(Peripheral) Temperature and microcirculation Prof. Jan Bakker MD, PhD Chair dept Intensive Care Adults jan.bakker@erasmusmc.nl www.intensivecare.me
Intensive Care Med (2005) 31:1316 1326 DOI 10.1007/s00134-005-2790-2 R E V I E W Alexandre Lima Jan Bakker Noninvasive monitoring of peripheral perfusion Clinical assessment Temperature and temperature gradients Ttoe ΔT[Central-Toe], ΔT[Proximal-Distal] Optical monitoring PFI, NIRS, OPS/SDF, LDF Transcutaneous PO2 and PCO2
Temperature and perfusion Anesthesiology 1988;68:836 842 1988;69:357 364 1990 73:541 545 1995;83:1212-1219 r=0.98 Forearm-Finger Tgradient ( o C) Perfusion Index (u)
Correlates of thenar NIRS derived tissue O2 saturation after cardiac surgery Uilkema et al. Interact Cardiovasc Thorac Surg 2007;6(3):265-269 23 patients 70 yr (46-84) Duration MV 10h (5-48) CABG: 9 CABG+valve: 6 AVR: 5 MVR: 3 rs 0.48, P<0.001
Vascular Occlusion Test 1 3 min 30 mm Hg above SAP
Peripheral vasoconstriction influences thenar oxygen saturation as measured by NIRS Lima et al. Intensive Care Med 2012 (in press) 8 healthy volunteers (26±6 yr) use of cooling blanket cooling of the periphery without change in core temperature (tympanic temperature) water temperature 32 o C measurements: baseline, 30 after start cooling, 30 after suspension of cooling (rewarmed) StO2 measured with 15 mm probe on thenar muscle CO measured by NICOM (Cheetah) Skin vasoconstriction: 50% decrease in Tskin-diff or PI
Peripheral vasoconstriction influences thenar oxygen saturation as measured by NIRS Lima et al. Intensive Care Med 2012 (in press) Baseline Cold 30 Rewarmed 30 HR (b/min) MAP (mmhg) SV (ml) CO (L/min) Core Temp ( o C) 76 [70-83] 67 [58-73] 70 [67-74] 93 [88-101] 100 [92-107] 95 [87-100] 110 [76-125] 139 [132-147] 114 [106-164] 8,6 [8,0-9,4] 10,1 [8,9-12,2] 7,9 [7,3-10,1] 36,8 [36,6-36,9] 36,6 [36,4-36,9] 36,6 [36,4-36,9] median [IQR]
Peripheral vasoconstriction influences thenar oxygen saturation as measured by NIRS Lima et al. Intensive Care Med 2012 (in press) Baseline Cold 30 Rewarmed 30 StO2 (%) RincStO2 (%/sec) Tskin-diff ( o C) CRT (sec) PI (%) 82 [80-87] 72 [70-77] * 80 [79-85] 3,0 [2,8-3,3] 1,7 [1,1-2,0] * 3,2 [3,0-4,2] 1,0 [-1,6-1,8] 3,1 [1,8-4,3] * 1,2 [-0,3-2,7] 2,5 [2,0-3,0] 8,5 [7,2-11,0] * 4,0 [3,0-5,7] 10,0 [9,1-11,7] 2,5 [2,0-3,8] * 9,1 [8,2-11,7] median [IQR]
Peripheral vasoconstriction influences thenar oxygen saturation as measured by NIRS Lima et al. Intensive Care Med 2012 (in press)
Relation of NIRS with changes in peripheral circulation in critically ill patients Lima et al. Crit Care Med 2011;39:1649-1654 73 critically ill patients Age: 57 (17-90) SOFA: 6 (1-15) APACHE II: 23 (6-35) Septic shock n=33 Shock without sepsis: n= 25 No shock or sepsis: n=15
Relation of NIRS with changes in peripheral circulation in critically ill patients Lima et al. Crit Care Med 2011;39:1649-1654 mixed linear model over 3 days Upslope (%/s) estimate (95% CI) HR b/min -0.001 (-0.09;0.09) MAP (mmhg) Abnormal Peripheral Circulation -0.02 (-0.13;0.075) -1.1 (-0.8;-1.4)**
Skin temperature and systemic circulation Cool vs. warm skin Similar: Heart rate, blood pressure, PAOP, Hemoglobin, FiO 2, PaO 2, PaCO 2 Cardiac Index Arterial ph SvO 2 Lactate Cool 2.9 ± 1.2 7.32 ± 0.2 60 ± 4 4.7 ± 1.5 Warm 4.3 ± 1.2 * 7.39 ± 0.07 * 68 ± 8 * 2.2 ± 1.6 * Kaplan et al. J Trauma 2001;50:620-628
The prognostic value of the subjective assessment of peripheral perfusion in critically ill patients Alexandre Lima, MD; Tim C. Jansen, MD; Jasper van Bommel, MD, PhD; Can Ince, PhD; Jan Bakker, MD, PhD Table 1. Demographic data of the patients Number of patients 50 Age (yrs) 51 (17 80) Male/female 39/11 Sequential Organ Failure 8 (2 15) Assessment score admission Acute Physiology and Chronic 23 (13 35) Health Evaluation II Admission category Pneumonia 9 Trauma 8 Abdominal sepsis 7 Postoperative 5 Chronic obstructive 3 pulmonary disease Cardiogenic shock 2 Hepatic encephalopathy 2 Hypovolemic/hemorrhagic 2 shock Mediastinitis 2 Meningitis 2 Pancreatitis 2 Postcardiac arrest 2 Cerebrovascular accident 1 Lung cancer 1 Systemic lupus erythematosus 1 Urosepsis 1 Survivor/nonsurvivor 35/15 Objective Parameters Subjective Evaluation Normal (n 27) Abnormal (n 23) T skin-diff ( C) 0.2 2.8 4.6 2.8 0.01 T c-toe ( C) 6.5 3.4 10 4.1 0.01 PFI 2.3 1.6 0.7 0.8 0.01 T, forearm-to-fingertip skin-temperature gradient; T, central-to-toe temperature differ- Patients with abnormal peripheral perfusion were more likely to have increased lactate had significantly less decreases in lactate levels had OR 7.4 of increasing organ failure p Values are given as mean (range) whereap- Crit Care Med 2009; 37:934 938
