Abstract
BackgroundManagement of tissue perfusion following cardiac surgery is a challenging task where common clinical parameters do not reflect microcirculatory dysfunction. Heterogeneity in blood flow perfusion and abnormalities in capillary density characterize microcirculatory dysfunction. The restoration of a normal microcirculation may become a novel target for therapy in the future in addition to macrocirculatory parameters. The aim of this study is to determine how the sublingual microcirculatory parameters vary at the bedside in post-cardiac surgery patients which underwent diuretic therapy to correct fluid overload.MethodsIn this prospective observational pilot study, video clips of sublingual microcirculation in post-cardiac surgery patients receiving furosemide and/or spironolactone to achieve normal fluid balance were recorded using Cytocam-IDF imaging. Data was obtained on the first (T0), second (T1), and third (T2) day after the patients left the intensive care unit (ICU). Measurements were analyzed off-line to obtain the following microcirculatory parameters: total vessel density (TVD), microcirculatory flow index (MFI), proportion of perfused vessel (PPV), and perfused vessel density (PVD). Macrocirculatory parameters and body weight were also collected at these time points.ResultsNinety measurements were performed in ten post ICU cardiac surgery patients. Thirteen measurements were excluded due to quality reasons; these excluded measurements were spread across the patients and time points, and there was no loss of patients or time points. An increase in TVD was observed from T0 to T1 (20 ± 2.7 to 24 ± 3.2 mm/mm2; p = 0.0410) and from T0 to T2 (20 ± 2.7 to 26 ± 3.3 mm/mm2; p = 0.0005). An increase in PVD was present from T0 to T1 (19 ± 2.3 to 24 ± 3.5 mm/mm2; p = 0.0072) and from T0 to T2 (19 ± 2.3 to 26 ± 3.4 mm/mm2, p = 0.0008). Fluid overload was assessed through a positive cumulative fluid balance on the day of ICU discharge.ConclusionsCytocam-IDF imaging to monitor microcirculation as a daily parameter is feasible and could become a valuable tool to non-invasively assess the tissue oxygenation at the bedside. An increase in TVD and PVD (functional capillary density) indicated the recruitment of the sublingual microcirculation in patients with diuretic therapy. Future research is needed to prove the correlation between the recruitment of the sublingual microcirculation and the de-escalation phase of the fluid management.
Highlights
Management of tissue perfusion following cardiac surgery is a challenging task where common clinical parameters do not reflect microcirculatory dysfunction
Future research is needed to prove the correlation between the recruitment of the sublingual microcirculation and the deescalation phase of the fluid management
The excluded clips were spread across the patients and time points, and there was no loss of patients or time points
Summary
Management of tissue perfusion following cardiac surgery is a challenging task where common clinical parameters do not reflect microcirculatory dysfunction. Cardiac surgery including or excluding cardiopulmonary bypass (CPB) is associated with several microcirculatory alterations and consequent reduction in tissue oxygenation (Kara et al 2016). In spite of a rigid control of hemodynamic parameters, complications are frequently observed after cardiac surgery during the perioperative period in the intensive care unit and ward. Positive cumulative fluid balance due to excessive fluid administration during the perioperative period may cause complications such as respiratory distress, kidney failure, intra-abdominal hypertension (IAH), and impaired wound healing (Malbrain et al 2014; Prowle et al 2010; Xu et al 2015) in post-intensive care unit (ICU) cardiac surgery patients (Haase-Fielitz et al 2017) and in sepsis (Kelm et al 2015; Loflin and Winters 2017; Vincent et al 2006). Morbidity is increased and quality of life after surgery (Ghaferi et al 2009) is decreased
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