Intensive Care Med DOI 10.

1007/s00134-010-1912-7

REVIEW

Joachim Boldt Can Ince

The impact of uid therapy on microcirculation and tissue oxygenation in hypovolemic patients: a review

Received: 21 October 2009 Accepted: 7 March 2010 Copyright jointly held by Springer and ESICM 2010

J. Boldt ()) Department of Anesthesiology and Intensive Care Medicine, Klinikum der Stadt Ludwigshafen, Bremserstr. 79, 67063 Ludwigshafen, Germany e-mail: boldtj@gmx.net Fax: ?49-621-5033024 C. Ince Department of Intensive Care, Erasmus MC University Hospital Rotterdam, Rotterdam, The Netherlands

Abstract Purpose: An optimal volume replacement strategy aims to restore systemic hemodynamics with the ultimate goals of improving organ perfusion and microcirculation for sustaining adequate tissue oxygenation. This review presents the (patho)physiological basis of hypovolemia, microcirculation, and tissue oxygenation and presents a literature review on the effects of plasma substitutes on microperfusion and oxygenation in the clinical setting. Methods: Literature review of the effects of uid therapy on microcirculation and tissue oxygenation using PubMed search including original papers in English from 1988 to 2009. Results: We identied a total of 14 articles dealing with the effects of different crystalloids and colloids on organ perfusion, microcirculation, and tissue oxygenation in patients. The results are divergent, but there is a general trend that colloids are superior to crystalloids in improving organ perfusion, microcirculation, and tissue oxygenation. Due to the limited number of studies and

different study conditions, a metaanalysis on the effects of the volume replacement strategies on microcirculation is not possible. Conclusions: Improving the microcirculation by volume replacement appears to be a promising issue when treating the critically ill. The growing insights from animal experiments have to be translated into the clinical setting to identify the optimal uid regimen for correcting hypovolemia. New techniques for monitoring microcirculation at the bedside might provide such endpoints, although these have to be validated also in the clinical setting. Whether improved microperfusion and tissue oxygenation by uid therapy will also improve patient outcomes will have to be proven by future studies. Keywords Volume replacement Crystalloids Albumin Gelatins Hydroxyethyl starch Microcirculation Tissue oxygenation Patients

Introduction
Circulating volume and microcirculatory decits may occur in the surgical, trauma, burn, and intensive care patient. While bleeding causes absolute volume decits, vasodilation mediated by vasoactive substances produces relative volume decits. Hypovolemia may also develop

in the absence of obvious uid loss secondary to generalized impairment of the endothelial barrier caused by inammation resulting in capillary leakage and uid shift from the intravascular to the interstitial space. Restoration of intravascular volume can be regarded as a cornerstone of therapy in the critically ill. Diagnosis, choice of uids, and identication of hemodynamic targets, however,

remain controversial. One of the reasons for this uncertainty is that uid resuscitation has traditionally been targeted to correct macrocirculation, whereas the physiological impact of uids at the microcirculatory level is still unclear. Uncorrected microcirculatory alterations result in inadequate oxygen transport to achieve sufcient oxidative phosphorylation and, ultimately, cause tissue damage and organ dysfunction [14]. The primary aim of optimal uid resuscitation should be to achieve adequate perfusion without compromising oxygen transport by excessive hemodilution. It still remains unclear whether this can be achieved by correction of hypovolemia itself or whether the kind of volume replacement is also of importance. The ideal volume replacement strategy should correct hypovolemia and restorate systemic hemodynamics, but also improve microcirculatory perfusion and tissue oxygenation [5, 6]. The purpose of this review is to consider the current insights into the effects of uid therapy on microcirculation and oxygen transport to the parenchymal cells. A review of the literature will be given with regard to the effects of commonly used plasma substitutes on organ perfusion, microcirculation, and tissue oxygenation in the clinical setting.

