Hemodynamic support: focus on monitoring tools or treatments?

Advanced Hemodynamic Management in Patients with Septic Shock

In patients with sepsis and septic shock, the hemodynamic management in both early and later phases of these "organ dysfunction syndromes" is a key therapeutic component. It needs, however, to be differentiated between "early goal-directed therapy" (EGDT) as proposed for the first 6 hours of emergency department treatment by Rivers et al. in 2001 and "hemodynamic management" using advanced hemodynamic monitoring in the intensive care unit (ICU). Recent large trials demonstrated that nowadays protocolized EGDT does not seem to be superior to "usual care" in terms of a reduction in mortality in emergency department patients with early identified septic shock who promptly receive antibiotic therapy and fluid resuscitation. "Hemodynamic management" comprises (a) making the diagnosis of septic shock as one differential diagnosis of circulatory shock, (b) assessing the hemodynamic status including the identification of therapeutic conflicts, and (c) guiding therapeutic interventions. We propose two algorithms for hemodynamic management using transpulmonary thermodilution-derived variables aiming to optimize the cardiocirculatory and pulmonary status in adult ICU patients with septic shock. The complexity and heterogeneity of patients with septic shock implies that individualized approaches for hemodynamic management are mandatory. Defining individual hemodynamic target values for patients with septic shock in different phases of the disease must be the focus of future studies.

Individualizing hemodynamic optimization during the management of circulatory collapse

The best method of hemodynamic monitoring to guide the resuscitation and management of the critically ill patient is unclear. The evaluated article presents data from a prospective randomized controlled trial that recruited 120 shocked patients (n = 60 in each arm) to compare volume-limited versus pressure-limited hemodynamic management. Patients were randomized into two protocolized fluid therapy algorithms using either the upper limits of hemodynamic indices of arterial pulse contour cardiac output and transpulmonary thermodilution (TPTD) analysis (extra vascular lung water <10 ml/kg and global end-diastolic volume index 850 ml/m(2)) or pulmonary artery catheter pressures (<18-20 mmHg). Primary outcomes were ventilator-free days, duration of mechanical ventilation, intensive care unit and hospital stay. Secondary outcomes included sequential organ failure assessment scores and mortality. No benefit was found between pulmonary artery catheter and TPTD in the primary outcomes; interestingly, the nonseptic patients who were monitored with TPTD spent longer on mechanical ventilation and in the intensive care unit.