One of the women, the 23-year-old primipara Eva Rumpel, gave
birth to a healthy child on 9 January 1843. The same night she
developed a painfully swollen abdomen and became ill, feverish, and
sweaty, with rapid pulse and severe thirst. The initiated treatment
was bloodletting and clystering. The next evening she deteriorated,
became delirious, with anxious breathing, a tense abdomen, cold
extremities and rapid pulse, finally losing consciousness. Again,
bloodletting followed. At 4:30 a.m., 36 h after the onset of the
first symptoms, she died. During autopsy, severe purulent
endometritis, vaginal pus, pulmonary edema, and shock liver and
shock spleen were found.
Slide 5
Skin temperature and systemic circulation Cool 2.9 1.2 7.32 0.2
60 4 4.7 1.5 Cardiac Index Arterial pH SvO 2 Lactate Warm 4.3 1.2 *
7.39 0.07 * 68 8 * 2.2 1.6 * Cool vs. warm skin Similar: Heart
rate, blood pressure, PAOP, Hemoglobin, FiO 2, PaO 2, PaCO 2 Cool
vs. warm skin Similar: Heart rate, blood pressure, PAOP,
Hemoglobin, FiO 2, PaO 2, PaCO 2 Kaplan et al. J Trauma
2001;50:620-628
Slide 6
Studies in clinical shock and hypotension Cohn et al. JAMA
1964;190(10):113-118 When metaraminol was discontinued, the
peripheral pulses disappeared, cuff pressure could not be obtained
and diaphoresis became marked. A rapid infusion of 500 ml of 10%
low molecular weight dextran resulted in immediate clinical
improvement with cessation of sweating and return of strong
peripheral pulses. Six hours later, when peripheral pulses again
became weak a slow infusion of 500 ml 6% dextran again resulted in
improvement. He made an uneventful recovery. Important observations
1. Inaccuracy of auscultatory blood pressure 2. Unrecognized
myocardial factor in hypotension 3. Unrecognized need for blood
volume expansion 4. Selection of proper vasopressor drug
Slide 7
Fluid Resuscitation Septic Shock: Initial fluid resuscitation
Chest 1984;85:336-340 Am Rev Respir Dis 1985;131:912- 916 Am Rev
Respir Dis 1986;134:873- 878 Crit Care Med 1987;15:26-28
Anesthesiology 1998;89:1313-1321
Slide 8
Lactate to guide fluid resuscitation Pre hospital Pre
fluidsPost fluids HR b/min 102 7 986 SAP mmHg 100 11 1197* DAP
mmHg589724* Lactate mmol/L 7.2 1.5 5.50.9* 10 Patients with
clinically suspected hypovolemia and increased lactate level
(>3.5 mmol/l) Goal: 1000 ml NaCl 0.9% in 30 minutes
Slide 9
Chytra et al. Crit Care 2007;11:R24 Doppler n=80 Conventional
n=82 range sd ** t=12h colloids1167426 1293300crystalloid1334320
682322 ** Esophageal doppler guided fluid resuscitation Multiple
trauma >2000 ml blood loss
Slide 10
The Golden Hour and the Silver Day: Detection and Correction of
Occult Hypoperfusion within 24 Hours Improves Outcome from Major
Trauma Blow et al. J Trauma 1999;47(5):964 79 patients Lactate >
2,5 mmol/L but hemodynamically stable (SAP>100, HR 1 mL/kg per
hour) Lactate cleared
Admission Evolution during first 24h ICU mortality StO 2 n=221
Normal (>75%) n=166 Normal n=160 15% Abnormal n=21 57% Abnormal
( 1,4 - Capillary refill time (CRT) < 5 seconds - Delta of
temperature between the forearm and the finger (T) < 3C - Tissue
oxygen saturation (StO 2 ) > 70%
Slide 27
PERIPHERAL PERFUSION TARGETED FLUID MANAGEMENT IN CRITICALLY
ILL PATIENTS: A PILOT STUDY Sophie Nebout and Michel van
Genderen
Slide 28
Mottling score predicts survival in septic shock Intensive Care
Med (2011) 37:801807
Slide 29
Out-of-hospital shock care Wang et al. Crit Care Med
2011;39(11):2431-2439)
Slide 30
Lactate containing fluids Crit Care Med 2011;39:2419-2424
1.792.05
Slide 31
Lactate containing fluids Crit Care Med 2011;39:2419-2424 29
1840