Macrocirculatory and Microcirculatory Endpoints in Sepsis Resuscitation

2020 ◽  
pp. 088506662098258
Author(s):  
Garrick Mok ◽  
Ariel Hendin ◽  
Peter Reardon ◽  
Michael Hickey ◽  
Sara Gray ◽  
...  
Keyword(s):  
Septic Shock ◽  
Cardiac Output ◽  
Mean Arterial Pressure ◽  
Disease Process ◽  
Tissue Perfusion ◽  
Common Disease ◽  
Capillary Refill Time ◽  
Successful Resuscitation ◽  
Capillary Refill ◽  
Initial Resuscitation

Sepsis is a common disease process encountered by physicians. Sepsis can lead to septic shock, which carries a hospital mortality rate in excess of 40%. Although the Surviving Sepsis Guidelines recommend targeting a mean arterial pressure (MAP) of 65 mmHg and normalization of lactate, these endpoints do not necessarily result in tissue perfusion in states of shock. While MAP and lactate are commonly used markers in resuscitation, clinicians may be able to improve their resuscitation by broadening their assessment of the microcirculation, which more adequately reflects tissue perfusion. As such, in order to achieve a successful resuscitation, clinicians must optimize both macrocirculatory (MAP, cardiac output) and microcirculatory (proportion of perfused vessels, lactate, mottling, capillary refill time) endpoints. This review will summarize various macrocirculatory and microcirculatory markers of perfusion that can be used to guide the initial resuscitation of patients with sepsis.

scholarly journals Effects of capillary refill time-vs. lactate-targeted fluid resuscitation on regional, microcirculatory and hypoxia-related perfusion parameters in septic shock: a randomized controlled trial

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Ricardo Castro ◽  
Eduardo Kattan ◽  
Giorgio Ferri ◽  
Ronald Pairumani ◽  
Emilio Daniel Valenzuela ◽  
...  
Keyword(s):  
Septic Shock ◽  
Randomized Controlled Trial ◽  
Fluid Resuscitation ◽  
Controlled Trial ◽  
Tissue Perfusion ◽  
Capillary Refill Time ◽  
Capillary Refill ◽  
Randomized Controlled ◽  
Microcirculatory Flow ◽  
The Impact

Abstract Background Persistent hyperlactatemia has been considered as a signal of tissue hypoperfusion in septic shock patients, but multiple non-hypoperfusion-related pathogenic mechanisms could be involved. Therefore, pursuing lactate normalization may lead to the risk of fluid overload. Peripheral perfusion, assessed by the capillary refill time (CRT), could be an effective alternative resuscitation target as recently demonstrated by the ANDROMEDA-SHOCK trial. We designed the present randomized controlled trial to address the impact of a CRT-targeted (CRT-T) vs. a lactate-targeted (LAC-T) fluid resuscitation strategy on fluid balances within 24 h of septic shock diagnosis. In addition, we compared the effects of both strategies on organ dysfunction, regional and microcirculatory flow, and tissue hypoxia surrogates. Results Forty-two fluid-responsive septic shock patients were randomized into CRT-T or LAC-T groups. Fluids were administered until target achievement during the 6 h intervention period, or until safety criteria were met. CRT-T was aimed at CRT normalization (≤ 3 s), whereas in LAC-T the goal was lactate normalization (≤ 2 mmol/L) or a 20% decrease every 2 h. Multimodal perfusion monitoring included sublingual microcirculatory assessment; plasma-disappearance rate of indocyanine green; muscle oxygen saturation; central venous-arterial pCO2 gradient/ arterial-venous O2 content difference ratio; and lactate/pyruvate ratio. There was no difference between CRT-T vs. LAC-T in 6 h-fluid boluses (875 [375–2625] vs. 1500 [1000–2000], p = 0.3), or balances (982[249–2833] vs. 15,800 [740–6587, p = 0.2]). CRT-T was associated with a higher achievement of the predefined perfusion target (62 vs. 24, p = 0.03). No significant differences in perfusion-related variables or hypoxia surrogates were observed. Conclusions CRT-targeted fluid resuscitation was not superior to a lactate-targeted one on fluid administration or balances. However, it was associated with comparable effects on regional and microcirculatory flow parameters and hypoxia surrogates, and a faster achievement of the predefined resuscitation target. Our data suggest that stopping fluids in patients with CRT ≤ 3 s appears as safe in terms of tissue perfusion. Clinical Trials: ClinicalTrials.gov Identifier: NCT03762005 (Retrospectively registered on December 3rd 2018)

scholarly journals Skin mottling score and capillary refill time to assess mortality of septic shock since pre-hospital setting

