Monitoring Microcirculation: Utility and Barriers - A Point-of-View Review

Microcirculation is a particular organ of the cardiovascular system. The goal of this narrative review is a critical reappraisal of the present knowledge of microcirculation monitoring, mainly focused on the videomicroscopic evaluation of sublingual microcirculation in critically ill patients. We discuss the technological developments in handheld videomicroscopy, which have resulted in adequate tools for the bedside monitoring of microcirculation. By means of these techniques, a large body of evidence has been acquired about the role of microcirculation in the pathophysiological mechanisms of shock, especially septic shock. We review the characteristics of sublingual microcirculation in septic shock, which mainly consist in a decrease in the perfused vascular density secondary to a reduction in the proportion of perfused vessels along with a high heterogeneity in perfusion. Even in patients with high cardiac output, red blood cell velocity is decreased. Thus, hyperdynamic flow is absent in the septic microcirculation. We also discuss the dissociation between microcirculation and systemic hemodynamics, particularly after shock resuscitation, and the different behavior among microvascular beds. In addition, we briefly comment the effects of some treatments on microcirculation. Despite the fact that sublingual microcirculation arises as a valuable goal for the resuscitation in critically ill patients, significant barriers remain present for its clinical application. Most of them are related to difficulties in video acquisition and analysis. We comprehensively analyzed these shortcomings. Unfortunately, a simpler approach, such as the central venous minus arterial PCO₂ difference, is a misleading surrogate for sublingual microcirculation. As conclusion, the monitoring of sublingual microcirculation is an appealing method for monitoring critically ill patients. Nevertheless, the lack of controlled studies showing benefits in terms of outcome, as well as technical limitations for its clinical implementation, render this technique mainly as a research tool.