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Original Study

Measurements of microvascular perfusion in


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.
Footnotes
a
MicroScan, MicroVision Medical, Amsterdam, the Netherlands.
b
Hydromorphone hydrochloride, Baxter, Deereld, IL.
c
Acepromazine maleate, Butler Animal health Supply, Dublin, OH.
d
Hospira, Inc, Lake Forest, IL.
e
Abraxis Pharmaceutical Products, Schaumburg, IL.
f
Hospira, Inc, Lake Forest, IL.
g
Abbott Laboratories, North Chicago, IL.
h
AVA 3.0 MicroScan Analysis Software, MicroVision Medical,
Amsterdam, the Netherlands.
i
Stata 8.0 for Windows, Stata Corporation, College Station, TX.
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