Esophageal Doppler-guided fluid management decreases blood lactate levels in multiple-trauma patients: a randomized controlled trial

Ivan Chytra, Richard Pradl, Roman Bosman, Petr Pelnár, Eduard Kasal, Alexandra Zidková, Ivan Chytra, Richard Pradl, Roman Bosman, Petr Pelnár, Eduard Kasal, Alexandra Zidková

Abstract

Introduction: Esophageal Doppler was confirmed as a useful non-invasive tool for management of fluid replacement in elective surgery. The aim of this study was to assess the effect of early optimization of intravascular volume using esophageal Doppler on blood lactate levels and organ dysfunction development in comparison with standard hemodynamic management in multiple-trauma patients.

Methods: This was a randomized controlled trial. Multiple-trauma patients with blood loss of more than 2,000 ml admitted to the intensive care unit (ICU) were randomly assigned to the protocol group with esophageal Doppler monitoring and to the control group. Fluid resuscitation in the Doppler group was guided for the first 12 hours of ICU stay according to the protocol based on data obtained by esophageal Doppler, whereas control patients were managed conventionally. Blood lactate levels and organ dysfunction during ICU stay were evaluated.

Results: Eighty patients were randomly assigned to Doppler and 82 patients to control treatment. The Doppler group received more intravenous colloid during the first 12 hours of ICU stay (1,667 +/- 426 ml versus 682 +/- 322 ml; p < 0.0001), and blood lactate levels in the Doppler group were lower after 12 and 24 hours of treatment than in the control group (2.92 +/- 0.54 mmol/l versus 3.23 +/- 0.54 mmol/l [p = 0.0003] and 1.99 +/- 0.44 mmol/l versus 2.37 +/- 0.58 mmol/l [p < 0.0001], respectively). No difference in organ dysfunction between the groups was found. Fewer patients in the Doppler group developed infectious complications (15 [18.8%] versus 28 [34.1%]; relative risk = 0.5491; 95% confidence interval = 0.3180 to 0.9482; p = 0.032). ICU stay in the Doppler group was reduced from a median of 8.5 days (interquartile range [IQR] 6 to16) to 7 days (IQR 6 to 11) (p = 0.031), and hospital stay was decreased from a median of 17.5 days (IQR 11 to 29) to 14 days (IQR 8.25 to 21) (p = 0.045). No significant difference in ICU and hospital mortalities between the groups was found.

Conclusion: Optimization of intravascular volume using esophageal Doppler in multiple-trauma patients is associated with a decrease of blood lactate levels, a lower incidence of infectious complications, and a reduced duration of ICU and hospital stays.

Figures

Figure 1
Figure 1
Flow of participants through the trial. ICU, intensive care unit.
Figure 2
Figure 2
Fluid management algorithm in the Doppler group. FTc, corrected flow time; ICU, intensive care unit; SV, stroke volume.