mediators and hypoxemia result in abnormal blood ow distributions and shunting leading to a mismatch between oxygen delivery and oxygen need by the parenchymal cells, and thus heterogeneous hypoxemia, and organ dysfunction [9, 10]. Distributive shock provides the biggest challenge with regard to identifying endpoints for assessing an adequate uid replacement [11]. Currently these endpoints are aimed at correcting changes in systemic hemodynamics. Fluid resuscitation can cause an apparent improvement in systemic circulation while leaving regional and microcirculatory oxygenation and perfusion underresuscitated. In animal investigations it has been shown that uid resuscitation improved organ blood ow of the gut and kidneys, while leaving other areas hypoxemic [12]. This is important in the light of recent clinical studies using new techniques for monitoring microcirculation, which have shown the persistence of microcirculatory underresuscitation in the presence of normalized systemic hemodynamic variables and association with adverse clinical outcome [5, 1315]. Adequate microcirculation relies on the function of the different components of the microcirculation. Red and white blood cells, endothelial cells, and smooth muscle cells have to function in close harmony to guarantee adequate microcirculatory blood ow to transport oxygen to the tissues. The function of each of these cellular Pathophysiology of the hypovolemic microcirculation and subcellular systems is affected by hypovolemia.

Hypovolemia leads to inadequate perfusion of the microcirculation resulting in insufcient oxygen availability to meet the needs of mitochondrial oxidative phosphorylation [2, 7]. Weil and Shubin [8] in their keynote paper classied the different types of shock into four main categories: hypovolemic, cardiogenic, obstructive, and distributive shock (Fig. 1, 2). Hypovolemic shock can be described as the condition whereby there is a decrease in circulating volume. Cardiogenic shock occurs where there is a loss of cardiac contractility with elevation of diastolic lling pressure and volume. Obstructive shock can occur as a result of massive pulmonary embolism, tension pneumothorax, or pericardial tamponade where there is a physical obstruction in the circulation resulting in impaired diastolic lling and increased afterload. Distributive shock involves a defect in the (micro)vascular distribution of a normal or even of a supranormal cardiac output resulting in inadequate regional oxygen delivery. Hypovolemia induced by distributive shock is highly heterogeneous and targets the microcirculation. Its detection by measuring systemic hemodynamics is complicated by shunting of the microcirculation resulting in microcirculatory alterations and hypoxia with normal systemic hemodynamics and oxygen-derived variables [9]. Distributive shock especially occurs under conditions of inammation and infection such as in sepsis and reperfusion injury. Inammatory

Fig. 1 The classication of shock according to Weil and Shubin [8]. I Normal conditions. II Cardiogenic shock, related to cardiac pump failure resulting from loss of the pump function of the heart. III Hypovolemic shock as a result of decreased circulating volume from, for example, hemorrhage. IV Obstructive shock as result of an obstruction in the cardiovascular circuit as a result of, for example, massive pulmonary embolism, tension pneumothorax, or pericardial tamponade. V Distributive shock where vascular dysfunction is unable to distribute a normal or even high cardiac output, resulting in underperfused microcirculatory areas being shunted by well perfused areas

Fig. 2 The impact of uid therapy on the microcirculation. Fluid administration is the therapy of choice following shock. The amount and/or composition of the uids, however, can either have benecial or deleterious effects on the microcirculation

Deleterious effects on the microcirculation include dysfunction of endothelial signal transductory pathways by inammatory mediators and reactive oxygen species, deterioration of endothelial barrier function (e.g., glycocalyx), alterations in red blood cell function (deformability, aggregability), and increased leukocyte adhesion and activation [6, 9]. Any one of these alterations either alone or acting together can lead to a loss of functional capillary density resulting in heterogeneous abnormalities in the distribution of blood to the microcirculatory network, enhanced oxygen diffusion distances from the perfused intracapillary lumens to the tissue cell, tissue hypoxemia, and nally organ dysfunction. Administration of uids to correct hypovolemia may modulate microcirculatory function by various mechanisms. The most important is increasing ow by enhanced lling of the vasculature, thus generating forcing pressure promoting microcirculatory perfusion. Fluids also modify the hemorheology of blood by decreasing viscosity, which additionally promotes blood ow. There are different effects of uids on blood viscosity depending on the composition of the uid; the microcirculation can be either improved or impaired by these effects [16]. Excessive hemodilution can cause shunting of the microcirculation and impair regional tissue oxygenation [14]. This effect can differ among the different organ systems [12]. Acid-base balance has been shown to be inuenced by the administration of uids [17]. Alterations in acid-base status can cause deleterious effects on organ function (e.g., kidney function [18]). Saline solution appears to have the most negative effect on the (micro)circulation

