Multimodal individualized concept of hemodynamic monitoring.

PURPOSE OF REVIEW: To discuss the pathophysiological rationale of advanced hemodynamic monitoring in the critically ill and also to highlight the importance of a multimodal, individualized approach. RECENT FINDINGS: There are several clinical studies and animal experiments evaluating, which hemodynamic endpoint should be the best target during fluid management. Recent systematic reviews and meta-analyses also investigated the effects of advanced hemodynamic endpoints targeted hemodynamic management on outcome mainly in high-risk surgical patients. Although most of these studies report positive results, this knowledge does not seem to affect our everyday practice. According to large international surveys, most physicians still rely on inappropriate indices. One of the reasons could be that target values applied in these studies can be misleading in the individual patient. Therefore, we describe the concept of an individualized approach, in which normalizing the components of oxygen delivery are put in the context of the patients' individual response by evaluating components of oxygen consumption, and organ perfusion. SUMMARY: Advanced hemodynamic monitoring-based management provides a number of benefits, which could be better tailored for the patients' actual needs by putting this into a multimodal, individualized approach.

Continuous central venous oxygen saturation assisted intraoperative hemodynamic management during major abdominal surgery: a randomized, controlled trial.

BACKGROUND: Major abdominal surgery is associated with significant risk of morbidity and mortality in the perioperative period. Optimising intraoperative fluid administration may result in improved outcomes. Our aim was to compare the effects of central venous pressure (CVP), and central venous oxygen saturation (ScvO2)-assisted fluid therapy on postoperative complications in patients undergoing high risk surgery. METHODS: Patients undergoing elective major abdominal surgery were randomised into control and ScvO2 groups. The target level of mean arterial pressure (MAP) was ≥ 60 mmHg in both groups. In cases of MAP < 60 mmHg patients received either a fluid or vasopressor bolus according to the CVP < 8 mmHg in the control group. In the ScvO2 group, in addition to the MAP, an ScvO2 of <75% or a >3% decrease indicated need for intervention, regardless of the actual MAP. Data are presented as mean ± standard deviation or median (interquartile range). RESULTS: We observed a lower number of patients with complications in the ScvO2 group compared to the control group, however it did not reach statistical significance (ScvO2 group: 10 vs. CONTROL GROUP: 19; p = 0.07). Patients in the ScvO2 group (n = 38) received more colloids compared to the control group (n = 41) [279(161) vs. 107(250) ml/h; p < 0.001]. Both groups received similar amounts of crystalloid (1126 ± 471 vs. 1049 ± 431 ml/h; p = 0.46) and norepinephrine [37(107) vs. 18(73) mcg/h; p = 0.84]. Despite similar blood loss in both groups, the ScvO2 group received more blood transfusions (63% vs. 37%; p = 0.018). More patients in the control group had a postoperative PaO2/FiO2 < 200 mmHg (23 vs. 10, p < 0.01). Twenty eight day survival was significantly higher in the ScvO2 group (37/38 vs. 33/41 p = 0.018). CONCLUSION: ScvO2-assisted intraoperative haemodynamic support provided some benefits, including significantly better postoperative oxygenation and 28 day survival rate, compared to CVP-assisted therapy without a significant effect on postoperative complications during major abdominal surgery. TRIAL REGISTRATION: ClinicalTrials.gov NCT02337010.

Comparison of Macintosh Laryngoscope, King Vision®, VividTrac®, AirAngel Blade®, and a Custom-Made 3D-Printed Video Laryngoscope for Difficult and Normal Airways in Mannequins by Novices-A Non-Inferiority Trial.

