ABSTRACT
Objective:@#Poor tissue perfusion/cellular hypoxia may persist despite restoration of the macrocirculation (Macro). This article reviewed the literatures of coherence between hemodynamics and tissue perfusion in circulatory shock.@*Data sources:@#We retrieved information from the PubMed database up to January 2018 using various search terms or/and their combinations, including resuscitation, circulatory shock, septic shock, tissue perfusion, hemodynamic coherence, and microcirculation (Micro).@*Study selection:@#The data from peer-reviewed journals printed in English on the relationships of tissue perfusion, shock, and resuscitation were included.@*Results:@#A binary (coherence/incoherence, coupled/uncoupled, or associated/disassociated) mode is used to describe resuscitation coherence. The phenomenon of resuscitation incoherence (RI) has gained great attention. However, the RI concept requires a more practical, systematic, and comprehensive framework for use in clinical practice. Moreover, we introduce a conceptual framework of RI to evaluate the interrelationship of the Macro, Micro, and cell. The RI is divided into four types (Type 1: Macro-Micro incoherence + impaired cell; Type 2: Macro-Micro incoherence + normal cell; Type 3: Micro-Cell incoherence + normal Micro; and Type 4: both Macro-Micro and Micro-cell incoherence). Furthermore, we propose the concept of dynamic circulation-perfusion coupling to evaluate the relationship of circulation and tissue perfusion during circulatory shock.@*Conclusions:@#The concept of RI and dynamic circulation-perfusion coupling should be considered in the management of circulatory shock. Moreover, these concepts require further studies in clinical practice.
ABSTRACT
Objective The relationship of venous-to-arterial CO2difference(Pv-aCO2)/ arterial-central venous O2difference (Ca-vO2) ratio, peripheral perfusion index(PI) and lactate clearance(LC) were investigated during resuscitation in septic patients. And, the meaning of the combination PI and Pv-aCO2/Ca-vO2ratio to interpret incoherence of lactate clear was explored. Methods The patients with sepsis were prospectively observed, who admitted to critically care medicine department of Peking Union Medical College Hospital. The hemodynamic parameters, simultaneous arterial and central venous blood gas analysis and PI were obtained at the enrollment (T0) and 8 hours (T8) during resuscitation. The lactate clearance was defined as 8h-LC≥10% and non-lactate clearance was defined as 8h-LC≤10%. Additionally, the patients were divided as three sub-groups according to the PI value at T8: the normalized PI group with PI≥1.4,the mild impaired PI with 1.4＜PI＜0.6 and severe impaired PI with PI≤0.6. Results A total of 84 patients were enrolled in this study. There was no significant difference in Pv-aCO2/Ca-vO2ratio in the three groups. However, the PI≤0.6 group had a significantly higher Pv-aCO2than other groups. Moreover, the patients with non-lactate clearance (13/32) had a higher Pv-aCO2/Ca-vO2ratio than the patients with lactate clearance in PI≥1.4 group (1.9±0.7 vs. 1.3±1.0, P=0.01). Multivariate analysis showed both Pv-aCO2/Ca-vO2ratio [Exp(B) 2.235,95% CI 1.232-4.055,P=0.008] and acute physiology and chronic health evaluation Ⅱ(APACHEⅡ) [Exp(B)1.087,95%CI 1.022-1.156,P=0.008] were independent risk factor of non-lactate clearance. 8h-PI was significantly negative correlated with the 8 h Pv-aCO2gap (r=-0.311, P=0.004), but not significantly with Pv-aCO2/Ca-vO2ratio (r=-0.094, P=0.385). Conclusions Both high Pv-aCO2/Ca-vO2 ratio and low PI were related to non-lactate clearance after resuscitation in sepsis. Combined PI and Pv-aCO2/Ca-vO2ratio could interpret incoherence of latacte clearance after resuscitation.