[19]. Infusion of large amounts of saline results in increased plasma chloride concentration and causes a reduction in the strong ion difference, which in turn produces an increase in free hydrogen ions [20]. This effect can be avoided when using more plasma-adapted (balanced) crystalloids [21]. Release of inammatory mediators secondary to hypovolemia is another important factor contributing to microcirculatory dysfunction. The volume replacement strategy can modulate inammatory activation, generation of reactive oxygen, and leukocyte adhesion to the microcirculatory endothelium [22]. Saline solution appears to be the most pro-inammatory uid, whereas certain colloids (especially when dissolved in a balanced solution) may be more benecial in controlling the inammatory process [2325]. Studies using intravital microscopy have shown this to be the case by imaging the effects of different uids on leukocyte adherence on organ microvascular surfaces [26, 27]. In this context colloids showed more benecial effects on the microcirculation than saline resuscitation in a variety of experimental models using direct observation of leukocyte endothelial interaction [27, 28]. The use of crystalloids as volume replacement has been shown to impair microcirculation and to cause vascular leakage resulting in uid shift to the interstitial space [29, 30]. The negative effects on oxygen transport pathways occur as a result of increased diffusion path length and poor oxygen solubility in aqueous solutions causing reduced oxygen availability and impaired cellular respiration. The glycocalyx is a gel-like structure that forms the interface between the intracapillary lumen and the endothelial cells, and its integrity is highly sensitive to oxidative stress [31]. It is likely that endothelial dysfunction and microcirculatory deterioration resulting from hypovolemia and reperfusion injury are caused by a loss of the endothelial glycocalyx [32]. Depletion of this barrier results in leukocyte adhesions and loss of the endothelial barrier function [33, 34]. This in turn results in alterations of the Starling forces promoting tissue edema. The loss of this important supracellular compartment of the microcirculation may form an important rationale for using colloids [32]. Of the colloids, starches have been shown to protect the glycocalyx barrier [35]. It is expected that modications of the molecular and pharmacological properties of colloids as well as of the solvent may provide additional protection of the glycocalyx and thereby of the microcirculation.

How can the effects of volume replacement be monitored?

Currently, endpoints of volume replacement are aimed at correcting changes in systemic hemodynamic variables.

These include giving volume challenges either by administering a uid bolus or by autotransfusion by passive leg raising resulting in changes in systemic hemodynamic variables such as stroke volume or venous pressure [11]. Fluid resuscitation can cause an apparent improvement in systemic circulation while leaving regional and microcirculatory oxygenation and perfusion uncorrected [12]. New techniques have been introduced at the bedside aimed at monitoring various aspects of the microcirculation and tissue oxygenation. These have been applied to various areas of the body, and various parameters related to microcirculatory function and tissue oxygenation have been measured. At present, no unifying monitoring technique exists that measures all aspects of microcirculatory function in an integrated fashion, and each technique has its limitations in this respect. It is worth noting that in fact all hemodynamic monitoring modalities suffer from this drawback and that no single technique can be used to measure the integrative function of the cardiovascular system to achieve hemodynamic homeostasis from lung to mitochondria. Thus each microcirculatory monitoring technique should be interpreted for its sensitivity and specicity in identifying a particular physiological component and its ability to predict impending adverse events. It has to be emphasized that these microcirculatory monitoring techniques are at an early stage of development and have to be validated for guiding volume therapy in the clinical setting. Currently used bedside monitoring techniques for assessing the inuence of volume therapy on microcirculation are described below. Laser Doppler owmetry (LDF) is used for nonquantitative assessment of blood ow and has been applied mainly to the cutaneous microcirculation [36]. Tissue CO2 can be measured using gastric CO2 tonometers or by tissue CO2 electrodes [37]. These measurements have been mostly applied either in the stomach or intestines or sublingually and are assumed to be a measure of the adequacy of microcirculatory perfusion [3642]. In early studies such CO2 measurements and arterial bicarbonate were entered into the HendersonHasselbalch equation to obtain intestinal mucosal pH (pHi). This calculation was later abandoned and instead tissue-to-arterial gradient (pCO2 gap) was used. A more direct method of evaluating microcirculatory perfusion is by direct imaging of the microcirculation using the recently introduced orthogonal polarizing spectrum (OPS) or sidestream dark eld (SDF) imaging [43, 44]. These are optical techniques that are incorporated into hand-held microscopes for direct visual observation of the microcirculation on mucosal organ surfaces. In the perioperative setting these techniques have mainly been applied to study the sublingual microcirculation. Tissue oxygenation has classically been measured by use of Clark electrodes [45] although more modern