References

    1. Rackow EC, Weil MH. Physiology of blood flow and oxygen utilization by peripheral tissue in circulatory shock. Clin Chem. 1990;36:1544–1546.
    1. American College of Surgeons . Advanced Trauma Life Support Manual. 6. Chicago, IL; Shock.
    1. Manikis P, Jankowski S, Zhang H, Kahn RJ, Vincent JL. Correlation of serial blood lactate levels to organ failure and mortality after trauma. Am J Emerg Med. 1995;13:619–622. doi: 10.1016/0735-6757(95)90043-8.
    1. Rixen D, Siegel JH. Bench-to-bedside review: oxygen debt and its metabolic correlates as quantifiers of the severity of hemorrhagic and post-traumatic shock. Crit Care. 2005;9:441–453. doi: 10.1186/cc3526.
    1. Regel G, Grotz M, Weltner T, Sturm JA, Tscherne H. Pattern of organ failure following severe trauma. World J Surg. 1996;20:422–429. doi: 10.1007/s002689900067.
    1. Sauaia A, Moore FA, Moore EE, Norris JM, Lezotte DC, Hamman RF. Multiple organ failure can be predicted as early as 12 hours after injury. J Trauma. 1998;45:291–301.
    1. Claridge JA, Crabtree TD, Pelletier SJ, Butler K, Sawyer RG, Young JS. Persistent occult hypoperfusion is associated with a significant increase in infection rate and mortality in major trauma patients. J Trauma. 2000;48:8–14.
    1. Crowl AC, Young JS, Kahler DM, Claridge JA, Chrzanowski DS, Pomphrey M. Occult hypoperfusion is associated with increased morbidity in patients undergoing early femur fracture fixation. J Trauma. 2000;48:260–267.
    1. Cerovic O, Golubovic V, Spec-Marn A, Kremzar B, Vidmar G. Relationship between injury severity and lactate levels in severely injured patients. Intensive Care Med. 2003;29:1300–1305. doi: 10.1007/s00134-003-1753-8.
    1. Blow O, Magliore L, Claridge JA, Butler K, Young JS. The golden hour and the silver day: detection and correction of occult hypoperfusion within 24 hours improves outcome from major trauma. J Trauma. 1999;47:964–969.
    1. McNelis J, Marini CP, Jurkiewicz A, Szomstein S, Simms HH, Ritter G, Nathan IM. Prolonged lactate clearance is associated with increased mortality in the surgical intensive care unit. Am J Surg. 2001;182:481–485. doi: 10.1016/S0002-9610(01)00755-3.
    1. Abramson D, Scalea TM, Hitchcock R, Trooskin SZ, Henry SM, Greenspan J. Lactate clearance and survival following injury. J Trauma. 1993;35:584–588.
    1. Husain FA, Martin MJ, Mullenix PS, Steele SR, Elliott DC. Serum lactate and base deficit as predictors of mortality and morbidity. Am J Surg. 2003;185:485–491. doi: 10.1016/S0002-9610(03)00044-8.
    1. Meregalli A, Oliveira RP, Friedman G. Occult hypoperfusion is associated with increased mortality in hemodynamically stable, high-risk, surgical patients. Crit Care. 2004;8:R60–65. doi: 10.1186/cc2423.
    1. Smith I, Kumar P, Molloy S, Rhodes A, Newman PJ, Grounds RM, Bennett ED. Base excess and lactate as prognostic indicators for patients admitted to intensive care. Intensive Care Med. 2001;27:74–83. doi: 10.1007/s001340051352.
    1. Scalea TM, Maltz S, Yelon J, Trooskin SZ, Duncan AO, Sclafani SJ. Resuscitation of multiple trauma and head injury: role of crystalloid fluids and inotropes. Crit Care Med. 1994;22:1610–1615.
    1. Abou-Khalil B, Scalea TM, Trooskin SZ, Henry SM, Hitchcock R. Hemodynamic responses to shock in young trauma patients: need for invasive monitoring. Crit Care Med. 1994;22:633–639. doi: 10.1097/00003246-199404000-00020.
    1. Wo CC, Shoemaker WC, Appel PL, Bishop MH, Kram HB, Hardin E. Unreliability of blood pressure and heart rate to evaluate cardiac output in emergency resuscitation and critical illness. Crit Care Med. 1993;21:218–223. doi: 10.1097/00003246-199302000-00012.
    1. Polonen P, Ruokonen E, Hippelainen M, Poyhonen M, Takala J. A prospective, randomized study of goal-oriented hemodynamic therapy in cardiac surgical patients. Anesth Analg. 2000;90:1052–1059. doi: 10.1097/00000539-200005000-00010.
