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Early lactate-guided therapy in intensive care unit patients: A multicenter, open-label, randomized controlled trial

RATIONALE It is unknown whether lactate monitoring aimed to decrease levels during initial treatment in critically ill patients improves outcome. OBJECTIVES To assess the effect of lactate monitoring and resuscitation directed at decreasing lactate levels in intensive care unit (ICU) patients admitted with a lactate level of greater than or equal to 3.0 mEq/L. METHODS Patients were randomly allocated to two groups. In the lactate group, treatment was guided by lactate levels with the objective to decrease lactate by 20% or more per 2 hours for the initial 8 hours of ICU stay. In the control group, the treatment team had no knowledge of lactate levels (except for the admission value) during this period. The primary outcome measure was hospital mortality. MEASUREMENTS AND MAIN RESULTS The lactate group received more fluids and vasodilators. However, there were no significant differences in lactate levels between the groups. In the intention-to-treat population (348 patients), hospital mortality in the control group was 43.5% (77/177) compared with 33.9% (58/171) in the lactate group (P = 0.067). When adjusted for predefined risk factors, hospital mortality was lower in the lactate group (hazard ratio, 0.61; 95% confidence interval, 0.43-0.87; P = 0.006). In the lactate group, Sequential Organ Failure Assessment scores were lower between 9 and 72 hours, inotropes could be stopped earlier, and patients could be weaned from mechanical ventilation and discharged from the ICU earlier. CONCLUSIONS In patients with hyperlactatemia on ICU admission, lactate-guided therapy significantly reduced hospital mortality when adjusting for predefined risk factors. As this was consistent with important secondary endpoints, this study suggests that initial lactate monitoring has clinical benefit. Clinical trial registered with www.clinicaltrials.gov (NCT00270673).

Increased blood lacate levels: An important warning signal in surgical practice

Both in emergency and elective surgical patients increased blood lactate levels warn the physician that the patient is at risk of increased morbidity and decreased changes of survival. Prompt therapeutic measures to restore the balance between oxygen demand and supply are warranted in these patients.

Why Opioids and Sedatives May Prolong Life Rather Than Hasten Death After Ventilator Withdrawal in Critically Ill Patients

The process of death in patients in whom cardiorespiratory support is withdrawn is related to the occurrence of tissue hypoxia that results from an imbalance between the demand for oxygen and the delivery of oxygen to the organs. Limiting the demand for oxygen may thus delay the occurrence of tissue hypoxia. Because the demand for oxygen increases significantly after ventilator withdrawal and because sedatives and opioids are known to decrease the demand for oxygen in patients with cardiorespiratory distress, these agents might thus actually prolong life rather than hasten death.

Postoperative sublingual microcirculatory derangement following esophagectomy is prevented with dobutamine.

INTRODUCTION Esophagectomy with gastric tube reconstruction is characterized by high postoperative morbidity rates. Recently it was shown that decreased sublingual microvascular blood flow (MBF) preoperatively was associated with increased rate of complications after abdominal surgery. Similar observations in severely septic patients could be treated with dobutamine, independent of cardiac output. Based on these considerations we hypothesized that sublingual MBF derangements are more likely to be found in patients undergoing high risk surgery such as esophagectomy, and if present, might be prevented with administration of low dose dobutamine. METHODS In this single-centre, prospective, double-blinded study, we randomized 20 patients admitted to the Intensive Care Unit following esophagectomy with gastric tube reconstruction into two groups. The intervention group (D) received a small dose of dobutamine (2.5 μg/kg/min) directly postoperative until two days postoperatively, whereas the placebo group (P) received a similar volume of saline. A subset of patients undergoing pancreaticoduodenectomy surgery was included as control group (C) for comparison with the study group. Sublingual MBF was determined one day prior to surgery until two days postoperatively. RESULTS At the first postoperative day, patients in the esophagectomy/placebo group (P), showed a significant lower microvascular flow index, perfused vessel density and proportion of perfused vessels compared to baseline (p < 0.001) and the pancreaticoduodenectomy group (C) (p < 0.001). Administration of dobutamine significantly prevented the overall decrease in microvascular blood flow the first postoperative day. CONCLUSION Postoperative sublingual MBF is markedly impaired in esophagectomy patients compared to patients who underwent a pancreaticoduodenectomy and could be prevented by early administration of a small dose dobutamine.

A WEANING MARKER FROM VENO-ARTERIAL EXTRA CORPOREAL MEMBRANE OXYGENATION USING A NOVEL MICROCIRCULATORY IMAGING

Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used in the treatment of cardiogenic shock. However, marker of successful weaning remains largely unknown. We sought to examine microcirculation as a new method for weaning. Methods: Weaning was performed by

Clinical Significance of Peripheral Circulation Abnormalities in Critically Ill Patients

The development of therapeutic goals and priorities for the intensive care setting depends on an accurate evaluation of the adequacy of organ perfusion. Clinically, the major causes of poor tissue perfusion can be divided into systemic and regional causes. Although inadequate systemic circulatory function may be directly measured, regional causes of altered tissue perfusion are more difficult to measure and more tenuous in appearance. From an etiological perspective, the most common cause of regional hypoperfusion in critically ill patients is an alteration in peripheral vascular function. A variety of factors contribute to these derangements in the peripheral circulation, and most of these alterations are present in both septic and non-septic shock.