Assessment of Regional Perfusion and Organ Function: Less and Non-invasive Techniques.

Wolfgang Huber,Gerhard Schneider,Roland Schmid,Robert Zanner,Tobias Lahmer

doi:10.3389/fmed.2019.00050

Wolfgang Huber, Gerhard Schneider + Show 3 more

Open Access

https://doi.org/10.3389/fmed.2019.00050

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Abstract

Sufficient organ perfusion essentially depends on preserved macro- and micro-circulation. The last two decades brought substantial progress in the development of less and non-invasive monitoring of macro-hemodynamics. However, several recent studies suggest a frequent incoherence of macro- and micro-circulation. Therefore, this review reports on interactions of macro- and micro-circulation as well as on specific regional and micro-circulation. Regarding global micro-circulation the last two decades brought advances in a more systematic approach of clinical examination including capillary refill time, a graded assessment of mottling of the skin and accurate measurement of body surface temperatures. As a kind of link between macro- and microcirculation, a number of biochemical markers can easily be obtained. Among those are central-venous oxygen saturation (ScvO2), plasma lactate and the difference between central-venous and arterial CO2 (cv-a-pCO2-gap). These inexpensive markers have become part of clinical routine and guideline recommendations. While their potential to replace parameters of macro-circulation such as cardiac output (CO) is limited, they facilitate the interpretation of the adequacy of CO and other macro-circulatory markers. Furthermore, they give additional hints on micro-circulatory impairment. In addition, a number of more sophisticated technical approaches to quantify and visualize micro-circulation including video-microscopy, laser flowmetry, near-infrared spectroscopy (NIRS), and partial oxygen pressure measurement have been introduced within the last 20 years. These technologies have been extensively used for scientific purposes. Moreover, they have been successfully used for educational purposes and to visualize micro-circulatory disturbances during sepsis and other causes of shock. Despite several studies demonstrating the association of these techniques and parameters with outcome, their practical application still is limited. However, future improvements in automated and “online” diagnosis will help to make these technologies more applicable in clinical routine. This approach is promising with regard to several studies which demonstrated the potential to guide therapy in different types of shock. Finally several organs have specific patterns of circulation related to their special anatomy (liver) or their auto-regulatory capacities (brain, kidney). Therefore, this review also discusses specific issues of monitoring liver, brain, and kidney circulation and function.

Highlights

Macro-CirculationOrgan function directly depends on appropriate supply of oxygen and energy
A more recent study investigating the prognostic value of the subjective assessment of peripheral perfusion in critically ill patients showed that central to toe temperature and the skin temperature gradient between the forearm and the index finger were significantly different for patients with and without abnormal peripheral perfusion which was substantially associated to outcome [27]
Its use is recommended for correction of congenital heart defects during childhood as well as operations of the aortic arch in children and adults

Summary

INTRODUCTION

Organ function directly depends on appropriate supply of oxygen and energy. To maintain these prerequisites of cellular integrity and organ function, as well as to remove waste products and toxic metabolites, sufficient circulation, and perfusion are required. A more recent study investigating the prognostic value of the subjective assessment of peripheral perfusion in critically ill patients showed that central to toe temperature and the skin temperature gradient between the forearm and the index finger were significantly different for patients with and without abnormal peripheral perfusion which was substantially associated to outcome [27]. Several recent studies report on comparable predictive capacities of surface temperature measured with non-contact infrared thermometers While these devices are ubiquitously available and easy to use, the approach of thermal imagery is predominantly of scientific and potentially clinical interest. A structured combination of clinical parameters of the skin perfusion might improve resuscitation compared to standard algorithms [44] (Table 4)

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Findings

14 CO2-exhalation 13 CO2-exhalation