title: The microcirculation is preserved in emergency department low-acuity sepsis patients without hypotension.
abstract: OBJECTIVE
  Microcirculatory dysfunction plays an important role in sepsis pathophysiology. Previous studies using sidestream dark-field (SDF) imaging have demonstrated microcirculatory flow abnormalities in patients with septic shock; however, the microcirculation is relatively unstudied in lower-acuity sepsis patients. The hypothesis was that patients with sepsis, but without hypotension, will demonstrate signs of flow abnormalities compared to noninfected control patients.
  
  
  METHODS
  This was a prospective, observational study in a convenience sample of patients with sepsis and noninfected controls, conducted in three urban, tertiary care emergency departments (EDs) in the United States. Sepsis was defined as suspected infection plus two or more systemic inflammatory response syndrome (SIRS) criteria; those with hypotension were excluded. Noninfected controls were ED patients without infection and without SIRS criteria. SDF imaging was obtained in all study patients during ED evaluation. Recommended microcirculatory flow parameters were measured, and the difference in these measures between sepsis patients and noninfected controls were calculated. The authors also correlated microcirculatory flow parameters with patient variables, including serum lactate.
  
  
  RESULTS
  A total of 106 patients were enrolled: 63 with sepsis and 43 noninfected controls. There were no differences in microcirculatory flow scores between sepsis patients and noninfected controls. Median microvascular flow index (MFI; with interquartile range [IQR] was 3.00 (IQR = 2.73 to 3.00) in sepsis patients versus 2.93 (IQR = 2.73 to 3.00) in control patients (p = 0.33), and mean proportion of perfused small vessels (PPV) was 91.5% (95% CI = 89.7% to 93.3%) versus 91.8% (95% CI = 89.7% to 93.9%), with a mean difference of 0.3% (95% CI = -2.5% to 3.1%; p = 0.84). Similarly, there were no significant differences in total vessel density, perfused vessel density, or heterogeneity index (HI). In the subset of infected patients for whom serum lactates were obtained (n % 37), MFI and PPV were negatively correlated with elevated serum lactate values: r = -0.32, p = 0.04; and r = -0.44, p < 0.01, respectively.
  
  
  CONCLUSIONS
  Measureable microcirculatory flow abnormalities were not observed in patients with early sepsis in the absence of hypotension. However, microcirculatory abnormalities were correlated with elevated serum lactate in normotensive sepsis patients, supporting the notion that impaired microcirculatory flow is coupled with cellular distress.
authors.affiliation: Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
authors.forename: Michael R
authors.initials: MR
authors.lastname: Filbin
authors.forename: Peter C
authors.initials: PC
authors.lastname: Hou
authors.forename: Michael
authors.initials: M
authors.lastname: Massey
authors.forename: Apurv
authors.initials: A
authors.lastname: Barche
authors.forename: Erica
authors.initials: E
authors.lastname: Kao
authors.forename: Alex
authors.initials: A
authors.lastname: Bracey
authors.forename: Simon
authors.initials: S
authors.lastname: Skibsted
authors.forename: Yuchiao
authors.initials: Y
authors.lastname: Chang
authors.forename: Nathan I
authors.initials: NI
authors.lastname: Shapiro
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D015415:Biomarkers / Q000097:blood; D001783:Blood Flow Velocity; D016022:Case-Control Studies; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D007022:Hypotension / Q000209:etiology; D019344:Lactic Acid / Q000097:blood; D016014:Linear Models; D008297:Male; D008833:Microcirculation; D008875:Middle Aged; D015999:Multivariate Analysis; D062072:Patient Acuity; D011446:Prospective Studies; D018805:Sepsis / Q000097:blood / Q000150:complications / Q000503:physiopathology*; D018746:Systemic Inflammatory Response Syndrome / Q000097:blood / Q000150:complications / Q000503:physiopathology; D014481:United States; D055815:Young Adult
chemical_list: D015415:Biomarkers; D019344:Lactic Acid