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Measurements of microvascular perfusion in healthy anesthetized dogs using orthogonal polarization spectral imaging. 15 client-owned, systemically healthy dogs that were undergoing general anesthesia for an elective procedure.
Measurements of microvascular perfusion in healthy anesthetized dogs using orthogonal polarization spectral imaging. 15 client-owned, systemically healthy dogs that were undergoing general anesthesia for an elective procedure.
Measurements of microvascular perfusion in healthy anesthetized dogs using orthogonal polarization spectral imaging. 15 client-owned, systemically healthy dogs that were undergoing general anesthesia for an elective procedure.
healthy anesthetized dogs using orthogonal polarization spectral imaging Deborah C. Silverstein, DVM, DACVECC; Antonio Pruett-Saratan, II and Kenneth J. Drobatz, DVM, MSCE, DACVECC, DACVIM Abstract Objective To determine normal microvascular assessment parameters for healthy, anesthetized dogs. Design Prospective investigational descriptive study. Setting University Teaching Hospital. Animals Fifteen client-owned, systemically healthy dogs that were undergoing general anesthesia for an elective procedure. Interventions A sidestream dark-eld videomicroscope probe was placed in the mouth at the mucogingival junction above the canine tooth and 3 video recordings of the microcirculation were made for later analysis by 2 independent, blinded reviewers. Measurements and Main Results The videos were analyzed to determine the total vessel density, proportion of perfused vessels, microcirculatory ow index, and perfused vessel density. A range of values for these indices were obtained and reported. Conclusions The microcirculation of normal dogs is readily observable using the videomicroscope and recorded video segments can be used to determine microcirculatory measurements. These values may prove useful for comparison in future studies that examine canine microcirculatory parameters. (J Vet Emerg Crit Care 2009; 19(6): 579587) doi: 10.1111/j.1476-4431.2009.00488.x Keywords: capillary imaging, cardiovascular monitoring, microcirculation, resuscitation, shock Introduction Optimizing tissue perfusion is a cornerstone of critical care medicine. In order to prevent cellular dysfunction, cellular death, and subsequent organ failure, cells must receive adequate perfusion from the local microcircu- lation. 13 The microcirculation is comprised of the arterioles (diameter 20150 mm), capillaries (diameter o20 mm), and venules (20200 mm) and is responsible for transporting oxygen and nutrients to tissue cells, ensuring adequate immunological function, and, dur- ing disease states, delivering drugs to target cells. 4,5 Although the endothelial surface of the microcircula- tory network is the largest organ in the body (40.5 km 2 in humans), it remains one of the most difcult to study. 6,7 The endothelium is a highly active organ that continuously regulates microvascular thrombosis, - brinolysis, leukocyte adhesion and migration, vascular tone, permeability, and blood ow in states of health and disease. 7 There is evidence to show that microvas- cular alterations and dysfunction are frequent in hu- mans suffering from shock, especially septic shock, despite the presence of normal (or even supranormal) systemic hemodynamics (also known as cryptic shock). 3,810 Consequently, maximizing both macro- and microcirculatory blood ow as early as possible may improve survival in septic patients. 11 The function and dysfunction of the microcirculatory network are an integral part of the inammatory dis- ease processes and development of organ failure. With sepsis, all 3 elements of the microvascular network are deranged, specifically arteriolar hyporesponsiveness to vasoconstrictors and vasodilators, a reduced number Gift support: The Barry and Savannah French-Poodle Memorial Fund. The authors declare no conicts of interest. Address correspondence and reprint requests to Dr. Deborah Silverstein, DVM, DACVECC, Department of Clinical Studies, Matthew J. Ryan Veterinary Hospital, University of Pennsylvania, 3900 Delancey Street, Philadelphia, PA 19104-6010. Email: dcsilver@vet.upenn.edu From the Department of Clinical Studies, Matthew J. Ryan Veterinary Hospital, University of Pennsylvania, Philadelphia, PA 19104-6010 Journal of Veterinary Emergency and Critical Care 19(6) 2009, pp 579587 doi:10.1111/j.1476-4431.2009.00488.x & Veterinary Emergency and Critical Care Society 2009 579 of perfused capillaries, and venular obstruction by the sequestration of activated neutrophils. 