2019 ◽  
Vol 37 (4) ◽  
pp. 664-671 ◽  
Author(s):  
Romain Jouffroy ◽  
Anastasia Saade ◽  
Jean Pierre Tourtier ◽  
Papa Gueye ◽  
Emmanuel Bloch-Laine ◽  
...  
Keyword(s):  
Septic Shock ◽  
Hospital Setting ◽  
Capillary Refill Time ◽  
Capillary Refill

Optimal Adrenergic Support in Septic Shock Due to Peritonitis

2003 ◽  
Vol 98 (4) ◽  
pp. 888-896 ◽  
Author(s):  
Qinghua Sun ◽  
Zizhi Tu ◽  
Suzana Lobo ◽  
George Dimopoulos ◽  
Nathalie Nagy ◽  
...  
Keyword(s):  
Septic Shock ◽  
Cardiac Output ◽  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Blood Lactate ◽  
Lactate Concentration ◽  
Blood Lactate Concentration ◽  
The Other ◽  
Control Group ◽  
Lower Blood

Background The authors evaluated optimal adrenergic support using norepinephrine, dopamine, and dobutamine in a clinically relevant model of septic shock. Methods Twenty-eight mature, female, anesthetized sheep (weight, 30.5 +/- 3.6 kg) underwent cecal ligation and perforation and were randomized into four groups of seven animals to be treated with norepinephrine, dopamine-norepinephrine, dobutamine-norepinephrine, or no adrenergic agent. In all groups, lactated Ringer's solution was administered to restore cardiac filling pressures to baseline. In the norepinephrine group, norepinephrine (0.5-5 microg. kg(-1). min(-1)) was titrated to maintain mean arterial pressure between 75-85 mmHg. In the dopamine-norepinephrine group, dopamine was given first, and norepinephrine was added only when mean arterial pressure remained below 75 mmHg despite the infusion of 20 microg. kg(-1). min(-1) dopamine. In the dobutamine-norepinephrine group, dobutamine was started at the same time as norepinephrine and titrated up to 20 microg. kg(-1). min(-1) to get a 15% increase in cardiac output. Results The dobutamine-norepinephrine group had greater cardiac output; superior mesenteric blood flow, oxygen delivery (Do(2)), and oxygen consumption ([OV0312]o(2)); and lower blood lactate concentration and partial pressure of carbon dioxide (Pco(2)) gap than the controls did. Cumulative urine output was significantly higher in the dobutamine-norepinephrine group than in the other groups. Survival time was significantly longer in the dobutamine-norepinephrine (24 +/- 4 h), dopamine- norepinephrine (24 +/- 6 h), and norepinephrine (20 +/- 1 h) groups than the control group (17 +/- 2 h; P < 0.05 vs. other groups), and significantly longer in the combined dopamine-norepinephrine and dobutamine-norepinephrine groups (24 +/- 5 h) than in the norepinephrine alone group (P < 0.05). Histologic examination of lung biopsies revealed less severe lesions in the dobutamine-norepinephrine group than in the control and norepinephrine alone groups. Anatomic alterations in the lung, liver, and small intestine were less severe in the dobutamine-norepinephrine group than in the other groups. Conclusions In this prolonged septic shock model, association of norepinephrine with either dopamine or dobutamine resulted in the longest survival and the least severe pulmonary lesions. The combination of dobutamine with norepinephrine was associated with a better myocardial performance, greater Do(2) and [OV0312]o(2), lower blood lactate concentration and Pco(2) gap, and less anatomic injury.

Capillary refill time exploration during septic shock

2014 ◽  
Vol 40 (7) ◽  
pp. 958-964 ◽  
Author(s):  
H. Ait-Oufella ◽  
N. Bige ◽  
P. Y. Boelle ◽  
C. Pichereau ◽  
M. Alves ◽  
...  
Keyword(s):  
Septic Shock ◽  
Capillary Refill Time ◽  
Capillary Refill

Capillary Refill

PEDIATRICS ◽  
1994 ◽  
Vol 94 (1) ◽  
pp. 136-136
Author(s):  
Donald D. Vernon ◽  
J. Michael Dean
Keyword(s):  
Ambient Temperature ◽  
Clinical Assessment ◽  
Tissue Perfusion ◽  
Healthy Children ◽  
Capillary Refill Time ◽  
Capillary Refill

We are writing to comment on the article by Gorelick et al, "Effective Ambient Temperature and Capillary Refill in Healthy Children" (Pediatrics 1993;92:699-702) and, in particular, the accompanying editorial by Barth (Pediatrics 1993;92:723-724). It is hardly surprising that capillary refill time is affected by ambient temperature or that it is an imperfect indicator of tissue perfusion. We hope that their intention was not to imply that clinical assessment of perfusion is a useless endeavor, however.

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