Review| Volume 54, ISSUE 3, P811-817, March 2023

Definition of occult hypoperfusion in trauma: A systematic literature review

Published:January 11, 2023DOI:


      • ·
        Definitions for occult hypoperfusion in trauma (tOH) differ markedly in the literature.
      • ·
        The described impact of tOH on outcome differs between studies, and it´s role in trauma remains unclear.
      • ·
        A systematic review was performed to identify utilized criteria for tOH in recent literature.
      • ·
        The following definition for tOH is proposed: Lactate > 2 mmol/l or BE 〈-3 mmol/l plus SBP 〉 90 mmHg and PR < 120 bpm.



      Occult hypoperfusion (OH) entails inadequate tissue oxygenation in the presence of normal vital signs. Numerous studies have demonstrated that this phenomenon is associated with impaired outcome and increased mortality, however definitions of OH differ between studies. The aim of the current study was to identify and evaluate the published definitions of the term `occult hypoperfusion` in trauma (tOH).

      Material & methods

      A review of literature was performed using the Medline database. The following MeSH terms have been used: occult hypoperfusion, severe trauma, polytrauma, resuscitation. Clinical studies on OH were included and utilized definitions have been compared. A predefined data-interpretation process was applied to create an integrative definition for tOH.


      A total of 43 publications used the term OH. A definition of OH was provided in 16 manuscripts. A pooled mean number of participants of 729 (SD: 1158) was found per study. The majority of manuscripts combine multiple parameters for inadequate tissue oxygenation and normal vital signs to define OH in trauma. In 12 manuscripts, specific cut-off values for hemodynamic parameters (SBP/PR/UP) and in 11/16 papers exact metabolic thresholds (lactate/B.E) were defined. The following definition best integrates definitions in current literature: Lactate > 2 mmol/l or BE <-3 mmol/l (to define inadequate oxygenation) plus SBP > 90 mmHg and PR < 120 bpm (to define normal macroperfusion).


      The current systematic review demonstrates that definitions of occult hypoperfusion in trauma differ in the literature. The following comprehensive definition for (tOH) is proposed: Lactate > 2 mmol/l or BE <-3 mmol/l plus SBP > 90 mmHg and PR < 120 bpm. This recommendation appears to represent current literature on tOH and may improve the identification of trauma patients at risk for OH and related complicated courses. Further validation studies are required to demonstrate the clinical role of tOH and the proposed definition.


