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Review
. 2023 May 16;27(1):190.
doi: 10.1186/s13054-023-04474-x.

The future of intensive care: the study of the microcirculation will help to guide our therapies

J Duranteau  1 , D De Backer  2 , K Donadello  3 , N I Shapiro  4 , S D Hutchings  5   6 , A Rovas  7 , M Legrand  8 , A Harrois  9 , C Ince  10
Affiliations
Review

The future of intensive care: the study of the microcirculation will help to guide our therapies

J Duranteau et al. Crit Care. .

Abstract

The goal of hemodynamic resuscitation is to optimize the microcirculation of organs to meet their oxygen and metabolic needs. Clinicians are currently blind to what is happening in the microcirculation of organs, which prevents them from achieving an additional degree of individualization of the hemodynamic resuscitation at tissue level. Indeed, clinicians never know whether optimization of the microcirculation and tissue oxygenation is actually achieved after macrovascular hemodynamic optimization. The challenge for the future is to have noninvasive, easy-to-use equipment that allows reliable assessment and immediate quantitative analysis of the microcirculation at the bedside. There are different methods for assessing the microcirculation at the bedside; all have strengths and challenges. The use of automated analysis and the future possibility of introducing artificial intelligence into analysis software could eliminate observer bias and provide guidance on microvascular-targeted treatment options. In addition, to gain caregiver confidence and support for the need to monitor the microcirculation, it is necessary to demonstrate that incorporating microcirculation analysis into the reasoning guiding hemodynamic resuscitation prevents organ dysfunction and improves the outcome of critically ill patients.

Keywords: Artificial intelligence; Hand-held vital microscopes; Hemodynamic resuscitation; ICU; Microcirculation.

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Conflict of interest statement

Duranteau J.: LFB, Edwards Lifesciences, RenalSense, Sophysa, Amomed, Fresenius and Octapharma. De Backer D.: no competing interest. Donadello K.: no competing interest. Shapiro N.I.: no competing interest. Hutchings S.D.: no competing interest. Rovas A.: no competing interest. Legrand M. no competing interest. Harrois A.: no competing interest. Ince C. CSO of Active Medical BV, Leiden The Netherlands, a company which provides devices, software, education and services related to clinical microcirculation.

Figures

Fig. 1
Fig. 1
Different parameters of macrocirculation and microcirculation optimization
Fig. 2
Fig. 2
Illustration of the different types of microvascular alterations occurring despite macrovascular optimization of the macrocirculation. A Heterogeneous distribution, with perfused capillaries next to non-circulating capillaries, observed mainly in inflammatory and/or severe septic states. B Dilution of red blood cells occurring during hemodilution (for example in hemorrhagic shock during fluid resuscitation) and anemia. C Congestion due to increased venous pressure. D Tissue edema with increased oxygen diffusion distances
Fig. 3
Fig. 3
The challenge for the future of microcirculation monitoring in ICU
Fig. 4
Fig. 4
Integrative diagnostic platform: the future diagnostic platform will include hemodynamic components from macro to microcirculation, cellular and subcellular components and the immune function of cells. Artificial intelligence could assist in the development of algorithms and allow clinicians to make therapeutic decisions regarding the treatment of microcirculatory alterations
Fig. 5
Fig. 5
Proposal of an algorithm for the optimization of macro- and microcirculations. In the future, the hemodynamic optimization will have to individualize the microcirculation and the microcirculation. The concomitant evaluation of macro- and microhemodynamics will allow to test the coherence between macro- and microcirculation. In the absence of coherence between macro and microcirculation and in the face of persistent microvascular alterations despite macrovascular hemodynamic optimization, the microvascular response to the following therapeutic options can be tested taking into account the values of the microvascular parameters and the clinical context: 1 Performance of a fluid challenge. 2 Administration, or increase in doses, of vasopressors, or combination of another vasopressor (e.g., vasopressin if the primary vasopressor used is norepinephrine) (taking into account the individualized blood pressure level) if perfusion pressure is low. 3 Administration of packed red blood cells (especially if capillary density and/or microvascular hemoglobin is decreased). 4 In the future, strategies testing vasodilators or even antithrombotic molecules could be considered in case of persistence of microvascular alterations despite the previous therapeutic options and according to ongoing and future studies. PPV: Pulse pressure variation; SV: stroke volume; SVV: stroke volume variation; CVP: central venous pressure; ScvO2: central venous oxygen saturation; Pv-aCO2 gap: venous-to-arterial carbon dioxide difference. The order of interventions is indicative, and prioritization may vary according to patient. In each case, the effect of the interventions should be carefully checked
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Comment in

References

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