versions of such electrodes use solid state or oxygendependent uorescence quenching methods. These electrodes are applied either trans- or subcutaneously, or as needles that can be inserted into muscle tissue. An alternative method to gain information about microcirculatory oxygen availability is the use of the oxygen-dependent optical properties of microcirculatory Hb, which can be monitored using near infrared spectroscopy (NIRS) [46]. This technique has been applied in the thenar, calf, and forearm, and on the forehead. A more comprehensive presentation of these techniques will be provided in another review paper to be published in Intensive Care Medicine as part of this current series dedicated to microcirculation.

Clinical studies on the effects of uid therapy on microcirculation and tissue oxygenation
A PubMed analysis was carried out to investigate the literature on the effects of uids on the microcirculation and tissue oxygenation in the clinical setting. We included all original studies published in English from 1988 to 2009 and only studies in patients (no volunteer studies) were included (Table 1). Keywords for the search included [microcirculation], [microperfusion] [tissue blood ow] [organ perfusion] [tissue oxygenation] in connection with [hypovolemia], [volume therapy/replacement], [uid therapy/replacement], [crystalloids], [Ringers lactate], [saline solution], [normal saline], [(human) albumin], [gelatin(s)], [dextran(s)], [hydroxyethyl starch, HES], and [hypertonic solution]. Articles were only included when the methods for assessing organ perfusion, microcirculation, and tissue oxygenation were given. Obviously we may have missed several ongoing studies and indeed several are currently under review, but nevertheless we feel this overview gives a comprehensive review of the state of the current art. Crystalloids In two prospective, randomized studies in patients undergoing abdominal aortic and gynecologic surgery, the inuence of Ringers lactate (RL) for intraoperative volume replacement on gastric mucosal perfusion was assessed by measuring gastric intramucosal pH (pHi) by tonometry [47, 48]. In one study, RL did not improve gastric mucosal perfusion [47], while in the other one RL also increased gastric mucosal perfusion, but not nearly as much as HES 200/0.5 did [48]. In patients undergoing major abdominal surgery, volume replacement using saline solution resulted in decreased skeletal muscle tissue pO2 (ptiO2), whereas ptiO2 increased signicantly in the patients given HES 130/0.4 in saline [49]. This difference

Table 1 Effects of volume administration on organ perfusion, microcirculation, and tissue oxygenation Reference (year) Boldt [52] (1991) Patients Cardiac surgery Design Pros rand Fluids Model Method LDF skin Main results Both increased LDF; HHES showed signicantly higher increase in LDF than HES 200/0.5 HES signicantly increased gastric mucosal perfusion Trauma patients: no differences in pHi; septic patients: decrease in pHi blunted only by HES, decrease in pHi by HA Only HES improved microvascular blood ow, RL did not pHi remained unchanged with HES and slightly increased with gelatin (from 7.27 to 7.31) No correction of abnormal intramucosal pCO2 gap by HES RL decreased (muscle) tissue oxygenation, whereas it was increased by use of HES 130/0.4 CO2 gap lower in unbalanced volume group indicating improved gastric mucosal perfusion with balanced volume replacement strategy pHi lower with gelatin than with HES 200/ 0.62; HES reduced splanchnic perfusion signicantly less HES signicantly improved splanchnic blood ow; RL was not as effective as HES Both regimens increased tissue oxygenation; more uids were better for improving tissue oxygenation; differences were not seen by systemic hemodynamic monitoring

