Top

Critical Care

Published in:

Open Access 01-02-2007 | Research

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

Authors: Ivan Chytra, Richard Pradl, Roman Bosman, Petr Pelnář, Eduard Kasal, Alexandra Židková

Published in: Critical Care | Issue 1/2007

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.

Available only for authorised users

Rackow EC, Weil MH: Physiology of blood flow and oxygen utilization by peripheral tissue in circulatory shock. Clin Chem 1990, 36: 1544-1546.PubMed

American College of Surgeons: Shock. In Advanced Trauma Life Support Manual. 6th edition. Chicago, IL;

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. 10.1016/0735-6757(95)90043-8CrossRefPubMed

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. 10.1186/cc3526PubMedCentralCrossRefPubMed

Regel G, Grotz M, Weltner T, Sturm JA, Tscherne H: Pattern of organ failure following severe trauma. World J Surg 1996, 20: 422-429. 10.1007/s002689900067CrossRefPubMed

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.CrossRefPubMed

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.CrossRefPubMed

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.CrossRefPubMed

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. 10.1007/s00134-003-1753-8CrossRefPubMed

10.

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.CrossRefPubMed

11.

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. 10.1016/S0002-9610(01)00755-3CrossRefPubMed

12.

Abramson D, Scalea TM, Hitchcock R, Trooskin SZ, Henry SM, Greenspan J: Lactate clearance and survival following injury. J Trauma 1993, 35: 584-588.CrossRefPubMed

13.

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. 10.1016/S0002-9610(03)00044-8CrossRefPubMed

14.

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. 10.1186/cc2423PubMedCentralCrossRefPubMed

15.

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. 10.1007/s001340051352CrossRefPubMed

16.

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.CrossRefPubMed

17.

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. 10.1097/00003246-199404000-00020CrossRefPubMed

18.

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. 10.1097/00003246-199302000-00012CrossRefPubMed

19.

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. 10.1097/00000539-200005000-00010CrossRefPubMed

20.

Side CD, Gosling RG: Non-surgical assessment of cardiac function. Nature 1971, 232: 335-336. 10.1038/232335a0CrossRefPubMed

21.

Singer M, Clarke J, Bennett ED: Continuous hemodynamic monitoring by esophageal Doppler. Crit Care Med 1989, 17: 447-452.CrossRefPubMed

22.

Mythen MG, Webb AR: Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Arch Surg 1995, 130: 423-429.CrossRefPubMed

23.

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.PubMedCentralCrossRefPubMed

24.

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. 10.1093/bja/88.1.65CrossRefPubMed

25.

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. 10.1097/00000542-200210000-00012CrossRefPubMed

26.

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. 10.1136/bmj.38156.767118.7CPubMedCentralCrossRefPubMed

27.

Singer M, Bennet ED: Noninvasive optimization of left ventricular filling using esophageal Doppler. Crit Care Med 1991, 19: 1132-1137.CrossRefPubMed

28.

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. 10.1093/bja/aei223CrossRefPubMed

29.

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. 10.1046/j.1365-2044.2002.02708.xCrossRefPubMed

30.

Carrasco G: Instruments for monitoring intensive care unit sedation. Crit Care 2000, 4: 217-225. 10.1186/cc697PubMedCentralCrossRefPubMed

31.

Chaney JC, Derdak S: Minimally invasive hemodynamic monitoring for the intensivist: current and emerging technology. Crit Care Med 2002, 30: 2338-2345. 10.1097/00003246-200210000-00025CrossRefPubMed

32.

Laupland KB, Bands CJ: Utility of esophageal Doppler as a minimally invasive hemodynamic monitor: a review. Can J Anaesth 2002, 49: 393-401.CrossRefPubMed

33.

Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM: CDC definitions for nosocomial infections. Am J Infect Control 1988, 16: 128-140. 10.1016/0196-6553(88)90053-3CrossRefPubMed

34.

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.

35.

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.

36.

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. 10.1186/cc3887PubMedCentralCrossRefPubMed

37.

Bakker J, de Lima AP: Increased blood lactate levels: an important warning signal in surgical practice. Crit Care 2004, 8: 96-98. 10.1186/cc2841PubMedCentralCrossRefPubMed

38.

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. 10.1067/msy.2003.80CrossRefPubMed

39.

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. 10.1097/00000539-199908000-00050PubMed

40.

Bichel T, Kalangos A, Rouge JC: Can gastric intramucosal pH (pHi) predict outcome of paediatric cardiac surgery? Paediatr Anaesth 1999, 9: 129-134. 10.1046/j.1460-9592.1999.9220324.xCrossRefPubMed

41.

Poeze M, Greve JW, Ramsay G: Meta-analysis of hemodynamic optimization: relationship to methodological quality. Crit Care 2005, 9: R771-779. 10.1186/cc3902PubMedCentralCrossRefPubMed

Title: Esophageal Doppler-guided fluid management decreases blood lactate levels in multiple-trauma patients: a randomized controlled trial
Authors: Ivan Chytra
Richard Pradl
Roman Bosman
Petr Pelnář
Eduard Kasal
Alexandra Židková
Publication date: 01-02-2007
Publisher: BioMed Central
Published in: Critical Care / Issue 1/2007
Electronic ISSN: 1364-8535
DOI: https://doi.org/10.1186/cc5703

Keynote webinar | Spotlight on medication adherence

Springer Medicine

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

Abstract

Introduction

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 1/2007

Singer M, Webb AR: Oxford Handbook of Critical Care for PDAs, 2nd edition. Oxford: Oxford University Press; 2006.

Inducibility of the endogenous antibiotic peptide β-defensin 2 is impaired in patients with severe sepsis

Tobin MJ: Principles and Practice of Mechanical Ventilation, 2nd Ed.

Not if but when; no longer why but how

Meperidine and skin surface warming additively reduce the shivering threshold: a volunteer study

Risk factors for post-traumatic stress disorder symptoms following critical illness requiring mechanical ventilation: a prospective cohort study