Narrative review: clinical assessment of peripheral tissue perfusion in septic shock

Abstract Background Vitamin C has potential protective effects through anti-oxydant and anti-inflammatory properties. However, the effect of Vitamin C supplementation on microvascular function and peripheral tissue perfusion in human sepsis remains unknown. We aimed to determine vitamin C effect on microvascular endothelial dysfunction and peripheral tissue perfusion in septic shock patients. Methods Patients with septic shock were prospectively included after initial resuscitation. Bedside peripheral tissue perfusion and skin microvascular reactivity in response to acetylcholine iontophoresis in the forearm area were measured before and 1 hour after intravenous Vitamin C supplementation (40 mg/kg). Norepinephrine dose was not modified during the studied period. Results We included 30 patients with septic shock. SOFA score was 11 [8–14], SAPS II was 66 [54-79] and in-hospital mortality was 33%. Half of these patients had vitamin C deficiency at inclusion. Vitamin C supplementation strongly improved microvascular reactivity (AUC 2263 [430-4246] vs 5362 [1744-10585] UI, p=0.0004). In addition, Vitamin C supplementation improved mottling score (p=0.06), finger-tip (p=0.0003) and knee capillary refill time (3.7 [2.6-5.5] vs 2.9 [1.9-4.7] s, p<0.0001), as well as and central-to-periphery temperature gradient (6.1 [4.9-7.4] vs 4.6 [3.4-7.0] °C, p<0.0001). The beneficial effects of Vitamin C were observed both in patients with or without Vitamin C deficiency. Conclusion In resuscitated septic shock patients, vitamin C supplementation improved peripheral tissue perfusion and microvascular reactivity whatever plasma levels of vitamin C.

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Effects of capillary refill time-vs. lactate-targeted fluid resuscitation on regional, microcirculatory and hypoxia-related perfusion parameters in septic shock: a randomized controlled trial

Annals of Intensive Care ◽

10.1186/s13613-020-00767-4 ◽

2020 ◽

Vol 10 (1) ◽

Author(s):

Ricardo Castro ◽

Eduardo Kattan ◽

Giorgio Ferri ◽

Ronald Pairumani ◽

Emilio Daniel Valenzuela ◽

...

Keyword(s):

Septic Shock ◽

Randomized Controlled Trial ◽

Fluid Resuscitation ◽

Controlled Trial ◽

Tissue Perfusion ◽

Capillary Refill Time ◽

Capillary Refill ◽

Randomized Controlled ◽

Microcirculatory Flow ◽

The Impact

Abstract Background Persistent hyperlactatemia has been considered as a signal of tissue hypoperfusion in septic shock patients, but multiple non-hypoperfusion-related pathogenic mechanisms could be involved. Therefore, pursuing lactate normalization may lead to the risk of fluid overload. Peripheral perfusion, assessed by the capillary refill time (CRT), could be an effective alternative resuscitation target as recently demonstrated by the ANDROMEDA-SHOCK trial. We designed the present randomized controlled trial to address the impact of a CRT-targeted (CRT-T) vs. a lactate-targeted (LAC-T) fluid resuscitation strategy on fluid balances within 24 h of septic shock diagnosis. In addition, we compared the effects of both strategies on organ dysfunction, regional and microcirculatory flow, and tissue hypoxia surrogates. Results Forty-two fluid-responsive septic shock patients were randomized into CRT-T or LAC-T groups. Fluids were administered until target achievement during the 6 h intervention period, or until safety criteria were met. CRT-T was aimed at CRT normalization (≤ 3 s), whereas in LAC-T the goal was lactate normalization (≤ 2 mmol/L) or a 20% decrease every 2 h. Multimodal perfusion monitoring included sublingual microcirculatory assessment; plasma-disappearance rate of indocyanine green; muscle oxygen saturation; central venous-arterial pCO2 gradient/ arterial-venous O2 content difference ratio; and lactate/pyruvate ratio. There was no difference between CRT-T vs. LAC-T in 6 h-fluid boluses (875 [375–2625] vs. 1500 [1000–2000], p = 0.3), or balances (982[249–2833] vs. 15,800 [740–6587, p = 0.2]). CRT-T was associated with a higher achievement of the predefined perfusion target (62 vs. 24, p = 0.03). No significant differences in perfusion-related variables or hypoxia surrogates were observed. Conclusions CRT-targeted fluid resuscitation was not superior to a lactate-targeted one on fluid administration or balances. However, it was associated with comparable effects on regional and microcirculatory flow parameters and hypoxia surrogates, and a faster achievement of the predefined resuscitation target. Our data suggest that stopping fluids in patients with CRT ≤ 3 s appears as safe in terms of tissue perfusion. Clinical Trials: ClinicalTrials.gov Identifier: NCT03762005 (Retrospectively registered on December 3rd 2018)