Background: Endotracheal intubation (ETI) is a cornerstone of airway management. The gold standard device for ETI is still the direct laryngoscope (DL). However, video laryngoscopes (VLs) are now also widely available and have several proven advantages. The VL technique has been included in the major airway management guidelines. During the COVID-19 pandemic, supply chain disruption has raised demand for 3D-printed medical equipment, including 3D-printed VLs. However, studies on performance are only sparsely available; thus, we aimed to compare 3D-printed VLs to the DL and other VLs made with conventional manufacturing technology. Methods: Forty-eight medical students were recruited to serve as novice users. Following brief, standardized training, students executed ETI with the DL, the King Vision® (KV), the VividTrac® (VT), the AirAngel Blade® (AAB), and a custom-made 3D-printed VL (3DVL) on the Laerdal® airway management trainer in normal and difficult airway scenarios. We evaluated the time to and proportion of successful intubation, the best view of the glottis, esophageal intubation, dental trauma, and user satisfaction. Results: The KV and VT are proved to be superior (p < 0.05) to the DL in both scenarios. The 3DVL's performance was similar (p > 0.05) or significantly better than that of the DL and mainly non-inferior (p > 0.05) compared to the KV and VT in both scenarios. Regardless of the scenario, the AAB proved to be inferior (p < 0.05) even to the DL in the majority of the variables. The differences between the devices were more pronounced in the difficult airway scenario. The user satisfaction scores were in concordance with the aforementioned performance of the scopes. Conclusions: Based upon our results, we cannot recommend the AAB over the DL, KV, or VT. However, as the 3DVL showed, 3D printing indeed can provide useful or even superior VLs, but prior to clinical use, meticulous evaluation might be recommended.

Acquired Hemophilia A after SARS-CoV-2 Infection: A Case Report and an Updated Systematic Review.

The role of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has been implicated in the pathogenesis of acquired hemophilia A (AHA). The aim of this study is to report our case and to summarize clinical studies on de novo AHA after SARS-CoV-2 infection. We performed a systematic search on the association of SARS-CoV-2 with AHA in four medical databases up to 28 May 2023. Eligible studies should include de novo AHA patients who had SARS-CoV-2 infection before or concomitant with the diagnosis of AHA. Findings were synthesized narratively. In addition, we report the case of a 62-year-old female patient, who presented to our clinic with left flank pain 2 weeks after SARS-CoV-2 infection. Clinical investigations confirmed AHA and imaging studies revealed retroperitoneal bleeding. Her hemostasis was successfully secured with bypassing agents; however, despite immunosuppressive therapy, high inhibitor titer persisted. In the systematic review, we identified only 12 relevant cases with a questionable cause-effect relationship between SARS-CoV-2 infection and AHA. Based on the qualitative analysis of the relevant publications, current clinical evidence is insufficient to support a cause-effect relationship. The analysis of data from ongoing AHA registries can serve further evidence.

Antibiotic Consumption Patterns in European Countries Might Be Associated with the Prevalence of Type 1 and 2 Diabetes.

