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Fluid management is an important measure for the treatment of sepsis.
The main purpose of fluid resuscitation is to correct tissue hypoxia and maintain organ function
.
However, such problems are often encountered in clinical practice.
After taking symptomatic and supportive treatment, the central venous pressure (CVP), mean arterial pressure (MAP) and other macrocirculatory indicators have reached the preset range, but the patient’s metabolic acidosis, Multiple organ disorders continue to progress [1].
What is the reason for this? This issue will be discussed at the 2021 European Society of Intensive Medicine (ESICM) annual meeting
.
The "scam" sepsis of the big cycle is often accompanied by hemodynamic instability, and its manifestations are diverse.
The patient may have a fast heart rate, or a disturbance of consciousness or a drop in blood pressure, a decrease in urine output, and sometimes only manifested as thirst or Metabolic acidosis may also have multiple parameters exceeding normal [2]
.
In severe cases, septic shock may occur, which increases the risk of death [3]
.
In the past, EGDT (early goal-directed therapy) was recommended for fluid resuscitation.
This type of treatment program pays more attention to the indicators related to the macrocirculation, such as the aforementioned CVP and MAP
.
In the ProCESS study published in the New England Journal of Medicine [4], after randomizing septic shock patients who had adopted EGDT, standard treatment, and conventional treatment, it was found that the corresponding indicators of the large cycle obtained under different resuscitation strategies were significantly different, but There was no significant difference in the 90-day mortality rate among the three groups
.
Subsequent studies [5] further showed that in non-surviving patients, microcirculation perfusion was imbalanced, and the perfusion vessel density within 72 hours was significantly lower than that of surviving patients
.
This series of studies reminds us that merely monitoring macrocirculation indicators cannot completely correct tissue hypoxia
.
"Decoupling" between the macrocirculation and the microcirculation-hemodynamic incoordination In 2015, Professor Ince first proposed the concept of "hemodynamic consistency"[6], the core of which is the relationship between the macrocirculation and the microcirculation Relationship: Resuscitation measures aimed at correcting macrocirculation indicators should also correct microcirculation perfusion and deliver oxygen to parenchymal cells, so that cells can play a role in supporting organ functions
.
At the same time, Inc also elaborated on the possible mechanism of the loss of hemodynamic consistency: First, the production of reactive nitrogen clusters and reactive oxygen species caused the loss of vascular regulation, and combined with the lack of endothelial cell function and barrier function to cause tissue hypoxia; secondly The resuscitation measures themselves destroy the effectiveness of the cardiovascular system in transporting oxygenated blood to the organs; in addition, the use of vasoactive drugs will make the body’s endogenous receptor-mediated vascular regulation ineffective, which will further cause the consistency of hemodynamics.
Lost
.
Microcirculation monitoring As the understanding of microcirculation gradually deepens, more and more attention is paid to the improvement of microcirculation in treatment, and the monitoring of microcirculation has become particularly important
.
At the 2021 ESICM conference, Professor Vanina Edul also mentioned the method of monitoring microcirculation in his speech on microcirculation (Figure 1), which can be roughly divided into the following three categories.
Among them, the capillary refill time (CRT) is more important, and the near-infrared Spectroscopy is very practical in clinical practice [7]: Figure 1: 2021 ESICM lecture topic: Microcirculation 1) Peripheral circulation assessment: including skin temperature, skin mottling score, capillary refilling time, etc.
; 2) Temperature gradient: including Toe temperature, center-toe temperature difference, toe-peripheral temperature difference, forearm-fingertip temperature difference, etc.
; 3) Optical methods: including peripheral perfusion index, near infrared spectroscopy technology, laser Doppler technology, video microscopic imaging technology, etc.
.
There are many indicators for microcirculation evaluation.
In the “Second Expert Consensus of Sublingual Microcirculation Evaluation in Critically Ill Patients” [8], it is recommended to select corresponding indicators for microcirculation evaluation according to different types of shock and microvascular abnormalities.
Corresponding indicators should be selected according to different intervention methods to assess changes in microcirculation
.
The hemodynamic management of patients with sepsis is inseparable from the improvement of microcirculation.
For patients with sepsis, early identification of hemodynamic disorders can help patients better improve organ failure.
