Regional perfusion monitoring in shock.

PURPOSE OF REVIEW: Despite restoration of adequate systemic blood flow in patients with shock, single organs may remain hypoperfused. In this review, we summarize the results of a literature research on methods to monitor single organ perfusion in shock. We focused on methods to measure heart, brain, kidney, and/or visceral organ perfusion. Furthermore, only methods that can be used in real-time and at the bedside were included. RECENT FINDINGS: We identified studies on physical examination techniques, electrocardiography, echocardiography, contrast-enhanced ultrasound, near-infrared spectroscopy, and Doppler sonography to assess single organ perfusion. SUMMARY: Physical examination techniques have a reasonable negative predictive value to exclude single organ hypoperfusion but are nonspecific to detect it. Technical methods to indirectly measure myocardial perfusion include ECG and echocardiography. Contrast-enhanced ultrasound can quantify myocardial perfusion but has so far only been used to detect regional myocardial hypoperfusion. Near-infrared spectroscopy and transcranial Doppler sonography can be used to assess cerebral perfusion and determine autoregulation thresholds of the brain. Both Doppler and contrast-enhanced ultrasound techniques are novel methods to evaluate renal and visceral organ perfusion. A key limitation of most techniques is the inability to determine adequacy of organ blood flow to meet the organs' metabolic demands.

Emergency critical care: closing the gap between onset of critical illness and intensive care unit admission.

Critical illness is an exquisitely time-sensitive condition and follows a disease continuum, which always starts before admission to the intensive care unit (ICU), in the majority of cases even before hospital admission. Reflecting the common practice in many healthcare systems that critical care is mainly provided in the confined areas of an ICU, any delay in ICU admission of critically ill patients is associated with increased morbidity and mortality. However, if appropriate critical care interventions are provided before ICU admission, this association is not observed. Emergency critical care refers to critical care provided outside of the ICU. It encompasses the delivery of critical care interventions to and monitoring of patients at the place and time closest to the onset of critical illness as well as during transfer to the ICU. Thus, emergency critical care covers the most time-sensitive phase of critical illness and constitutes one missing link in the chain of survival of the critically ill patient. Emergency critical care is delivered whenever and wherever critical illness occurs such as in the pre-hospital setting, before and during inter-hospital transfers of critically ill patients, in the emergency department, in the operating theatres, and on hospital wards. By closing the management gap between onset of critical illness and ICU admission, emergency critical care improves patient safety and can avoid early deaths, reverse mild-to-moderate critical illness, avoid ICU admission, attenuate the severity of organ dysfunction, shorten ICU length of stay, and reduce short- and long-term mortality of critically ill patients. Future research is needed to identify effective models to implement emergency critical care systems in different healthcare systems.

Acquired Factor XIII Deficiency Is Common during ECMO Therapy and Associated with Major Bleeding Events and Transfusion Requirements.

BACKGROUND: Bleeding events are frequent complications during extracorporeal membrane oxygenation therapy (ECMO). OBJECTIVE: To determine the rate of acquired factor XIII deficiency and its association with major bleeding events and transfusion requirements in adults undergoing ECMO therapy. MATERIALS AND METHODS: A retrospective single centre cohort study. Adult patients receiving veno-venous or veno-arterial ECMO therapy during a 2-year period were analysed and screened for factor XIII activity measurements. Factor XIII deficiency was defined based on the lowest factor XIII activity measured during ECMO therapy. RESULTS: Among 84 subjects included into the analysis, factor XIII deficiency occurred in 69% during ECMO therapy. There were more major bleeding events (OR, 3.37; 95% CI, 1.16-10.56; p = 0.02) and higher transfusion requirements (red blood cells, 20 vs. 12, p < 0.001; platelets, 4 vs. 2, p = 0.006) in patients with factor XIII deficiency compared to patients with normal factor XIII activity. In a multivariate regression model, factor XIII deficiency was independently associated with bleeding severity (p = 0.03). CONCLUSIONS: In this retrospective single centre study, acquired factor XIII deficiency was observed in 69% of adult ECMO patients with a high bleeding risk. Factor XIII deficiency was associated with higher rates of major bleeding events and transfusion requirements.

Treatment of Refractory Cardiac Arrest by Controlled Reperfusion of the Whole Body: A Multicenter, Prospective Observational Study.

