Early increases in microcirculatory perfusion during protocol-directed resuscitation are associated with reduced multi-organ failure at 24 h in patients with sepsis.
OBJECTIVE
Sepsis mortality is closely linked to multi-organ failure, and impaired microcirculatory blood flow is thought to be pivotal in the pathogenesis of sepsis-induced organ failure. We hypothesized that changes in microcirculatory flow during resuscitation are associated with changes in organ failure over the first 24 h of sepsis therapy.


METHODS
Prospective observational study.


METHODS
Emergency Department and Intensive Care Unit.


METHODS
Septic patients with systolic blood pressure <90 mmHg despite intravenous fluids or lactate >or=4.0 mM/L treated with early goal-directed therapy (EGDT).


RESULTS
We performed Sidestream Dark Field (SDF) videomicroscopy of the sublingual microcirculation <3 h from EGDT initiation and again within a 3-6 h time window after initial. We imaged five sites and determined the mean microcirculatory flow index (MFI) (0 no flow to 3 normal) blinded to all clinical data. We calculated the Sequential Organ Failure Assessment (SOFA) score at 0 and 24 h, and defined improved SOFA a priori as a decrease >or=2 points. Of 33 subjects; 48% improved SOFA over 0-24 h. Age, APACHE II, and global hemodynamics did not differ significantly between organ failure groups. Among SOFA improvers, 88% increased MFI during EGDT, compared to 47% for non-improvers (P = 0.03). Median change in MFI was 0.23 for SOFA improvers versus -0.05 for non-improvers (P = 0.04).


CONCLUSIONS
Increased microcirculatory flow during resuscitation was associated with reduced organ failure at 24 h without substantial differences in global hemodynamics. These data support the hypothesis that targeting the microcirculation distinct from the macrocirculation could potentially improve organ failure in sepsis.
Trzeciak
Stephen
S
Department of Medicine, Divisions of Cardiovascular Disease and Critical Care Medicine, UMDNJ-Robert Wood Johnson Medical School at Camden, Cooper University Hospital, One Cooper Plaza D363, Camden, NJ 08103, USA. trzeciak-stephen@cooperhealth.edu
McCoy
Jonathan V
JV
Phillip Dellinger
R
R
Arnold
Ryan C
RC
Rizzuto
Michael
M
Abate
Nicole L
NL
Shapiro
Nathan I
NI
Parrillo
Joseph E
JE
Hollenberg
Steven M
SM
D000368:Aged; D005260:Female; D005440:Fluid Therapy; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008833:Microcirculation / Q000502:physiology*; D008875:Middle Aged; D009060:Mouth Floor / Q000098:blood supply; D009102:Multiple Organ Failure / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D011446:Prospective Studies; D018805:Sepsis / Q000503:physiopathology / Q000628:therapy*; D012720:Severity of Illness Index; D012772:Shock, Septic / Q000628:therapy