The rescue sepsis will be released at the 2021 ESICM conference.
Symptom Exercise Guidelines (2021) [9] (Figure 2) also added the recommendation to use CRT to guide fluid resuscitation, highlighting that clinical attention should be paid to microcirculation monitoring to guide fluid therapy
.
Figure 2: 2021 ESICM-2021 International Sepsis and Septic Shock Management Guidelines: Rescue Sepsis Campaign Professor Icne [6] proposed an optimization model for volume management based on microcirculation
.
This model, based on the use of a handheld microscope to optimize the oxygen-carrying capacity of the microcirculation, may provide physiological support for each patient to obtain the optimal amount of fluid (plan), and the microcirculation fluid response marks a successful fluid therapy
.
Professors Ashish K Khanna and Kunal Karamchandani proposed a treatment strategy that combines macrocirculation and microcirculation [10] (Figure 3)
.
Since the evaluation technology of microcirculation is not popular, the best solution for the treatment of microcirculation has not been found.
A reasonable solution is to solve the related indicators of the macrocirculation first
.
If a patient with septic shock has organ dysfunction, first measure the condition of the macrocirculation and perform treatment.
Early resuscitation measures will also improve the microcirculation to a certain extent.
If the patient improves clinically, no microcirculation monitoring or intervention is required
.
However, if the organ function deteriorates further, it may mean that the patient has uncoordinated hemodynamic consistency.
At this time, intervention for the macrocirculation may affect the microcirculation, so it is reasonable to monitor the microcirculation and intervene in the microcirculation in a timely manner Of
.
Figure 3: Resuscitation strategies for septic shock based on the macrocirculation and microcirculation [10] These are recent explorations of microcirculation function, but in the process of these studies, it is necessary to put the correction of the instability of the macrocirculation in the first place, because the circulation Failure to cause tissue hypoxia is the most prominent problem in shock.
If this problem is not solved, other treatments will not play a good role [1]
.
Human albumin can not only improve the macrocirculation, but also improve the microcirculation by reducing the degradation of vascular endothelial glycocalyx.
The 2021 rescue sepsis campaign guidelines still recommend sepsis and septic shock for initial resuscitation.
For those who require a large amount of crystal fluid Of patients recommend the combined use of human albumin [9]
.
The latest expert consensus in China pointed out that the use of human albumin in fluid resuscitation of patients with septic shock may improve the mortality rate [11]
.
In recent years, a number of clinical data have confirmed that human albumin can improve the general circulation through colloid function, such as colloid function can resolve arterial hypovolemia, improve vasoconstriction system and improve organ perfusion [12]
.
The ALBIOS study showed that compared with the crystalloid group, the proportion of patients who reached the target MAP within 6 hours in the 20% concentration of human albumin group was higher, and the average arterial pressure of the 20% concentration of human albumin group was significantly higher than that of the crystalloid group [13]
.
In addition to the colloidal function of human albumin in hemodynamic management of sepsis, its non-colloid function also brings multiple benefits to patients
.
The degradation of eGC can cause microcirculation disorders.
Human albumin carries sphingosine-1-phosphonic acid (S1P) derived from red blood cells to the endothelium, and mediates eGC recovery by inhibiting the activity of matrix metalloproteinases (MMP)
.
Animal studies have shown that compared with the model without human albumin treatment, the model after treatment with human albumin has significantly lower eGC degradation-related markers in the coronary effluent [14]
.
Human albumin can also reduce the antioxidant effect, increase endothelial function activation markers, protect endothelial function, thereby improving tissue hypoxia [15]
.
Experts commented on the microcirculation-related topics that this conference focused on, and it is also one of the hot topics discussed in the academic community in recent years
.
Hemodynamic management is undoubtedly important in the management of sepsis patients and can improve the overall mortality rate, but it is necessary to pay attention to the hemodynamic consistency of the macrocirculation and the microcirculation: the macrocirculation is the cornerstone of the microcirculation resuscitation.
Many interventions (such as volume expansion, vasoconstrictor active drugs, cardiotonic, etc.
) need to affect the microcirculation by acting on the macrocirculation.
Avoid leaving the macrocirculation and talking about microcirculation resuscitation, and avoid overemphasizing the direct effect of clinical intervention on the microcirculation.