Background: Survival following cardiac arrest (CA) remains poor after conventional cardiopulmonary resuscitation (CCPR) (6-26%), and the outcomes after extracorporeal cardiopulmonary resuscitation (ECPR) are often inconsistent. Poor survival is a consequence of CA, low-flow states during CCPR, multi-organ injury, insufficient monitoring, and delayed treatment of the causative condition. We developed a new strategy to address these issues. Methods: This all-comers, multicenter, prospective observational study (69 patients with in- and out-of-hospital CA (IHCA and OHCA) after prolonged refractory CCPR) focused on extracorporeal cardiopulmonary support, comprehensive monitoring, multi-organ repair, and the potential for out-of-hospital cannulation and treatment. Result: The overall survival rate at hospital discharge was 42.0%, and a favorable neurological outcome (CPC 1+2) at 90 days was achieved for 79.3% of survivors (CPC 1+2 survival 33%). IHCA survival was very favorable (51.7%), as was CPC 1+2 survival at 90 days (41%). Survival of OHCA patients was 35% and CPC 1+2 survival at 90 days was 28%. The subgroup of OHCA patients with pre-hospital cannulation showed a superior survival rate of 57.1%. Conclusions: This new strategy focusing on repairing damage to multiple organs appears to improve outcomes after CA, and these findings should provide a sound basis for further research in this area.

Blood flow but not cannula positioning influences the efficacy of Veno-Venous ECMO therapy.

Despite being vital in treating intensive-care patients with lung failure, especially COVID-19 patients, Veno-Venous Extra-Corporeal Membrane Oxygenation does not exploit its full potential, leaving ample room for improvement. The objective of this study is to determine the effect of cannula positioning and blood flow on the efficacy of Veno-Venous Extra-Corporeal Membrane Oxygenation, in particular in relationship with blood recirculation. We performed 98 computer simulations of blood flow and oxygen diffusion in a computerized-tomography-segmented right atrium and venae cavae for different positions of the returning and draining cannulae and ECMO flows of 3 L/min and [Formula: see text]. For each configuration we measured how effective Veno-Venous Extra-Corporeal Membrane Oxygenation is at delivering oxygen to the right ventricle and thus to the systemic circulation. The main finding is that VV-ECMO efficacy is largely affected by the ECMO flow (global peak blood saturation: [Formula: see text]; average inter-group saturation gain: 9 percentage points) but only scarcely by the positioning of the cannulae (mean saturation ± standard deviation for the 3 L/min case: [Formula: see text]; for the [Formula: see text] case: [Formula: see text]). An important secondary outcome is that recirculation, more intense with a higher ECMO flow, is less detrimental to the procedure than previously thought. The efficacy of current ECMO procedures is intrinsically limited and fine-tuning the positions of the cannulae, risking infections, offers very little gain. Setting a higher ECMO flow offers the biggest benefit despite mildly increasing blood recirculation.

[The role of the microcirculation in the pathogenesis of organ dysfunction]. / Die Rolle der Mikrozirkulation in der Entstehung des Organversagens.

The microcirculation includes all blood and lymph vessels with a diameter < 100 µm. Microcirculatory dysfunction is common in critically ill patients and is closely associated with both the severity of (multi-)organ dysfunction and mortality. The nature and extent of microcirculatory dysfunction differ depending on the underlying disease and are most pronounced in patients with systemic inflammation (e. g. sepsis), specific infections (e. g. malaria, dengue) or thrombocytopenia-associated multiple organ failure. This manuscript provides an overview of the pathophysiology, monitoring and therapy of microcirculatory dysfunction in the critically ill patient.

[Diagnosing acute organ ischemia : A practical guide for the emergency and intensive care physician]. / Diagnostik der akuten Organischämie : Eine Praxisanleitung für Notfall- und Intensivmediziner.

Ischemia refers to a reduction or interruption of the blood flow to one or more organs. Early recognition of shock, a global ischemic state of the body, is of key importance in emergency and intensive care medicine. The physical examination and point-of-care laboratory diagnostics (i.e. lactate, base deficit, central/mixed venous oxygen saturation, venous-arterial carbon dioxide partial tension) are the methods of choice to diagnose shock in clinical practice. Importantly, a state of shock can also be present in patients with normo- or hypertensive arterial blood pressures. In shock, hypoperfusion of vital and visceral organs occurs. In the second part of this article, physical examination techniques, laboratory and diagnostic methods to detect shock-related hypoperfusion of the brain, heart, kidney and gastrointestinal tract are reviewed.