Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Institute of Cardiology, Bogotà, Colombia.
BMC Pediatr. 2024 Jan 20;24(1):68. doi: 10.1186/s12887-024-04524-5.
In children with sepsis, circulatory shock and multi-organ failure remain major contributors to mortality. Prolonged capillary refill time (PCRT) is a clinical tool associated with disease severity and tissue hypoperfusion. Microcirculation assessment with videomicroscopy represents a promising candidate for assessing and improving hemodynamic management strategies in children with sepsis. Particularly when there is loss of coherence between the macro and microcirculation (hemodynamic incoherence). We sought to evaluate the association between PCRT and microcirculation changes in sepsis.
This was a prospective cohort study in children hospitalized with sepsis. Microcirculation was measured using sublingual video microscopy (capillary density and flow and perfused boundary region [PBR]-a parameter inversely proportional to vascular endothelial glycocalyx thickness), phalangeal tissue perfusion, and endothelial activation and glycocalyx injury biomarkers. The primary outcome was the association between PCRT and microcirculation changes.
A total of 132 children with sepsis were included, with a median age of two years (IQR 0.6-12.2). PCRT was associated with increased glycocalyx degradation (PBR 2.21 vs. 2.08 microns; aOR 2.65, 95% CI 1.09-6.34; p = 0.02) and fewer 4-6 micron capillaries recruited (p = 0.03), with no changes in the percentage of capillary blood volume (p = 0.13). Patients with hemodynamic incoherence had more PBR abnormalities (78.4% vs. 60.8%; aOR 2.58, 95% CI 1.06-6.29; p = 0.03) and the persistence of these abnormalities after six hours was associated with higher mortality (16.5% vs. 6.1%; p < 0.01). Children with an elevated arterio-venous CO difference (DCO) had an abnormal PBR (aOR 1.13, 95% CI 1.01-1.26; p = 0.03) and a lower density of small capillaries (p < 0.05). Prolonged capillary refill time predicted an abnormal PBR (AUROC 0.81, 95% CI 0.64-0.98; p = 0.03) and relative percentage of blood in the capillaries (AUROC 0.82, 95% CI 0.58-1.00; p = 0.03) on admission. A normal CRT at 24 h predicted a shorter hospital stay (aOR 0.96, 95% CI 0.94-0.99; p < 0.05).
We found an association between PCRT and microcirculation changes in children with sepsis. These patients had fewer small capillaries recruited and more endothelial glycocalyx degradation. This leads to nonperfused capillaries, affecting oxygen delivery to the tissues. These disorders were associated with hemodynamic incoherence and worse clinical outcomes when the CRT continued to be abnormal 24 h after admission.
在脓毒症患儿中，循环衰竭和多器官衰竭仍然是导致死亡率的主要原因。毛细血管再充盈时间（PCRT）是一种与疾病严重程度和组织低灌注相关的临床工具。视频显微镜下的微循环评估是评估和改善脓毒症患儿血流动力学管理策略的有前途的候选方法。特别是当宏观和微观循环之间存在不连贯时（血流动力学不连贯）。我们旨在评估 PCRT 与脓毒症患者微循环变化之间的关系。
这是一项在因脓毒症住院的儿童中进行的前瞻性队列研究。使用舌下视频显微镜（毛细血管密度和血流以及灌注边界区[PBR]-与血管内皮糖萼厚度成反比的参数）、甲床组织灌注以及内皮激活和糖萼损伤生物标志物来测量微循环。主要结局是 PCRT 与微循环变化之间的关联。
共纳入 132 名脓毒症患儿，中位年龄为 2 岁（IQR 0.6-12.2）。PCRT 与糖萼降解增加相关（PBR 2.21 与 2.08 微米；优势比 2.65，95%置信区间 1.09-6.34；p=0.02）和招募的 4-6 微米毛细血管减少（p=0.03），但毛细血管血容量百分比无变化（p=0.13）。血流动力学不连贯的患者 PBR 异常更为常见（78.4%与 60.8%；优势比 2.58，95%置信区间 1.06-6.29；p=0.03），并且这些异常在六小时后持续存在与更高的死亡率相关（16.5%与 6.1%；p<0.01）。动静脉 CO 差（DCO）升高的患儿 PBR 异常（优势比 1.13，95%置信区间 1.01-1.26；p=0.03）和小毛细血管密度降低（p<0.05）。延长的毛细血管再充盈时间预测异常 PBR（AUROC 0.81，95%置信区间 0.64-0.98；p=0.03）和毛细血管内血液的相对百分比（AUROC 0.82，95%置信区间 0.58-1.00；p=0.03）在入院时。24 小时时正常的 CRT 预测住院时间更短（优势比 0.96，95%置信区间 0.94-0.99；p<0.05）。
我们发现脓毒症患儿 PCRT 与微循环变化之间存在关联。这些患者招募的小毛细血管减少，内皮糖萼降解增加。这导致无灌注的毛细血管，影响组织的氧输送。这些紊乱与血流动力学不连贯有关，并且在入院后 24 小时 CRT 持续异常时临床结局更差。