Several publications have raised the issue that the development of diabetes precedes the alteration of the microbiome (dysbiosis) and the role of environmental factors. Antibiotic use induces dysbiosis, and we wanted to estimate the associations between the consumption of antibiotics and the prevalence of diabetes (both types 1 and 2; T1D and T2D, respectively) in European countries. If such an association exists, the dominant use antibiotic classes might be reflected in the prevalence rates of T1D and T2D in different countries. Comparisons were performed between the prevalence of diabetes estimated for 2019 and featured in the Diabetes Atlas and the average yearly consumption of antibiotic classes between 2010 and 2109, calculated from the European Centre for Disease Prevention and Control (ECDC) yearly reports on antibiotic consumption in Europe. Pearson's correlation and variance analyses were used to estimate the possible relationship. Strong positive (enhancer) associations were found between the prevalence of T1D and the consumption of tetracycline (J01A: p = 0.001) and the narrow-spectrum penicillin (J01CE: p = 0.006; CF: p = 0.018). A strong negative (inhibitor) association was observed with broad-spectrum, beta-lactamase-resistant penicillin (J01CR: p = 0.003), macrolide (J01F: p = 0.008), and quinolone (J01M: p = 0.001). T2D showed significant positive associations with cephalosporin (J01D: p = 0.048) and quinolone (J01M: p = 0.025), and a non-significant negative association was detected with broad-spectrum, beta-lactamase-sensitive penicillin (J01CA: p = 0.067). Countries showing the highest prevalence rates of diabetes (top 10) showed concordance with the higher consumption of "enhancer" and the lower consumption of "inhibitor" antibiotics (top 10), as indicated by variance analysis. Countries with high prevalence rates of T1D showed high consumption of tetracycline (p = 0.015) and narrow-spectrum, beta-lactamase sensitive penicillin (p = 0.008) and low consumption of "inhibitor" antibiotics [broad-spectrum, beta-lactamase-resistant, combination penicillin (p = 0.005); cephalosporin (p = 0.036); and quinolone (p = 0.003)]. Countries with high prevalence rates of T2D consumed more cephalosporin (p = 0.084) and quinolone (p = 0.054) and less broad-spectrum, beta-lactamase-sensitive penicillin (p = 0.012) than did other countries. The development of diabetes-related dysbiosis might be related to the higher consumption of specific classes of antibiotics, showing positive (enhancer) associations with the prevalence of diabetes, and the low consumption of other classes of antibiotics, those showing negative (inhibitory) associations. These groups of antibiotics are different in T1D and T2D.

Alzheimer's Disease-Related Dysbiosis Might Be Triggered by Certain Classes of Antibiotics with Time-Lapse: New Insights into the Pathogenesis?

BACKGROUND: Several putative factors are identified in the literature as causative agents or risk factors for the development of Alzheimer's disease (AD). The amyloid cascade hypothesis has been the main hypothesis about the pathophysiology of AD for decades, but recent studies raised the possible role of dysbiosis in the development of AD, which prevents memory loss. OBJECTIVE: Finding possible associations between antibiotic consumption patterns and the prevalence of AD in European countries. METHODS: Antibiotic consumption (European Centre for Disease Prevention and Control, ECDC) for 1997-2007, 2008-2018, and as the whole 1997-2018 period, has been compared to the AD prevalence for 2018 expressed in percentage of the population and statistically analyzed by Pearson calculation. RESULTS: A significant positive correlation has been found between the AD prevalence (2018) and the average quinolone consumption for the years 1997-2007 (r: 0.37, p: 0.044). A similar association was not observed for the entire 22 years (1997-2018) of the average quinolone consumption, and the years 2008-2018, indicating 10-20 years of time-lapse between the antibiotic exposure and the development of AD. The ratio of broad-spectrum and narrow-spectrum antibiotics (B/N) estimated in the ECDC database for the years of 2008-2018 showed a strong positive association with AD prevalence (2018) (r: 0.406, p: 0.026) and a positive correlation tendency for the entire 22 years 1997-2018 (r: 0.344, p: 0.063), but none for the years 1997-2007 (r: 0.256, p: 0.241). CONCLUSION: Our study indicated the possible sequential role of certain classes of antibiotics in the development of dysbiosis leading to amyloid deposits of AD, which strengthen the possible role of different mediator molecules (short-chain fatty acids, lipopolysaccharides, etc.) produced by the altered microbiome in the development of AD.

"Growth-Promoting Effect" of Antibiotic Use Could Explain the Global Obesity Pandemic: A European Survey.