6% HES 200/0.5 To double vs. HHES vs. no reduction in uids PCWP HES 200/0.5 no control 10% HES 200 vs. 20% HA To increase stroke volume Volume replacement on ICU

Mythen [53] (1995) Cardiac surgery Boldt [51] (1996)

Pros

pHi tonometry pHi tonometry

Trauma and Pros rand sepsis ICU

Marik [47] (1997) Asfar [54] (2000)

Abdominal aortic surgery Sepsis

Pros rand Pros rand

RL vs. HES 450/ 0.7 HES 200/0.62 vs. gelatin

Perioperative volume replacement Hemodynamic stabilization

pHi tonometry pHi tonometry

Forrest [55] (2000) Sepsis

Pros

10% HES 264/0.45 Keep PAOP [15 mmHg Saline vs. HES 130/0.4

pHi tonometry

Lang [49] (2001)

Abdominal surgery

Pros rand

Wilkes [59] (2001) Elective surgeries

Pros rand doubleblinded

Balanced vs. unbalanced volume therapy HES ? cryst

Microsensory pO2 Perioperative volume catheters replacement (PCWP 12 16 mmHg) Hemodynamic Gastric pHi stabilization tonometry (using algorithm)

Rittoo [56] (2002)

Abdominal aortic surgery Gynecology

Pros rand

Gelatin vs. HES 200/0.62

Volume expansion

pHi tonometry

Guo [48] (2003)

Pros rand

Rl vs. HES 200/0.5 Intraoperative volume replacement Crystalloids 8 vs. 1618 mL kg-1 h-1 Perioperative uid replacement

pHi tonometry

Arkilic [50] (2003) Colon resection surgery

Pros rand

Polarographic subcutaneous tissue O2 tension

Table 1 continued Reference (year) Hofman [57] (2005) Al-Rawi [62] (2005) Mahmood [58] (2009) Patients Cardiac surgery SAH patients Abdominal aortic surgery Design Pros Fluids HES 200/0.5 no control Model Postoperative uid load Observation Perioperative volume expansion over 24 h Method pHi tonometry Main results HES increased cardiac output, but not splanchnic mucosal perfusion Signicant increase in CPP, PbO2, and FV by 23.5% saline Least drop in pHi with HES 200/0.62; most pronounced drop in pHi with gelatin

Observational 23.5% HS Pros rand Gelatin, HES 200/ 0.62, HES 130/ 0.4

CPP, PbO2, FV pHi tonometry

HES Hydroxyethylstarch, HA human albumin, pHi gastric intramucosal pHi, RL Ringers lactate, HS hypertonic saline, HHES hypertonic saline plus hydroxyethylstarch, pros prospective, rand randomized, LDF laser Doppler ow, PCWP pulmonary capillary wedge pressure, SAH subarachnoid hemorrhage (SAH), CPP

cerebral perfusion pressure, PbO2 brain tissue oxygen, FV middle cerebral artery ow velocity, PAOP pulmonary artery occlusion pressure, pHi gastric intramucosal pH, ICU intensive care unit, pCO2 gap arterial-to-intramucosal pCO2 difference, ANH acute normovolemic hemodilution

was not identied by monitoring only systemic hemodynamics. Arkilic et al. [50] investigated the effects of conservative (2,183 972 mL) versus aggressive (3,815 1,853 mL) unspecied crystalloid resuscitation in elective colon resection surgery and measured subcutaneous oxygen tension using oxygen electrodes and capillary blood ow by a thermal diffusion system. They found that supplemental uid administration increased both tissue oxygen tension and capillary blood ow showing the most increase with the higher doses of uids. The difference between conservative and aggressive crystalloid resuscitation seen in the microcirculation was not identied by monitoring systemic hemodynamics. Colloids Human albumin (HA) In one study in trauma intensive care unit (ICU) patients, volume replacement with HA given over 5 days to guarantee stable hemodynamics assessed with the help of a pulmonary artery catheter (PAC) did not change normal gastric mucosal perfusion measured by tonometry (no changes in pHi). In septic patients, however, pHi was signicantly decreased by HA administration despite adequate correction of hypovolemia, suggesting ongoing perfusion abnormalities in this area by volume resuscitation with HA [51].

