Severe Impairment of Microcirculatory Perfused Vessel Density Is Associated With Postoperative Lactate and Acute Organ Injury After Cardiac Surgery.
Severe Impairment of Microcirculatory Perfused Vessel Density Is Associated With Postoperative Lactate and Acute Organ Injury After Cardiac Surgery.
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DOI：
10.1053/j.jvca.2020.04.045
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发表时间：
2021-01
影响因子：
2.8
通讯作者：
Abella BS
中科院分区：
文献类型：
--
作者：
Greenwood JC;Jang DH;Hallisey SD;Gutsche JT;Horak J;Acker MA;Bermudez CA;Zhou VL;Chatterjee S;Shofer FS;Kilbaugh TJ;Augoustides JGT;Meyer NJ;Bakker J;Abella BS
心脏手术后复苏需要解决与显著发病率和死亡率相关的多种病理生理过程。尽管有正常的全身血流动力学，但功能性微循环紊乱先前已被描述过，但必须与临床结果联系起来。作者假设心脏手术后微循环功能障碍包括毛细血管血流受损和弥散能力受损，灌注血管密度最低的受试者术后乳酸水平和急性器官损伤评分会增加。前瞻性观察性研究。单一的三级大学心血管外科重症监护病房。25名成人接受择期心脏手术，需要体外循环。在重症监护室手术前和术后2至4小时使用入射暗场显微镜对舌下微循环进行成像。与基线测量值相比，术后各血管微血管流动指数（2.9 [2.8-2.9]v 2.5 [2.4-2.7], p < 0.0001）和灌注血管密度明显受损（20.7 [19.3-22.9]v 16.3 [12.8-17.9], p < 0.0001）。灌注血管密度最低四分位数（<12.8 mm/mm2）与术后24和48小时乳酸水平（6.0±2.9 v 1.8±1.2,p < 0.05）、乳酸峰值水平（7.6±2.8 v 2.8±1.5,p = 0.03）和序贯器官衰竭评估（SOFA）评分显著升高相关。在心脏手术患者中，术后早期复苏时微循环对流血流量和弥漫性血容量明显下降。以最低四分位数为代表的灌注血管密度严重受损与高乳酸血症和早期器官损伤显著相关。
Resuscitation after cardiac surgery needs to address multiple pathophysiological processes that are associated with significant morbidity and mortality. Functional microcirculatory derangements despite normal systemic hemodynamics have been previously described but must be tied to clinical outcomes. The authors hypothesized that microcirculatory dysfunction after cardiac surgery would include impaired capillary blood flow and impaired diffusive capacity and that subjects with the lowest quartile of perfused vessel density would have an increased postoperative lactate level and acute organ injury scores. Prospective, observational study. A single, tertiary university cardiovascular surgical intensive care unit. 25 adults undergoing elective cardiac surgery requiring cardiopulmonary bypass. Sublingual microcirculation was imaged using incident dark field microscopy before and 2 to 4 hours after surgery in the intensive care unit. Compared with baseline measurements, postoperative vessel-by-vessel microvascular flow index (2.9 [2.8–2.9] v 2.5 [2.4–2.7], p < 0.0001) and perfused vessel density were significantly impaired (20.7 [19.3–22.9] v 16.3 [12.8–17.9], p < 0.0001). The lowest quartile of perfused vessel density (<12.8 mm/mm2) was associated with a significantly increased postoperative lactate level (6.0 ± 2.9 v 1.8 ± 1.2, p < 0.05), peak lactate level (7.6 ± 2.8 v 2.8 ± 1.5, p = 0.03), and sequential organ failure assessment (SOFA) score at 24 and 48 hours. In patients undergoing cardiac surgery, there was a significant decrease in postoperative microcirculatory convective blood flow and diffusive capacity during early postoperative resuscitation. Severely impaired perfused vessel density, represented by the lowest quartile of distribution, is significantly related to hyperlactatemia and early organ injury.
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