12 Patients suf- fering from shock and inadequate cellular perfusion undergo several compensatory physiologic functions to preserve cellular function, often leading to microvas- cular derecruitment in compliant vascular beds, such as those in the skin and splanchnic regions, in order to redirect blood ow to the more vital organs. 12 Regulation of the microcirculation balances regional tissue oxygen transport and metabolic needs of the tis- sues to ensure that supply matches demand. An intri- cate interplay of many neuroendocrine, paracrine, and mechanosensory pathways occurs in order to maintain adequate cellular perfusion. 13 In animals with sepsis or systemic inammatory response syndrome, perfu- sion characteristics are severely altered due to de- creased deformability of RBCs with inherent increased viscosity, 14 an increased percentage of activated neutro- phils with decreased deformability and increased ag- gregability secondary to upregulation of adhesion molecules, 12,15 activation of the clotting cascade with brin deposition and the formation of microthrombi, 16 dysfunction of vascular autoregulatory mecha- nisms, 17,18 and enhanced perfusion to large arteriove- nous shunts. These adverse changes may be secondary to decreases in blood ow and subsequent shunting of oxygen transport from the arterial to the venous com- partment, leading to microcirculatory hypoxia. 19 For example, capillary density has been shown to decrease in canine intestinal mucosa during endotoxemia 20 and experimental models of sepsis have demonstrated impaired microcirculatory ow velocity, microvessels with slow or absent ow, heterogenous regional perfusion, and a decreased density of perfused capillaries. 2124 Systemic hemodynamic indices are therefore maintained at the expense of impaired microcirculatory perfusion. If this state of hypoperfusion is not reversed in a timely manner, organ dysfunction results and may prove fatal. The mea- surements of global hemodynamic indices reect only a small portion of the whole-body circulatory blood ow and may lead to inappropriate management and further microcirculatory compromise. 3,25,26 Ideally, direct monitoring of the microcirculation would enable an accurate assessment and treatment plan for individual critically ill patients. Several tech- niques have been used to assess microcirculatory ow in severely diseased patients. There are indirect meth- ods, such as DO 2 and VO 2 , blood lactate levels, 27,28 in- testinal capnography, 29,30 and mixed venous oxygen saturation. 19 These methods evaluate oxygenation downstream from the pathological processes in the circulatory network. A direct assessment of micro- circulatory perfusion has been studied using intravital microscopy (IVM) in animals, but this technique requires large equipment and potentially toxic uorescent dyes for contrast enhancement, making it impractical to perform on a routine basis in humans or small animal clinical patients. 31,32 A more recently de- veloped method for observing the microcirculation, or- thogonal polarization spectral (OPS) imaging, creates a high-contrast image from reected light in the tis- sues. 33,34 This technique has been validated by com- parison to IVM. 35 The subject medium is illuminated with light that has been linearly polarized in 1 plane, while imaging the remitted light through another po- larizer (analyzer) oriented in a plane orthogonal to that of the illumination. In order to form the image, the light is collected, passed through a spectral lter to isolate the wavelength region, and linearly polarized. A beam splitter is used to reect the light towards the target tissue and an objective lens focuses the light onto a region of approximately 1 mm in diameter. Light that is emitted from the target is collected by the same lens and an image of the illuminated region is then formed. Contrast is obtained from the absorption of linearly polarized light by hemoglobin in the blood (both oxygenated and deoxygenated). Subsequently, RBCs in the microcirculation appear black on the white back- ground of the surrounding tissue. A 5 objective lens is used (with on-screen magnication of 326) during the measurement and data are recorded for later measurements. A new and improved model of OPS technology uses a videomicroscope a with sidestream dark eld imaging so the illuminated light and reected light travel via different pathways and surface reections do not in- terfere with the image quality. 