Effect; the end point of shock recovery is to restore cell oxygen metabolism and organ function, and microcirculation is a bridge connecting the macrocirculation and cells.
If the coupling relationship between the macrocirculation and the microcirculation is not correctly understood, only the goal of the macrocirculation can be used as a guide.
Citation, ignoring the response of the microcirculation may lead to clinical treatment deviation
.
In the 2021 rescue sepsis campaign guidelines, sepsis and septic shock are still recommended for initial resuscitation, and the combined use of human albumin is recommended for patients who require a large amount of crystalloids
.
Human albumin can improve the macrocirculation through colloid function, and improve the microcirculation by protecting the glycocalyx of the vascular endothelium.
It is a liquid treatment option that is beneficial to the microcirculation function
.
Hemodynamic coherence and the rationale for monitoring the microcirculation.
Crit Care.
2015;19 Suppl 3(Suppl 3):S8.
7.
Vanina Edul.
Why is macrocirculation disconnected from microcirculation in sepsis? 2021 ESICM.
8.
Ince, C.
, Boerma, EC, Cecconi, M.
et al.
Second consensus on the assessment of sublingual microcirculation in critically ill patients: results from a task force of the European Society of Intensive Care Medicine.
Intensive Care Med 44, 281–299 (2018).
9.
Evans, L.
, Rhodes, A.
, Alhazzani, W.
et al.
Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021.
Intensive Care Med (2021) .
10.
Khanna AK, Karamchandani K.
Macrocirculation and Microcirculation: The "Batman and Superman" Story of Critical Care Resuscitation.
Anesth Analg.
2021 Jan;132(1):280-283.
11.
Yu YT, Liu J, Hu B , et al. .
The content of the information published by this site does not mean that it agrees with its description and opinions, but only provides more information
.
If copyright issues are involved, please contact us, and we will deal with it as soon as possible
.
Only for medical and health professionals to understand the information
.
Such information cannot replace professional medical guidance in any way, nor should it be regarded as diagnosis and treatment advice
.
If such information is used for purposes other than understanding the information, this site and the author shall not bear related responsibilities
.
-End-
The main purpose of fluid resuscitation is to correct tissue hypoxia and maintain organ function
.
However, such problems are often encountered in clinical practice.
After taking symptomatic and supportive treatment, the central venous pressure (CVP), mean arterial pressure (MAP) and other macrocirculatory indicators have reached the preset range, but the patient’s metabolic acidosis, Multiple organ disorders continue to progress [1].
What is the reason for this? This issue will be discussed at the 2021 European Society of Intensive Medicine (ESICM) annual meeting
.
The "scam" sepsis of the big cycle is often accompanied by hemodynamic instability, and its manifestations are diverse.
The patient may have a fast heart rate, or a disturbance of consciousness or a drop in blood pressure, a decrease in urine output, and sometimes only manifested as thirst or Metabolic acidosis may also have multiple parameters exceeding normal [2]
.
In severe cases, septic shock may occur, which increases the risk of death [3]
.
In the past, EGDT (early goal-directed therapy) was recommended for fluid resuscitation.
This type of treatment program pays more attention to the indicators related to the macrocirculation, such as the aforementioned CVP and MAP
.
In the ProCESS study published in the New England Journal of Medicine [4], after randomizing septic shock patients who had adopted EGDT, standard treatment, and conventional treatment, it was found that the corresponding indicators of the large cycle obtained under different resuscitation strategies were significantly different, but There was no significant difference in the 90-day mortality rate among the three groups
.
Subsequent studies [5] further showed that in non-surviving patients, microcirculation perfusion was imbalanced, and the perfusion vessel density within 72 hours was significantly lower than that of surviving patients
.
This series of studies reminds us that merely monitoring macrocirculation indicators cannot completely correct tissue hypoxia
.
"Decoupling" between the macrocirculation and the microcirculation-hemodynamic incoordination In 2015, Professor Ince first proposed the concept of "hemodynamic consistency"[6], the core of which is the relationship between the macrocirculation and the microcirculation Relationship: Resuscitation measures aimed at correcting macrocirculation indicators should also correct microcirculation perfusion and deliver oxygen to parenchymal cells, so that cells can play a role in supporting organ functions
.
