TY - JOUR
T1 - Lactate and microcirculation as suitable targets for hemodynamic optimization in resuscitation of circulatory shock
AU - Kiyatkin, Michael E.
AU - Bakker, Jan
N1 - Publisher Copyright:
© 2017 Wolters Kluwer Health, Inc. All rights reserved.
PY - 2017/8/1
Y1 - 2017/8/1
N2 - Purpose of review: A discussion of recent research exploring the feasibility of perfusion-guided resuscitation of acute circulatory failure with a focus on lactate and microcirculation. Recent findings: 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. Summary: 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).
AB - Purpose of review: A discussion of recent research exploring the feasibility of perfusion-guided resuscitation of acute circulatory failure with a focus on lactate and microcirculation. Recent findings: 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. Summary: 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).
KW - lactate
KW - microcirculation
KW - shock
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U2 - 10.1097/MCC.0000000000000423
DO - 10.1097/MCC.0000000000000423
M3 - Review article
C2 - 28537998
AN - SCOPUS:85019555052
SN - 1070-5295
VL - 23
SP - 348
EP - 354
JO - Current Opinion in Critical Care
JF - Current Opinion in Critical Care
IS - 4
ER -