Qualitative real-time analysis by nurses of sublingual microcirculation in intensive care unit: the MICRONURSE study

Sébastien Tanaka, Anatole Harrois, Camille Nicolaï, Mélanie Flores, Sophie Hamada, Eric Vicaut, Jacques Duranteau, Sébastien Tanaka, Anatole Harrois, Camille Nicolaï, Mélanie Flores, Sophie Hamada, Eric Vicaut, Jacques Duranteau

Abstract

Introduction: We aimed to determine i) the feasibility of nurses taking bedside measurements of microcirculatory parameters in real time in intensive care patients; and ii) whether such measurements would be comparable to those obtained by the classical delayed semi quantitative analysis made by a physician.

Methods: This prospective observational study was conducted in a university hospital and was approved by our local Institutional Review Board (IRB 00006477). After ICU admission and study inclusion, a set of measurements of macrocirculatory and microcirculatory parameters was taken by the nurse in charge of the patient every 4 h within the first 12 h after admission and before and after every hemodynamic therapeutic intervention. Seventy-four sublingual microvascular measurements were performed with incident dark field illumination (IDF) microscopy in 20 mechanically ventilated patients hospitalized in the ICU.

Results: There were no significant differences between the microvascular flow index (MFI) taken in real time by the nurses and the delayed evaluation by the physician. In fact, the nurses' real-time measurement of MFI demonstrated good agreement with the physician's delayed measurement. The mean difference between the two MFIs was -0.15, SD = 0.28. The nurses' real-time MFI assessment showed 97 % sensitivity (95 % CI: 84-99 %) and 95 % specificity (95 % CI: 84-99 %) at detecting a MFI <2.5 obtained by a physician upon delayed semiquantitative measurement. Concerning the density, 81 % of the paramedical qualitative density measurements corresponded with the automatized total vessel density (TVD) measurements. The nurses' real-time TVD assessment showed 77 % sensitivity (95 % CI: 46-95 %) and 100 % specificity (95 % CI: 89-100 %) at detecting a TVD <8 mm/mm(2).

Conclusion: A real-time qualitative bedside evaluation of MFI by nurses showed good agreement with the conventional delayed analysis by physicians. The bedside evaluations of MFI and TVD were highly sensitive and specific for detecting impaired microvascular flow and low capillary density. These results suggest that this real-time technique could become part of ICU nurse routine surveillance and be implemented in algorithms for hemodynamic resuscitation in future clinical trials and regular practice. These results are an essential step to demonstrate whether these real-time measurements have a clinical impact in the management of ICU patients.

Figures

Fig. 1
Fig. 1
Different types of microvascular density (poor, normal and rich)
Fig. 2
Fig. 2
Nurses’ real-time bedside qualitative evaluations of mean fluorescence intensity (MFI) vs physician’s delayed semiquantitative MFI evaluation
Fig. 3
Fig. 3
Bland-Altman plot showing the limits of agreement (bias ± 2 SD) between paired values for the nurses’ real-time bedside qualitative mean fluorescence intensity (MFI) evaluations and the physician’s delayed semiquantitative MFI evaluation

