Dataset Information

Sublingual microcirculation: a case report.

ABSTRACT:

Introduction

Sublingual microcirculation monitoring is suitable for bedside use in critically ill patients. We present a case in which severely impaired sublingual microcirculation was the first alarming sign of an early deterioration of the patient's medical situation.

Case presentation

This is the case of a 58-year-old white woman admitted to our intensive care unit after the removal of parts of her small intestine due to a volvulus. Her microcirculation was checked the day after surgery in terms of an ongoing study and predicted a massive deterioration of her clinical situation.

Conclusions

This case highlights the potential value of monitoring the microcirculation in critically ill patients. Two full hours could have been saved for diagnostic workup and earlier treatment had we considered the impaired microcirculation alone as a warning sign. Regardless of the supposed cause, impaired microcirculation should alert the responsible physician and should be followed by a diagnostic workup. Sublingual microcirculation monitoring can be useful in intensive care units to detect a deteriorated microcirculation earlier than with standard monitoring.

SUBMITTER: Scheuzger JD

PROVIDER: S-EPMC6560767 | biostudies-literature | 2019 Jun

REPOSITORIES: biostudies-literature

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Publications

Sublingual microcirculation: a case report.

Scheuzger Jonas D JD Zehnder Anna A Yeginsoy Desirée D Siegemund Martin M

Journal of medical case reports 20190612 1

<h4>Introduction</h4>Sublingual microcirculation monitoring is suitable for bedside use in critically ill patients. We present a case in which severely impaired sublingual microcirculation was the first alarming sign of an early deterioration of the patient's medical situation.<h4>Case presentation</h4>This is the case of a 58-year-old white woman admitted to our intensive care unit after the removal of parts of her small intestine due to a volvulus. Her microcirculation was checked the day afte ...[more]

PMID: 31186057

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Project description:BackgroundLittle is known about the microcirculatory alterations in patients with chronic mesenteric ischemia (CMI). We hypothesized that patients with CMI have an impaired microcirculatory function and show an oral microcirculatory response after caloric challenge compared to healthy controls.MethodsAll patients and controls received the standard workup for CMI. Sublingual micro-circulation was evaluated before (T0) and 20 minutes after (T1) feeding. The total vessel density (TVD; mm/mm2), perfused vessel density (PVD; mm/mm2), proportion of perfused vessels (PPV; %) and microvascular flow index (MFI; AU) were assessed.ResultsWe included 12 patients (63.2 years [IQR 48.8-70.4 years], 67% males) and 12 controls (32.7 years [IQR 27.7-38.1 years], 42% males). At baseline, patients with CMI had a decreased PPV of the sublingual small vessels (median 84.8% vs 95.7%, P=0.006), PPV of all vessels (PPV median 85.4% vs 95.3%, P=0.007) and microvascular flow index of all vessels (MFIa; median 3.00 vs 2.80, P=0.039) compared to healthy controls. After caloric challenge, PVD increased significantly in both small vessels (perfused vessel density of the small vessels [PVDs]) and all vessels (perfused vessel density of all vessels [PVDa]; PVDs [T0]) median 16.3 [IQR 13.3-22.1] vs [T1] median 19.9 [IQR 14.2-26.2], P=0.008; PVDa [T0] median 19.1 [IQR 16.2-23.6] vs [T1] median 22.2 [IQR 16.5-28.9], P=0.02; proportion of perfused vessels of the small vessels (PPVs; [T0] median 84.8% [IQR 75.3-90.4] vs [T1] median 91.0% [IQR 80.1-93.8], P=0.010). In contrast, no significant changes in microcirculatory parameters were observed after caloric challenge in healthy controls.ConclusionPatients with CMI have an impaired sublingual microcirculation at baseline and show a significant response in the sublingual microcirculation after caloric challenge, whereas healthy controls have a normal microcirculation at baseline and show no reactive response upon a caloric challenge as seen in CMI patients. Sublingual microcirculation visualization may offer a rapid noninvasive method to identify patients at risk for having CMI.

