Relationship of systemic, hepatosplanchnic, and microcirculatory perfusion parameters with 6-hour lactate clearance in hyperdynamic septic shock patients: an acute, clinical-physiological, pilot study

Abstract

BackgroundRecent clinical studies have confirmed the strong prognostic value of persistent hyperlactatemia and delayed lactate clearance in septic shock. Several potential hypoxic and nonhypoxic mechanisms have been associated with persistent hyperlactatemia, but the relative contribution of these factors has not been specifically addressed in comprehensive clinical physiological studies. Our goal was to determine potential hemodynamic and perfusion-related parameters associated with 6-hour lactate clearance in a cohort of hyperdynamic, hyperlactatemic, septic shock patients.MethodsWe conducted an acute clinical physiological pilot study that included 15 hyperdynamic, septic shock patients undergoing aggressive early resuscitation. Several hemodynamic and perfusion-related parameters were measured immediately after preload optimization and 6 hours thereafter, with 6-hour lactate clearance as the main outcome criterion. Evaluated parameters included cardiac index, mixed venous oxygen saturation, capillary refill time and central-to-peripheral temperature difference, thenar tissue oxygen saturation (StO2) and its recovery slope after a vascular occlusion test, sublingual microcirculatory assessment, gastric tonometry (pCO2 gap), and plasma disappearance rate of indocyanine green (ICG-PDR). Statistical analysis included Wilcoxon and Mann–Whitney tests.ResultsFive patients presented a 6-hour lactate clearance <10%. Compared with 10 patients with a 6-hour lactate clearance ≥10%, they presented a worse hepatosplanchnic perfusion as represented by significantly more severe derangements of ICG-PDR (9.7 (8–19) vs. 19.6 (9–32)%/min, p < 0.05) and pCO2 gap (33 (9.1-62) vs. 7.7 (3–58) mmHg, p < 0.05) at 6 hours. No other systemic, hemodynamic, metabolic, peripheral, or microcirculatory parameters differentiated these subgroups. We also found a significant correlation between ICG-PDR and pCO2 gap (p = 0.02).ConclusionsImpaired 6-hour lactate clearance could be associated with hepatosplanchnic hypoperfusion in some hyperdynamic septic shock patients. Improvement of systemic, metabolic, and peripheral perfusion parameters does not rule out the persistence of hepatosplanchnic hypoperfusion in this setting. Severe microcirculatory abnormalities can be detected in hyperdynamic septic shock patients, but their role on lactate clearance is unclear. ICG-PDR may be a useful tool to evaluate hepatosplanchnic perfusion in septic shock patients with persistent hyperlactatemia.Trial registrationClinicalTrials.gov Identifier: NCT01271153

When to stop septic shock resuscitation: clues from a dynamic perfusion monitoring

“…The case of hyperlactatemia is paradigmatic. Although tissue hypoperfusion has been traditionally considered the most common cause of hyperlactatemia, there is increasing evidence for concomitant non-hypoxic and thus, non-flow dependent mechanisms [ 28 ],[ 29 ] that may influence the time course of lactate recovery rate. The distinction between these two scenarios (flow-responsive vs. non-flow dependent hyperlactatemia) should strongly impact the therapeutic approach [ 13 ].…”

Noninvasive Hemodynamic Assessment as Part of Preoperative Examination of Patients with Colorectal Cancer

“…Различия гемодинами ческого статуса в группах больных с III и IV стадиями демонстрируют реализацию токсического эффекта хи миотерапии [41][42][43]. Столь же вероятно, что гиперди намический тип кровообращения явился следствием реализации механизмов адаптации на этапно формиру ющийся дефицит ОЦК и изменения показателей кис лотно основного состояния [44].…”

“…The hyperdynamic type of blood circulation could also be a result of adaptation to deficit of blood volume and acid base disequilibrium [44].…”

Principles of Fluid Management

“…23,24 There may be biphasic and/or variable responses to normalization of resuscitation variables (eg, rapid initial improvement in ScvO 2 , capillary refill time, and lactate clearance may be followed by slower trends thereafter) and further delays to normalization due to confounding by impaired hepatosplanchnic hypoperfusion. 25,26 Microcirculatory capillary blood flow (ie, use of sublingual orthogonal polarization spectral imaging) is commonly found abnormal among critically ill patients. Recent observational data have shown that disturbance in sublingual microcirculatory flow failed to correlate with patient survival, possibly because of a significant dissociation observed between sublingual and intestinal microcirculatory perfusion after fluid resuscitation.…”