Direct assessment of microcirculation in shock: a randomized-controlled multicenter study

• DOI: 10.1007/s00134-023-07098-5
• Publication Date: 2023-06-06T16:46:26Z
• Authors: Raphael Romano Bruno; Jakob Wollborn; Karl Fengler; Moritz Flick; Christian Wunder; Sebastian Allgäuer; Holger Thiele; Mara Schemmelmann; Johanna Hornemann; Helene Mathilde E...; Filiz Demirtas; Lina Palici; Marcus Franz; Bernd Saugel; Eduardo Kattan; Daniel De Backer; Jan Bakker; Glenn Hernandez; Malte Kelm; Christian Jung
• Keywords: Original; Microcirculation; Resuscitation; 610; Généralités; Shock; Shock, Septic; 3. Good health; Sidestream-dark field video microscope; Intravital microscopy; Intensive Care Units; Intensive care; Intravital microscopy ; Intensive care ; Humans [MeSH] ; Prospective Studies [MeSH] ; Microcirculation [MeSH] ; Original ; Shock, Septic/drug therapy [MeSH] ; Microcirculation ; Shock ; Sidestream-dark field video microscope ; Medical and Health Sciences ; Intensive Care Units [MeSH] ; Resuscitation/methods [MeSH]; 03 Salud y bienestar; 617; Humans; 03 Good Health and Well-being; Prospective Studies

Shock is a life-threatening condition characterized by substantial alterations in the microcirculation. This study tests the hypothesis that considering sublingual microcirculatory perfusion variables in the therapeutic management reduces 30-day mortality in patients admitted to the intensive care unit (ICU) with shock.This randomized, prospective clinical multicenter trial-recruited patients with an arterial lactate value above two mmol/L, requiring vasopressors despite adequate fluid resuscitation, regardless of the cause of shock. All patients received sequential sublingual measurements using a sidestream-dark field (SDF) video microscope at admission to the intensive care unit (± 4 h) and 24 (± 4) hours later that was performed blindly to the treatment team. Patients were randomized to usual routine or to integrating sublingual microcirculatory perfusion variables in the therapy plan. The primary endpoint was 30-day mortality, secondary endpoints were length of stay on the ICU and the hospital, and 6-months mortality.Overall, we included 141 patients with cardiogenic (n = 77), post cardiac surgery (n = 27), or septic shock (n = 22). 69 patients were randomized to the intervention and 72 to routine care. No serious adverse events (SAEs) occurred. In the interventional group, significantly more patients received an adjustment (increase or decrease) in vasoactive drugs or fluids (66.7% vs. 41.8%, p = 0.009) within the next hour. Microcirculatory values 24 h after admission and 30-day mortality did not differ [crude: 32 (47.1%) patients versus 25 (34.7%), relative risk (RR) 1.39 (0.91-1.97); Cox-regression: hazard ratio (HR) 1.54 (95% confidence interval (CI) 0.90-2.66, p = 0.118)].Integrating sublingual microcirculatory perfusion variables in the therapy plan resulted in treatment changes that do not improve survival at all.