Peripheral perfusion cardiogenic shock Odd s ratio for day-30 mortality Oliguria 3.4 (2.8-4.2) Altered sensorium 2.1 (1.7-2.5) Cold, clammy skin 1.8 (1.5-2.3) Gusto I trial: 41.021 patients Am Heart J 1999;138:21-31
Research Low tissue oxygen saturation at the end of early goal-directed therapy is associated with worse outcome in critically ill patients Alexandre Lima, Jasper van Bommel, Tim C Jansen, Can Ince and Jan Bakker Critical Care 2009, 13(Suppl 5):S13 (doi:10.1186/cc8011) Patients with circulatory failure (increased lactate) enrolled in EGDT protocol (8 hours) immediately following admission Table 1 Patient demographic data Number of patients 22 Age (years) 62 (57 to 71) Male/female 16/6 Sequential Organ Failure Assessment score 7 (5 to 9) Acute Physiology and Chronic Health Evaluation II score 23 (16 to 30) Admission category Septic shock Circulatory failure not associated with sepsis Without circulatory failure or sepsis 3 pneumonia, 3 abdominal sepsis, 1 meningitis 3 hypovolemic/hemorrhagic, 3 cardiogenic, 4 postoperative, 2 trauma 1 cerebrovascular accident, 2 postoperative Noradrenaline use 16 (72%) Noradrenaline dose (µg/kg/minute) 0.16 (0.07 to 0.24) Dobutamine use 8 (36%) Dobutamine dose (µg/kg/minute) 4.3 (3.6 to 6.3) Mechanical ventilation 15 (68%) Survivor/nonsurvivor 17/5 Data expressed as number, as median (25th to 75th percentile), or as n (%).
n=22 abnormal peripheral perfusion n=14 2 hours normal peripheral perfusion n=8 29% 13% n=8 n=2 8 hours n=6 n=6 50% 50% Mortality 0% 0% StO2 ±60% StO2 ±80%
Clinical significance of low StO2 in patients with shock patients with abnormal peripheral circulation following EGDT have more organ failure
Dynamics of StO2 mortality StO2 n=221 Admission Evolution during first 24h Normal n=160 Normal (>75%) n=181 Abnormal n=21 Abnormal (<75%) n=40 Abnormal n=25 ICU mortality 15% 57% Normal n=15 13% 56% Odds for mortality: persistent low StO2 during first 24h 7.9 (CI: 3-21, P<0.001) Odds for mortality: when StO2 decreased to <75% during first 24h 7.1 (CI: 2-21, P<0.001) Odds for mortality: persistent low StO2 and low peripheral perfusion 9.9 (CI: 3-41ß, P<0.001)
Peripheral and microcirculatory perfusion abnormalities following out-of-hospital cardiac arrest Michel van Genderen et al. Crit Care Med 2012 (in press)
Peripheral and microcirculatory perfusion abnormalities following out-of-hospital cardiac arrest Michel van Genderen et al. Crit Care Med 2012 (in press) Conclusions: Following outof-hospital cardiac arrest, the early post-resuscitation phase is characterized by abnormalities in sublingual microcirculation and peripheral tissue perfusion, which are caused by vasoconstriction due to induced systemic hypothermia and not by impaired systemic blood flow. Persistence of these alterations is associated with organ failure and death, independent of systemic hemodynamics.
Abnormal peripheral perfusion effect of a stepwise increasing dose of NTG T baseline T max T end Capillary refill time, sec 9 [8-12] 4 * [4-6] 7* [4-10] Perfusion index, % 0.7 [0.4-1.8] 2.7 * [2.1-3.0] 1.6 * [1.1-2.0] Tskin-difference, 0 C 3 [2.1-3.4] 0.8 * [-1.1-1.4] 1.4 * [0.8-2.0] StO2 (%) 77 [64-82] 85 * [74-92] 83 [73-88] Values are expressed as median [25th-75th] * P<0.05 vs. TBL1 and TBL2
Conclusions Core and peripheral temperature relate to peripheral perfusion by vascular tone Peripheral perfusion is related to peripheral tissue oxygenation and microcirculatory function by vascular tone Abnormal peripheral perfusion is related to decreased lactate clearance increased organ failure and mortality Peripheral perfusion can be improved by NTG Patient outcome after improving peripheral perfusion is unknown