1. Optimal fluid resuscitation: Lactate?
Jan Bakker
chair dept Intensive Care Adults

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? Stroke Volume Venous Return clinical characteristics?

4. One of the women, the 23-year-old primipara Eva Rumpel, gave birth to a healthy child on 9 January 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. Skin temperature and systemic circulation
Cool vs. warm skin
Similar: Heart rate, blood pressure, PAOP, Hemoglobin, FiO2, PaO2, PaCO2
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 ± *
68 ± 8 *
2.2 ± 1.6 *
Kaplan et al. J Trauma 2001;50:

6. Important observations
Studies in clinical shock and hypotension Cohn et al. JAMA 1964;190(10):
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 Resuscitation Septic Shock: Initial fluid resuscitation
Chest 1984;85:
Am Rev Respir Dis 1985;131:
Am Rev Respir Dis 1986;134:
Crit Care Med 1987;15:26-28
Anesthesiology 1998;89:

8. Lactate to guide fluid resuscitation Pre hospital
10 Patients with clinically suspected hypovolemia and increased lactate level (>3.5 mmol/l)
Goal: 1000 ml NaCl 0.9% in 30 minutes
Pre fluids
Post fluids
HR b/min
102 ± 7
98±6
SAP mmHg
100 ± 11
119±7*
DAP mmHg
58±9
72±4*
Lactate mmol/L
7.2 ± 1.5
5.5±0.9*

9. Esophageal doppler guided fluid resuscitation Multiple 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 Trauma Blow 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)
Lactate cleared <6h
Lactate cleared 6-12h
Lactate cleared 12-24h
No clearance in 24h
No of patients 19 11 14
Only fluids
16 (84%)
8 (73%)
10 (71%)
Vasopressors
3 (16%)
3 (27%)
4 (29%)
MOF
3 (21%)
6 (43%)
Survival
100%

11. Early lactate-guided therapy in ICU patients Jansen et al
Early lactate-guided therapy in ICU patients Jansen et al. AJRCCM 2010;182:
0-8 hours
9-72 hours
control
protocol
Fluids (L)
2.2±1.7
2.7±2.0
10.0±6.1
8.5±5.0
Any vasodilator
20.2%
42.5%
27.1%
43.2%
p=0.011
p=0.055
p<0.001
p=0.005
no differences in RBC transfusion

12. Early lactate-guided therapy in ICU patients Jansen et al
Early lactate-guided therapy in ICU patients Jansen et al. AJRCCM 2010;182:

13. Low StO2 at the end of EGDT Severity of disease

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

15. Dynamics of StO2 mortality
Admission
Evolution during first 24h
ICU mortality
StO2
n=221
Normal
(>75%) n=166
n=160
15%
Abnormal
n=21
57%
(<75%) n=39
n=15
13%
n=25
56%
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? Stroke Volume Venous Return clinical characteristics?
improvement in clinical signs
increase in MAP
decrease in Lactate
Stroke Volume
Venous Return

17. Intraoperative fluid optimization in high risk surgical patients Benes et al. Crit Care 2010;14:R118
SVV optimized (n=51)
Control (n=54)
OR fluids
Crystalloids (ml)
2321±681
2459±930
Colloids (ml)
1425 ( )
1000 ( )*
8h ICU admission
1587±371
1528±475
0 (0-500)
0 (0-250)
Lactate levels
Baseline
1.48±0.44
1.42±0.43
End of surgery
1.78±0.83
2.25±1.12*
4h postOP
1.75±0.86
2.14±1.11*
8h postOP
1.85±0.86
2.10±1.18*

18. Adjusted: hourly lactate during surgery and 2,6,12,24h after surgery
Restricted peri-operative fluid administration adjusted by serum lactate level improved outcome after major elective surgery for gastrointestinal malignancy Wenkui et al. Surgery 2010;147:
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 additional bolus of ml HAES 6%
Lactate >4.1 mmol/L additional bolus 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 malignancy Wenkui et al. Surgery 2010;147:
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 oxygenation Ospina-Tascon et al. Intensive Care Med 2010;36:
24 patients at 24h
23 patients at 48h
2.1
( )
1.9*
( )
1.8
( )
1.9
( )

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):

23. Why fluids? Stroke Volume Venous Return 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

26. PERIPHERAL PERFUSION TARGETED FLUID MANAGEMENT IN CRITICALLY ILL PATIENTS: A PILOT STUDY Sophie 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 STUDY Sophie 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 care Wang et al
Out-of-hospital shock care Wang et al. Crit Care Med 2011;39(11): )

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

31. Lactate containing fluids29
1840
Crit Care Med 2011;39:

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