At the same time, Inc also elaborated on the possible mechanism of the loss of hemodynamic consistency: First, the production of reactive nitrogen clusters and reactive oxygen species caused the loss of vascular regulation, and combined with the lack of endothelial cell function and barrier function to cause tissue hypoxia; secondly The resuscitation measures themselves destroy the effectiveness of the cardiovascular system in transporting oxygenated blood to the organs; in addition, the use of vasoactive drugs will make the body’s endogenous receptor-mediated vascular regulation ineffective, which will further cause the consistency of hemodynamics.
Lost
.
Microcirculation monitoring As the understanding of microcirculation gradually deepens, more and more attention is paid to the improvement of microcirculation in treatment, and the monitoring of microcirculation has become particularly important
.
At the 2021 ESICM conference, Professor Vanina Edul also mentioned the method of monitoring microcirculation in his speech on microcirculation (Figure 1), which can be roughly divided into the following three categories.
Among them, the capillary refill time (CRT) is more important, and the near-infrared Spectroscopy is very practical in clinical practice [7]: Figure 1: 2021 ESICM lecture topic: Microcirculation 1) Peripheral circulation assessment: including skin temperature, skin mottling score, capillary refilling time, etc.
; 2) Temperature gradient: including Toe temperature, center-toe temperature difference, toe-peripheral temperature difference, forearm-fingertip temperature difference, etc.
; 3) Optical methods: including peripheral perfusion index, near infrared spectroscopy technology, laser Doppler technology, video microscopic imaging technology, etc.
.
There are many indicators for microcirculation evaluation.
In the “Second Expert Consensus of Sublingual Microcirculation Evaluation in Critically Ill Patients” [8], it is recommended to select corresponding indicators for microcirculation evaluation according to different types of shock and microvascular abnormalities.
Corresponding indicators should be selected according to different intervention methods to assess changes in microcirculation
.
The hemodynamic management of patients with sepsis is inseparable from the improvement of microcirculation.
For patients with sepsis, early identification of hemodynamic disorders can help patients better improve organ failure.
The rescue sepsis will be released at the 2021 ESICM conference.
Symptom Exercise Guidelines (2021) [9] (Figure 2) also added the recommendation to use CRT to guide fluid resuscitation, highlighting that clinical attention should be paid to microcirculation monitoring to guide fluid therapy
.
Figure 2: 2021 ESICM-2021 International Sepsis and Septic Shock Management Guidelines: Rescue Sepsis Campaign Professor Icne [6] proposed an optimization model for volume management based on microcirculation
.
This model, based on the use of a handheld microscope to optimize the oxygen-carrying capacity of the microcirculation, may provide physiological support for each patient to obtain the optimal amount of fluid (plan), and the microcirculation fluid response marks a successful fluid therapy
.
Professors Ashish K Khanna and Kunal Karamchandani proposed a treatment strategy that combines macrocirculation and microcirculation [10] (Figure 3)
.
Since the evaluation technology of microcirculation is not popular, the best solution for the treatment of microcirculation has not been found.
A reasonable solution is to solve the related indicators of the macrocirculation first
.
If a patient with septic shock has organ dysfunction, first measure the condition of the macrocirculation and perform treatment.
Early resuscitation measures will also improve the microcirculation to a certain extent.
If the patient improves clinically, no microcirculation monitoring or intervention is required
.
However, if the organ function deteriorates further, it may mean that the patient has uncoordinated hemodynamic consistency.
At this time, intervention for the macrocirculation may affect the microcirculation, so it is reasonable to monitor the microcirculation and intervene in the microcirculation in a timely manner Of
.
Figure 3: Resuscitation strategies for septic shock based on the macrocirculation and microcirculation [10] These are recent explorations of microcirculation function, but in the process of these studies, it is necessary to put the correction of the instability of the macrocirculation in the first place, because the circulation Failure to cause tissue hypoxia is the most prominent problem in shock.
If this problem is not solved, other treatments will not play a good role [1]
.
Human albumin can not only improve the macrocirculation, but also improve the microcirculation by reducing the degradation of vascular endothelial glycocalyx.
The 2021 rescue sepsis campaign guidelines still recommend sepsis and septic shock for initial resuscitation.