Hydroxethyl starch (HES) Hydroxyethyl starch (HES) refers to a class of synthetic colloid solutions that are modied natural polysaccharides, similar to glycogen. HES is derived from amylopectin, a highly branched starch that is obtained from waxy maize or potatoes. Polymerized D-glucose units are joined primarily by 1-4 linkages with occasional 1-6 branching linkages. Substituting hydroxyethyl for hydroxyl groups results in highly increased solubility and retards hydrolysis of the compound by amylase, thereby delaying its breakdown and elimination from the blood. The hydroxyethyl groups are introduced mainly at carbon positions C2, C3, and C6 of the anhydroglucose residues. The available HES preparations are characterized by concentration (hypooncotic: 3%; isooncotic: 6%; hyperoncotic: 10%), molar substitution (MS; low: \0.5; medium: 0.5; high: [0.5), the mean molecular weight [Mw, low-molecular weight (LMW)-HES: 70 kD; medium-molecular weight (MMW)-HES: 130264 kD; high-molecular weight (HMW)-HES: [450 kD], the origin (potato-derived versus maize-derived HES), and the solvent (balanced and unbalanced HES preparations). Eleven studies using HES in the clinical setting were identied [47, 49, 5157]. Two studies in septic [54, 55] and one study in cardiac surgery patients [57] showed unchanged organ perfusion by HES. In all of these studies, pHi (or pCO2 gap) was measured by tonometry to assess the inuence of volume replacement therapy on gastric mucosal perfusion. Eight studies in patients undergoing cardiac, vessel, trauma, or gynecologic surgery showed that HES improved organ perfusion or tissue oxygenation or that decrease in perfusion was blunted by adminstration of HES [4749, 5153, 56, 58]. In six of them, gastric mucosal perfusion (pHi) was measured using tonometry and administration of HES was

Dextrans No study in the clinical setting during the past 20 years was found showing the effects of dextrans on organ perfusion, microcirculation, or tissue oxygenation in patients.

associated with signicantly improved gastric mucosal perfusion [47, 48, 51, 53, 56, 58]. In one study in cardiac surgery patients, LDF was used to measure skin microcirculatory perfusion [52]. Microcirculatory blood ow showed better skin perfusion with HES 200/0.5 than with other HES preparations (HES 70/0.5 and HES 450/0.7). That the type of HES preparation seems to be of importance concerning modulation of the microcirculation has also been shown in a study of patients undergoing abdominal aortic surgery [58]. When using HES 200/0.62, pHi was signicantly less decreased compared to HES 130/0.4. In a study in patients undergoing major abdominal surgery, the inuence of 6% HES 130/0.4 on tissue pO2 was compared to patients who received saline solution for volume replacement [49]. Skeletal muscle tissue pO2 (ptiO2) was monitored for 24 h after surgery using exible minimally invasive microsensory pO2 catheters. Although systemic hemodynamics and systemic oxygenation data were similar in both groups, ptiO2 increased signicantly in the HES 130/0.4-treated patients (?59%), but decreased in the RL group (-23%). Gelatins Three studies were found that used gelatins for improving organ perfusion [54, 56, 58]. Gelatin was given for hemodynamic stabilization in patients suffering from sepsis or undergoing aortic surgery and compared to use of HES. pHi was measured by tonometry to assess gastric mucosal perfusion. In the hypovolemic septic patients [54], use of gelatin very moderately increased pHi (from 7.27 to 7.31) suggesting improved splanchnic perfusion. Of particular importance was also that no difference in systemic hemodynamic variables was found between the two volume replacement strategies, but only on gastric tonometry data. In two other studies from one research group performed in patients undergoing abdominal aortic surgery, either gelatin or HES (HES 200/0.62 or HES 130/0.4) was administered for volume expansion [56, 58]. HES 200/0.62-treated patients showed signicantly less reduced splanchnic perfusion than those administered gelatin. Plasma-adapted versus non-plasma-adapted volume replacement strategy In a prospective, randomized, blinded trial in elderly surgical patients, either a plasma-adapted (balanced) intraoperative uid regimen consisting of Hartmanns solution and 6% HES preparation dissolved in a balanced electrolyte solution (Hextend) or a nonplasma-adapted (unbalanced) regimen consisting of 0.9% sodium chloride solution and 6% HES dissolved in 0.9% sodium chloride solution was given to guarantee stable

