Date Published: March 5, 2019
Publisher: Public Library of Science
Author(s): Roberta Domizi, Elisa Damiani, Claudia Scorcella, Andrea Carsetti, Roberta Castagnani, Sara Vannicola, Sandra Bolognini, Vincenzo Gabbanelli, Simona Pantanetti, Abele Donati, Jörn Karhausen.
Previous studies described impaired microvascular perfusion and tissue oxygenation as reliable predictors of Multiple Organ Failure in major trauma. However, this relationship has been incompletely investigated. The objective of this analysis is to further evaluate the association between organ dysfunction and microcirculation after trauma.
This is a retrospective subgroup analysis on 28 trauma patients enrolled for the Microcirculation DAIly MONitoring in critically ill patients study (NCT 02649088). Patients were divided in two groups according with their Sequential Organ Failure Assessment (SOFA) score at day 4. At admission and every 24 hours, the sublingual microcirculation was evaluated with Sidestream Darkfield Imaging (SDF) and peripheral tissue perfusion was assessed with Near Infrared Spectroscopy (NIRS) and Vascular Occlusion Test (VOT). Simultaneously, hemodynamic, clinical/laboratory parameters and main organ supports were collected.
Median SOFA score at Day 4 was 6.5. Accordingly, patients were divided in two groups: D4-SOFA ≤6.5 and D4-SOFA >6.5. The Length of Stay in Intensive Care was significantly higher in patients with D4-SOFA>6.5 compared to D4-SOFA≤6.5 (p = 0.013). Total Vessel Density of small vessels was significantly lower in patients with high D4-SOFA score at Day 1 (p = 0.002) and Day 2 (p = 0.006) after admission; the Perfused Vessel Density was lower in patients with high D4-SOFA score at Day 1 (p = 0.007) and Day 2 (p = 0.033). At Day 1, NIRS monitoring with VOT showed significantly faster tissue oxygen saturation downslope (p = 0.018) and slower upslope (p = 0.04) in patients with high D4-SOFA.
In our cohort of major traumas, sublingual microcirculation and peripheral microvascular reactivity were significantly more impaired early after trauma in those patients who developed more severe organ dysfunctions. Our data would support the hypothesis that restoration of macrocirculation can be dissociated from restoration of peripheral and tissue perfusion, and that microvascular alterations can be associated with organ failure.
In the last decades, advancements in prehospital and emergency hospital care led to a reduction in early mortality after multiple trauma. However, the occurrence of multi-organ failure (MOF) remains a major problem in severely injured patients and is responsible for delayed mortality, morbidity and prolonged stay in intensive care units [1,2].
This is a retrospective subgroup analysis of the Microcirculation DAIly MONitoring in critically ill patients study (MicroDAIMON– NCT 02649088). The MicroDAIMON was a single-center prospective observational study where sublingual microcirculation and peripheral oxygenation measurements were performed in 97 adult critically ill patients (with respiratory, post-traumatic and general medical/surgical acute problems) on a daily basis from admission to ICU-discharge/death.
Of the cohort of 97 patients enrolled in the MicroDAIMON study, 39 were admitted with a diagnosis of multiple trauma.
In this retrospective analysis of prospectively collected data on 28 patients with major trauma, patients with higher SOFA score at day 4 (D4-SOFA>6.5) after admission in ICU showed significantly lower sublingual microvascular density in the first two days in the ICU as compared to those with a SOFA score ≤6.5 at day 4, while no differences were observed in parameters of microcirculatory blood flow quality. In addition, a higher peripheral tissue oxygen extraction rate and impaired microvascular reactivity at admission were associated with a SOFA score >6.5 at day 4. These microcirculatory disturbances occurred despite early haemodynamic stabilization, as suggested by similar values of MAP, HR, lactate and ScvO2 in the two groups, although patients with a D4-SOFA>6.5 required higher doses of norepinephrine in the first 4 days.
In our cohort of patients with major trauma, sublingual microcirculation and peripheral microvascular reactivity were significantly impaired among those patients who then showed more severe organ dysfunction. Our data suggest that early impairment in microvascular perfusion after severe trauma may be associated with development of organ failure. Our study would support the hypothesis that restoration of macrocirculation can be dissociated from restoration of peripheral and tissue perfusion.