The Microcirculation as a Therapeutic Target in the Treatment of Sepsis and Shock

Vanina S. Kanoore Edul, M.D.; Arnaldo Dubin, M.D., Ph.D.; Can Ince, Ph.D.

Disclosures

Semin Respir Crit Care Med. 2011;32(5):558-568. 

In This Article

Sublingual Area for Microcirculatory Evaluation in Septic Patients

Since the introduction of OPS and SDF imaging devices into clinical practice, clinical studies have repeatedly confirmed the findings of experimental research. Sublingual mucosa became the window for microcirculation evaluation in critically ill patients because it can be easily monitored at bedside, is accessible, and is noninvasive. Clinical studies have shown that severe microcirculatory sublingual alterations are present in critically ill patients and have an important prognostic value. Finally, sublingual microvascular alterations can be modified by therapeutic interventions.

De Backer and colleagues in their landmark study showed that septic patients with severe sublingual microcirculatory alterations had a bad prognosis in terms of outcome, with septic survivors showing a higher proportion of perfused capillaries than nonsurvivors.[49] Interestingly, these microcirculatory disturbances improved after the topical application of acetylcholine, highlighting that those changes might be reversible. Sakr et al observed the behavior of sublingual microcirculation in septic patients in a day-by-day observation, revealing that only survivors showed improvements in those alterations. In addition, the best predictor of survival was the behavior in sublingual microcirculation during the first day, and not the response of systemic hemodynamics variables.[50] Trzeciak et al studied septic patients during the early goal-directed therapy (EGDT).[51] Compared with controls, septic patients had decreases in capillary microcirculatory flow index (MFI) and density and increases in microcirculatory perfusion heterogeneity. These alterations were also more severe in nonsurvivors. Contrary to the findings of De Backer et al[49] and Sakr et al,[50] there were good correlations between microcirculatory parameters and global hemodynamics and oxygen transport. The reason for this discrepancy may be related to the fact that Trzeciak et al studied patients at the very beginning of admission, when global variables were still severely altered.[51] Furthermore, in another study performed during EGDT, improvements in sublingual microcirculation in the initial hours of resuscitation were associated with reductions in organ failures 24 hours later.[52] These studies underscore that, as in the study by Top et al,[53] the time of syndrome evolution and prior therapy received have a defining and modulating effect on the relationship of microcirculatory alterations to hemodynamic variables and the response to treatment. In a recent study, we showed that microcirculatory alterations that did not respond to therapy in critically ill pediatric patients represent the most sensitive hemodynamic variable that predicts outcome.[53]

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