hemodynamics using a specic algorithm [59]. Similar amounts of HES (approximately 2,500 mL) and crystalloids (approximately 1,500 mL) were given in both groups. Splanchnic perfusion was assessed by gastric tonometry. Systemic hemodynamics were without group differences, while hyperchloremic acidosis was seen only in the non-plasma-adapted volume group, and better gastric mucosal perfusion was provided by the balanced volume replacement strategy compared with saline-based uids. Hypertonic solutions Great enthusiasm has been expressed for hypertonic saline (HS) or hypertonic/colloid solutions (HCS) in the treatment of hypovolemic shock (small volume resuscitation). Hypertonic volume replacement has been proposed to correct microcirculatory dysfunction associated with hypovolemia and its subsequent inammatory effect. HS has been shown to increase perfusion pressure, improve capillary ow distribution, and offer endothelial de-swelling effects [60, 61]. Because hemodynamic effects of HS solutions are reported to be rather transient, HS is often mixed with colloids [hypertonic saline plus hyperoncotic dextran (HSD) or hypertonic saline plus hypertonic HES (HHES)]. In a study in cardiac surgery patients using HHES to double low pulmonary capillary wedge pressure (PCWP), skin microcirculatory blood ow measured by LDF was signicantly increased in comparison to HES 200/0.5 [52]. In an observational study in patients with subarachnoid hemorrhage, Al-Rawi et al. [62] administered extremely hypertonic saline solution (23.5%). A signicant increase in cerebral perfusion pressure, brain tissue oxygenation, and middle cerebral artery ow velocity was found accompanied by a signicant decrease in intracranial pressure. An improvement in cerebral metabolic status in terms of lactate-pyruvate ratio was also seen after infusion of this extreme hypertonic solution.

Discussion
In recent years, microcirculation has gotten increased attention in the treatment of the critically ill patient. This includes the choice for the ideal volume replacement strategy to improve microcirculation. Interestingly, we found only 14 papers on this issue over the past 20 years. This dearth of information on the different volume replacement strategies for organ perfusion, microcirculation, or tissue oxygenation is remarkable as there is an ongoing controversy concerning the ideal plasma substitute to correct hypovolemia. Due to the small number of studies and the divergent study designs, we decided not

