Resolution and outcome of acute circulatory failure does not correlate with hemodynamics

INTRODUCTION Hemodynamic goals in the treatment of acute circulatory failure (ACF) are controversial. In critical care, organ failures can be assessed using Sequential Organ Failure Assessment and its refinement, total maximal Sequential Organ Failure Assessment (TMS). We studied the associations between resolution of ACF and hemodynamics in the early (< 24 hours) phase of intensive care unit care and their relation to TMS and mortality. PATIENTS AND METHODS Eighty-three patients with ACF (defined as arterial lactate > 2 mmol/l and/or base deficit > 4) who had pulmonary artery catheters and stayed for longer than 24 hours in the intensive care unit were included. Hemodynamics, oxygen transport, vasoactive drugs and TMS scores were recorded. Normalisation of hyperlactatemia and metabolic acidosis in less than 24 hours after admission was defined as a positive response to hemodynamic resuscitation. RESULTS Fifty-two patients responded to resuscitation. Nonresponders had higher mortality than responders (52% versus 33%, P = 0.044). Hospital mortality was highest (63%) among nonresponders who received vasoactive drugs. The TMS scores of nonresponders (median [interquartile range], 12 9-16) were higher than the scores of responders (10 7-12, P = 0.019). Late accumulation of TMS scores was associated with increasing mortality, and if the TMS score increase occurred > 5 days after admission then the mortality was 77%. Responders had higher mean arterial pressure at 24 hours, but it was no different between survivors and nonsurvivors. No other hemodynamic and oxygen transport variables were associated with the success of resuscitation or with mortality. CONCLUSIONS Except for the mean arterial pressure at 24 hours, invasively derived hemodynamic and oxygen transport variables are not associated with the response to resuscitation or with mortality. Positive response to resuscitation in ACF is associated with less severe organ failures as judged by TMS scores. Late accumulation of the TMS score predicts poor outcome.