36 With this modality, a light guide is surrounded by green (530 nm) light emit- ting diodes (LEDs). The light from the LEDs is absorbed by the hemoglobin of erythrocytes and results in the ability to observe the owing cells. The videos are re- corded and later analyzed to determine the total vessel density (TVD), proportion of perfused vessels (PPV), microcirculatory ow index (MFI), and perfused vessel density (PVD). The density of the vessels represents the actual number of vessels in the region of interest (col- lapsed vessels are not visualized) whereas the PPV in- dicates how many of those vessels have blood ow present and therefore may be capable of delivering ox- ygen to the tissues. The microcirculatory ow index reects the movement of the RBCs that are visualized in motion to assess their ow within the vessel. The PVD is derived from the other values and represents the functional density of vessels available for perfusion of the given tissue and the heterogeneity of perfusion. These measurements might allow the clinician to eval- uate and monitor the microvascular sequelae of condi- tions or therapies known to affect the microcirculation & Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00488.x 580 D.C. Silverstein et al. (eg, shock, infection/inammation, vasoactive drug administration). The clinician may be able to use this information to assess perfusion to the tissues and gauge response to therapeutic interventions. The aim of this study was to describe the use of the videomicroscope technology mentioned above to visu- alize the microcirculation in healthy anesthetized dogs and to report a range of values for TVD, PPV, MFI, and PVD in these animals. Material and Methods Animals, monitoring, and anesthetic technique Fifteen healthy dogs (based on an unremarkable his- tory, physical examination, PCV, total plasma protein, blood glucose, and BUN stick) that were anesthetized for elective surgery were included. The animals were premedicated with hydromorphone hydrochloride b (0.10.2 mg/kg, IM) and acepromazine maleate c (0.01 mg/kg, IM). Anesthesia was induced with either thiopental sodium d (1016 mg/kg, IV) or propofol e (24 mg/kg, IV) and diazepam f (0.250.5 mg/kg, IV), and anesthesia was maintained using isourane g (24%) in oxygen (100%). Premedication was per- formed 3045 minutes before induction and microcir- culatory measurements were made approximately 60 minutes following premedication administration. Following the induction of anesthesia and setup of pa- tient monitoring devices (ECG, ultrasonic Doppler ow monitor, and pulse oximeter), the heart rate and rhythm, blood pressure, hemoglobin saturation, mu- cous membrane color, and capillary rell time (CRT) were recorded. Animals with abnormal cardiovascular parameters (blood pressure o100 mmHg or heart rate 4160 or o60/min), heavily pigmented oral mucosa at the mucogingival junction bilaterally, or a CRT of 42 seconds were excluded from the study. Application of probe After gentle removal of saliva from the mucogingival junction above a canine tooth using an isotonic-saline drenched gauze sponge, the microvascular network of the mucosa above the canine tooth was studied using the videomicroscope with a 5 objective providing 167 magnication. The probe tip was applied without pressure lateral and parallel to the canine tooth with the tip at the mucogingival junction (Figure 1). Three se- quences of at least 20 seconds, each from different ad- jacent areas, were recorded using a computer and hard drive (Figure 2), and stored on an external hard drive for further analysis. Video recordings Using the results of a recent consensus on OPS video- microscope image acquisition and analysis, 37 the following parameters were derived and assessed from the stored video clips: TVD (mm/mm 2 ), PPV (%), MFI, and PVD (mm/mm 2 ). All values were determined for small vessels (o20 mm, mostly capillaries), other vessels (mostly venules), and all vessels. The TVD was devel- oped by De Backer et al 8 and is founded on the prin- ciple that vessel density is proportional to the number of vessels crossing arbitrary lines. In this score, 3 equi- distant horizontal and 3 equidistant vertical lines are drawn on a representative microcirculatory image viewed on the computer screen. Vessel density is cal- culated as the number of vessels crossing the lines di- vided by the total length of the lines (Figure 3). Vessel perfusion was categorized as present (contin- uous ow for at least 20 s), absent (no ow for at least Figure1: The videomicroscope placement for video acquisition in a normal, anesthetized dog. Figure2: Videomicroscope and video setup for image recording in a normal, anesthetized dog. & Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00488.x 581 Microvascular perfusion measurements in normal dogs 20 s), or intermittent (at least 50% of the time with no ow). The PPV was calculated as follows: 100 (total number of vessels [no ow1intermittent ow])/total number of vessels. PVD, an estimate of functional cap- illary density, was calculated by multiplying TVD by the PPV. In order to determine the MFI, the microcirculatory video images visualized on the computer screen were divided into 4 quadrants (Figure 4). The predominant type of ow in each quadrant determined the value: absent ow (0), intermittent ow (1), sluggish ow (2), normal ow (3), or hyperdynamic ow (4). The values of the 4 quadrants were then averaged. 