to perform a meta-analysis or a systematic review. The identied studies differed markedly with regard to the study design: (1) Plasma substitutes were used under different conditions, e.g., in trauma, sepsis, hemorrhage or surgery. (2) The amount of uids that was administered differed widely among the studies making it difcult to distinguish between what effect is attributed to volume correction/expansion alone and what effect is specic for a certain plasma substitute. (3) Duration of volume administration differed; cases of single-shot versus continuous administration over hours were compared. (4) The endpoint of volume administration was not uniformly dened. Mostly xed amounts of volume were given. A goal-directed volume replacement strategy, however, is a better approach than infusing a xed amount of volume. (5) Although it is clear that measurement of systemic hemodynamic variables has limited sensitivity for identifying hemodynamic alterations associated with shock and resuscitation, most of the techniques used for assessing microcirculation are still at the stage of development and not yet ready for routine clinical use. Looking at the results of the 14 identied studies, there appears to be a trend that colloids are more effective in benecially modifying organ perfusion and microcirculation than crystalloids. One important objection to the results of these studies is that most of them used gastric tonometry to assess the effects of volume replacement on perfusiona surrogate marker of splanchnic perfusion whose validity has often been doubted. There is an urgent need for more information on the effect of uids on microcirculation as there is a current trend to keep the patients more on the dry side by restricting volume administration. From the pathophysiological point of view, use of vasopressors in an hypovolemic patient to keep up blood pressure may initiate a fatal process on the microperfusion level with detrimental sequel for organ function and even for the patients outcome. It has been demonstrated that the use of vasopressors has no effect on prompting microcirculatory ow, emphasizing that a guarantee of adequate microperfusion may not be reached simply by maintaining or even increasing arterial blood pressure. Whether the effects of a certain volume replacement strategy on microcirculation can be translated into its effects on patients outcome (survival) was beyond the scope of this review. Up to now it has not been shown that, by the choice of a certain volume replacement regimen, someones life was rescued, although benecial effects on inammation, microcirculation, and tissue oxygenation have been shown. This experience is similar to the introduction of new monitoring techniques, antibiotics, feeding strategies, or renal replacement strategies that have been shown to improve certain aspects in the management of the critically ill without improving overall survival. Our actual approach in the treatment of the critically ill aims to improve different parts in the mosaic

of pathophysiology of critical illness; improving microcirculation may be one important part in this therapeutic puzzle. As the commonly used plasma substitutes differ with regard to their physico-chemical characteristics, they also may differ with regard to their effects on organ perfusion, microcirculation, or tissue oxygenation. Based on the insights received from animal studies, questions that have to be addressed in the clinical setting will include how the different uids affect the determinants of microcirculatory function. Important issues will be the effects on capillary ow and capillary recruitment in terms of functional capillary density, the extent of leukocyte endothelial interaction and glycocalyx determination, release of inammatory mediators and reactive oxygen species, and nally the effects of the various uid types on tissue oxygenation. These effects have to be determined for the different types of shock and will have to be related to organ function and clinical outcome.

Conclusions
Although it is clear from our literature search that the data that are needed to draw denite conclusions concerning the optimal uid therapy and improvement in microcirculatory perfusion are not yet available, we will draw some careful conclusions from an evidence level E perspective. These can be summarized as follows: (1) A robust method or protocol for identifying hypovolemia and guiding uid resuscitation is yet being sought. (2) Although it is clear that uid therapy should be effective in correcting systemic hemodynamics, albeit based mainly on experimental studies, it should also be successful in correcting decits in microperfusion and tissue oxygenation. (3) There is a need for bedside monitoring techniques for guiding uid therapy integrating systemic, regional, microcirculatory, and oxygenation issues. (4) The choice between crystalloids and colloids is probably dependent on the patients condition and the cause of hypovolemia. (5) Compared to colloids, large amounts of crystalloids are needed to achieve similar systemic and microcirculatory endpoints leading to tissue edema and impaired tissue oxygenation. (6) It is expected that an optimal uid composition for correction of hypovolemia may have to include additional components needed to support organ perfusion, microcirculation, and tissue oxygenation. We hope that with this paper we have set the scene for important clinical investigations that will have to be carried out to nd the optimal uid composition and identify the optimal (micro)hemodynamic targets for volume resuscitation. We expect that protection of the microcirculatory function will play an important role in the future and will lead to improved treatment of the hypovolemic critically ill patient.

Acknowledgments The authors gratefully acknowledge the talents (Germany); Serumwerke Bernburg (Germany); Baxter (Europe). of Darryl Milstein who produced Figs. 1 and 2 in this paper. This Ince holds a patent on SDF imaging, has stock in Microvision Medical, and has received educational grants from Hutchinison study was supported only by an institutional grant. Technology, Baxter, Novartis, and Eli Lilly. Conict of interest statement Boldt and his institution have received funding from B. Braun (Germany); Fresenius-Kabi

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