PIIS0300957209005498.pdf

Resuscitation 81 (2010) 123–125

Contents lists available at ScienceDirect

Resuscitation

journal homepage: www.elsevier.com/locate/resuscitation

Case report

Imaging the human microcirculation during cardiopulmonary resuscitation

in a hypothermic victim of submersion trauma

Paul W.G. Elbers a , c , ∗ , Antonius J. Craenen a , Antoine Driessen d , Marco C. Stehouwer b ,

Luuk Munsterman a , Miranda Prins a , Mat van Iterson a , Peter Bruins a , Can Ince c

a Department of Anesthesia, Intensive Care and Pain Management, St. Antonius Ziekenhuis, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands

b Department of Perfusion, St. Antonius Ziekenhuis, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands

c Department of Translational Physiology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands

d Department of Cardiothoracic Surgery, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands

article info

abstract

Article history:

Received 13 August 2009

Received in revised form 5 September 2009

Accepted 26 September 2009

The microcirculation is essential for delivery of oxygen and nutrients to tissue. However, the human

microvascular response to cardiopulmonary resuscitation (CPR) is unknown. We report on the ﬁrst use

of sidestreamdarkﬁeld imaging to assess the humanmicrocirculationduring CPRwith amechanical chest

compression/decompressiondevice (mCPR).mCPRwas able toprovidemicrovascular perfusion. Capillary

ﬂow persisted even during brief mCPR interruption. However, indices of microvascular perfusion were

low and improved vastly after return of spontaneous circulation. Microvascular perfusion was relatively

independent from blood pressure. The microcirculation may be a useful monitor for determining the

adequacy of CPR.

Keywords:

Microcirculation

Sidestream dark ﬁeld imaging

Cardiopulmonary resuscitation

Mechanical compression/decompression

Hypothermia

Extracorporeal circulation

Cardiopulmonary bypass

Submersion

Trauma

1. Introduction

this technique to directly observe the sublingual microcirculation

during CPR in a victim of submersion trauma.

The microcirculation delivers oxygen and nutrients to tissue.

This makes adequate microvascular perfusion a key objective in

cardiopulmonary resuscitation (CPR). Animal CPR experiments

have shown that global haemodynamic parameters do not always

reﬂect microvascular perfusion. 1–6 It is currently unknown if

such discrepancy exists in humans, because human microvas-

cular assessment during CPR has long been a virtual technical

impossibility. Such knowledge is essential to determine the efﬁ-

cacy of CPR in establishing adequate blood ﬂow to tissue. As

such, microvascular perfusion might serve as an end point for

CPR.

Orthogonal polarized spectral (OPS) imaging and its improved

successor sidestreamdarkﬁeld (SDF) imaging, have enabledhuman

microvascular imaging in real time. 7 For the ﬁrst time, we applied

2. Case report

A 27-year-old man drove into a canal and was liberated

after approximately 45min of cold submersion. There were no

detectable signs of life and protocolized resuscitation was begun

using mechanical chest compression/decompression at a rate of

100min − 1 (mCPR, LUCAS ® , Jolife, Lund, Sweden). Following intuba-

tion, manual interposed ventilations at 15–20min − 1 were started.

On arrival at the hospital, mCPR was continued. Pupils were

widely dilated and unresponsive to light and the electrocardiogram

was isoelectric. Initial tympanic temperature was 22 ◦ C.

The patient was transported to the operating room for rewarm-

ing using extracorporeal circulation (ECC). During preparation for

ECC, a ﬁrst series of microvascular recordings was made. This was

done during a brief period (<20 s) of mCPR switch-off as requested

by the surgeon. Up until this time point, there was no spontaneous

heart rhythm and mCPR had been ongoing.

Full ECC ﬂow (5 Lmin − 1 ) was reached approximately 2 h after

initiation of mCPR, which was used continuously until then. The

A Spanish translated version of the abstract of this article appears as Appendix

in the ﬁnal online version at doi:10.1016/j.resuscitation.2009.09.032 .

∗ Corresponding author at: St. Antonius Ziekenhuis, Koekoekslaan 1, 3435 CM,

Nieuwegein, The Netherlands.