38 The TVD, PPV, MFI, and PVD were acquired using computer software h designed for this purpose. The videos were analyzed independently in triplicate by 2 blinded, experienced video reviewers using the software. Statistical analysis Continuous variables were assessed for normality us- ing the Shapiro-Wilks test. Variables that were normally distributed based on this test were described using mean (SD) while median (range) were used to describe not normally distributed variables. For the vessel mea- surements, median (range) were reported to give the reader better descriptive information of the ndings since establishing true reference intervals would have required a much greater number of evaluations than the number used in this study. The video reviewer inter- and intraobserver variabil- ities for 10 patient videos were assessed using the Bland-Altman method to plot the differences between the paired variables against their mean. For all analyses a P-value o0.05 was considered significant. All ana- lyses were performed using a statistical software package. i Results Application of probe The sidestream dark-eld videomicroscope probe was technically challenging upon initial use, but appropri- ate technique was acquired after approximately 3 total hours of practice. Once the probe was placed on the mucosa, the pressure applied was gradually decreased in order to maximize the image quality without causing pressure artifacts. In order to adequately focus the im- age, the cap on the end of the probe must be tightly secured. The hand holding the probe must remain Figure3: Determination of vessel density as originally de- scribed by De Backer et al. 8 Vessel density is calculated as the number of vessels crossing the lines divided by the total length of the lines. Perfusion is then categorized visually as present (continuous ow for at least 20 s), absent (no ow for at least 20 s) or intermittent (at least 50% of time with no ow). The proportion of perfused vessels (PPV [%]) and perfused vessel density are then calculated. A 20-mm cut-off is used to separate small vessels (mostly capillaries) from large vessels (mostly ve- nules). (Adapted from De Backer D, Hollenberg S, Boerma C, et al. How to evaluate the microcirculation: report of a round table conference. Crit Care 2007; 11(5):R101. Reprint with permission.) (Published by BioMed Central) Figure4: Determination of the microcirculatory ow index score as originally described by Boerma et al. 38 The image is divided into 4 quadrants and the predominant type of ow (absent 50, intermittent 51, sluggish52, and normal 53) is assessed in each quadrant. The microcirculatory ow index score represents the averaged values of the 4 quadrants. A 20- mm cut-off is used to separate small vessels (mostly capillaries) from large vessels (mostly venules). (Adapted from De Backer D, Hollenberg S, Boerma C, et al. How to evaluate the microcircula- tion: report of a round table conference. Crit Care 2007; 11(5):R101. Reprint with permission.) (Published by BioMed Central) & Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00488.x 582 D.C. Silverstein et al. extremely steady, therefore resting the hand on an ob- ject during video acquisition proved necessary. Patient movement greatly disrupted image acquisition. It was difcult to visualize the microcirculation of animals with large amounts of pigmentation in the mouth, es- pecially at the site designated for probe placement. Overall, video data was acquired without problems as long as the above troubleshooting techniques were applied. Signalment and results of anesthetic monitoring Twenty dogs were initially included but 1 dog was ex- cluded because the blood pressure was 85 mmHg and 4 dogs were excluded due to pigmented mucous mem- branes at the mucogingival junction bilaterally, leaving 15 dogs to be fully evaluated, including 12 mixed breed dogs, 1 Labrador Retriever, 1 German Shepherd, and 