Clinical observations indicated a higher rate of obesity among children who received antibiotics at early ages. Experimental studies supported the role of the modified gut microbiome in the development of obesity as well. For identifying antibiotic classes that might promote or inhibit obesity-related dysbiosis, a database of the average yearly antibiotic consumption (2008-2018) has been developed using the European Center for Disease Prevention and Control (ECDC) yearly reports of antibiotic consumption in the community for the major antibiotic classes in 30 European countries, which were compared to the childhood and adult obesity prevalence featured in the Obesity Atlas. Pearson's chi-square test was applied to estimate positive/negative correlations between antibiotic consumption and obesity. One-way ANOVA has been applied to test the differences in antibiotic consumption between groups, and logistic regression analysis was performed to determine the odds ratios (OR) of antibiotic consumption for obesity. Strong, positive associations were estimated between childhood obesity and the total consumption of systemic antibiotics, broad-spectrum, beta-lactamase-resistant penicillin, cephalosporin, and quinolone, and a negative correlation was found with the consumption of tetracycline, broad-spectrum, beta-lactamase-sensitive penicillin, and narrow-spectrum, beta-lactamase-sensitive penicillin. Our observation indicated that the "growth-promoting effect" of the consumption of certain antibiotic classes might be identified as a possible etiology in the development of obesity and might be the explanation for the obesity "pandemic".

Antibiotic Consumption Patterns in European Countries Are Associated with the Prevalence of Parkinson's Disease; the Possible Augmenting Role of the Narrow-Spectrum Penicillin.

Parkinson's disease: Parkinson's disease (PD) is the second-most common neurodegenerative disease, affecting at least 0.3% of the worldwide population and over 3% of those over 80 years old. According to recent research (2018), in 2016, 6.1 million (95% uncertainty interval (UI) 5.0-7.3) individuals had Parkinson's disease globally, compared with 2.5 million (2.0-3.0) in 1990. The pandemic-like spreading of PD is considered a slow-moving disaster. Most recent studies indicated the possible role of an altered microbiome, dysbiosis, in the development of PD, which occurs long before the clinical diagnosis of PD. Antibiotics are considered as major disruptors of the intestinal flora and we have hypothesized that, as different classes of antibiotics might induce different dysbiosis, certain classes of antibiotics could trigger the PD-related dysbiosis as well. Comparative analyses were performed between the average yearly antibiotic consumption of 30 European countries (1997-2016) and the PD prevalence database (estimated for 2016). We divided the time frame of antibiotic consumption of 1997-2016 into four subsections to estimate the possible time lapse between antibiotic exposure and the prevalence, prevalence change, and PD-related death rates estimated for 2016. Our results indicated that countries with high consumption of narrow-spectrum penicillin experienced a higher increase in PD prevalence than the others. Countries reporting a decline in PD from 1990 to 2016 demonstrated a reduction in the consumption of narrow-spectrum penicillin in this period.

A new species of Pseudosinella Schäffer, 1897 (Collembola, Entomobryidae) from Hungary and Romania, with redescription of the related species Pseudosinellahuetheri Stomp, 1971.

A new species of the genus Pseudosinella Schäffer, 1897 from Hungary and Romania is described and illustrated. Pseudosinellahartnerae sp. nov. belongs to the group with 5+5 eyes, and can be identified by its unique labial chaetotaxy (M1m2rel1L2) within this group. Pseudosinellahuetheri Stomp, 1971, the closest related species sharing the same dorsal macrochaetae formula (R0R1R2001/00/0101+2), is also redescribed here based on the holotype. Comparative analysis between the two species and among other related species is provided.

Mean arterial pressure targeted fluid resuscitation may lead to fluid overload: A bleeding-resuscitation animal experiment.

