Detailing the cardiovascular profile in shock patients

Daniel De Backer

Evaluation of the cardiovascular profile of critically ill patients is one of the most important actions performed in critically ill patients. It allows recognition that the patient is in shock and characterization of the type of circulatory failure. This step is crucial to initiate supportive interventions and to cure the cause responsible for the development of shock. Evaluation of tissue perfusion allows identification of the patient insufficiently resuscitated and also to trigger therapeutic interventions. Monitoring tissue perfusion can be achieved by lactate, venoarterial gradients in PCO2, and central venous or mixed venous oxygen saturation. Ultimately, monitoring the microcirculation may help not only to identify alterations in tissue perfusion but also to identify the type of alterations: diffuse decrease in microvascular perfusion versus heterogeneity in the alterations, as in sepsis, with well perfused areas in close vicinity to poorly perfused areas. Regarding supportive therapy, a step-by-step approach is suggested, with fluid optimization followed by vasoactive support to preserve perfusion pressure and global and regional blood flows. The different variables should be integrated into decision and management pathways, and therapies adapted accordingly.