Optimal fluid resuscitation: Lactate?

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

2. Clinical indices of perfusion • MAP • Urine output • Mentation • Capillary refill • Skin perfusion • Skin temperature • Muscle tissue oxygenation (NIRS) • Lactate • pH, BE • Mixed/Central SO2 • Mixed venous PCO2

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

4. 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.

5. Cool vs. warm skin Similar: Heart rate, blood pressure, PAOP, Hemoglobin, FiO2, PaO2, PaCO2 Skin temperature and systemic circulation Cardiac Index Arterial pH SvO2 Lactate Cool 2.9 ± 1.2 7.32 ± 0.2 60 ± 4 4.7 ± 1.5 Warm 4.3 ± 1.2 * 7.39 ± 0.07 * 68 ± 8 * 2.2 ± 1.6 * Kaplan et al. J Trauma 2001;50:620-628

6. Studies in clinical shock and hypotensionCohn 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

7. Fluid ResuscitationSeptic 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

8. Lactate to guide fluid resuscitationPre hospital 10 Patients with clinically suspected hypovolemia and increased lactate level (>3.5 mmol/l) Goal: 1000 ml NaCl 0.9% in 30 minutes

9. Esophageal doppler guided fluid resuscitationMultiple trauma ** 682±322 1167±426 colloids 1334±320 1293±300 crystalloid range ** sd t=12h t=12h Conventional n=82 Doppler n=80 Chytra et al. Crit Care 2007;11:R24 >2000 ml blood loss

10. The Golden Hour and the Silver Day: Detection and Correction of Occult Hypoperfusion within 24 Hours Improves Outcome from Major TraumaBlow et al. J Trauma 1999;47(5):964 79 patients Lactate > 2,5 mmol/L but hemodynamically stable (SAP>100, HR<120, UP> 1 mL/kg per hour)

11. Early lactate-guided therapy in ICU patientsJansen et al. AJRCCM 2010;182:752-761 p=0.011 p=0.055 p<0.001 p=0.005 no differences in RBC transfusion

12. Early lactate-guided therapy in ICU patientsJansen et al. AJRCCM 2010;182:752-761

13. N=12 N=10 N=12 N=10 Low StO2 at the end of EGDTSeverity of disease

14. Low StO2 at the end of EGDTlactate clearance during treatment N=12 (end of resuscitation) N=10 (end of resuscitation)

15. Dynamics of StO2mortality UNPUBLISHED DATA Odds for mortality: persistent low StO2 during first 24h 7.9(CI: 3-21, P<0.001) Odds for mortality: when StO2 decreased to <75% during first 24h 7.1(CI: 2-21, P<0.001) Odds for mortality: persistent low StO2 and low peripheral perfusion 9.9(CI: 3-41ß, P<0.001)

16. Why fluids? clinical characteristics? clinical characteristics? improvement in clinical signs increase in MAP decrease in Lactate Stroke Volume Venous Return

17. Intraoperative fluid optimization in high risk surgical patientsBenes et al. Crit Care 2010;14:R118

18. Restricted peri-operative fluid administration adjusted by serum lactate level improved outcome after major elective surgery for gastrointestinal malignancyWenkui et al. Surgery 2010;147:542-552 • Restricted: lactate (when the surgeon thought it could be helpful) and fluids as clinically required (HR, BP, UO,CVP) • Adjusted: hourly lactate during surgery and 2,6,12,24h after surgery • Lactate 1.7-4.0 additional bolus of 250-500 ml HAES 6% • Lactate >4.1 mmol/L additional bolus 500-1000 ml HAES 6% • max 1500 ml HAES, then albumin 5%

19. Restricted peri-operative fluid administration adjusted by serum lactate level improved outcome after major elective surgery for gastrointestinal malignancyWenkui et al. Surgery 2010;147:542-552 96% 94% 58% 23% 19% 24% 16% 4% * Overall complications Major complications Systemic complications 45% 16% 19% 85% 44% 63% * *

20. Effects of fluids on tissue perfusion and oxygenationOspina-Tascon et al. Intensive Care Med 2010;36:949-955 24 patients at 24h 23 patients at 48h 2.1 (1.2-2.9) 1.9* (1.1-2.6) 1.8 (1.4-2.4) 1.9 (1.4-2.5)

21. Tissue perfusion is independent of systemic fluid responsiveness in septic ICU patients and healthy volunteers UNPUBLISHED DATA in 34% of the patients the PLR induced increases in SV, however it did not induce any change in any parameter of regional tissue perfusion Fluid responsiveness of the systemic circulation, but not of regional perfusion parameters, can be predicted with a PLR test.

22. Effect of Dobutamine on microcirculatory flow De Backer et al. Crit Care Med 2006;34(2):403-408

23. Why fluids? clinical characteristics? small changes in lactate levels around normal levels no clear changes in clinical signs surgical cases clinical characteristics? improvement in clinical signs increase in MAP decrease in Lactate Stroke Volume Venous Return

24. Conclusions • Fluids are administered to increase venous return and subsequently to increase stroke volume when cardiac reserve is present • Severe hypovolemia is associated with strong clinical signs including increased lactate levels • Fluid resuscitation is associated with improvement of these clinical signs • Fluid resuscitation to fluid-unresponsiveness is associated with lower lactate levels in the “normal” range • Fluid restriction guided by lactate levels is associated with improved morbidity

25. www.intensivecare.me

26. PERIPHERAL PERFUSION TARGETED FLUID MANAGEMENT IN CRITICALLY ILL PATIENTS: A PILOT STUDYSophie Nebout and Michel van Genderen 40 adult septic shock patients admitted to the ICUIntensive Care with hemodynamic instability (MAP<65 mmHg and Lactate>3.0 mmol/l) Intervention: In the intervention group fluid management is targeted on peripheral perfusion parameters while in the control group fluid is administered in order to optimize cardiac output. ‘Good’ peripheral perfusion is defined as at least 3 out of 4 of the following criteria: - Peripheral flow index (PFI) > 1,4 - Capillary refill time (CRT) < 5 seconds - Delta of temperature between the forearm and the finger (∆T°) < 3°C - Tissue oxygen saturation (StO2) > 70%

27. PERIPHERAL PERFUSION TARGETED FLUID MANAGEMENT IN CRITICALLY ILL PATIENTS: A PILOT STUDYSophie Nebout and Michel van Genderen

28. Mottling score predicts survival in septic shock Intensive Care Med (2011) 37:801–807

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

30. Lactate containing fluids 1.79 2.05 Crit Care Med 2011;39:2419-2424

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

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