INTRODUCTION: Fluid resuscitation is the cornerstone of treatment in hemorrhagic shock. Despite increasing doubts, several guidelines recommend to maintain mean arterial pressure (MAP) >65 mmHg as the most frequent indication of fluid therapy. Our aim was to investigate the effects of a MAP-guided management in a bleeding-resuscitation animal experiment. MATERIALS AND METHODS: After anesthesia and instrumentation (tbsl) animals were bled till the initial stroke volume index dropped by 50% (t0). Fluid replacement was performed in 4 equivalent steps (t1-4) with balanced crystalloid solution to reach the baseline values of MAP. Invasive hemodynamic measurements and blood gas analyses were performed after each step. RESULTS: Mean arterial pressure dropped from tbsl to t0 (114±11 vs 76.9±16.9 mmHg, p<0.001) and returned to baseline by t4 (101.4±14.4 mmHg). From tbsl-t0 stroke volume index (SVI), cardiac index (CI) decreased (SVI: 40±8.6 vs 19.3±3.6 ml/m2, p<0.001; CI: 3.4±0.3 vs 1.9±0.3 l/min/m2, p<0.001), pulse pressure variation (PPV) increased (13.2±4.3 vs 22.1±4.3%, p<0.001). There was a decrease in oxygen delivery (464±45 vs 246±26.9 ml/min, p<0.001), central venous oxygen saturation (82.8±5.4 vs 53.6±12.1%, p<0.001) and increase in lactate levels (1.6±0.4 vs 3.5±1.6 mmol/l, p<0.005). SVI, CI and PPV returned to their initial values by t2. To normalize MAP fluid therapy had to be continued till t4, with the total infused volume of 4.5±0.8 l. CONCLUSION: In the current experiment bleeding led to hemorrhagic shock, while MAP remained higher than 65 mmHg. Furthermore, MAP was unable to indicate the normalization of SVI, CI and PPV that resulted in unnecessary fluid administration. Our data give further evidence that MAP may be an inappropriate parameter to follow during fluid resuscitation.

Monitoring of Tissue Oxygenation: an Everyday Clinical Challenge.

PURPOSE OF REVIEW: The aim of this article is to study the overview of pathophysiology and clinical application of central venous oxygen saturation monitoring in critically ill patients and during the perioperative period. RECENT FINDINGS: There are several clinical studies and animal experiments evaluating the effects of goal-directed hemodynamic stabilization on critically ill patients. Recent systematic reviews and meta-analyses found that advanced hemodynamic endpoints-targeted management has a positive effect on outcome in high-risk surgical patients. As all interventions aim to improve tissue oxygenation, it is of utmost importance to monitor the balance between oxygen delivery and consumption. For this purpose, central venous blood gas analysis provides an easily available tool in the everyday clinical practice. The adequate interpretation of central venous oxygen saturation renders the need of careful evaluation of several physiological and pathophysiological circumstances. When appropriately evaluated, central venous oxygen saturation can be a valuable component of a multimodal individualized approach, in which components of oxygen delivery are put in the context of the patients' individual oxygen consumption. In addition to guide therapy, central venous oxygen saturation may also serve as an early warning sign of inadequate oxygen delivery, which would otherwise remain hidden from the attending physician. SUMMARY: With the incorporation of central venous oxygen saturation in the everyday clinical routine, treatment could be better tailored for the patients' actual needs; hence, it may also improve outcome.

Early procalcitonin kinetics and appropriateness of empirical antimicrobial therapy in critically ill patients: A prospective observational study.

PURPOSE: The purpose was to investigate the value of procalcitonin (PCT) kinetics in predicting the appropriateness of empirical antimicrobial treatment in critically ill patients. MATERIALS AND METHODS: This prospective observational study recruited patients in whom empirical antimicrobial therapy was started for suspected infection. Biochemical and physiological parameters were measured before initiating antimicrobials (t0), 8 hourly (t8, t16, t24), and then daily (day2-6). Patients were grouped post hoc into appropriate (A) and inappropriate (IA) groups. RESULTS: Of 209 patients, infection was confirmed in 67%. Procalcitonin kinetics were different between the IA (n = 33) and A groups (n = 108). In the IA group, PCT levels (median [interquartile range]) increased: t0= 2.8 (1.2-7.4), t16= 8.6 (4.8-22.1), t24= 14.5 (4.9-36.1), P< .05. In the A group, PCT peaked at t16 and started to decrease by t24: t0= 4.2 (1.9-12.8), t16= 6.99 (3.4-29.1), t24= 5.2 (2.0-16.7), P< .05. Receiver operating characteristic analysis revealed that a PCT elevation greater than or equal to 69% from t0 to t16 had an area under the curve for predicting inappropriate antimicrobial treatment of 0.73 (95% confidence interval, 0.63-0.83), P< .001; from t0 to t24, a greater than or equal to 74% increase had an area under the curve of 0.86 (0.77-0.94), P< .001. Hospital mortality was 37% in the A group and 61% in the IA group (P= .017). CONCLUSIONS: Early response of PCT in the first 24 hours of commencing empirical antimicrobials in critically ill patients may help the clinician to evaluate the appropriateness of therapy.