E-mail address: info@acidbase.org (P.W.G. Elbers).

doi: 10.1016/j.resuscitation.2009.09.032

124

P.W.G. Elbers et al. / Resuscitation 81 (2010) 123–125

Table 1

Microvascular, macrohaemodynamic, laboratory and drug data.

mCPR

Sinus rhythm

Perfused vessel density (small vessels, mm − 1 )

3.80

9.01

Percentage of perfused vessels (small vessels)

64%

97%

Microvascular ﬂow index (small vessels)

1.8

3.0

Perfused vessel density (large vessels, mm − 1 )

1.28

3.31

Percentage of perfused vessels (large vessels)

75%

100%

Microvascular ﬂow index (large vessels)

2.2

3.0

NIBP (mmHg)

70/40

n/a

ABP (mmHg)

n/a

90/50 (67)

CVP (mmHg)

n/a

HR (min − 1 )

n/a

108

PaO 2 (kPa)

15.3

n/a

SpO 2

96%

80%

Hb (mM)

5.9

28%

6.88

7.02

PaCO 2 (kPa)

12.9

9.6

HCO 3 − (mM)

17.6

18.1

Base excess (mM)

−

12.9

K + (mM)

3.58

3.79

Temperature (rectal, ◦ C)

Midazolam (mg)

5 a

Propofol (mg h − 1 )

200

Noradrenalin (

500

200

Dexamethason (mg) 50

Calcium (mg) 100

Magnesium (mg) 3000

NIBP: non-invasive blood pressure; ABP: arterial blood pressure; CVP: central

venous pressure; HR: heart rate.

a Midazolam 5mg was given at the start of rewarming, >50min before cardiover-

sion.

b Adrenalin was given at regular intervals according to the CPR protocol except

during surgery for cannulation for ECC.

Fig. 1. Stills of video clips of themicrocirculation immediately following brief inter-

ruption of mCPR (a) and after ROSC (b). Actual video clips of these time points may

be found in the online supplement. These clearly show persistent but decreased

microvascular perfusion during mCPR.

LM) performed the analysis independently and their results were

averaged.

4. Results

rectal temperature at this point was 23.9 ◦ C. Slow rewarming was

begun according to our local protocol. At 30 ◦ C, successful car-

dioversion fromventricular ﬁbrillation to sinus rhythmwas carried

out. Rewarming was continued up to mild hypothermia (33 ◦ C).

Pump ﬂow was slowly decreased and subsequently stopped. At

this time point circulation was spontaneous and a second series of

microvascular recordings was made.

After about 10min, ECC weaning proved unsuccessful because

of inadequate oxygenation (SpO 2 70–80%) at 100% F i O 2 . ECC was

restarted and the patient was transferred to the ICU. After 72 h,

brain stem reﬂexes were absent and did not improve. Eventually,

active treatment waswithdrawn and the patient died of pulmonary

complications.

Fig. 1 shows stills of the acquired video clips. Movies are

available in the online supplement. mCPR switch-off did not

obviously inﬂuence microvascular ﬂow. Microvascular perfusion

scores, macrohaemodynamic parameters and administered drugs

may be found in Table 1 . Microvascular ﬂow was present during

mCPR. However, PVD markedly improved after return of sponta-

neous circulation (ROSC). The change in PVD was much larger than

the change in blood pressure.

5. Discussion

This is the ﬁrst paper to report on the human microvascular

response to CPR. We showed that mCPR generates microvascu-

lar ﬂow, which persists during short interruptions. However, all

microvascular perfusion scores are considerably lower compared

to after ROSC. Further, the difference in PVD is much larger than the

difference in systemic blood pressure. This adds to the large body of

evidence that macrovascular parameters do not necessarily reﬂect

microvascular perfusion. 9

We previously studied hypertensive patients after routine car-

diac surgery. These had a PVD of 5.59 for small microvessels (PPV

80%, MFI 2.8), about twice the value for mCPR and two thirds of the

value after ROSC. 10 The latter may represent post-hypoperfusion

hyperemia. Weil’s group used OPS imaging in experimental cardiac

arrest in pigs. They reported a brain and sublingual microvascu-

lar MFI of 1.2–1.5 during manual CPR which improved to 3 after

ROSC. 1,2,4,5 This is comparable to our results.

3. Microcirculatory imaging

m 2 of

tissue surface. The local ethics committee waived the need for

informed consent for studies using SDF imaging as it is consid-

ered non-invasive. Following recent guidelines, 8 we determined

microvascular ﬂow index (MFI), perfused vessel density (PVD)

and proportion of perfused vessels (PPV) both for large and small

microvesselswith a cut-off diameter of 20

750

m. Two authors (PWGE,

Adrenalin (

Sidestream dark ﬁeld imaging has been described in detail

previously. 7 In brief, a handheld video microscope emits strobo-

scopic green light (530 nm), which is absorbed by hemoglobin.

Thus, a negative image ofmoving red blood cells is transmitted back

towards a camera, representing approximately 940

P.W.G. Elbers et al. / Resuscitation 81 (2010) 123–125

125

There are limitations to our study that need to be addressed.

