Measuring circulating blood volume in newborn infants using pulse dye densitometry and indocyanine green

Background: Circulating blood volume (BV) is an important, but often unconsidered, variable in newborn infants undergoing intensive care. The data on validation and repeatability of BV measurement are limited. Aim: To validate and test the repeatability of measuring BV in newborn infants using indocyanine green (ICG) and pulse dye densitometry (PDD). Methods: Validation– Paired measurements of BV were made using the fetal hemoglobin (HbF) dilution and the PDD method. Repeatability– The BV was measured twice at an interval of 30–40 min in a second group of infants. Results: Validation– Data from three of 13 infants studied were excluded because of probe dislodgement or ICG injection error. The median (range) birth weight of the 10 infants whose data were analyzed was 1032 g (740–2384 g) and seven (70%) were receiving either mechanical ventilation or nasal CPAP. The median BV measured by HbF dilution was 66.2 ml·kg^?1 (43.7–81.0 ml·kg^?1) and by the PDD method was 68.9 ml·kg^?1 (49.3–101.0 ml·kg^?1). The mean difference was 5.92 ml·kg^?1 (sd 17.33 ml·kg^?1). Repeatability– Twelve infants were studied and three excluded because of probe dislodgement/motion artifact or ICG injection error. The median weight of the nine infants whose data were analyzed was 1208 g (795–2600 g). The median (range) BV1 and BV2 were 70.5 ml·kg^?1 (53.1–160 ml·kg^?1) and 87.5 ml·kg^?1 (38.0–248.0 ml·kg^?1), respectively. Mean difference of the two BV estimates (BV1–BV2) was ?24.6 ml·kg^?1 (sd 33.3 ml·kg^?1) and coefficient of repeatability was 66.5 ml·kg^?1. Conclusion: Pulse dye densitometry can be used to measure BV in the newborn infant at the cotside but the repeatability measurements suggest that its use is limited.     

吲哚菁绿荧光显像技术在腹腔镜胆囊切除术中的应用初探

目的 评价吲哚菁绿（indocyanine green,ICG）荧光显像技术在腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）中对肝外胆管显像的临床价值。方法 回顾性分析2019 年1 月至2019 年5 月乐山市人民医院收治的30 例在ICG荧光显像技术导航下完成LC的患者临床资料。术前外周静脉注射ICG,术中 利用近红外光三维显像胆总管及胆囊管结构。结果 行LC的30 例患者中有27 例（90%）术中胆囊管及胆总管均经ICG显像成功;2 例胆囊管未显像,胆总管显像;1 例胆囊管与胆总管均未显像。平均手术时间为35（27～65）min,术中平均出血量为3（0～10）mL,术后平均住院时间为3（2～5）d。术后患者恢复顺利,1 例脐部伤口红肿,其余患者术后随访1～5 个月无并发症发生。结论 LC术中利用ICG荧光显像技术可以实现术中对胆总管及胆囊管的早期定位显像,有助于术中实现对肝外胆管系统的可视化,避免术中因对肝外胆管显示不清引发的医源性肝外胆管损伤,保障手术安全,具有良好的应用前景。     

The role of near‐infrared fluorescence imaging with indocyanine green dye in pedicle division with the paramedian forehead flap

The paramedian forehead flap is considered the gold standard for nasal reconstruction following oncologic surgery. During the 21‐day delay in two‐stage surgery protocols, many patients report considerably reduced quality of life because of the pedicle. This prospective case series study examined the usefulness of near‐infrared (NIR) fluorescence with indocyanine green (ICG) for flap perfusion assessment and identified variables associated with time to flap perfusion. Ten patients (mean age 75.3 ± 11.6 years) with diagnosis of basal cell carcinoma (n = 9) or squamous cell carcinoma (n = 1) underwent intravenous indocyanine injection and NIR fluorescence imaging for assessment of flap vascularisation 2 to 3 weeks after stage 1 surgery. NIR fluorescence imaging showed 90% to 100% perfusion areas in all patients after 14 to 21 days. Early pedicle division occurred in two patients on postoperative days 14 and 16. One minor complication (wound healing disorder) was seen following flap takedown after 14 days. There were no associations between time to flap perfusion and defect size or flap area. NIR fluorescence imaging with ICG dye is a useful method for non‐invasive perfusion assessment when used in conjunction with clinical assessment criteria. However, a decision for early pedicle division may raise risk of complications in specific patient groups and must therefore be made with great care.     

