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DOES MONITORING REGIONAL CIRCUALTION VARIABLES
INFLUENCE OUTCOME ?
Daniel De Backer Department of Intensive
Care Erasme University Hospital Brussels, Belgium
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PATHOGENESIS OF ORGAN FAILURE IN SEVERE SEPSIS
WHOLE BODY
REGIONAL

• gastric tonometry
• ShO2
• ICG

ORGAN FAILURE
MICROCIRCULATORY
MITOCHONDRIAL

• OPS (sublingual)
• PslCO2

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IS THERE A LINK BETWEEN REGIONAL AND SYSTEMIC
CIRCULATIONS ?
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LeDoux et al CCM 2827292000
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LeDoux et al CCM 2827292000
gt Manipulation of global hemodynamics may fail
to alter regional circulations
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Percentage of vessels perfused (small vessels)

100
De Backer et al AJRCCM 16698-1042002
80
60
40
20
0
Volunteers (10)
p lt0.001 vs volunteers
DDB USI
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• Influence of systemic factors on the
  microcirculation ?

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Nakajima et al AJRCCM 16415262001
Mice intravital µscopy
Low ETX 1.5 mg/kg, MAP 70 mmHg High ETX 10
mg/kg, MAP 40 mmHg HEM MAP 40 mmHg
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De Backer et al AJRCCM 166982002
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De Backer et al CCM 344032006
Change in capillary perfusion

DOBU 5 mcg/kg.min
L/min.M²
Change in cardiac index
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De Backer et al CCM 344032006
Change in capillary perfusion

DOBU 5 mcg/kg.min
mmHg
Change in arterial pressure
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IS THERE A LINK BETWEEN REGIONAL AND SYSTEMIC
CIRCULATIONS ?
No regional and microcirculatory alterations may
occur, even after correction of global
hemodynamic alterations.
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DOES MONITORING OF REGIONAL CIRCULATIONS OR
MICROCIRCULATION PREDICT OUTCOME ?
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Sakka et al Chest 12217152002
ICG-PDR
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Sakka et al Chest 12217152002
ICG-PDR
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• Gastric tonometry in septic patients
• Increased mucosal PCO2 (or decreased pHi)
• Maynard et al JAMA 270 1203 1993
• Friedman et al CCM 23 1185 1995
• Oud et al Chest 115 1390 1999
• Levy et al CCM 31 474 2003

Association with outcome
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PCO2gap as a marker of mortality in ICU
ventilated patients
Levy B et al CCM 314742003
N 95 patients
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PCO2gap as a marker of mortality in ICU
ventilated patients
Levy B et al CCM 314742003
N 95 patients
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Variables associated with outcome on admission
and after hemodynamic stabilization
Poeze et al CCM 3324942005
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MICROVASCULAR PERFUSION IN SEVERE HEART FAILURE
Heart failure and cardiogenic shock
De Backer et al AHJ 147912004
Capillary perfusion
100
p lt 0.05
80
60
40
20
0
Survivors
Non Survivors
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• ROC curve area
• Baseline
• APACHE II 0.74
• Lactate 0.68
• Changes between day 1 and day 2
• heart rate 0.57
• mean arterial pressure 0.53
• CVP 0.51
• PAOP 0.64
• cardiac index 0.51
• SvO2 0.52
• DO2 0.52
• VO2 0.50
• Lactate 0.63
• Microvascular perfusion 0.77
• SOFA score 0.61

Sakr et al CCM 3218252004
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Sublingual capnometry in patients with
circulatory failure
Marik. Chest. 2001 120923
22 patients (76 data sets)
Admission
PslCO2-PaCO2 (mm Hg)

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Sublingual capnometry in patients with
circulatory failure
Rackow et al. Chest. 2001 1201633
50 patients
Admission
PslCO2-PaCO2 (mm Hg)

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Sublingual capnometry versus traditional
markers of tissue oxygenation in critically ill
patients
Marik et al. Crit Care Med. 2003 31 818-822
N 54 ICU unstable ICU patient (septic shock 39)
Prediction of mortality Best cut-off value for
PslCO2-gap 25 mm Hg
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DOES MONITORING OF REGIONAL CIRCULATIONS OR
MICROCIRCULATION PREDICT OUTCOME ?
Yes monitoring regional and microcirculatory
alterations may help to identify patients at
greater risk of death
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RESUSCITATION CENTERED ON REGIONAL CIRCULATIONS ?
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EFFICACY OF pHi GUIDED THERAPY
Gutierrez G et al Lancet 3391951992
260 critically ill patients Therapy guided on pHi
(dobutamine-fluids), goal 7.35 Data analyzed
according to 2 subgroups (pHi lt or gt7.35)
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EFFICACY OF pHi GUIDED THERAPY
Gutierrez G et al Lancet 3391951992
Survival rate
Days after admission in ICU
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EFFICACY OF pHi GUIDED THERAPY
Gutierrez G et al Lancet 3391951992
Survival rate
Days after admission in ICU
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Mythen M et al.
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• Problems with these interventional studies
• Underpowered studies
• Investigate the technique as well as the
  interventions

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CONCLUSIONS
Monitoring the splanchnic circulation and the
microcirculation can be useful to identify
patients with under-resuscitated areas, despite
correction of global hemodynamic variables.
Regional and microcirculatory alterations are
associated with a poor outcome.
Whether resuscitation guided on regional
monitoring can affect outcome remains to be
determined.