its activities are run by a company called Active Medical BV of which he owns shares. The other authors have no other conflicts of interest to declare.

2020 Annals of Translational Medicine. All rights reserved.

Figures

Figure 1
Figure 1
Sublingual microcirculation images of (I): healthy patient; (II): fluid resuscitated shock patient. (I) Normal visualization of capillary network in the sublingual area. Capillaries in (II) are denoted by A, B and C, in hemodilution. Also, the total number of vessels are considerably reduced in (II) compared to (I).
Figure 2
Figure 2
Type 1: flow heterogeneity. Heterogeneous perfusion as encountered in septic patients. Glycocalyx destruction is evident in the lower capillary. Leukocytes migrate through the endothelial cells and induce tissue damage via cytokines and other various mechanisms.
Figure 3
Figure 3
Type 2: hemodilution. Increased distance between red blood cells in the capillary. Capillary hematocrit is decreased and tissue oxygenation is impaired albeit an unimpeded blood flow in the capillary.
Figure 4
Figure 4
Type 3: stasis. Increased vascular resistance by excess use of vasopressors, or increased venous pressures impede or totally occlude the blood flow (R: resistance).
Figure 5
Figure 5
Type 4: edema. Tissue edema caused by increased capillary leak result into increased oxygen diffusion distance and reduced oxygen transport.

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