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Hemodynamic coherence and the rationale for monitoring the microcirculation

机译：血流动力学一致性和监测微循环的原理

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This article presents a personal viewpoint of the shortcoming of conventional hemodynamic resuscitation procedures in achieving organ perfusion and tissue oxygenation following conditions of shock and cardiovascular compromise, and why it is important to monitor the microcirculation in such conditions. The article emphasizes that if resuscitation procedures are based on the correction of systemic variables, there must be coherence between the macrocirculation and microcirculation if systemic hemodynamic-driven resuscitation procedures are to be effective in correcting organ perfusion and oxygenation. However, in conditions of inflammation and infection, which often accompany states of shock, vascular regulation and compensatory mechanisms needed to sustain hemodynamic coherence are lost, and the regional circulation and microcirculation remain in shock. We identify four types of microcirculatory alterations underlying the loss of hemodynamic coherence: type 1, heterogeneous microcirculatory flow; type 2, reduced capillary density induced by hemodilution and anemia; type 3, microcirculatory flow reduction caused by vasoconstriction or tamponade; and type 4, tissue edema. These microcirculatory alterations can be observed at the bedside using direct visualization of the sublingual microcirculation with hand-held vital microscopes. Each of these alterations results in oxygen delivery limitation to the tissue cells despite the presence of normalized systemic hemodynamic variables. Based on these concepts, we propose how to optimize the volume of fluid to maximize the oxygen-carrying capacity of the microcirculation to transport oxygen to the tissues.
机译：本文提出了一种个人观点，即传统的血流动力学复苏程序在休克和心血管受损的情况下实现器官灌注和组织氧合的缺点，以及为什么在这种情况下监测微循环很重要。该文章强调，如果复苏程序是基于对系统变量的校正，则要使全身血液动力学驱动的复苏程序有效地纠正器官灌注和氧合作用，大循环和微循环之间必须保持一致。然而，在通常伴随休克状态的炎症和感染的情况下，维持血流动力学一致性所需的血管调节和补偿机制丧失，并且局部循环和微循环仍处于休克状态。我们确定了导致血液动力学一致性丧失的四种微循环改变：1型，异质性微循环血流; 2型。 2型，血液稀释和贫血引起的毛细血管密度降低;类型3，由于血管收缩或填塞引起的微循环血流减少;和类型4，组织水肿。这些微循环改变可以在床旁使用手持式生命显微镜直接观察舌下微循环。尽管存在归一化的全身血液动力学变量，但是这些改变中的每一个都导致向组织细胞的氧输送受限。基于这些概念，我们提出如何优化流体的体积，以最大程度地提高微循环的载氧能力，从而将氧气输送到组织。

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