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Influence of arterial pressure on tissue perfusion in septic shock

Critical Care ◽

10.1186/cc7318 ◽

2009 ◽

Vol 13 (Suppl 1) ◽

pp. P154

Author(s):

E Tishkov ◽

O Bukaev

Keyword(s):

Septic Shock ◽

Arterial Pressure ◽

Tissue Perfusion

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Lactate Clearance Versus Base Deficit Correction in Monotoring of Septic Shock

QJM ◽

10.1093/qjmed/hcab086.015 ◽

2021 ◽

Vol 114 (Supplement_1) ◽

Author(s):

Adel Mikhail Fahmy ◽

Ahmed Kamal ◽

Wael Abd Elmonem Mohamed Abdelwahab ◽

Ameer Shokry Ahmed

Keyword(s):

Septic Shock ◽

Clinical Utility ◽

Tissue Perfusion ◽

Lactate Clearance ◽

Serum Lactate ◽

Base Deficit ◽

Mortality And Morbidity ◽

Survivor Group ◽

Prediction Of Mortality ◽

Group I

Abstract Background Tissue perfusion and oxygenation monitoring is the fundamental of management to immediately identify and properly manage (impending) organ dysfunction in septic shock. This is a study of a prospective randomized trial that aims to comparing the prognostic value of lactate clearance versus base deficit correction as an indicator of tissue perfusion in septic shock, trying to prove the superiority of one over the other. Objective To assess the clinical utility of lactate clearance and arterial base deficit correction in predicting mortality in septic shock. Patients and Methods This is a Prospective randomized observational study that was conducted to assess the clinical utility of lactate clearance and arterial base deficit in predicting mortality in septic shock. This study included forty patients who were divided into two equal groups; each of twenty patients, group I (non-survivors), and group II (survivors). Results In this study, the base deficit values revealed statistically notable difference between the two groups at admission, 18 hours, 24 hours and 2 days of admission. The values revealed no notable difference at the 3rd. 4th, and 5th day of admission. At the 6th and 7th day of admission, the base deficit started to increase again in the non-survivor group with statistically notable increase in the values as compared to the survivor group. The cutoff point of base deficit to differentiate between nonsurvivors from survivors was > 11.43 with 62% sensitivity and 100% specificity. In this study, initial serum lactate levels at admission revealed higher accuracy in prediction of mortality as compared with initial base deficit. Conclusion Lactate clearance is a better predictor of mortality and morbidity than base deficit correction.

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Quantitative Analysis of Peripheral Tissue Perfusion Using Spatiotemporal Molecular Dynamics

PLoS ONE ◽

10.1371/journal.pone.0004275 ◽

2009 ◽

Vol 4 (1) ◽

pp. e4275 ◽

Cited By ~ 37

Author(s):

Yujung Kang ◽

Myunghwan Choi ◽

Jungsul Lee ◽

Gou Young Koh ◽

Kihwan Kwon ◽

...

Keyword(s):

Molecular Dynamics ◽

Quantitative Analysis ◽

Tissue Perfusion ◽

Peripheral Tissue

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Application of novel dynamic optical imaging for evaluation of peripheral tissue perfusion

International Journal of Cardiology ◽

10.1016/j.ijcard.2008.12.166 ◽

2010 ◽

Vol 145 (3) ◽

pp. e99-e101 ◽

Cited By ~ 15

Author(s):

Yujung Kang ◽

Jungsul Lee ◽

Kihwan Kwon ◽

Chulhee Choi

Keyword(s):

Optical Imaging ◽

Tissue Perfusion ◽

Peripheral Tissue

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Pengelolaan Ketidakefektifan Perfusi Jaringan Perifer Pada Pasien Post ORIF Hari Ke-3 Atas Indikasi Fraktur Femur Dextra 1/3 Distal Di RSUD Ungaran

Indonesian Journal of Nursing Research (IJNR) ◽

10.35473/ijnr.v3i2.895 ◽

2021 ◽

Vol 3 (2) ◽

pp. 41

Author(s):

Anggi Agustina ◽

Mukhamad Musta'in ◽

Maksum Maksum

Keyword(s):

Hospital Management ◽

Tissue Perfusion ◽

Regional Hospital ◽

Peripheral Tissue ◽

The Third

Fracture is the broken continuity of the bone. Based on type and size of the bone, bone can break when it is not strong enough to withstand the pressure applied to the bone. The purpose of this research was to determine the management of the ineffectiveness of peripheral tissue perfusion in Mrs.S suffering from third-day post ORIF with the indication of femur 1/3 distal dextra fracture in Cempaka room, Ungaran Regional Hospital. Management results obtained swollen femur on the third-day post ORIF. It can cause complications due to the ineffectiveness of peripheral tissue perfusion in the patient. A suggestion for nurses in the hospital is to be able to carry out routine observations in post-operative ORIF patients that might experience changing condition. Key words:ROM Exercise, Ineffective Peripheral Tissue Perfusion, Post ORIF

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Assessment of clinical parameters and immediate outcome of children with shock in a tertiary care hospital ASRAM, Eluru, Andhra Pradesh, India

International Journal of Contemporary Pediatrics ◽

10.18203/2349-3291.ijcp20170714 ◽

2017 ◽

Vol 4 (2) ◽

pp. 586

Author(s):

Arigela Vasundhara ◽

Manas Ranjan Sahoo ◽

Sai Silpa Chowdary

Keyword(s):

Septic Shock ◽

Cardiogenic Shock ◽

Tertiary Care ◽

Hypovolemic Shock ◽

Oxygen Demand ◽

Tissue Perfusion ◽

Multiple Organ ◽

Cellular Damage ◽

Care Hospital ◽

A Prospective Study

Background: Shock is a state of impaired tissue perfusion resulting in an imbalance between oxygen demand and supply. This widespread reduction in effective tissue perfusion causes insufficient or improper delivery and distribution of oxygen and nutrients, the end result of which is an altered cellular and sub cellular function leading to anaerobic metabolism and accumulation of lactic acid, and consequently cellular damage, multiple organ dysfunction and finally cardiovascular collapse.Methods: The present study was conducted in the department of Pediatrics at Alluri Sitarama Raju Academy of Medical Sciences hospital, Eluru, between December 2014 and June 2016. It is a prospective study. Children aged 1 month to 12 years with a clinical diagnosis of shock were included after written consent from parents.Results: Out of 75 children admitted with shock, 69.33% had septic shock, 25.33% had hypovolemic shock, 2.66% had distributive shock, 2.66% cardiogenic shock. Most common age group admitted with shock was 1 month-1 year 38.666%. Among 75 children with shock, 74.66% children survived and 25.33% children died. Mortality rate in cardiogenic shock was 100%, in septic shock 28.84%, in hypovolemic shock 10.52%.Conclusions: Septic shock was the most common type of shock. Most common cause for septic shock was pneumonia. Septic shock has got highest mortality in the present study.Need for inotropes and mechanical ventilaton indicates poor prognosis in shock.

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Microcirculatory effects of norepinephrine in patients with septic shock: a microdialysis study

10.21203/rs.3.rs-17259/v1 ◽

2020 ◽

Author(s):

Amira Fatnassi ◽

Chihebeddine Romdhani ◽

Widd Kaabi ◽

Iheb Labbene ◽

Zied Hajjej ◽

...

Keyword(s):

Septic Shock ◽

Lactate Concentration ◽

Inverse Correlation ◽

Tissue Perfusion ◽

Control Group ◽

Adrenergic Drug ◽

Microdialysis Study ◽

And Control ◽

Stable Flow ◽

Pyruvate Ratio

Abstract Background: The management of septic shock requires the administration of an alpha-adrenergic drug such as norepinephrine, after optimization of the patient’s preload, to maintain adequate mean arterial pressure. Nevertheless, with optimal macrocirculatory parameters, alterations of tissue perfusion can occur. This study aimed to investigate the effect of norepinephrine dosage on microcirculation parameters, studied by microdialysis, in patients with septic shock. Methods: We conducted a retrospective study. We included all patients aged over 16 years in septic shock. We studied three groups (levosimendan, dobutamine, and control group). We administrated norepinephrine before inclusion, at stable flow for more than an hour. We performed hemodynamic monitoring of macrocirculation by echocardiography. We analyzed microcirculation parameters (lactate, pyruvate, and lactate/pyruvate ratio) every six hours during the first three days, by muscle microdialysis (CMA 600, CMA microdialysis AB, Stockholm, Sweden). We studied correlations between microcirculation parameters and norepinephrine doses.Results: We included thirty patients in the study (ten patients in each group). Demographic characteristics and mortality were comparable across the three groups. In total, we analyzed 390 samples of interstitial muscle fluid. We did not find any correlation between norepinephrine doses and the lactate concentration in the muscle, as well as the ratio of lactate/ pyruvate concentration in the muscle (p > 0.05) for all groups. We found a weak inverse correlation between norepinephrine doses and muscle pyruvate levels (p < 0.05) for the dobutamine group and the control group and but not for the levosimendan group.Conclusions: Noradrenaline dose has little effect on microcirculation when administered for hemodynamic optimization, as recommended by the Surviving Sepsis Campaign.

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