References

    1. Trzeciak S, McCoy JV, Phillip Dellinger R, Arnold RC, Rizzuto M, Abate NL, et al. Early increases in microcirculatory perfusion during protocol-directed resuscitation are associated with reduced multi-organ failure at 24 h in patients with sepsis. Intensive Care Med. 2008;34:2210–7. doi: 10.1007/s00134-008-1193-6.
    1. De Backer D, Creteur J, Preiser JC, Dubois MJ, Vincent JL. Microvascular blood flow is altered in patients with sepsis. Am J Respir Crit Care Med. 2002;166:98–104. doi: 10.1164/rccm.200109-016OC.
    1. Sakr Y, Dubois MJ, De Backer D, Creteur J, Vincent JL. Persistent microcirculatory alterations are associated with organ failure and death in patients with septic shock. Crit Care Med. 2004;32:1825–31. doi: 10.1097/01.CCM.0000138558.16257.3F.
    1. De Backer D, Donadello K, Sakr Y, Ospina-Tascon G, Salgado D, Scolletta S, et al. Microcirculatory alterations in patients with severe sepsis: impact of time of assessment and relationship with outcome. Crit Care Med. 2013;41:791–9. doi: 10.1097/CCM.0b013e3182742e8b.
    1. Ince C. The microcirculation is the motor of sepsis. Crit Care. 2005;9:S13–9. doi: 10.1186/cc3753.
    1. Harrois A, Dupic L, Duranteau J. Targeting the microcirculation in resuscitation of acutely unwell patients. Curr Opin Crit Care. 2011;17:303–7. doi: 10.1097/MCC.0b013e3283466ba0.
    1. Bateman RM, Walley KR. Microvascular resuscitation as a therapeutic goal in severe sepsis. Crit Care. 2005;9:S27–32. doi: 10.1186/cc3756.
    1. Nencioni A, Trzeciak S, Shapiro NI. The microcirculation as a diagnostic and therapeutic target in sepsis. Intern Emerg Med. 2009;4:413–8. doi: 10.1007/s11739-009-0297-5.
    1. Trzeciak S, Dellinger RP, Parrillo JE, Guglielmi M, Bajaj J, Abate NL, et al. Early microcirculatory perfusion derangements in patients with severe sepsis and septic shock: relationship to hemodynamics, oxygen transport, and survival. Ann Emerg Med. 2007;49:88–98. doi: 10.1016/j.annemergmed.2006.08.021.
    1. Tachon G, Harrois A, Tanaka S, Kato H, Huet O, Pottecher J, et al. Microcirculatory alterations in traumatic hemorrhagic shock. Crit Care Med. 2014;42:1433–41. doi: 10.1097/CCM.0000000000000223.
    1. De Backer D, Ospina-Tascon G, Salgado D, Favory R, Creteur J, Vincent JL. Monitoring the microcirculation in the critically ill patient: current methods and future approaches. Intensive Care Med. 2010;36:1813–25. doi: 10.1007/s00134-010-2005-3.
    1. Bezemer R, Dobbe JG, Bartels SA, Boerma EC, Elbers PW, Heger M, et al. Rapid automatic assessment of microvascular density in sidestream dark field images. Med Biol Eng Comput. 2011;49:1269–78. doi: 10.1007/s11517-011-0824-1.
    1. Aykut GV, Veenstra G, Scorcella C, Ince C, Boerma C. Cytocam-IDF (incident dark field illumination) imaging for bedside monitoring of the microcirculation. Intensive Care Med Exp. 2015;3:40. doi: 10.1186/s40635-015-0040-7.
    1. De Backer D, Hollenberg S, Boerma C, Goedhart P, Buchele G, Ospina-Tascon G, et al. How to evaluate the microcirculation: report of a round table conference. Crit Care. 2007;11:R101. Accessed 2007.
    1. Massey MJ, Larochelle E, Najarro G, Karmacharla A, Arnold R, Trzeciak S, et al. The microcirculation image quality score: development and preliminary evaluation of a proposed approach to grading quality of image acquisition for bedside videomicroscopy. J Crit Care. 2013;28:913–7. doi: 10.1016/j.jcrc.2013.06.015.
    1. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet. 1986;1:307–10. doi: 10.1016/S0140-6736(86)90837-8.
    1. Yuruk K, Bartels SA, Milstein DM, Bezemer R, Biemond BJ, Ince C. Red blood cell transfusions and tissue oxygenation in anemic hematology outpatients. Transfusion. 2012;52:641–6. doi: 10.1111/j.1537-2995.2011.03312.x.
    1. De Backer D, Creteur J, Dubois MJ, Sakr Y, Koch M, Verdant C, et al. The effects of dobutamine on microcirculatory alterations in patients with septic shock are independent of its systemic effects. Crit Care Med. 2006;34:403–8. doi: 10.1097/01.CCM.0000198107.61493.5A.
    1. Pottecher J, Deruddre S, Teboul JL, Georger JF, Laplace C, Benhamou D, et al. Both passive leg raising and intravascular volume expansion improve sublingual microcirculatory perfusion in severe sepsis and septic shock patients. Intensive Care Med. 2010;36:1867–74. doi: 10.1007/s00134-010-1966-6.
    1. Arnold RC, Parrillo JE, Phillip Dellinger R, Chansky ME, Shapiro NI, Lundy DJ, et al. Point-of-care assessment of microvascular blood flow in critically ill patients. Intensive Care Med. 2009;35:1761–6. doi: 10.1007/s00134-009-1517-1.
    1. Genzel-Boroviczeny O, Christ F, Glas V. Blood transfusion increases functional capillary density in the skin of anemic preterm infants. Pediatr Res. 2004;56:751–5. doi: 10.1203/01.PDR.0000141982.38959.10.

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