1 Bernese Mountain Dog. There were 9 female dogs (1 spayed, 8 intact) and 6 male dogs (2 castrated, 4 intact) with ages ranging from 5 months to 9 years. The dogs weighed between 3.3 and 29.5 kg (mean 17.3 kg, SD 8.1 kg). Elective procedures included 12 spays or neuters and 3 orthopedic procedures (1 elbow arthroscopy, 2 stie surgeries). The average drug doses were: hydromorphone hydrochloride 0.18mg/kg (0.08 mg/kg), acepromazine maleate 0.01 mg/kg, thio- pental sodium 14 mg/kg (3.8 mg/kg) (n512), propofol 3.2 mg/kg (1.6mg/kg) (n53), and diazepam 0.37mg/kg (0.22 mg/kg) (n53). The mean systolic blood pressure was 133 mmHg (26 mmHg). All dogs were in sinus rhythm and the mean heart rate was 106 beats/min (22/min). All dogs had pink mucous membranes with a CRT o2 seconds. Video analysis Each movie review and analysis took approximately 1 hour to complete. Except for 1 outlier, there was acceptable intra- and interobserver agreement for all microcirculatory indices (Po0.05, Tables 13). The median and ranges of values obtained by each video reviewer, as well as the com- bined results, are shown in Table 4. During the analysis of the videos of this study, RBC velocity was automatically measured with the software program, but found to exceed the speed that could be determined using the designated software and the re- sults are therefore not reported. Discussion This study describes the successful use of a commer- cially available OPS videomicroscope to obtain micro- circulatory video images for analysis in dogs. Appropriate technique for adequate video acquisition was readily learned. Because patient movement inter- feres with the quality of the obtained data, animals must be anesthetized, heavily sedated, or severely ill. Animals with pigmented mucous membranes in the area used for placement of the videoscope are difcult to image and therefore not easily studied using this technique. Overall, video acquisition was easily per- formed. Because capillaries and venules are collapsible, it is important that excessive amounts of pressure are avoided when placing the videomicroscope against the mucous membranes. The application of pressure can also result in decreased ow in the large venules (420 mm). In order to avoid applying pressure to the site, it is generally recommended that, following place- ment of the microscope probe, the microscope is pulled back gently until contact is lost and then advanced Table1: Intraobserver variability for 10 videos analyzed in triplicate by Reviewer 1 Variable Variability interval Mean difference TVD small (vessels/mm) 2.663 to 4.169 0.753 TVD other (vessels/mm) 1.023 to 0.711 0.156 TVD all (vessels/mm) 3.046 to 4.236 0.595 PPV small 3.983 to 3.737 0.123 PPV other 3.695 to 3.501 0.097 PPV all 1.542 to 1.596 0.027 MFI small 0.236 to 0.236 0 MFI other 0.263 to 0.381 0.059 MFI all 0.192 to 0.268 0.038 PVD small (vessels/mm) 2.765 to 4.113 0.674 PVD other (vessels/mm) 0.929 to 0.725 0.102 PVD all (vessels/mm) 3.094 to 4.236 0.571 TVD, total vessel density; PPV, proportion of perfused vessels; MFI, mi- crocirculatory ow index; PVD, perfused vessel density; small, small ves- sels (o20 mm); other, vessels 420 mm; all, small and large vessels. Table2: Intraobserver variability for 10 videos analyzed in triplicate by Reviewer 2 Variable Variability interval Mean difference TVD small (vessels/mm) 3.945 to 1.521 1.212 TVD other (vessels/mm) 1.341 to 1.257 0.042 TVD all (vessels/mm) 4.115 to 1.605 1.255 PPV small 5.907 to 6.327 0.210 PPV other 5.340 to 5.094 0.123 PPV all 0.923 to 1.099 0.088 MFI small 00 0 MFI other 0.183 to 0.133 0.025 MFI all 0.095 to 0.069 0.013 PVD small (vessels/mm) 3.941 to 4.569 1.186 PVD other (vessels/mm) 1.341 to 1.257 0.042 PVD all (vessels/mm) 4.00 to 1.550 1.225 TVD, total vessel density; PPV, proportion of perfused vessels; MFI, mi- crocirculatory ow index; PVD, perfused vessel density; small, small ves- sels (o20 mm); other, vessels 420 mm; all, small and large vessels. & Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00488.x 583 Microvascular perfusion measurements in normal dogs again slowly to the point at which contact in regained. 37 The reproducibility of normal quantitative measure- ments and MFIs suggests that this technology might be useful for unraveling the complex pathophysiology of microvascular ow impairment in critically ill dogs. Despite the fact that the macrocirculation distributes blood ow globally throughout the body, the microcir- culation is a vital component of the cardiovascular sys- tem that is required for perfusion of individual tissue beds. In the earliest stages of incipient shock, microcir- culatory blood ow indices might serve as early indi- cators of tissue ischemia and signal the onset of overt circulatory collapse and multiorgan failure. 