吲哚菁绿荧光显影导航技术在肝胆外科手术中的应用进展

吲哚菁绿荧光显影已经广泛地应用于肝胆外科手术中, 在原发性肝癌、肠癌肝转移、肝胆管结石、肝移植等良恶性肝胆外科手术中, 其能够提高手术效能, 改善手术患者的预后。笔者通过复习相关的国内外研究进展, 结合ICG导航技术在肝胆外科常见疾病手术中的应用进行相应的总结, 并作进一步的探讨和展望。     

吲哚菁绿在肝胆腹腔镜手术领域中的应用现状

随着荧光病变检测技术的发展,吲哚菁绿（ICG）作用已从术前肝功能的评估发展到肿瘤诊断、癌前病变及淋巴管的可视化、术中肿瘤检测及指导手术的精准化。ICG荧光引导的肝脏切除手术从根本上提高了肝脏解剖能力及手术的质量,同时也提高了微创（腹腔镜和机器人）肝胆外科手术的安全性和准确性。由于ICG荧光技术可以更好地显示癌灶,引导切除的边缘远离肿瘤边界,当今的肝胆外科手术已不能缺少ICG的应用。鉴于研究ICG相关临床应用已成为热点,本文讨论了ICG荧光成像在肝胆外科手术中的应用现状。     

吲哚菁绿荧光融合影像技术在腹腔镜肝切除术中的应用

目的 总结和探讨在腹腔镜肝切除术中应用吲哚菁绿荧光融合影像（ICG-FI）技术的经验与意义。方法 回顾性分析哈尔滨医科大学附属第二医院2018年5月至2020年12月收治的41例接受腹腔镜肝切除术的肝细胞癌患者的临床病例资料。根据是否应用ICG-FI分为ICG组（n=20）与非ICG组（n=21）,比较两组病例资料,手术结果和并发症情况。结果 ICG组较非ICG组手术时间[（176.8±42.8）min vs(222.6±72.0)min,P=0.018]和术后住院时间[（5.6±1.5）d vs (7.2±3.0)d,P=0.038]更短,并发症发生率更低[20.0%(4/20) vs 52.4%(11/21),P=0.031]。结论 在腹腔镜肝切除术中,应用ICG-FI能够缩短手术时间及患者住院时间,并发症发生率更低,从而增加手术安全性,值得广泛应用。     

Estimation of circulating blood volume in infants using the pulse dye densitometry method

BACKGROUND: Estimation of hemodynamics is important for critically ill infants. Pulse dye densitometry (PDD) using indocyanine green (ICG), which enables measurements of circulating blood volume at the bedside, has recently been developed for adults. METHODS: We conducted a basic investigation to determine whether this method can be applied to infants and measured circulating blood volume in 25 infants whose gestational ages ranged from 24 to 40 weeks (median, 32 weeks). At first, to validate the accuracy of measurements, arterial ICG concentrations determined by blood sample measurements were compared using a spectrophotometer ([ICG blood]) and by noninvasive measurement using PDD ([ICG pdd]) in seven infants. Next, blood volumes in 25 infants were estimated by the PDD method. RESULTS: There was a positive relationships between [ICG blood] and [ICG pdd] (r = 0.913, P < 0.0001). Using Bland Altman analysis, the bias between the two methods was 0.24 +/- 0.30 mg.l(-1) (95% confidence interval: 0.39-0.09 mg.l(-1)) and the limits of agreement (2 sd) were -0.36 and 0.84 mg.l(-1), respectively. Mean (sd) blood volume was 94.9 ml.kg(-1) (24.3). The values obtained by this study are almost the same as previously reported values obtained by using other methods. CONCLUSIONS: PDD using ICG can be used to monitor of hemodynamics in infants.     