    1. Side CD, Gosling RG. Non-surgical assessment of cardiac function. Nature. 1971;232:335–336. doi: 10.1038/232335a0.
    1. Singer M, Clarke J, Bennett ED. Continuous hemodynamic monitoring by esophageal Doppler. Crit Care Med. 1989;17:447–452.
    1. Mythen MG, Webb AR. Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Arch Surg. 1995;130:423–429.
    1. Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ. 1997;315:909–912.
    1. Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, Newman P. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth. 2002;88:65–71. doi: 10.1093/bja/88.1.65.
    1. Gan TJ, Soppitt A, Maroof M, el-Moalem H, Robertson KM, Moretti E, Dwane P, Glass PS. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology. 2002;97:820–826. doi: 10.1097/00000542-200210000-00012.
    1. McKendry M, McGloin H, Saberi D, Caudwell L, Brady AR, Singer M. Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery. BMJ. 2004;329:258–261. doi: 10.1136/bmj.38156.767118.7C.
    1. Singer M, Bennet ED. Noninvasive optimization of left ventricular filling using esophageal Doppler. Crit Care Med. 1991;19:1132–1137.
    1. Wakeling HG, McFall MR, Jenkins CS, Woods WG, Miles WF, Barclay GR, Fleming SC. Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth. 2005;95:634–642. doi: 10.1093/bja/aei223.
    1. Conway DH, Mayall R, Abdul-Latif MS, Gilligan S, Tackaberry C. Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery. Anaesthesia. 2002;57:845–849. doi: 10.1046/j.1365-2044.2002.02708.x.
    1. Carrasco G. Instruments for monitoring intensive care unit sedation. Crit Care. 2000;4:217–225. doi: 10.1186/cc697.
    1. Chaney JC, Derdak S. Minimally invasive hemodynamic monitoring for the intensivist: current and emerging technology. Crit Care Med. 2002;30:2338–2345. doi: 10.1097/00003246-200210000-00025.
    1. Laupland KB, Bands CJ. Utility of esophageal Doppler as a minimally invasive hemodynamic monitor: a review. Can J Anaesth. 2002;49:393–401.
    1. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections. Am J Infect Control. 1988;16:128–140. doi: 10.1016/0196-6553(88)90053-3.
    1. Pradl R, Chytra I, Kasal E, Bosman R, Židková A. Early hemodynamic optimization in multiple trauma patients by transesophageal Doppler. Intensive Care Med. 2004;30:s130.
    1. Chytra I, Pradl R, Bosman R, Pelnář P, Kasal E, Židková A. Optimization of intravascular volume in multiple trauma patients using esophageal Doppler – preliminary results. Anest Intenziv Med. 2006;17:156–163.
    1. Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds M, Bennet D. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial [ISRCTN38797445] Crit Care. 2005;9:R687–693. doi: 10.1186/cc3887.
    1. Bakker J, de Lima AP. Increased blood lactate levels: an important warning signal in surgical practice. Crit Care. 2004;8:96–98. doi: 10.1186/cc2841.
    1. Arkilic CF, Taguchi A, Sharma N, Ratnaraj J, Sessler DI, Read TE, Fleshman JW, Kurz A. Supplemental perioperative fluid administration increases tissue oxygen pressure. Surgery. 2003;133:49–55. doi: 10.1067/msy.2003.80.
    1. Bennett-Guerrero E, Welsby I, Dunn TJ, Young LR, Wahl TA, Diers TL, Phillips-Bute BG, Newman MF, Mythen MG. The use of a postoperative morbidity survey to evaluate patients with prolonged hospitalization after routine, moderate-risk, elective surgery. Anesth Analg. 1999;89:514–519. doi: 10.1097/00000539-199908000-00050.
    1. Bichel T, Kalangos A, Rouge JC. Can gastric intramucosal pH (pHi) predict outcome of paediatric cardiac surgery? Paediatr Anaesth. 1999;9:129–134. doi: 10.1046/j.1460-9592.1999.9220324.x.
    1. Poeze M, Greve JW, Ramsay G. Meta-analysis of hemodynamic optimization: relationship to methodological quality. Crit Care. 2005;9:R771–779. doi: 10.1186/cc3902.

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