Journal of Clinical Monitoring and Computing

, Volume 31, Issue 5, pp 981–988 | Cite as

Impact of microcirculatory video quality on the evaluation of sublingual microcirculation in critically ill patients

  • Elisa Damiani
  • Can Ince
  • Claudia Scorcella
  • Roberta Domizi
  • Andrea Carsetti
  • Nicoletta Mininno
  • Silvia Pierantozzi
  • Erica Adrario
  • Rocco Romano
  • Paolo Pelaia
  • Abele DonatiEmail author
Original Research


We aimed to assess the impact of image quality on microcirculatory evaluation with sidestream dark-field (SDF) videomicroscopy in critically ill patients and explore factors associated with low video quality. This was a retrospective analysis of a single-centre prospective observational study. Videos of the sublingual microcirculation were recorded using SDF videomicroscopy in 100 adult patients within 12 h from admittance to the intensive care unit and every 24 h until discharge/death. Parameters of vessel density and perfusion were calculated offline for small vessels. For all videos, a quality score (−12 = unacceptable, 1 = suboptimal, 2 = optimal) was assigned for brightness, focus, content, stability, pressure and duration. Videos with a total score ≤8 were deemed as unacceptable. A total of 2455 videos (853 triplets) was analysed. Quality was acceptable in 56 % of videos. Lower quality was associated with worse microvascular density and perfusion. Unreliable triplets (≥1 unacceptable or missing video, 65 % of total) showed lower vessel density, worse perfusion and higher flow heterogeneity as compared to reliable triplets (p < 0.001). Quality was higher among triplets collected by an extensively-experienced investigator or in patients receiving sedation or mechanical ventilation. Perfused vessel density was higher in patients with Glasgow Coma Scale (GCS) ≤8 (18.9 ± 4.5 vs. 17.0 ± 3.9 mm/mm2 in those with GCS >8, p < 0.001) or requiring mechanical ventilation (18.0 ± 4.5 vs. 17.2 ± 3.8 mm/mm2 in not mechanically ventilated patients, p = 0.059). We concluded that SDF video quality depends on both the operator’s experience and patient’s cooperation. Low-quality videos may produce spurious data, leading to an overestimation of microvascular alterations.


Microcirculation Sidestream dark field imaging Microcirculatory image quality Critically ill patients 



The authors wish to thank all those who participated in the data collection and analysis, and the medical and nurse staff of the Intensive Care Unit of Azienda Ospedaliera Universitaria “Ospedali Riuniti” of Ancona (Italy) for their support in the realisation of this work. No external funding was received for the realisation of this work.

Compliance with ethical standards

Conflict of interest

CI is the inventor of sidestream dark field imaging technology and holds shares in MicroVision Medical and was a consultant for this company more than 4 years ago but has had no further contact with the company since then. He has no other competing interests in this field and there are no other relationships or activities that could appear to have influenced the submitted work. The other authors declare that they have no conflict of interest.

Supplementary material

10877_2016_9924_MOESM1_ESM.pdf (704 kb)
Supplementary material 1 (PDF 703 kb)