自体乳房重建中皮瓣相关并发症影响因素分析及术中使用吲哚菁绿造影的经济学效益

目的探讨自体乳房重建中皮瓣相关并发症的影响因素,以及术中使用吲哚菁绿(indocyanine green,ICG)造影的经济学效益。方法回顾分析2013年7月-2018年6月收治的符合选择标准的150例自体乳房重建的乳房切除术后患者(152个乳房)。对年龄、体质量指数、术前新辅助化疗(neoadjuvant chemotherapy,NC)、胸部放疗史、合并糖尿病、供区手术史、胸壁重建、重建时机、皮瓣类型、术中ICG造影进行单因素分析,初步筛选单因素分析中有统计学意义的临床因素,纳入皮瓣相关并发症及皮瓣局部坏死的logistic多因素回归分析(逐步后退法)。根据以上多因素分析结果,将患者分为4组:ICG+NC组(A组)、ICG+非NC组(B组)、非ICG+NC组(C组)、非ICG+非NC组(D组),计算每组患者的人均额外治疗费用(ICG造影费用+处理皮瓣相关并发症的费用)。结果术后152个皮瓣均成活。共有33个皮瓣发生皮瓣相关并发症,包括22个皮瓣局部坏死、9个局部感染、5个血肿、5个单纯脂肪液化、2个吻合口血栓形成。单因素分析显示,术前NC、皮瓣类型及术中ICG造影是发生皮瓣相关并发症的影响因素(P<0.05)。多因素分析显示,术前NC、未使用ICG造影是发生皮瓣相关并发症的危险因素(P<0.05),也是发生皮瓣局部坏死的危险因素(P<0.05)。对于NC患者,术中使用ICG造影会大大节省人均额外治疗费用,A组较C组人均额外治疗费用少花费1378元。对于未行NC者,术中使用ICG造影会增加人均额外治疗费用,B组较D组人均额外治疗费用多花费747元。结论在自体乳房重建中,ICG造影可降低皮瓣相关并发症的发生率,尤其是皮瓣局部坏死发生率;而NC则相反。对于非NC患者,ICG造影的性价比不高,经济条件允许下可使用;但对于NC患者,ICG造影性价比较高,建议使用。     

Uptake of indocyanine green by hepatocytes under inflow occlusion of the liver

BACKGROUND: It is not clear that hepatic venous backflow actually contributes to hepatic tissue oxygenation under inflow occlusion of the liver. In order to prove that substances delivered via the hepatic vein can be utilized and/or metabolized in hepatocytes during inflow occlusion, hepatic uptake in bile and excretion of indocyanine green (ICG) were investigated in pigs. MATERIALS AND METHODS: Animals were divided into two groups: an inflow occlusion (IO) group (N = 6) and a total hepatic vascular exclusion (THVE) group (N = 3) using a bypass. One milligram of ICG per kilogram body weight was administered at the beginning of blood flow occlusion, the retention rate in the blood (ICG R) measured, and the ICG in the hepatic tissue measured by near-infrared (NIR) spectroscopy. Furthermore, the ICG concentration was measured in bile excreted by intermittent perfusion of the liver. RESULTS: ICG R declined with time in both groups; however, ICG R in the IO group decreased much faster than in the THVE group. There were significant differences between the two groups after 30 min of occlusion (P < 0.05). ICG in the hepatic tissue could be detected as a peak at 805 nm 10 min after ICG injection, and the peak became steeper with time. On the other hand, ICG was not detected at all in the hepatic tissue after 180 min in the THVE group. ICG was excreted in the bile after 60 min under IO and increased with time. On the contrary, ICG was not excreted in the bile at all under THVE. There were significant differences between the two groups after 90 min (P < 0.05). CONCLUSION: These results indicate that ICG can be extracted in hepatocytes and excreted in bile under IO of the liver. Consequently, substances such as oxygen and drugs, which are delivered via the hepatic vein, can be utilized and/or metabolized in hepatocytes under IO.     

Perioperative monitoring of indocyanine green clearance and plasma disappearance rate in patients undergoing liver transplantation

Introduction. Indocyanine green (ICG) elimination tests have been repeatedly suggested as an early predictor of graft function in patients with liver transplantation. Conventionally, ICG clearance (Cl_ICG) is measured by a series of blood samples with subsequent laboratory analysis. More recently bedside techniques have become available to measure ICG concentrations in vivo and in addition to Cl_ICG, the plasma disappearance rate of ICG (PDR_ICG) is increasingly being used. The aim of this study was to assess and to compare the normal time courses of Cl_ICG and PDR_ICG in liver transplant recipients. Methods. Cl_ICG and PDR_ICG were measured perioperatively and at various times up to 24 h after liver transplantation. The bedside transpulmonary indicator dilution technique with an arterial fiberoptic-thermistor catheter was used to assess the ICG concentration time curve together with total circulating blood volume (V_{d circ}). Results. Similar patterns of the time courses of Cl_ICG and PDR_ICG with a fast recovery of ICG elimination in the early reperfusion period were observed. Compared to healthy subjects, Cl_ICG was supranormal and PDR_ICG was slightly subnormal. In this study, V_{d circ} was increased at baseline and remained increased during surgery. Conclusions. PDR_ICG and Cl_ICG are well suited to monitor onset and maintenance of graft function in patients undergoing liver transplantation. The PDR_ICG values measured tend to be relatively lower than Cl_ICG because of an increased blood volume in these patients. By knowing these differences it is justified to monitor liver function in a very simple manner with PDR_ICG.      

