Abstract
Microcirculatory alterations are frequently observed in critically ill patients undergoing major surgery and those who suffer from trauma or sepsis. Despite the need for adequate fluid administration to restore microcirculation, there is no consensus regarding optimal fluid therapy for these patients. The recent recognition of the importance of the endothelial glycocalyx layer in capillary fluid and solute exchange has largely changed our views on fluid therapy in critical illness. Given that disease status largely differs among critically ill patients, fluid therapy must not be considered generally, but rather tailored to the clinical condition of each patient. This review outlines the current understanding of context-sensitive volume expansion by fluid solutions and considers its clinical implications for critically ill patients. The modulation of capillary hydrostatic pressure through the appropriate use of vasopressors may increase the effectiveness of fluid infusion and thereby reduce detrimental effects resulting from excessive fluid administration.
Highlights
In critically ill patients, including high-risk patients undergoing major surgery and patients with trauma or sepsis, adequate fluid administration is essential for the maintenance of tissue perfusion
The larger the macromolecule, the larger the effect capillary hydrostatic pressure (PC) has on permeability across the endothelial glycocalyx (EG) layer. These findings suggest that PC plays a crucial role in volume expansion by colloid solutions via the control of fluid filtration and permeation of colloid molecules across the EG layer
Fluid administration is useful for restoring microcirculation by correcting hypovolemia, the volume expanding effects of the fluid solution is context-sensitive
Summary
In critically ill patients, including high-risk patients undergoing major surgery and patients with trauma or sepsis, adequate fluid administration is essential for the maintenance of tissue perfusion. The rational therapy for hypotension caused by anesthetics is the appropriate use of vasopressors that normalize the decreased vascular tone Vasopressors, such as norepinephrine, increase tissue perfusion pressure, but there remains a potential risk that the resulting vasoconstriction impairs microcirculatory blood flow in vulnerable organs, such as the intestinal tract and kidneys, to hypovolemia. In the initial stages of sepsis, aggressive fluid administration is expected to restore microcirculation by reopening collapsed capillaries (Fig. 6c, blue line), given that low PC increases the plasma volume expanding effect of the fluid solution. Given that early goal-directed therapy for septic shock patients requires aggressive fluid volume loading in the first 6 h based on MAP (â„65 mmHg), central venous pressure (â„8 mmHg), central venous oxygen saturation (â„70 %), and urine output (â„0.5 ml kgâ1 hâ1), resultant fluid overload causes increased use of fluidrelated medical interventions such as diuresis and increased hospital mortality [66]. Given that SVV before fluid challenge was comparable between responders and non-responders (12 vs. 13 %),
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