title: Early increases in microcirculatory perfusion during protocol-directed resuscitation are associated with reduced multi-organ failure at 24 h in patients with sepsis.
abstract: 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.
authors.affiliation: 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
authors.forename: Stephen
authors.initials: S
authors.lastname: Trzeciak
authors.forename: Jonathan V
authors.initials: JV
authors.lastname: McCoy
authors.forename: R
authors.initials: R
authors.lastname: Phillip Dellinger
authors.forename: Ryan C
authors.initials: RC
authors.lastname: Arnold
authors.forename: Michael
authors.initials: M
authors.lastname: Rizzuto
authors.forename: Nicole L
authors.initials: NL
authors.lastname: Abate
authors.forename: Nathan I
authors.initials: NI
authors.lastname: Shapiro
authors.forename: Joseph E
authors.initials: JE
authors.lastname: Parrillo
authors.forename: Steven M
authors.initials: SM
authors.lastname: Hollenberg
mesh_terms: 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