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Optimal fluid resuscitation: Lactate? Jan Bakker chair dept Intensive Care Adults jan.bakker@erasmusmc.nl Jan Bakker chair dept Intensive Care Adults jan.bakker@erasmusmc.nl

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Clinical indices of perfusion MAP Urine output Mentation Capillary refill Skin perfusion Skin temperature Muscle tissue oxygenation (NIRS) Lactate pH, BE Mixed/Central SO 2 Mixed venous PCO 2

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Why fluids? Stroke Volume Venous Return clinical characteristics!!! clinical characteristics?

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One of the women, the 23-year-old primipara Eva Rumpel, gave birth to a healthy child on 9 January 1843. The same night she developed a painfully swollen abdomen and became ill, feverish, and sweaty, with rapid pulse and severe thirst. The initiated treatment was bloodletting and clystering. The next evening she deteriorated, became delirious, with anxious breathing, a tense abdomen, cold extremities and rapid pulse, finally losing consciousness. Again, bloodletting followed. At 4:30 a.m., 36 h after the onset of the first symptoms, she died. During autopsy, severe purulent endometritis, vaginal pus, pulmonary edema, and shock liver and shock spleen were found.

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Skin temperature and systemic circulation Cool 2.9 1.2 7.32 0.2 60 4 4.7 1.5 Cardiac Index Arterial pH SvO 2 Lactate Warm 4.3 1.2 * 7.39 0.07 * 68 8 * 2.2 1.6 * Cool vs. warm skin Similar: Heart rate, blood pressure, PAOP, Hemoglobin, FiO 2, PaO 2, PaCO 2 Cool vs. warm skin Similar: Heart rate, blood pressure, PAOP, Hemoglobin, FiO 2, PaO 2, PaCO 2 Kaplan et al. J Trauma 2001;50:620-628

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Studies in clinical shock and hypotension Cohn et al. JAMA 1964;190(10):113-118 When metaraminol was discontinued, the peripheral pulses disappeared, cuff pressure could not be obtained and diaphoresis became marked. A rapid infusion of 500 ml of 10% low molecular weight dextran resulted in immediate clinical improvement with cessation of sweating and return of strong peripheral pulses. Six hours later, when peripheral pulses again became weak a slow infusion of 500 ml 6% dextran again resulted in improvement. He made an uneventful recovery. Important observations 1. Inaccuracy of auscultatory blood pressure 2. Unrecognized myocardial factor in hypotension 3. Unrecognized need for blood volume expansion 4. Selection of proper vasopressor drug

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Fluid Resuscitation Septic Shock: Initial fluid resuscitation Chest 1984;85:336-340 Am Rev Respir Dis 1985;131:912- 916 Am Rev Respir Dis 1986;134:873- 878 Crit Care Med 1987;15:26-28 Anesthesiology 1998;89:1313-1321

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Lactate to guide fluid resuscitation Pre hospital Pre fluidsPost fluids HR b/min 102 7 986 SAP mmHg 100 11 1197* DAP mmHg589724* Lactate mmol/L 7.2 1.5 5.50.9* 10 Patients with clinically suspected hypovolemia and increased lactate level (>3.5 mmol/l) Goal: 1000 ml NaCl 0.9% in 30 minutes

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Chytra et al. Crit Care 2007;11:R24 Doppler n=80 Conventional n=82 range sd ** t=12h colloids1167426 1293300crystalloid1334320 682322 ** Esophageal doppler guided fluid resuscitation Multiple trauma >2000 ml blood loss

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The Golden Hour and the Silver Day: Detection and Correction of Occult Hypoperfusion within 24 Hours Improves Outcome from Major Trauma Blow et al. J Trauma 1999;47(5):964 79 patients Lactate > 2,5 mmol/L but hemodynamically stable (SAP>100, HR 1 mL/kg per hour) Lactate cleared

Admission Evolution during first 24h ICU mortality StO 2 n=221 Normal (>75%) n=166 Normal n=160 15% Abnormal n=21 57% Abnormal ( 1,4 - Capillary refill time (CRT) < 5 seconds - Delta of temperature between the forearm and the finger (T) < 3C - Tissue oxygen saturation (StO 2 ) > 70%

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PERIPHERAL PERFUSION TARGETED FLUID MANAGEMENT IN CRITICALLY ILL PATIENTS: A PILOT STUDY Sophie Nebout and Michel van Genderen

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Mottling score predicts survival in septic shock Intensive Care Med (2011) 37:801807

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Out-of-hospital shock care Wang et al. Crit Care Med 2011;39(11):2431-2439)

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Lactate containing fluids Crit Care Med 2011;39:2419-2424 1.792.05

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Lactate containing fluids Crit Care Med 2011;39:2419-2424 29 1840

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Why fluids? Stroke Volume Venous Return clinical characteristics? clinical characteristics!!! clinical characteristics?