Severe Impairment of Microcirculatory Perfused Vessel Density Is Associated With Postoperative Lactate and Acute Organ Injury After Cardiac Surgery.
OBJECTIVE
Resuscitation after cardiac surgery needs to address multiple pathophysiological processes that are associated with significant morbidity and mortality. Functional microcirculatory derangements despite normal systemic hemodynamics have been previously described but must be tied to clinical outcomes. The authors hypothesized that microcirculatory dysfunction after cardiac surgery would include impaired capillary blood flow and impaired diffusive capacity and that subjects with the lowest quartile of perfused vessel density would have an increased postoperative lactate level and acute organ injury scores.


DESIGN
Prospective, observational study.


SETTING
A single, tertiary university cardiovascular surgical intensive care unit.


PARTICIPANTS
25 adults undergoing elective cardiac surgery requiring cardiopulmonary bypass.


INTERVENTION
Sublingual microcirculation was imaged using incident dark field microscopy before and 2 to 4 hours after surgery in the intensive care unit.


MEASUREMENTS AND MAIN RESULTS
Compared with baseline measurements, postoperative vessel-by-vessel microvascular flow index (2.9 [2.8-2.9] v 2.5 [2.4-2.7], p < 0.0001) and perfused vessel density were significantly impaired (20.7 [19.3-22.9] v 16.3 [12.8-17.9], p < 0.0001). The lowest quartile of perfused vessel density (<12.8 mm/mm2) was associated with a significantly increased postoperative lactate level (6.0 ± 2.9 v 1.8 ± 1.2, p < 0.05), peak lactate level (7.6 ± 2.8 v 2.8 ± 1.5, p = 0.03), and sequential organ failure assessment (SOFA) score at 24 and 48 hours.


CONCLUSION
In patients undergoing cardiac surgery, there was a significant decrease in postoperative microcirculatory convective blood flow and diffusive capacity during early postoperative resuscitation. Severely impaired perfused vessel density, represented by the lowest quartile of distribution, is significantly related to hyperlactatemia and early organ injury.
['Greenwood|John C|JC|', 'Jang|David H|DH|', 'Hallisey|Stephen D|SD|', 'Gutsche|Jacob T|JT|', 'Horak|Jiri|J|', 'Acker|Michael A|MA|', 'Bermudez|Christian A|CA|', 'Zhou|Victoria L|VL|', 'Chatterjee|Shampa|S|', 'Shofer|Frances S|FS|', 'Kilbaugh|Todd J|TJ|', 'Augoustides|John G T|JGT|', 'Meyer|Nuala J|NJ|', 'Bakker|Jan|J|', 'Abella|Benjamin S|BS|']
D000328:Adult D006348:Cardiac Surgical Procedures D006439:Hemodynamics D006801:Humans D019344:Lactic Acid D008833:Microcirculation D009060:Mouth Floor D011446:Prospective Studies
cardiac surgery resuscitation microcirculation critical care shock