  1. 1.
    Donati A, Domizi R, Damiani E, Adrario E, Pelaia P, Ince C. From macrohemodynamic to the microcirculation. Crit Care Res Pract. 2013;2013:892710. doi: 10.1155/2013/892710.PubMedPubMedCentralGoogle Scholar
  2. 2.
    Goedhart PT, Khalilzada M, Bezemer R, Merza J, Ince C. Sidestream Dark Field (SDF) imaging: a novel stroboscopic LED ring-based imaging modality for clinical assessment of the microcirculation. Opt Express. 2007;15:15101–14.CrossRefPubMedGoogle Scholar
  3. 3.
    De Backer D, Creteur J, Preiser JC, Dubois MJ, Vincent JL. Microvascular blood flow is altered in patients with sepsis. Am J Respir Crit Care Med. 2002;166:98–104.CrossRefPubMedGoogle Scholar
  4. 4.
    Sakr Y, Dubois MJ, De Backer D, Creteur J, Vincent JL. Persistent microvascular alterations are associated with organ failure and death in patients with septic shock. Crit Care Med. 2004;32:1825–31.CrossRefPubMedGoogle Scholar
  5. 5.
    De Backer D, Creteur J, Dubois MJ, Sakr Y, Vincent JL. Microvascular alterations in patients with acute severe heart failure and cardiogenic shock. Am Heart J. 2004;147:91–9.CrossRefPubMedGoogle Scholar
  6. 6.
    De Backer D, Donadello K, Sakr Y, Ospina-Tascon G, Salgado D, Scolletta S, Vincent JL. Microcirculatory alterations in patients with severe sepsis: impact of time of assessment and relationship with outcome. Crit Care Med. 2013;41:791–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Tachon G, Harrois A, Tanaka S, Kato H, Huet O, Pottecher J, Vicaut E, Duranteau J. Microcirculatory alterations in traumatic hemorrhagic shock. Crit Care Med. 2014;42:1433–41.CrossRefPubMedGoogle Scholar
  8. 8.
    Pranskunas A, Koopmans M, Koetsier PM, Pilvinis V, Boerma EC. Microcirculatory blood flow as a tool to select ICU patients eligible for fluid therapy. Intensive Care Med. 2013;39:612–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Dubin A, Pozo MO, Casabella CA, Pálizas F Jr, Murias G, Moseinco MC, Kanoore Edul VS, Pálizas F, Estenssoro E, Ince C. Increasing arterial blood pressure with norepinephrine does not improve microcirculatory blood flow: a prospective study. Crit Care. 2009;13:R92.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    De Backer D, Hollenberg S, Boerma EC, Goedhart P, Buchele G, Ospina-Tascon G, Dobbe I, Ince C. How to evaluate the microcirculation: report of a roundtable conference. Crit Care. 2007;11:R101.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Sallisalmi M, Oksala N, Pettila V, Tenhunen J. Evaluation of sublingual microcirculatory blood flow in the critically ill. Acta Anaesthesiol Scand. 2012;56:298–306.CrossRefPubMedGoogle Scholar
  12. 12.
    Massey MJ, LaRochelle E, Najarro G, Karmacharla A, Arnold R, Trzeciak S, Angus DC, Shapiro NI. The microcirculation image quality score: development and preliminary evaluation of a proposed approach to grading quality of image acquisition for bedside videomicroscopy. J Crit Care. 2013;28:913–7.CrossRefPubMedGoogle Scholar
  13. 13.
    Donati A, Damiani E, Luchetti M, Domizi R, Scorcella C, Carsetti A, Gabbanelli V, Carletti P, Bencivenga R, Vink H, Adrario E, Piagnerelli M, Gabrielli A, Pelaia P, Ince C. Microcirculatory effects of the transfusion of leukodepleted or non-leukodepleted red blood cells in patients with sepsis: a pilot study. Crit Care. 2014;18:R33.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Morelli A, Donati A, Ertmer C, Rehberg S, Lange M, Orecchioni A, Cecchini V, Landoni G, Pelaia P, Pietropaoli P, Van Aken H, Teboul JL, Ince C, Westphal M. Levosimendan for resuscitating the microcirculation in patients with septic shock: a randomized controlled study. Crit Care. 2010;14:R232.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Boerma EC, Mathura KR, van der Voort PH, Spronk PE, Ince C. Quantifying bedside-derived imaging of microcirculatory abnormalities in septic patients: a prospective validation study. Crit Care. 2005;9:R601–6.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Groner W, Winkelman JW, Harris AG, Ince C, Bouma GJ, Messmer K, Nadeau RG. Orthogonal polarization spectral imaging: a new method for study of the microcirculation. Nat Med. 1999;5:1209–12.CrossRefPubMedGoogle Scholar
  17. 17.
    Moore JP, Dyson A, Singer M, Fraser J. Microcirculatory dysfunction and resuscitation: why, when, and how. Br J Anaesth. 2015;115:366–75.CrossRefPubMedGoogle Scholar
  18. 18.
    Kanoore Edul VS, Dubin A, Ince C. The microcirculation as a therapeutic target in the treatment of sepsis and septic shock. Semin Respir Crit Care Med. 2011;32:558–68.CrossRefPubMedGoogle Scholar
  19. 19.
    Donati A, Tibboel D, Ince C. Towards an integrative physiological monitoring of the critically ill: from cardiovascular to microcirculatory and cellular function monitoring at the bedside. Crit Care. 2013;17(Suppl. 1):S5.PubMedPubMedCentralGoogle Scholar
  20. 20.
    Ince C. The rationale for microcirculatory-guided fluid therapy. Curr Opin Crit Care. 2014;20:301–8.CrossRefPubMedGoogle Scholar
  21. 21.
    Donati A, Damiani E, Botticelli L, Adrario E, Lombrano MR, Domizi R, Marini B, Van Teeffelen JW, Carletti P, Girardis M, Pelaia P, Ince C. The aPC treatment improves microcirculation in severe sepsis/septic shock syndrome. BMC Anesthesiol. 2013;13:25.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Damiani E, Adrario E, Luchetti MM, Scorcella C, Carsetti A, Mininno N, Pierantozzi S, Principi T, Strovegli D, Bencivenga R, Gabrielli A, Romano R, Pelaia P, Ince C, Donati A. Plasma free hemoglobin and microcirculatory response to fresh or old blood transfusions in sepsis. PLoS ONE. 2015;10:e0122655.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Gilbert-Kawai E, Coppel J, Bountziouka V, Ince C, Martin D, For the Caudwell Xtreme Everest and Xtreme Everest 2 Research Group. A comparison of the quality of image acquisition between the incident dark field and sidestream dark field videomicroscopes. BMC Med Imaging. 2016;16:10.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Aykut G, Veenstra G, Scorcella C, Ince C, Boerma C. Cytocam-IDF (incident dark field illumination) imaging for bedside monitoring of the microcirculation. Intensive Care Med Exp. 2015;3:40.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2016

Authors and Affiliations

  • Elisa Damiani
    • 1
  • Can Ince
    • 2
  • Claudia Scorcella
    • 1
  • Roberta Domizi
    • 1
  • Andrea Carsetti
    • 1
  • Nicoletta Mininno
    • 1
  • Silvia Pierantozzi
    • 1
  • Erica Adrario
    • 1
  • Rocco Romano
    • 1
  • Paolo Pelaia
    • 1
  • Abele Donati
    • 1
    Email author
  1. 1.Anaesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public HealthUniversità Politecnica delle MarcheAnconaItaly
  2. 2.Department of Translational Physiology, Academic Medical CentreUniversity of AmsterdamAmsterdamThe Netherlands

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