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

Glenn Hernandez, Tomas Regueira, Alejandro Bruhn, Ricardo Castro, Maximiliano Rovegno, Andrea Fuentealba, Enrique Veas, Dolores Berrutti, Jorge Florez, Eduardo Kattan, Celeste Martin, Can Ince, Glenn Hernandez, Tomas Regueira, Alejandro Bruhn, Ricardo Castro, Maximiliano Rovegno, Andrea Fuentealba, Enrique Veas, Dolores Berrutti, Jorge Florez, Eduardo Kattan, Celeste Martin, Can Ince

Abstract

Background: Recent 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.

Methods: We 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.

Results: Five 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).

Conclusions: Impaired 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 registration: ClinicalTrials.gov Identifier: NCT01271153.

Figures

Figure 1
Figure 1
Evolution of gastric-to-arterial pCO2gradients (pCO2gap in mmHg) and indocyanine green plasma disappearance rates (ICG-PDR in%/min) in patients exhibiting a 6-hour lactate clearance ≥ or <10%. Patients with lower lactate clearance rates exhibited a significant increase in pCO2 gap and a decrease in ICG-PDR.
Figure 2
Figure 2
Correlation between pooled indocyanine green plasma disappearance rate (ICG-PDR) and gastric-to-arterial pCO2gradient (pCO2gap) values.

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