For those who require a large amount of crystal fluid Of patients recommend the combined use of human albumin [9]
.
The latest expert consensus in China pointed out that the use of human albumin in fluid resuscitation of patients with septic shock may improve the mortality rate [11]
.
In recent years, a number of clinical data have confirmed that human albumin can improve the general circulation through colloid function, such as colloid function can resolve arterial hypovolemia, improve vasoconstriction system and improve organ perfusion [12]
.
The ALBIOS study showed that compared with the crystalloid group, the proportion of patients who reached the target MAP within 6 hours in the 20% concentration of human albumin group was higher, and the average arterial pressure of the 20% concentration of human albumin group was significantly higher than that of the crystalloid group [13]
.
In addition to the colloidal function of human albumin in hemodynamic management of sepsis, its non-colloid function also brings multiple benefits to patients
.
The degradation of eGC can cause microcirculation disorders.
Human albumin carries sphingosine-1-phosphonic acid (S1P) derived from red blood cells to the endothelium, and mediates eGC recovery by inhibiting the activity of matrix metalloproteinases (MMP)
.
Animal studies have shown that compared with the model without human albumin treatment, the model after treatment with human albumin has significantly lower eGC degradation-related markers in the coronary effluent [14]
.
Human albumin can also reduce the antioxidant effect, increase endothelial function activation markers, protect endothelial function, thereby improving tissue hypoxia [15]
.
Experts commented on the microcirculation-related topics that this conference focused on, and it is also one of the hot topics discussed in the academic community in recent years
.
Hemodynamic management is undoubtedly important in the management of sepsis patients and can improve the overall mortality rate, but it is necessary to pay attention to the hemodynamic consistency of the macrocirculation and the microcirculation: the macrocirculation is the cornerstone of the microcirculation resuscitation.
Many interventions (such as volume expansion, vasoconstrictor active drugs, cardiotonic, etc.
) need to affect the microcirculation by acting on the macrocirculation.
Avoid leaving the macrocirculation and talking about microcirculation resuscitation, and avoid overemphasizing the direct effect of clinical intervention on the microcirculation.
Effect; the end point of shock recovery is to restore cell oxygen metabolism and organ function, and microcirculation is a bridge connecting the macrocirculation and cells.
If the coupling relationship between the macrocirculation and the microcirculation is not correctly understood, only the goal of the macrocirculation can be used as a guide.
Citation, ignoring the response of the microcirculation may lead to clinical treatment deviation
.
In the 2021 rescue sepsis campaign guidelines, sepsis and septic shock are still recommended for initial resuscitation, and the combined use of human albumin is recommended for patients who require a large amount of crystalloids
.
Human albumin can improve the macrocirculation through colloid function, and improve the microcirculation by protecting the glycocalyx of the vascular endothelium.
It is a liquid treatment option that is beneficial to the microcirculation function
.
Hemodynamic coherence and the rationale for monitoring the microcirculation.
Crit Care.
2015;19 Suppl 3(Suppl 3):S8.
7.
Vanina Edul.
Why is macrocirculation disconnected from microcirculation in sepsis? 2021 ESICM.
8.
Ince, C.
, Boerma, EC, Cecconi, M.
et al.
Second consensus on the assessment of sublingual microcirculation in critically ill patients: results from a task force of the European Society of Intensive Care Medicine.
Intensive Care Med 44, 281–299 (2018).
9.
Evans, L.
, Rhodes, A.
, Alhazzani, W.
et al.
Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021.
Intensive Care Med (2021) .
10.
Khanna AK, Karamchandani K.
Macrocirculation and Microcirculation: The "Batman and Superman" Story of Critical Care Resuscitation.
Anesth Analg.
2021 Jan;132(1):280-283.
11.
Yu YT, Liu J, Hu B , et al. .
The content of the information published by this site does not mean that it agrees with its description and opinions, but only provides more information
.
If copyright issues are involved, please contact us, and we will deal with it as soon as possible
.
Only for medical and health professionals to understand the information
.
Such information cannot replace professional medical guidance in any way, nor should it be regarded as diagnosis and treatment advice
.
If such information is used for purposes other than understanding the information, this site and the author shall not bear related responsibilities
.
-End-
