Effects of goal-directed fluid therapy on microcirculation during human study and animal experiment

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Fluid resuscitation remains one of the cornerstone’s in the management of acute bleeding. According to Starling's “Three-compartment model”, four-times more crystalloids (Cryst) have the same volume-replacement (VR) effect as colloids (Coll). However, this VR ratio remains a controversial issue as it may be affected by the degradation of the endothelial glycocalyx layer (GX), a situation often found in the critically ill. On the other hand, macro- and microcirculatory effects of solutions are difficult to compare, because the endpoints of resuscitation seldom based on similar criteria. Our aims were: (1) to compare the effects of Coll and Cryst based fluid resuscitation during an experimental stroke volume index (SVI) guided haemorrhage and resuscitation animal model; (2) to investigate the effects of Cryst and Coll’s on the microcirculation during free flap surgery when management was guided by detailed haemodynamic assessment. In our animal experiment, anesthetized and mechanically ventilated pigs were randomised to receive Coll or Cryst infusion. Animals were bled until baseline SVI (Tbsl) dropped by 50% (T0), followed by resuscitation until initial SVI was reached (T4) in four steps. In our clinical trial patients undergoing maxillofacial tumour resection and free flap reconstruction were randomised into groups treated with either intra-operative Cryst or Coll solutions. In the animal experiment, hemodynamic changes and GX degradation products serum levels followed similar pattern without significant difference between the groups. Animals received significantly less resuscitation fluid in the Coll as compared to the Cryst-group. In the clinical trial there was no difference between the groups regarding patient characteristics. Both groups remained haemodynamically stable throughout, but patients in the Cryst group required approximately 1.5 times more total fluid volume than in the Coll group. There was no significant difference in the microcirculatory blood flow between the groups as indicated by laser-Doppler flowmetry. We concluded that: (1) volume-replacement ratio for solutions follows the Starling's principle when the GX is intact, and (2) when fluid management is guided by detailed haemodynamic assessment there was no difference between the effects of solutions on the microcirculation, hence it may not be the type of the fluid, but the appropriate VR caused haemodynamic stability and perfusion that is responsible for microcirculatory blood flow.

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