Abstract
BackgroundWe sought to determine the effects of alternative resuscitation strategies on microcirculatory perfusion and examine any association between microcirculatory perfusion and mortality in sepsis.MethodsThis was a prospective, formally designed substudy of participants in the Protocolized Care in Early Septic Shock (ProCESS) trial. We recruited from six sites with the equipment and training to perform these study procedures. All subjects were adults with septic shock, and each was assigned to alternative resuscitation strategies. The two main analyses assessed (1) the impact of resuscitation strategies on microcirculatory perfusion parameters and (2) the association of microcirculatory perfusion with 60-day in-hospital mortality. We measured sublingual microcirculatory perfusion using sidestream dark field in vivo video microscopy at the completion of the 6-h ProCESS resuscitation protocol and then again at 24 and 72 h.ResultsWe enrolled 207 subjects (demographics were similar to the overall ProCESS cohort) and observed 40 (19.3%) deaths. There were no differences in average perfusion characteristics between treatment arms. Analyzing the relationship between microcirculatory perfusion and mortality, we found an association between vascular density parameters and mortality. Total vascular density (beta = 0.006, p < 0.003), perfused vascular density (beta = 0.005, p < 0.04), and De Backer score (beta = 0.009, p < 0.01) were higher overall in survivors in a generalized estimating equation model, and this association was significant at the 72-h time point (p < 0.05 for each parameter).ConclusionsMicrocirculatory perfusion did not differ between three early septic shock treatment arms. We found an association between microcirculatory perfusion parameters of vascular density at 72 h and mortality.Trial registrationClinicalTrials.gov, NCT00510835. Registered on August 2, 2007.
Highlights
We sought to determine the effects of alternative resuscitation strategies on microcirculatory perfusion and examine any association between microcirculatory perfusion and mortality in sepsis
We studied patients enrolled in the Protocolized Care for Early Septic Shock (ProCESS) study, a randomized clinical trial of three alternative resuscitation strategies that included the administration of fluids, vasopressors, blood, and dobutamine
We report the suggested measures of proportion of perfused vessels (PPV), microcirculatory flow index (MFI), De Backer score, total vascular density (TVD), perfused vascular density (PVD), and heterogeneity index (Table 1) [29]
Summary
We sought to determine the effects of alternative resuscitation strategies on microcirculatory perfusion and examine any association between microcirculatory perfusion and mortality in sepsis. Patients with sepsis have high morbidity, mortality, and care costs. Improving outcomes requires an enhanced understanding of the complex pathophysiology of the disease. Organ dysfunction and multisystem organ failure are common precursors to death in sepsis. The smallest blood vessels of the microcirculation (< 20 μm in diameter) are the principal sites of gas and nutrient exchange between blood and underlying tissues [1]. Microcirculatory perfusion disturbances represent a direct physiologic link to multisystem organ dysfunction. Microcirculatory perfusion disturbances represent a potential universal link across organs and could alter insights and care
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