First, it is difﬁcult to draw conclusions from a single case. Second

our patient died and showed severe brain damage. Therefore, we

cannot tell whether the observed PVD is associated with adequate

microvascular brain perfusion. Further, we cannot be sure that

microvascular ﬂow persisted beyond the resuscitation period and

can therefore not relate it to outcome. In addition, the sublingual

microcirculation, albeit central,maynot reﬂect othermicrovascular

beds. 11 Next, betweenmeasurements, vasoactive drugs were given

such as adrenalin (epinephrine) and propofol. However, propo-

fol was shown to decrease PVD in humans. 12 The same is true

for adrenalin in pigs during CPR. 4 Finally, the difference in PVD

between mCPR and ROSC may be caused by rewarming. This is

consistent with ﬁndings in hamsters where capillary density was

reduced twofold at 18 ◦ C versus 37 ◦ C. 13 Conversely, we are cur-

rently studyingmicrovascular ﬂowduring hypothermic circulatory

arrest in humans. Preliminary analysis shows a PVD of approx-

imately 6mm − 1

development of optical spectroscopic tools for study of the micro-

circulation and tissue oxygenation, in which context CI holds

patents and shares.

All other authors declare no conﬂict of interest.

Appendix A. Supplementary data

Supplementary data associated with this article can be found, in

the online version, at doi:10.1016/j.resuscitation.2009.09.032 .

References

at 25 ◦ C, similar to our ﬁndings after cardiac

1. Fries M, Tang W, Chang YT, et al. Microvascular blood ﬂow during cardiopul-

monary resuscitation is predictive of outcome. Resuscitation 2006;71:248–53.

2. Fries M, Weil MH, Chang YT, et al. Microcirculation during cardiac arrest and

resuscitation. Crit Care Med 2006;34:S454–7.

3. Fries M, Weil MH, Sun S, et al. Increases in tissue PCO 2 during circula-

tory shock reﬂect selective decreases in capillary blood ﬂow. Crit Care Med

2006;34:446–52.

4. Ristagno G, Tang W, Huang L, et al. Epinephrine reduces cerebral perfusion

during cardiopulmonary resuscitation. Crit Care Med 2009;37:1408–15.

5. Ristagno G, TangW, Sun S, et al. Cerebral cortical microvascular ﬂow during and

following cardiopulmonary resuscitation after short duration of cardiac arrest.

Resuscitation 2008;77:229–34.

6. Ristagno G, Sun S, Tang W, et al. Effects of epinephrine and vasopressin on cere-

bral microcirculatory ﬂows during and after cardiopulmonary resuscitation. Crit

Care Med 2007;35:2145–9.

7. Goedhart P, Khalilzada M, Bezemer R, et al. Sidestreamdark ﬁeld (SDF) imaging:

a novel stroboscopic LED ring-based imaging modality for clinical assessment

of the microcirculation. Opt Express 2007;15:15101–14.

8. De Backer D, Hollenberg S, Boerma C, et al. How to evaluate themicrocirculation:

report of a round table conference. Crit Care 2007;11:R101.

9. Elbers PW, Ince C. Mechanisms of critical illness—classifying microcirculatory

ﬂow abnormalities in distributive shock. Crit Care 2006;10:221.

10. Elbers PW, Ozdemir A, van Iterson M, et al. Microcirculatory imaging in car-

diac anesthesia: ketanserin reduces blood pressure but not perfused capillary

density. J Cardiothorac Vasc Anesth 2009;23:95–101.

11. Wan Z, Ristagno G, Sun S, et al. Preserved cerebral microcirculation during car-

diogenic shock. Crit Care Med 2009;37:2333–7.

12. Koch M, De Backer D, Vincent JL, et al. Effects of propofol on human microcircu-

lation. Br J Anaesth 2008;101:473–8.

13. Kamler M, Goedeke J, Pizanis N, et al. In vivo effects of hypothermia on the

microcirculation during extracorporeal circulation. Eur J Cardiothorac Surg

2005;28:259–65.

surgery. 10

6. Conclusion

This is the ﬁrst report on human microvascular imaging during

CPR. mCPR is able to provide microvascular perfusion. How-

ever, indices of microvascular perfusion seem low and improve

vastly after conversion to sinus rhythm. Microvascular perfusion

was relatively independent from global hemodynamic parame-

ters in this setting. The microcirculation may prove a sensitive

monitor to determine the adequacy of CPR. Albeit prone to move-

ment artifacts, it may prove possible to use SDF imaging in this

context.

Conﬂict of interest statement

Prof. Can Ince is, as well as the afﬁliations listed in the

manuscript, chief scientiﬁc ofﬁcer of Microvision Medical. Micro-

vision Medical is a university-based company dedicated to the

Plik z chomika:

Inne pliki z tego folderu:

Inne foldery tego chomika: