Both passive leg raising and intravascular volume expansion improve sublingual microcirculatory perfusion in severe sepsis and septic shock patients

Abstract

Purpose: To assess sublingual microcirculatory changes following passive leg raising (PLR) and volume expansion (VE) in septic patients. Methods: This prospective study was conducted in two university hospital intensive care units and included 25 mechanically ventilated patients with severe sepsis or septic shock who were eligible for VE in the first 24 h of their admission. Pulse pressure variation (DPP), cardiac output (CO) and sublingual microcirculation indices were assessed at five consecutive steps: (1) semirecumbent position (Baseline 1), (2) during PLR manoeuvre (PLR), (3) after returning to semi-recumbent position (Baseline 2), (4) at the time when VE induced the same degree of preload responsiveness as PLR (VE DPP = PLR ) and (5) at the end of VE (VE END ). At each step, five sublingual microcirculation sequences were acquired using sidestream darkfield imaging to assess functional capillary density (FCD), microcirculatory flow index (MFI), proportion of perfused vessels (PPV) and flow heterogeneity index (FHI). Results: The PLR, VE DPP = PLR and VE END induced a significant increase in CO and a significant decrease in DPP compared to Baseline 1 and Baseline 2 values. Both PLR and VE induced significant increases in FCD, MFI and PPV and a significant decrease in FHI compared to Baseline 1 and Baseline 2 values. Conclusions: In preload responsive severe septic patients examined within the first 24 h of their admission, both PLR and VE improved sublingual microcirculatory perfusion. At the level of volume infusion used in this study, these changes in sublingual microcirculation were not explained by changes in rheologic factors or changes in arterial pressure.

A high mean arterial pressure target is associated with improved microcirculation in septic shock patients with previous hypertension: A prospective open-label study

“…Increasing the dose of NE significantly augments cardiac output by 11 to 17% [21], suggesting NE might recruit some blood from the large venous unstressed volume as another method of "endogenous fluid challenge". Since fluid challenge is demonstrated to improve microvascular perfusion in the early phase of septic shock [22,23], NE-induced microcirculatory improvement might occur because of its role on arterial pressure preservation and blood recruitment.…”

Avaliação da microcirculação: uma nova arma no manejo da sepse?

“…* Clinical Effects of hydrocortisone on microcirculatory alterations in patients with septic shock. Pottecher et al (21) 2010 Intensive Care Med. * Clinical Both passive leg raising and intravascular volume expansion improve sublingual microcirculatory perfusion in severe sepsis and septic shock patients.…”

“…There appeared to be no rheological influence, at least with the limited volume of infusion. (21) In a recent study, Ospina-Tascon et al compared a volume infusion of either crystalloids or colloids in two groups of patients: a group with severe sepsis for less than 24 hours and a group with severe sepsis for more than 48 hours. A significant increase in small vessel density and perfusion was shown only in the former group, which demonstrates the relevance of early optimization of microcirculation.…”

Actualización del bundle de reanimación inicial y monitorización integral de la perfusión tisular en la sepsis severa

“…Por ello la reposición del volumen circulante efectivo constituye el pilar fundamental de esta fase, con la finalidad de modular la respuesta inflamatoria y restaurar la perfusión tisular antes de que ocurra un daño irreversible 26 . El aporte precoz de fluidos ha demostrado mejorar significativamente pará-metros macro hemodinámicos, metabólicos y la micro circulación en pacientes con sepsis severa, independiente del tipo de fluido administrado 27,28 .…”