Project description:ObjectiveTo investigate the potential of employing sublingual microcirculation as an early noninvasive screening technique for diabetic nephropathy (DN).Research design and methodsWe recruited 89 patients with type 2 diabetes mellitus (T2DM) and 41 healthy subjects in this cross-sectional observational study. All participants underwent fluorescein fundus angiography, vibration perception testing, 10 g (Semmes-Weinstein) monofilament examination, nerve conduction velocity, and 24-h urine microalbumin determination. HbA1c, fasting plasma glucose, blood lipid, and estimated glomerular filtration rate(eGFR) were measured. Sublingual microcirculatory images were captured using side-stream dark-field (SDF) microcirculation microscopy, and total and perfused vascular density (TVD and PVD) were calculated.ResultsThe sublingual microcirculatory parameters denoting microvascular density and perfusion were negatively correlated with both fasting plasma glucose (TVD, r = - 0.316, P < 0.001; PVD, r = - 0.350, P < 0.001; PPV, r = - 0.279, P = 0.001) and HbA1c (TVD, r = - 0.367, P < 0.001; PVD, r = - 0.423, P < 0.001; PPV, r = - 0.399, P < 0.001). Diabetes patients already had a reduction in sublingual microcirculation compared with healthy control, and more severe reductions in TVD (7.07 ± 1.64 vs. 9.67 ± 1.94 mm/mm2, P < 0.001) and PVD (5.88 ± 1.82 vs. 8.64 ± 2.46 mm/mm2, P < 0.001) were found in those diabetes patients developed microvascular complications. Sublingual microcirculation impairment was accompanied with higher urinary albumin creatinine ratio (UACR). Receiver operating characteristic (ROC) analysis showed that TVD (area under the curve, AUC = 0.890 [0.836 0.944], P < 0.001) and PVD (AUC = 0.883 [0.826, 0.940], P < 0.001) could be indicators for DN screening. We derived a combined predictor index (CPI) considering both TVD and PVD for screening DN, and both the AUC (0.892, [0.838 0.945], P < 0.001) and cutoff point of 11.30 mm/mm2 showed great improvement (sensitivity: 95.5%, specificity: 67.4%).ConclusionsDiabetes patients experienced impaired sublingual microcirculation, which was closely correlated with UACR. Sublingual microcirculation monitoring could be used for the noninvasive early detection of DN.

Project description:BackgroundThe 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.MethodsThis 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.ResultsIn 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.ConclusionOur 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 registrationRetrospectively registered: Clinicaltrials.gov, NCT03960307.

Project description:IntroductionThe present study was designed to determine the effects of continuously infused norepinephrine (NE) plus (1) terlipressin (TP) or (2) arginine vasopressin (AVP) or (3) placebo on sublingual microcirculation in septic shock patients. The primary study end point was a difference of ≥ 20% in the microvascular flow index of small vessels among groups.MethodsThe design of the study was a prospective, randomized, double-blind clinical trial. NE was titrated to maintain mean arterial pressure (MAP) between 65 and 75 mmHg after establishment of normovolemia in 60 septic shock patients. Thereafter patients (n = 20 per group) were randomized to receive continuous infusions of either TP (1 μg/kg/hour), AVP (0.04 U/minute) or placebo (isotonic saline). In all groups, open-label NE was adjusted to maintain MAP within threshold values if needed. The sublingual microcirculatory blood flow of small vessels was assessed by sidestream dark-field imaging. All measurements, including data from right heart catheterization and norepinephrine requirements, were obtained at baseline and 6 hours after randomization.ResultsTP and AVP decreased NE requirements at the end of the 6-hour study period. The data are medians (25th and 75th interquartile ranges (IQRs)): 0.57 μg/kg/minute (0.29 to 1.04) vs. 0.16 μg/kg/minute (0.03 to 0.37) for TP and 0.40 μg/kg/minute (0.20 to 1.05) vs. 0.23 μg/kg/minute (0.03 to 0.77) for AVP, with statistical significance of P < 0.05 vs. baseline and vs. placebo. There were no differences in sublingual microcirculatory variables, systemic hemodynamics, oxygen transport and acid-base homeostasis among the three study groups during the entire observation period. The proportions of perfused vessels increased in relation to baseline within all study groups, and there were no significant differences between groups. The specific data were as follows (median (IQR)): 9.7% (2.6 to 19.8) for TP, 8.9% (0.0 to 17.8) for AVP, and 6.9% (3.5 to 10.1) for placebo (P < 0.05 vs. baseline for each comparison), as well as perfused vessel density 18.6% (8.6 to 36.9) for TP, 20.2% (-3.0 to 37.2) for AVP, and 11.4% (-3.0 to 19.4) for placebo (P < 0.05 vs. baseline for each comparison).ConclusionsThe present study suggests that to achieve a MAP of 65 to 75 mmHg in septic patients treated with NE, the addition of continuously infused low-dose TP or AVP does not affect sublingual microcirculatory blood flow. In addition, our results suggest that microcirculatory flow abnormalities are mainly related to other factors (for example, volume status, timing, hemodynamics and progression of the disease) rather than to the vasopressor per se.Trial registrationClinicalTrial.gov NCT00995839.

Dataset Information

Sublingual microcirculation: a case report.

Introduction

Case presentation

Conclusions

Publications

Sublingual microcirculation: a case report.

Similar Datasets

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