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Classification of microcirculatory abnormalities in distributive shock Can Ince Clinical Physiology Academic Medical Ce

Classification of microcirculatory abnormalities in distributive shock Can Ince Clinical Physiology Academic Medical Center University of Amsterdam. Declared interest: I am CSO of MicroVision Medical an AMC based company . Proposed reclassification of shock states

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Classification of microcirculatory abnormalities in distributive shock Can Ince Clinical Physiology Academic Medical Ce

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  1. Classification of microcirculatory abnormalities in distributive shock Can Ince Clinical Physiology Academic Medical Center University of Amsterdam Declared interest: I am CSO of MicroVision Medical an AMC based company

  2. Proposed reclassification of shock states with special reference to distributive defects. Weil MH, Shubin H (1971) Adv Exp Med Biol 23:13-23.

  3. Hypovolemic, cardiogenic, and obstructive shock occurs as a result of decrease in cardiac output leading to anaerobic tissue metabolism. • Septic shock results from distributive alterations in tissue perfusion caused by abnormal control of microvasculature with abnormal distribution of a normal or increased cardiac output. • Hence end-points have been difficult to define. • Vincent JL Hemodynamic support in septic shock • Intensive Care Medicine (2001) 27:S80-S92

  4. “…Our understanding of hemodynamic mechanisms (in distributive shock) depends not so much on the total volume of blood that flows past the aortic valve or the cardiac output as on the amount of blood delivered to the exchange sites. Even though cardiac output may be substantial, if that blood flow does not arrive at the exchange sites, the ultimate metabolic detriment is no different from low cardiac output without shunt flow.” Weil MH, Shubin H (1971) Adv Exp Med Biol 23:13-23.

  5. Shunting model of sepsis Implication : that active recruitment of the microcirculation is an important component of resuscitation. O2 a v lactate CO2 Ince C & Sinaasappel M (1999) Crit Care Med27:1369-1377

  6. Why the microcirculation is important in shock. • It is where oxygen exchange takes place. • Every parameter in the microcirculation is different than in the systemic circulation. • It plays a central role in the immune system. • During sepsis and shock it the first to go and last to recover. • Rescue of the microcirculation = resuscitation end-point.

  7. Sepsis is a disease of the microcirculation Spronk P, Zandstra D, Ince C (2004) Critical Care 8:462-468

  8. Sepsis is a disease of the microcirculation (vessels < 250 m) • Inflammatory activation • Coagulatory/RBC dysfunction • Endothelial barrier dysfunction • Capillary fall out • Weak microcirculatory units are shunted • Hypoxia, apoptosis, organ dysfunction Not detected by systemic variables Not responsive to therapy per se Spronk P, Zandstra D, Ince C (2004) Critical Care 8:462-468

  9. Microcirculatory and Mitochondrial Distress Syndrome (MMDS) MMDS = sepsis +genes+ therapy + time Ince C (2005) Critical Care 9:S13-S19

  10. Microcirculatory Mitochondrial Distress Syndrome . Critical Care (2005) 9:S13-S19 Initial Hit Co-morbidity Genes Time Therapy Circulatory Shock + Inflammation Resuscitation based on correction of systemic hemodynamics+ inflammation Time Therapy Microcirculatory Dysfunction Leukocytes Adhesion, Cytokines, ROS Endothelial Dysfunction Barrier, Communication Coagulation, Regulation RBC Deformability,Aggregation O2 transport Coagulation Natural Anticoagulants Microvascular Thrombosis Organ Failure Dysfunction Autoregulation Microcirculatory shunting supply-demand mismatch Hypoxia Cellular Distress Mitochondria Hibernation Apoptosis

  11. Microcirculation is shunted when µpO2becomes less than venous pO2values remain unchanged.

  12. Functional shunting is more severe in septic shock than in blood pressure matched hemorrhagic shock in pig intestines Ince C & Sinaasappel M (1999) Crit Care Medicine27:1369-1377

  13. Gut microcirculatory shunt (pO2 gap) and tissue CO2 pO2 gap tissue CO2 Gut Regional flow and oxygen delivery

  14. Hb based oxygen carriers (DCLHb) resuscitates gut serosa and mucosa equally following hemhorrhage. heart mucosa Van Iterson M, Siegemund M, Burhop K, Ince C (2003) J. of Trauma 55:1111-1124 serosa

  15. Dopexamin resuscitates the microcirculation of the mucosa but not of the serosa and gut tissue CO2.

  16. The NO donor SIN-1 resuscitates gut serosal and mucosal microcirculation as well as gastric CO2 Serosa (μpO2) Gastric CO2 Mucosa (μpO2) Siegemund M, van Bommel J, Vollebrecht K, Dries J, Ince C (2000) Intensive Care Med 26:S 362

  17. Microcirculation Recruitment Manoeuvres Correct pathological flow heterogeneity, microcirculatory shunting and restore autoregulatory dysfunction by control of inflammation, vascular function and coagulation. Open the microcirculation and keep it open by support of the pump, fluids, vasodilators and restricted use of vasopressor agents. Ince C (2005) Critical Care 9:S13-S19

  18. 3 cm OPS imaging validated against capillary microscopy Analyzer Polarizer Mathura et al. (2001) J. Applied Physiology 91:74-78.