1,23,24,39,40 With the use of IVM, experimental models of sepsis have shown areas of stopped ow next to areas of hyperdynamic ow in the microvessels, increased het- erogeneity of regional perfusion, and a low density of perfused capillaries. 21,41,42 Persistent microcirculatory dysfunction 22,23,43 has been associated with multiorgan failure and increased mortality rates in humans. 2,3,8,44 In clinical veterinary practice, microcirculatory per- fusion is grossly assessed by the mucous membrane color, CRT, pulse quality, and distal extremity temper- ature, but these provide merely a rough estimate of perfusion. 45 Distributive disorders are not consistently detectable in humans with sepsis and conventional monitoring of systemic hemodynamic- or oxygen-de- rived variables cannot reliably provide information re- garding microcirculatory ow. 3,8,44,46,47 Thus the OPS videomicroscope technology is particularly appealing. The microcirculation comprises all vessels o100 mm in diameter and consists of arterioles, capillaries, and venules. There are over 10 billion capillaries in the body where the transport of oxygen and nutrients to, and the removal of waste products from tissues occur. This is vital to ensure adequate immunological function and the delivery of therapeutic drugs to intended target cells in disease states. Since vessels are delineated ac- cording to their size, the 20 mm cut-off is intended to separate capillaries from venules. 37 This is based on the previous studies that found preservation of venular perfusion in disease states, but alterations in the smaller vessels as a more precise indicator of microcirculatory distress. 8,48 The methods used to analyze the microcirculation in this study included the TVD, PPV, MFI, and PVD. These are the recommended parameters based on a round table conference that was organized in 2007 to discuss image acquisition and analysis. The partici- pants used the Delphi methodology to formulate a consensus statement. 37 The combination of the PVD, PPV, and MFI are thought to comprehensively describe functional perfusion of the capillary beds. The PPV Table3: Interobserver variability for 10 videos analyzed in triplicate Variable Variability interval Mean difference TVD small (vessels/mm) 3.824 to 12.340 4.258 TVD other (vessels/mm) 0.622 to 0.278 0.172 TVD all (vessels/mm) 12.217 to 4.053 4.082 PPV small 2.151 to 1.639 0.256 PPV other 1.749 to 2.787 0.519 PPV all 1.091 to 0.565 0.263 MFI small 0.687 to 0.387 0.150 MFI other 0.290 to 0.398 0.054 MFI all 0.305 to 0.213 2.000 to 3.000 PVD small (vessels/mm) 3.858 to 12.250 4.196 PVD other (vessels/mm) 0.622 to 0.278 0.172 PVDall (vessels/mm) 4.088 to 12.128 4.020 TVD, total vessel density; PPV, proportion of perfused vessels; MFI, mi- crocirculatory ow index; PVD, perfused vessel density; small, small ves- sels (o20 mm); other, vessels 420 mm; all, small and large vessels. Table4: Descriptive statistical results for microcirculatory indices of normal dogs Reviewer 1 median (range) Reviewer 2 median (range) Combined median (range) TVD small (vessels/mm) 27 (17, 30) 22 (18, 28) 24 (17, 30) TVD other (vessels/mm) 0.04 (0, 1.4) 0.26 (0, 1.6) 0.07 (0, 106) TVD all (vessels/mm) 27 (17, 30) 22 (18, 28) 24 (17, 30) PPV small 100 (94, 100) 100 (93, 100) 100 (94, 100) n PPV other 0 (0,4.8) 0 (0, 7.4) 0 (0, 7.4) PPV all 100 (99, 100) 100 (100, 100) 100 (99, 100) n MFI small 2.9 (2, 3) 3 (2, 3) 3 (2, 3) MFI other 2.5 (2, 3) 2.4 (2, 3) 2.5 (2, 3) MFI all 2.7 (2, 3) 2.7 (2, 3) 2.7 (2, 3) PVD small (vessels/mm) 27 (17, 30) 22 (18, 28) 24 (17, 30) PVD other (vessels/mm) 0 (0, 4.8) 0.23 (0, 1.6) 0.07 (0, 1.6) PVD all (vessels/mm) 27 (17, 30) 22 (18, 28) 24 (17, 30) n Single outlier removed. TVD, total vessel density; PPV, proportion of perfused vessels; MFI, microcirculatory ow index; PVD, perfused vessel density; small, small vessels (o20 mm); other, vessels 420 mm; all, small and large vessels. & Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00488.x 584 D.C. Silverstein et al. alone does not distinguish between normal, sluggish, and hyperdynamic ows, but does provide information regarding the heterogeneity of blood ow. The PVD gives a dependable estimate of functional capillary density. The PPVand PVD are therefore especially use- ful in animals with heterogenous microcirculatory per- fusion. Although the MFI is semiquantitative and somewhat subjective, it has been found to successfully differentiate between health and disease. 