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Changes in the sublingual microcirculation and endothelial adhesion molecules during the course of severe meningococcal disease treated in the paediatric intensive care unit

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Abstract

Purpose

The sublingual microcirculation can be visualised in real time using sidestream dark-field (SDF) imaging. Endothelial activation mediated through adhesion molecules may alter flow patterns in the microcirculation. We studied sublingual microcirculatory disturbances in children with meningococcal disease (MCD) and simultaneously measured plasma levels of adhesion molecules.

Method

Twenty children admitted to the paediatric intensive care unit (PICU) with MCD were studied. Forty healthy children were controls. The sublingual microcirculation was assessed at admission and at timed intervals until extubation. The microvascular flow index (MFI), capillary density (CD), proportion of perfused vessels (PPV) and perfused vessel density (PVD) were measured using SDF imaging. Plasma intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), E-selectin and P-selectin were measured at admission and at timed intervals during the course of PICU treatment.

Results

Significant reductions in MFI, CD, PPV and PVD were found in children with MCD compared with controls (p < 0.005). These differences had resolved prior to extubation. Initial MFI values predicted the duration of mechanical ventilation, irrespective of the stage of illness at the time of presentation to PICU. There were negative correlations between the ICAM-1, VCAM-1 and E-selectin levels and the microcirculatory MFI and PPV values at the time of admission to PICU (p < 0.005).

Conclusions

Microcirculatory dysfunction is present in children with severe MCD with improvement alongside clinical recovery. Microcirculatory dysfunction correlated with markers of endothelial activation. Sublingual SDF imaging is feasible in children ventilated on PICU for severe sepsis and may prove useful in studies assessing illness severity and therapy.

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Acknowledgments

We thank the medical and nursing staff of the Paediatric Intensive Care Units in Liverpool and Manchester for their contribution to the management of these children, and to the parents and children for consenting to be included in the study. We also thank the Meningitis Research Foundation for funding the project. F.P. was supported by a grant from the Meningitis Research Foundation, UK (grant no. 0605.1).

Conflicts of interest

All authors declare that there are no potential, perceived, or real conflicts of interest in the preparation of this manuscript. The authors have full control of all primary data and agree to allow the journal to review their data if requested. The study sponsor was not involved in study design, the collection, analysis, and interpretation of data, the writing of the report or the decision to submit the paper for publication.

Ethical standards

This study has been approved by the local ethics committee and has therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki. All persons gave their informed consent prior to their inclusion in the study.

Author information

Authors and Affiliations

  1. Institute of Child Health, University of Liverpool, Alder Hey Children’s NHS Foundation Trust, Liverpool, L12 2AP, UK

    Fauzia Paize, Niten Makwana, Alistair P. J. Thomson, Ian Sinha & Enitan D. Carrol

  2. Department of Intensive Care, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK

    Richard Sarginson & Paul B. Baines

  3. Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK

    C. Anthony Hart & Christopher M. Parry

  4. Department of Infectious Diseases, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK

    Andrew Riordan & Enitan D. Carrol

  5. Department of Intensive Care, Royal Manchester Children’s Hospital, Manchester, UK

    Kay C. Hawkins

  6. Wellcome Trust Major Overseas Programme, Mahidol-Oxford Tropical Medicine Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia

    Christopher M. Parry

Authors
  1. Fauzia Paize
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  2. Richard Sarginson
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  7. C. Anthony Hart
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  9. Kay C. Hawkins
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Corresponding author

Correspondence to Fauzia Paize.

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Appendix

Appendix

Anaesthesia technique

Children aged 6 years or less were recruited from a non-syndromic population undergoing cosmetic cranioplasty for single-suture synostosis or surgery for spinal dysraphism. They were otherwise healthy and had no evidence of raised intracranial pressure. Anaesthesia was induced with either intravenous propofol (3–4 mg/kg) or sevoflurane by inhalation. They were then paralysed with atracurium (0.6 mg/kg), intubated and ventilated. Ventilation was adjusted to maintain normocapnia and an end-tidal sevoflurane value of 1.3 times the minimal alveolar concentration (MAC). Core temperature was maintained with a forced air-warming device (The Bair Hugger; Arizant Healthcare, Inc.).

Sublingual images and standard vital sign measurements were then obtained in the anaesthetic room before giving any further intravenous drugs or fluids and preparing the patient for surgery.

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Paize, F., Sarginson, R., Makwana, N. et al. Changes in the sublingual microcirculation and endothelial adhesion molecules during the course of severe meningococcal disease treated in the paediatric intensive care unit. Intensive Care Med 38, 863–871 (2012). https://doi.org/10.1007/s00134-012-2476-5

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  • DOI: https://doi.org/10.1007/s00134-012-2476-5

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