A discussion of recent research exploring the feasibility of perfusion-guided resuscitation of acute circulatory failure with a focus on lactate and microcirculation.
Upon diagnosis of shock, hyperlactemia is associated with poor outcome and, under appropriate clinical circumstances, may reflect inadequate tissue perfusion. Persistent hyperlactemia despite resuscitation is even more strongly correlated with morbidity and mortality. Importantly, there is minimal coherence between lactate trends and static hemodynamic measures such as blood pressure, especially after the initial, hypovolemic phase of shock. During this early period, lactate guided-resuscitation is effective and possibly superior to hemodynamic-guided resuscitation. Similar to hyperlactemia, impaired microcirculation is ubiquitous in shock and is evident even in the setting of hemodynamic compensation (i.e., occult shock). Moreover, persistent microcirculatory derangement is associated with poor outcome and may reflect ongoing shock and/or long-lasting damage. Although the wait continues for a microcirculation-guided resuscitation trial, there is progress toward this goal.
Although questions remain, a multimodal perfusion-based approach to resuscitation is emerging with lactate and microcirculation as core measures. In this model, hyperlactemia and microcirculatory derangement support the diagnosis of shock, may help guide resuscitation during the initial period, and may reflect resuscitation efficacy and iatrogenic harm (e.g., fluid overload).
aDepartment of Anesthesiology
bDivision of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, NewYork-Presbyterian Hospital
cDepartment of Pulmonary and Critical Care, Langone Medical Center-Bellevue Hospital, New York University, New York, New York, USA
dDepartment of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, The Netherlands
eFacultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
Correspondence to Jan Bakker, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, NewYork-Presbyterian Hospital, 622 West 168th St., Room PH 8–109, New York, NY 10032, USA. Tel: +1 917 208 7648; e-mail: email@example.com