aDepartment of Anesthesiology bDivision of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, NewYork-Presbyterian Hospital cDepartment of Pulmonary and Critical Care, Langone Medical Center-Bellevue Hospital, New York University, New York, New York, USA dDepartment of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, The Netherlands eFacultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
Curr Opin Crit Care. 2017 Aug;23(4):348-354. doi: 10.1097/MCC.0000000000000423.
A discussion of recent research exploring the feasibility of perfusion-guided resuscitation of acute circulatory failure with a focus on lactate and microcirculation.
Upon diagnosis of shock, hyperlactemia is associated with poor outcome and, under appropriate clinical circumstances, may reflect inadequate tissue perfusion. Persistent hyperlactemia despite resuscitation is even more strongly correlated with morbidity and mortality. Importantly, there is minimal coherence between lactate trends and static hemodynamic measures such as blood pressure, especially after the initial, hypovolemic phase of shock. During this early period, lactate guided-resuscitation is effective and possibly superior to hemodynamic-guided resuscitation. Similar to hyperlactemia, impaired microcirculation is ubiquitous in shock and is evident even in the setting of hemodynamic compensation (i.e., occult shock). Moreover, persistent microcirculatory derangement is associated with poor outcome and may reflect ongoing shock and/or long-lasting damage. Although the wait continues for a microcirculation-guided resuscitation trial, there is progress toward this goal.
Although questions remain, a multimodal perfusion-based approach to resuscitation is emerging with lactate and microcirculation as core measures. In this model, hyperlactemia and microcirculatory derangement support the diagnosis of shock, may help guide resuscitation during the initial period, and may reflect resuscitation efficacy and iatrogenic harm (e.g., fluid overload).
讨论最近研究中探索灌注指导急性循环衰竭复苏的可行性，重点关注乳酸和微循环。
休克诊断时，高乳酸血症与不良预后相关，在适当的临床情况下，可能反映组织灌注不足。尽管复苏后乳酸持续升高与发病率和死亡率的相关性更强。重要的是，乳酸趋势与静态血流动力学指标（如血压）之间几乎没有一致性，尤其是在休克的初始低血容量阶段之后。在这个早期阶段，乳酸指导复苏是有效的，并且可能优于血流动力学指导复苏。与高乳酸血症类似，微循环受损在休克中普遍存在，即使在血流动力学代偿（即隐匿性休克）的情况下也很明显。此外，持续的微循环紊乱与不良预后相关，可能反映持续的休克和/或长期损害。虽然仍在等待一项以微循环为指导的复苏试验，但朝着这一目标取得了进展。
尽管仍存在疑问，但以乳酸和微循环为核心指标的多模式灌注复苏方法正在出现。在该模型中，高乳酸血症和微循环紊乱支持休克的诊断，可能有助于指导初始阶段的复苏，并且可能反映复苏效果和医源性损害（例如，液体过载）。