Intraoperative assessment of ureter perfusion after revascularization of transplanted kidneys using intravenous indocyanine green fluorescence imaging

BackgroundKidney transplantation is the most valuable renal replacement therapy. One of the most common urologic complications following kidney transplantation is ureter anastomosis leakage, which leads to high morbidity along with kidney graft loss. We hypothesized that indocyanine green (ICG) fluorescence videography can assess ureter perfusion after revascularization of transplanted kidneys.MethodsWe conducted a prospective cross-sectional study in end-stage renal disease patients who underwent deceased donor kidney transplantation at Ramathibodi Hospital from September 2019 to January 2020. The segments of transplanted ureters were categorized as having good or poor perfusion based on the percentage from ICG fluorescence videography images. Then the results from ICG fluorescence videography were compared with histopathology which is considered the gold standard.ResultsThirty-one sections of dissected ureters were evaluated from 10 patients. Compared with pathological diagnosis of ureteral ischemia, ICG videography had sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and positive likelihood ratio of 100%, 92.6%, 66.7%, 100%, and 14, respectively. Accuracy was 93.6%. The area under the curve of ICG fluorescence videography was 0.96. The average ureter length that maintained good perfusion was 14 cm from the ureteropelvic junction. Adverse events from ICG were not observed in this study.ConclusionsWe conclude that ICG fluorescence videography is beneficial for detection of early ureteral ischemia in kidney transplantation patients, with negligible adverse events. However, further studies with larger numbers of patients are necessary to confirm our results and clinical outcomes regarding complication rates.     

吲哚菁绿荧光显像技术在复杂腹腔镜胆囊切除术中的临床应用

目的 探讨吲哚菁绿（indocyanine green,ICG）荧光显像技术在复杂腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）中的临床应用。方法 对2019年7月至2020年1月期间遂宁市中心医院肝胆外科收治的31例在ICG荧光显像技术辅助下完成复杂LC的患者临床资料进行回顾性分析。术前ICG皮试阴性,于术前60 min注射ICG,术中利用近红外光三维显像肝外胆管结构。在ICG显像引导下行LC。结果 31例患者均顺利完成LC手术,其中26例患者胆总管和胆囊管ICG显像;5例胆囊管未显像,但胆总管显像。手术时间41（25～89）min,术中出血量7（3～15）mL,术后住院时间3.5（2～6）d。所有患者术后恢复顺利,1例切口感染,1例剑突下伤口红肿,无胆漏等并发症发生,术后随访1～7个月无并发症发生。结论 利用ICG荧光显像技术优势,可以对肝外管道系统进行显像,辅助复杂腹腔镜胆囊切除术的顺利完成,避免医源性肝外胆管损伤,值得临床推广应用。     

LC术中经静脉注射吲哚菁绿最佳给药剂量的探讨

目的探讨LC术中经静脉注射吲哚菁绿(indocyaninegreen,ICG)的最佳给药剂量。方法回顾性收集2020年6月至11月中国医科大学附属盛京医院第二普通外科收治的行荧光导航LC的40例患者临床资料,患者通过信封法随机平分至ICG剂量为0.125 mg、0.250 mg、0.500 mg、1.000 mg四组中,观察患者肝外胆管显影时间及显影率、荧光强度及荧光强度对比值。结果随着给药剂量的增加,肝脏背景荧光强度亦明显增加;给药20 min时,0.125 mg组、0.250 mg组胆囊管-胆总管(CD-CBD)连接处荧光强度仍较低[(64.149±58.808) vs (101.495±58.247)],0.500 mg组、1.000 mg组CD-CBD连接处荧光强度则相对较高[(160.033±31.835) vs 167.678±43.101)]。此外,0.125 mg组显影时间较长,4组间肝脏[(92±29)s vs(53±30)s vs (33±12)s vs (31±11)s,F=15.500,P<0.05)、CD-CBD连接处[(933±101)s vs (75...     

吲哚菁绿近红外光成像在腹腔镜胃癌根治术中应用中国专家共识（2019版）

自1994年日本Kitano等^[1]首次报道腹腔镜远端胃癌根治术以来,经过20余年的发展,腹腔镜胃癌根治术在临床上得到了较广泛的应用^[2-4]。近年来,随着腹腔镜器械的进步和技术的发展,腹腔镜胃癌手术亦逐渐迈向精准医学时代。因此,腹腔镜胃肠外科医师仍在不断探索如何在腹腔镜下进行简便而精确的肿瘤定位与淋巴结导航。