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• W4256098609 abstract "Perhaps the most perpetual challenge facing the critical care clinician is treatment of shock. There are many forms of shock, all of which have in common an imbalance between tissue oxygen demand and supply. Shock may be caused by inadequate intravascular volume, because of hemorrhage; primary pump failure, as in cardiogenic shock; maldistribution of blood flow and tissue demand, as in septic shock; or complete cardiovascular collapse, as in anaphylaxis. These and several other causes of shock lead to cellular oxygen and nutrient demands that go unmet by circulatory supply. Some forms of shock, such as hemorrhage, are relatively easy to correct and, if treated promptly, are associated with a low mortality rate. On the other hand, shock due to inflammatory disorders such as sepsis or acute respiratory distress syndrome is complex in both origin and resolution, carries a high mortality rate and is difficult to treat. In these patients, the restoration of “adequate” tissue perfusion may be a daunting task. This issue of Critical Care Clinics addresses these areas of concern for the critical care clinician. In the beginning of the issue, several prominent authors discuss the means for monitoring hemodynamic function, which is the aspect of oxygen delivery most commonly manipulated in our efforts to restore tissue perfusion to the patient in shock. Hemodynamic monitoring has come a long way from simple measurements of arterial blood pressure and heart rate. The introduction of the pulmonary artery catheter (PAC) in the 1970s revolutionized our ability to monitor hemodynamic function in the critically ill patient. Although the PAC has undergone several transformations in recent years, a great deal of controversy remains as to whether or not the use of PACs has led to improved patient outcomes. Recognizing the importance of the growing field of evidence-based medicine, an article in which the use of PACs is assessed from that vantage point has been included, as well as a review of the new generation of PACs, which includes right ventricular ejection fraction measurements and continuous cardiac output recording. Recently, a great deal of excitement has been generated about noninvasive assessment of cardiac function, such as nuclear medicine imaging, transesophageal echocardiograms, and transthoracic bioimpedance. The next part of the issue deals with the question of tissue perfusion. Cardiac function is only one of the three major determinants of oxygen transport, which also include oxygen-carrying capacity and arterial oxygen saturation. The relationship between oxygen transport and tissue perfusion also may be complex, especially in disorders that involve abnormalities of the microcirculation. The question of adequate tissue perfusion is confounded further by the poorly understood relationship between oxygen delivery and oxygen consumption. This relationship and the surrounding controversy are discussed in this issue. What is adequate tissue perfusion? How do we monitor tissue perfusion? These are more than just stimulating academic questions for the intensivist. In inflammatory shock states, tissue hypoperfusion and hypoxia directly lead to, among other events, increased cytokine production, free oxygen radical generation, and the subsequent worsening of the microcirculatory abnormalities that characterize inflammatory disorders. The restoration of adequate tissue perfusion is essential to slow or halt the inflammatory process. Unfortunately, clinicians have few markers that reflect “adequate” tissue perfusion. The question we could ask as intensivists is, “When do we stop?” Our inability to assess the adequacy of tissue perfusion accurately makes it difficult to recognize when our therapeutic efforts have restored the balance between tissue demand and circulatory supply. Routine vital signs, such as blood pressure, heart rate, and urine output are all gross measures of hemodynamic function and tissue perfusion and do not allow for great precision in the assessment of tissue perfusion. The availability of one or several laboratory tests that would allow for the detection of early, subtle hypoperfusion of visceral beds is on every critical care clinician's wish list. Without question, the assessment of regional tissue perfusion would be of enormous help to the clinician during shock resuscitation. In inflammatory shock states such as sepsis, in which there may be severe alterations in regional blood flow, hypoperfusion of important visceral beds may go unnoticed by measurements of global oxygen transport. Organ-specific perfusion measurements may be of prognostic and therapeutic value in the treatment of shock. Unfortunately, we have even fewer established methods for the measurement of regional oxygen delivery and consumption than for global perfusion. Two of these methods, tonometry and near-infrared spectroscopy, are reviewed in this issue. Ultimately, the most important question that remains is whether or not these newer modes of hemodynamic monitoring and assessment of tissue perfusion demonstrate beneficial effects in outcomes studies. Several randomized, controlled trials have evaluated these new therapeutic goals in inflammatory shock, and are discussed in this issue. Unfortunately for the clinician, there is no definitive answer to this difficult question of adequate tissue perfusion. The goal of this issue of Critical Care Clinics is to provide the intensivist with further understanding and insight concerning this important clinical dilemma." @default.
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