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      Safety and feasibility of sublingual microcirculation assessment in the emergency department for civilian and military patients with traumatic haemorrhagic shock: a prospective cohort study

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          Abstract

          Objectives

          Sublingual microcirculatory monitoring for traumatic haemorrhagic shock (THS) may predict clinical outcomes better than traditional blood pressure and cardiac output, but is not usually performed until the patient reaches the intensive care unit (ICU), missing earlier data of potential importance. This pilot study assessed for the first time the feasibility and safety of sublingual video-microscopy for THS in the emergency department (ED), and whether it yields useable data for analysis.

          Setting

          A safety and feasibility assessment was undertaken as part of the prospective observational MICROSHOCK study; sublingual video-microscopy was performed at the UK-led Role 3 medical facility at Camp Bastion, Afghanistan, and in the ED in 3 UK Major Trauma Centres.

          Participants

          There were 15 casualties (2 military, 13 civilian) who presented with traumatic haemorrhagic shock with a median injury severity score of 26. The median age was 41; the majority (n=12) were male. The most common injury mechanism was road traffic accident.

          Primary and secondary outcome measures

          Safety and feasibility were the primary outcomes, as measured by lack of adverse events or clinical interruptions, and successful acquisition and storage of data. The secondary outcome was the quality of acquired video clips according to validated criteria, in order to determine whether useful data could be obtained in this emergency context.

          Results

          Video-microscopy was successfully performed and stored for analysis for all patients, yielding 161 video clips. There were no adverse events or episodes where clinical management was affected or interrupted. There were 104 (64.6%) video clips from 14 patients of sufficient quality for analysis.

          Conclusions

          Early sublingual microcirculatory monitoring in the ED for patients with THS is safe and feasible, even in a deployed military setting, and yields videos of satisfactory quality in a high proportion of cases. Further investigations of early microcirculatory behaviour in this context are warranted.

          Trial registration number

          NCT02111109.

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          Most cited references10

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          The microcirculation image quality score: development and preliminary evaluation of a proposed approach to grading quality of image acquisition for bedside videomicroscopy.

          Side-stream dark-field microscopy is currently used to directly visualize sublingual microcirculation at the bedside. Our experience has found inherent technical challenges in the image acquisition process. This article presents and assesses a quality assurance method to rate image acquisition quality before analysis.
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            A guide to human in vivo microcirculatory flow image analysis

            Various noninvasive microscopic camera technologies have been used to visualize the sublingual microcirculation in patients. We describe a comprehensive approach to bedside in vivo sublingual microcirculation video image capture and analysis techniques in the human clinical setting. We present a user perspective and guide suitable for clinical researchers and developers interested in the capture and analysis of sublingual microcirculatory flow videos. We review basic differences in the cameras, optics, light sources, operation, and digital image capture. We describe common techniques for image acquisition and discuss aspects of video data management, including data transfer, metadata, and database design and utilization to facilitate the image analysis pipeline. We outline image analysis techniques and reporting including video preprocessing and image quality evaluation. Finally, we propose a framework for future directions in the field of microcirculatory flow videomicroscopy acquisition and analysis. Although automated scoring systems have not been sufficiently robust for widespread clinical or research use to date, we discuss promising innovations that are driving new development. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1213-9) contains supplementary material, which is available to authorized users.
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              THE GLYCOCALYX AND TRAUMA: A REVIEW.

              In the United States trauma is the leading cause of mortality among those under the age of 45, claiming approximately 192,000 lives each year. Significant personal disability, lost productivity, and long-term healthcare needs are common and contribute 580 billion dollars in economic impact each year. Improving resuscitation strategies and the early acute care of trauma patients has the potential to reduce the pathological sequelae of combined exuberant inflammation and immune suppression that can co-exist, or occur temporally, and adversely affect outcomes. The endothelial and epithelial glycocalyx has emerged as an important participant in both inflammation and immunomodulation. Constituents of the glycocalyx have been used as biomarkers of injury severity and have the potential to be target(s) for therapeutic interventions aimed at immune modulation. In this review, we provide a contemporary understanding of the physiologic structure and function of the glycocalyx and its role in traumatic injury with a particular emphasis on lung injury.
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                Author and article information

                Journal
                BMJ Open
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2016
                21 December 2016
                : 6
                : 12
                : e014162
                Affiliations
                [1 ]NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital , Birmingham, UK
                [2 ]University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital , Birmingham, UK
                [3 ]Royal Centre for Defence Medicine, Queen Elizabeth Hospital , Birmingham, UK
                [4 ]Kings College Hospital , London, UK
                [5 ]Queen Elizabeth University Hospital, Govan , Glasgow, UK
                [6 ]Barts Health NHS Trust and Queen Mary University of London , London, UK
                [7 ]Rural Clinical School, University of Queensland, Bundaberg Hospital , Bundaberg, Queensland, Australia
                Author notes
                [Correspondence to ] Dr Sam D Hutchings; sam.hutchings@ 123456nhs.net
                Article
                bmjopen-2016-014162
                10.1136/bmjopen-2016-014162
                5223697
                28003301
                57ab8640-5df4-48a6-a03a-3ebba94a2261
                Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                : 5 September 2016
                : 14 October 2016
                : 5 December 2016
                Categories
                Emergency Medicine
                Research
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                Medicine
                microcirculation,sublingual,shock,haemorrhage,trauma management
                Medicine
                microcirculation, sublingual, shock, haemorrhage, trauma management

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