From the Guidelines
The primary treatment for microcirculatory incoherence, which is not a recognized medical condition, would involve addressing the underlying cause of microcirculatory dysfunction, such as sepsis, and following guidelines like those from the Surviving Sepsis Campaign, which emphasize early recognition, fluid resuscitation, and vasopressor use as needed 1.
Key Considerations
- Microcirculatory incoherence is not a standard medical term, suggesting the need to identify and treat the underlying condition causing microcirculatory issues.
- Conditions like sepsis, which can lead to microvascular dysfunction, require prompt treatment, including intravenous fluids for resuscitation and vasopressors to support blood pressure, as outlined in guidelines like those from the World Journal of Emergency Surgery 1.
- The management of sepsis, a potential cause of microcirculatory problems, involves early goal-directed therapy, which has been refined over time, with recent studies suggesting that clinical endpoints rather than predetermined protocols should guide resuscitation efforts 1.
Treatment Approach
- For sepsis, a condition that can cause microcirculatory dysfunction, the primary approach includes:
- Early recognition and administration of intravenous fluids for resuscitation.
- Use of vasopressors as needed to support blood pressure, with a mean arterial pressure (MAP) goal that may vary but is often around 65 mm Hg, though this can be adjusted based on individual patient response and specific clinical scenarios 1.
- Monitoring of clinical endpoints such as mean arterial pressure, skin color, capillary refill, mental status, and urinary output to guide fluid and vasopressor therapy.
Important Considerations
- The choice of fluid (crystalloid vs. colloid) and the rate of infusion should be tailored to the individual patient's response, with crystalloids being the first choice due to their tolerability and cost-effectiveness 1.
- The potential for fluid overload and its complications, such as intra-abdominal hypertension and abdominal compartment syndrome, especially in patients requiring surgical intervention, must be carefully managed 1.
- Repeated measurements of inferior vena cava (IVC) diameter by ultrasound can provide a simple and useful method for defining fluid requirements and guiding resuscitation efforts 1.
From the Research
Microcirculatory Incoherence Treatment
The primary treatment for microcirculatory incoherence is focused on improving microcirculatory perfusion. Some key points to consider:
- Classical hemodynamic interventions, such as fluids, red blood cell transfusions, vasopressors, and inotropic agents, have a limited impact on microcirculatory alterations 2.
- Fluids may improve microcirculation in the early phase of sepsis, and dobutamine can also improve microcirculation, although the effect varies among patients 2.
- Maintaining sufficient perfusion pressure can positively influence microcirculation, but the optimal mean arterial pressure levels are still controversial 2.
- Vasodilating agents, such as nitroglycerin, have shown promising results in some trials, but their use is not widely recommended due to inconsistent findings 2, 3.
- Other agents, including activated protein C, antithrombin, vitamin C, and steroids, may improve microcirculation 2, 4.
Microvascular Resuscitation
Microvascular resuscitation is a therapeutic goal in severe sepsis, aiming to improve microcirculatory function and prevent organ dysfunction. Strategies include:
- Hemodynamic resuscitation using volume resuscitation, vasopressors, and inotropes 4.
- Alternative vasoactive agents, such as vasopressin, may improve microcirculatory function 4.
- Targeted treatment of the endothelium, using activated protein C, can improve microvascular function and increase survival 4.
Monitoring Microcirculation
Monitoring microcirculatory coherence is essential to ensure that macrocirculatory resuscitation is effective in improving microcirculatory perfusion. Recent studies have shown that restoration of adequate macrocirculatory parameters is not always associated with improvement in microcirculatory perfusion 5, 6. Direct visualization of the sublingual microcirculation using hand-held vital microscopes can help identify microcirculatory alterations and guide treatment 6.