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        • Mizock B.A.
        Lactic acidosis.
        Dis Mon. 1989; 35: 233-300
        • Thom O.
        • Taylor D.M.
        • Wolfe R.E.
        • Myles P.
        • Krum H.
        • et al.
        Pilot study of the prevalence, outcomes and detection of occult hypoperfusion in trauma patients.
        Emerg Med J. 2010; 27: 470-472
        • Berger T.
        • Green J.
        • Horeczko T.
        • Hagar Y.
        • Garg N.
        • Suarez A.
        • et al.
        Shock index and early recognition of sepsis in the emergency department: pilot study.
        West J Emerg Med. 2013; 14: 168-174
        • Cecconi M.
        • Corredor C.
        • Arulkumaran N.
        • Abuella G.
        • Ball J.
        • Grounds R.M.
        • et al.
        Clinical review: goal-directed therapy-what is the evidence in surgical patients? The effect on different risk groups.
        Crit Care. 2013; 17: 209
        • Aya H.D.
        • Cecconi M.
        • Hamilton M.
        • Rhodes A.
        Goal-directed therapy in cardiac surgery: a systematic review and meta-analysis.
        Br J Anaesth. 2013; 110: 510-517
        • Kiyatkin M.E.
        • Bakker J.
        Lactate and microcirculation as suitable targets for hemodynamic optimization in resuscitation of circulatory shock.
        Curr Opin Crit Care. 2017; 23: 348-354
        • Barbee R.W.
        • Reynolds P.S.
        • Ward K.R.
        Assessing shock resuscitation strategies by oxygen debt repayment.
        Shock. 2010; 33: 113-122
        • Hatton G.E.
        • McNutt M.K.
        • Cotton B.A.
        • Hudson J.A.
        • Wade C.E.
        • Kao L.S.
        Age-dependent association of occult hypoperfusion and outcomes in Trauma.
        J Am Coll Surg. 2020; 230: 417-425
        • Blow O.
        • Magliore L.
        • Claridge J.A.
        • Butler K.
        • Young J.S.
        The golden hour and the silver day: detection and correction of occult hypoperfusion within 24 h improves outcome from major trauma.
        J Trauma. 1999; 47: 964-969
        • Meregalli A.
        • Oliveira R.P.
        • Friedman G.
        Occult hypoperfusion is associated with increased mortality in hemodynamically stable, high-risk, surgical patients.
        Crit Care. 2004; 8: R60-R65
        • Miami Trauma Clinical Trials Group
        Splanchnic hypoperfusion-directed therapies in trauma: a prospective, randomized trial.
        Am Surg. 2005; 71: 252-260
        • Paladino L.
        • Sinert R.
        • Wallace D.
        • Anderson T.
        • Yadav K.
        • Zehtabchi S.
        The utility of base deficit and arterial lactate in differentiating major from minor injury in trauma patients with normal vital signs.
        Resuscitation. 2008; 77: 363-368
        • Martin J.T.
        • Alkhoury F.
        • O’Connor J.A.
        • Kyriakides T.C.
        • Bonadies J.A.
        Normal vital signs belie occult hypoperfusion in geriatric trauma patients.
        Am Surg. 2010; 76: 65-69
        • Corradi F.
        • Brusasco C.
        • Vezzani A.
        • Palermo S.
        • Altomonte F.
        • Moscatelli P.
        • et al.
        Hemorrhagic shock in polytrauma patients: early detection with renal Doppler resistive index measurements.
        Radiology. 2011; 260: 112-118
        • Bar-Or D.
        • Salottolo K.M.
        • Orlando A.
        • Mains C.W.
        • Bourg P.
        • Offner P.J.
        Association between a geriatric trauma resuscitation protocol using venous lactate measurements and early trauma surgeon involvement and mortality risk.
        J Am Geriatr Soc. 2013; 61: 1358-1364
        • Vohra T.
        • Paxton J.
        Abnormal arterial blood gas and serum lactate levels do not alter disposition in adult blunt trauma patients after early computed tomography.
        West J Emerg Med. 2013;
        • Nguyen A.
        • Plurad D.S.
        • Bricker S.
        • Neville A.
        • Bongard F.
        • Putnam B.
        • Kim D.Y.
        Flat or fat? Inferior vena cava ratio is a marker for occult shock in trauma patients.
        J Surg Res. 2014; 192 (14(3):212-7): 263-267
        • Caputo N.D.
        • Kanter M.
        • Fraser R.
        • Simon R.
        Comparing biomarkers of traumatic shock: the utility of anion gap, base excess, and serum lactate in the ED.
        Am J Emerg Med. 2015; 33: 1134-1139
        • Silbert B.I.
        • Litton E.
        • Ho K.M.
        Central venous-to-arterial carbon dioxide gradient as a marker of occult tissue hypoperfusion after major surgery.
        Anaesth Intensive Care. 2015; 43: 628-634
        • Carlile C.
        • Wade C.E.
        • Baraniuk M.S.
        • Holcomb J.B.
        • Moore L.J.
        Evaluation of StO2 tissue perfusion monitoring as a tool to predict the need for lifesaving interventions in trauma patients.
        Am J Surg. 2015; 210: 10
        • Caputo N.
        • Reilly J.
        • Kanter M.
        • West J.
        A retrospective analysis of the respiratory adjusted shock index to determine the presence of occult shock in trauma patients.
        J Trauma Acute Care Surg. 2018; 84: 674-678
        • Radowsky J.S.
        • DuBose J.J.
        • Scalea T.M.
        • Miller C.
        • Floccare D.J.
        • Sikorski R.A.
        • et al.
        Handheld tissue oximetry for the prehospital detection of shock and need for lifesaving interventions: technology in search of an indication?.
        Air Med J. 2019; 38: 276-280
        • Johnson M.C.
        • Alarhayem A.
        • Convertino V.
        • Carter R 3rd C.K.
        • Stewart R.
        • et al.
        Comparison of compensatory reserve and arterial lactate as markers of shock and resuscitation.
        J Trauma Acute Care Surg. 2017; 83: 603-608
        • Carter 3rd, R.
        • Hinojosa-Laborde C.
        • Convertino V.A
        Variability in integration of mechanisms associated with high tolerance to progressive reductions in central blood volume: the compensatory reserve.
        Physiol Rep. 2016; 4: e12705
        • Casaletto J.J.
        Differential diagnosis of metabolic acidosis.
        Emerg Med Clin North Am. 2005; 23: 771-787
        • Shoemaker W.C.
        • Appel P.L.
        • Kram H.B.
        • Bishop M.
        • Abraham E.
        Hemodynamic and oxygen transport monitoring to titrate therapy in septic shock.
        New Horiz. 1993; 1: 145-159
        • Shoemaker W.C.
        • Appel P.L.
        • Kram H.B.
        • Waxman K.
        • Lee T.S.
        Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients.
        Chest. 1988; 94: 1176-1186
        • Howell M.D.
        • Donnino M.
        • Clardy P.
        • Talmor D.
        • Shapiro N.I.
        Occult hypoperfusion and mortality in patients with suspected infection.
        Intensive Care Med. 2007; 33: 1892-1899
        • Ander D.S.
        • Jaggi M.
        • Rivers E.
        • Rady M.Y.
        • Levine T.B.
        • Levine A.B.
        • et al.
        Undetected cardiogenic shock in patients with congestive heart failure presenting to the emergency department.
        Am J Cardiol. 1998; 82: 888-891
        • Rady M.Y.
        • Rivers E.P.
        • Nowak R.M.
        Resuscitation of the critically ill in the ED: responses of blood pressure, heart rate, shock index, central venous oxygen saturation, and lactate.
        Am J Emerg Med. 1996; 14: 218-225
        • Nast-Kolb D.
        • Waydhas C.
        • Gippner-Steppert C.
        • Schneider I.
        • Trupka A.
        • Ruchholtz S.
        • et al.
        Indicators of the posttraumatic inflammatory response correlate with organ failure in patients with multiple injuries.
        J Trauma. 1997; 42 (446-54; discussion 454-5)
        • Abramson D.
        • Scalea T.M.
        • Hitchcock R.
        • Trooskin S.Z.
        • Henry S.M.
        • Greenspan J.
        Lactate clearance and survival following injury.
        J Trauma. 1993; 35 (Oct584-8; discussion 588-9)