8,44,48 The MFI not only gives information about the presence or ab- sence of perfusion, but also differentiates between the different types of continuous ow (sluggish, normal, and high ow). In animals with heterogenous ow, the MFI can therefore prove especially useful. It is possible that additional variables would be informative, but further research in dogs will be required. The results of this study are consistent with what might be expected in a normally perfused animal; the TVD and PVD are comprised almost entirely of small, perfused vessels and the PPV is 100% for small vessels. Although all microvessels were analyzed, the small vessels (o20 mm) are of particular interest because these vessels represent the precapillary and capillary vessels 5 that participate in gas exchange and these vessels have been found to be most indicative of microcirculatory status. 8,10,48 The PPV indicates homogenous blood ow within the capillaries, which is an expected nding in normally perfused animals. There were approximately 24 perfused small vessels/mm, more than double the number reported in healthy human patients. 49 The nor- mal MFI was 2.5, with 3.0 representing normal ow in all vessels. This value might be affected by the subjec- tive nature of the score or the fact that the dogs of this study were anesthetized and this might have altered microvascular ow. One of the 3 dogs that received propofol had an MFI of 2.5 and the other 2 dogs had an MFI of 3.0. Although the videos were taken following a minimum of 20 minutes after induction, the effects of propofol or thiopental are unkown, especially at the microcirculatory level. From a clinically relevant per- spective, any MFI value 42 is most likely not of con- cern, but future case-controlled studies using normal and diseased dogs may provide further information. All of the dogs in the current study had an MFI of 2.0. Although the software used for video analysis has streamlined the process, video data analysis is still ex- tremely time consuming, even with ample experience, and therefore a third-party contractor was hired for analysis of the videos in the current study. This may limit the clinical utility of the OPS videomicroscope technology. In the present study, experienced, indepen- dent analyzers were hired to score the videos and the average single movie required approximately 1 hour to perform. Although a veterinarian could easily be trained to do the analyses, the time commitment is sig- nificant and precludes immediate interpretation. A de- lay of hours to days in a critically ill, dynamic patient precludes the use of this technology for making prog- nostic or therapeutic decisions and may therefore only be useful for research purposes. A more practical an- alytical approach, such as an algorithm or experienced video observer may prove benecial. Future uses for OPS videomicroscope technology are numerous in veterinary patients. It has been clearly shown that derangements of microcirculatory ow are one of the critical pathologic events in septic humans. 3,8 Examining the microcirculation of septic veterinary pa- tients and comparing the ndings to critical illness scores, conventional measurements of cardiovascular status, and outcome is currently underway. Addition- ally, the use of early goal-directed therapy, 44 various resuscitation uids and transfusion therapy, 50 va- sopressors, anesthetic drugs, and vasodilators could be more accurately monitored at the microcirculatory level in the future. For example, a randomized-con- trolled trial of exogenous nitric oxide to recruit the microcirculation in humans with sepsis is currently underway. Moreover, specic disease states such as diabetes, hypertension, and heart disease 48 may pro- duce distinctive microcirculatory pathologies that are not recognized with current diagnostic modalities. The microcirculation in various organ locations has been examined in humans and experimental ani- mals, including the sublingual region, brain, 51 small intestinal villi, colonic crypts, rectal crypts, hepatic acini, and postsinusoidal venules. 52,53 These may also prove to be valuable diagnostic tools for small animals in the future. 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A Comparison of Total Calcium, Corrected Calcium, and Ionized Calcium Concentrations As Indicators of Calcium Homeostasis Among Hypoalbuminemic Dogs Requiring Intensive Care
A Comparison of Total Calcium, Corrected Calcium, and Ionized Calcium Concentrations As Indicators of Calcium Homeostasis Among Hypoalbuminemic Dogs Requiring Intensive Care