The rationale for microcirculatory guided fluid therapy.
OBJECTIVE
The ultimate purpose of fluid administration in states of hypovolemia is to correct cardiac output to improve microcirculatory perfusion and tissue oxygenation. Observation of the microcirculation using handheld microscopes gives insight into the nature of convective and diffusive defect in hypovolemia. The purpose of this article is to introduce a new platform for hemodynamic-targeted fluid therapy based on the correction of tissue and microcirculatory perfusion assumed to be at risk during hypovolemia.


RESULTS
Targeting systemic hemodynamic targets and/or clinical surrogates of hypovolemia gives inadequate guarantee for the correction of tissue perfusion by fluid therapy especially in conditions of distributive shock as occur in inflammation and sepsis. Findings are presented, which support the idea that only clinical signs of hypovolemia associated with low microcirculatory flow can be expected to benefit from fluid therapy and that fluid overload causes a defect in the diffusion of oxygen transport.


CONCLUSIONS
We hypothesized that the optimal amount of fluid needed for correction of hypovolemia is defined by a physiologically based functional microcirculatory hemodynamic platform where convection and diffusion need to be optimized. Future clinical trials using handheld microscopes able to automatically evaluate the microcirculation at the bedside will show whether such a platform will indeed optimize fluid therapy.
Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
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D002302:Cardiac Output; D016638:Critical Illness / Q000401:mortality / Q000628:therapy*; D005260:Female; D005440:Fluid Therapy / Q000379:methods* / Q000401:mortality; D006439:Hemodynamics; D006801:Humans; D020896:Hypovolemia / Q000401:mortality / Q000517:prevention & control*; D008297:Male; D008833:Microcirculation; D017410:Practice Guidelines as Topic; D015424:Reperfusion / Q000379:methods*; D012151:Resuscitation / Q000379:methods