  19. First direct visualizations of the microcirculation in human internal organs using OPS imaging. SAH Brain tumours during hyperventilation Before HV Groner et al. (1999) Nature Med 5:1209 Mathura et al. (2001) The Lancet 58:1698 Mathura et al. (2001) J. Appl Physiol 91:74 Spronk et al. (2001)The Lancet 360:1395 Pennings et al. (2004) Stroke 35:1284 . After HV

  20. SDF imaging Calculate velocity (30.49 pixels/s) Sidestream Dark Field imaging for improved technique for observation of the microcirculation Ince C (2005) Critical Care 9:S13-S19

  21. Flow score: 0 = no flow 1 = intermittent 2 = sluggish 3 = continuous Small: 10-25 μm Medium: 26-50 μm Large: 51-100 μm Boerma et al (2005) Crit Care 9:R601-R606

  22. De Backer, Creteur, Preiser, Dubois, Vincent Am J Respir Crit Care Med (2002) 166:98-104.

  23. There was no difference in sytemic hemodynamic and oxygenation variables or the amount or type of drugs used between survivors and non-survivors. Microcirculatory dysfunction was the single most sensitive and specific predictor of outcome. Sakr et al. Crit Care Med (2004) 32:1825-1831

  24. Resuscitatation is affective in recruitment of capillaries and correction of sub-lingual CO2 Creteur, J., De Backer, D. Sakr, Y.Koch, M., Vincent, J.L. (2004) Crit Care Med Suppl Vol. 31 (12):419

  25. Nitroglycerin promotes microvascular recruitment in septic and cardiogenic shock patients Sublingual OPS imaging in a patient with septic shock after pressure guided volume resuscitation. the same patient after subsequent nitroglycerin 0.5 mg ivbolus Spronk, Ince, Gardien, Mathura, Oudemans-van Straaten, Zandstra DF. (2002) The Lancet 360:1395-1396.

  26. . Nitroglycerin promotes microvascular recruitment in pressure resuscitated septic shock patients sub-lingual OPS imaging Spronk, Ince, Gardien, Mathura, Oudemans-van Straaten, Zandstra DF. The Lancet 2002; 360(9343):1395-1396. • Capillary flow but to a much lesser degree venular flow, is impaired during pressure guided resuscitation from septic shock. • NO donor can recruit the microcirculation by promoting flow.

  27. The effects of dobutamine on microcirculatory alterations in patients with septic shock are independent of its systemic effects. De Backer D et al. (2006) Crit Care Med 2006; 34:403–408)

  28. Thrombolysis in fulminant purpura: observations on changes in microcirculatory perfusion during successful treatment. Spronk PE Rommes JH, Schaar C, Ince C (2006)Thromb Haemost. 95(3):576-8

  29. Microvascular flow index (MFI) of small vessels in the sublingual region versus the MFI in the stoma region Christian Boerma

  30. Inflammatory Response to Cardiopulmonary Bypass Mechanisms Involved and Possible Therapeutic Strategies S Wan, JL LeClerc, JL Vincent. Chest 1997;112

  31. ECMO reduces FCD in premature infants J.E. van Velzen, C Ince, D Tibbeau Proc. Symp.Micro. Mit. Dysfuntion in ICM (2003)

  32. Healthy sub lingual microcirculation observed by SDF imaging

  33. Cardiogenic Shock

  34. Capillary hemodynamics underlying distributive defect Functionally all classes cause a distributive defect and functional shunting of the microcirculation.

  35. Conclusions • Distributive shock has a bad • prognosis with difficult to define • hemodynamics end-points. • 2) It causes a distributive defect at the • capillary level of the microcirculation causing functional shunting of weak microcirculatory units. • 3) It is the reason why distributive shock cannot be adeqautely monitored by systemic hemodynamic parameters. • 4) OPS/SDF en tissue capnography provide an integrative evaluation of the functional state of the microcirculation. • 5) Microcirculatory Recruitment Maneuvres are affective in correcting distributive shock

  36. 200 A B 150 100 ν2 Vessel length (μm) ν3 ν1 50 0 1 3 4 5 2 3 4 0 1 2 Time (sec) A typical space-time diagram of microvascular bloodflow before pump (A) and during pump (B). showing a pulsatile flow and respectively a continuous flow. Ligth bands represent either plasma gaps or white blood cells and dark bands represent red blood cells. The slope (v) of a band in a space-time diagram is the velocity. The horizontal light and dark bands are indicative of variations in the background light intensity. Panel A shows waivy bands indicating pulsatile flowpattern with a rapid (v1) and a slow (v2) phase. Panel B shows straight linear bands indicating non-pulsatile continuous flowpattern. The velocities are v1=428 μm/sv2=86 μm/sv3=327μm/s.

  37. Microcirculation Recruitment Manoeuvres Ince C (2005) Critical Care 9:S13-S19 Correct pathological flow heterogeneity, microcirculatory shunting and restore autoregulatory dysfunction by control of inflammation, vascular function and coagulation. Avontuur (1997) Cardiovas Res 35:368-376.Siegmund M (2005) Inten Care Med 31:985-992. Open the microcirculation and keep it open by support of the pump, fluids, vasodilators and restricted use of vasopressor agents. : Boerma (2005) Acta Anaesthesiol Scand. 49(9):1387-90. Spronk (2001)The Lancet 360:1395-1396 Siegemund (2006) Intensive Care Med

  38. Heart and gut serosa Gut serosa and mucosa Brain cortex

  39. Signs of regional dysoxia in the presence of apparent adequate oxygen delivery. • Cytopathic hypoxia: mitochondrial dysfunction in the presence of adequate tissue oxygenation. Fink MP (1997) Acta Anaesth. Scan.110:87-95. • Shunting theory of sepsis: microcirculatory shut down of weak microcirculatory units creating hypoxic pockets. Ince C & Sinaasappel M (1999) Crit Care Med. 27:1369-1377.

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