Delta Procalcitonin Is a Better Indicator of Infection Than Absolute Procalcitonin Values in Critically Ill Patients: A Prospective Observational Study.

Purpose. To investigate whether absolute value of procalcitonin (PCT) or the change (delta-PCT) is better indicator of infection in intensive care patients. Materials and Methods. Post hoc analysis of a prospective observational study. Patients with suspected new-onset infection were included in whom PCT, C-reactive protein (CRP), temperature, and leukocyte (WBC) values were measured on inclusion (t 0) and data were also available from the previous day (t -1). Based on clinical and microbiological data, patients were grouped post hoc into infection- (I-) and noninfection- (NI-) groups. Results. Of the 114 patients, 85 (75%) had proven infection. PCT levels were similar at t -1: I-group (median [interquartile range]): 1.04 [0.40-3.57] versus NI-group: 0.53 [0.16-1.68], p = 0.444. By t 0 PCT levels were significantly higher in the I-group: 4.62 [1.91-12.62] versus 1.12 [0.30-1.66], p = 0.018. The area under the curve to predict infection for absolute values of PCT was 0.64 [95% CI = 0.52-0.76], p = 0.022; for percentage change: 0.77 [0.66-0.87], p < 0.001; and for delta-PCT: 0.85 [0.78-0.92], p < 0.001. The optimal cut-off value for delta-PCT to indicate infection was 0.76 ng/mL (sensitivity 80 [70-88]%, specificity 86 [68-96]%). Neither absolute values nor changes in CRP, temperature, or WBC could predict infection. Conclusions. Our results suggest that delta-PCT values are superior to absolute values in indicating infection in intensive care patients. This trial is registered with ClinicalTrials.gov identifier: NCT02311816.

Lung recruitment can improve oxygenation in patients ventilated in continuous positive airway pressure/pressure support mode.

BACKGROUND: Recruitment maneuvers are often used in critical care patients with hypoxemic respiratory failure. Although continuous positive airway pressure/pressure support (CPAP/PS) ventilation is a frequently used approach, but whether lung recruitment also improves oxygenation in spontaneously breathing patients has not been investigated yet. The primary objective was to analyze the effect of recruitment maneuver on oxygenation in patients ventilated in CPAP/PS mode. METHODS: Following baseline measurements PEEP was increased by 5 cmH2O. Recruitment maneuver was applied for 40 s with 40 cmH2O of PS. Measurements of the difference in PaO2/FiO2 and airway parameters measured by the ventilator were recorded immediately after recruitment then 15 and 30 min later. Thirty patients ventilated in CPAP/PS mode with a PEEP ≥5 cmH2O were enrolled in this prospective, observational study if their PaO2/FiO2 ratio was <300 mmHg or required an FiO2 >0.5. RESULTS: Following recruitment maneuver patients were considered as non-responders (NR, n = 15) if difference of PaO2/FiO2 <20% and responders (R, n = 15) if difference of PaO2/FiO2 ≥20%. In the NR-group, PaO2/FiO2 decreased non-significantly from baseline: median [interquartile], PaO2/FiO2 = 176 [120-186] vs. after recruitment: 169 [121-182] mmHg, P = 0.307 while in the R-group there was significant improvement: 139 [117-164] vs. 230 [211-323] mmHg, P = 0.01. At the same time points, dead space to tidal volume ratio (Vds/Vte) significantly increased in the NR-group Vds/Vte = 32 [27-37] vs. 36 [25-42]%, P = 0.013 but no significant change was observed in the R-group: 26 [22-34] vs. 27 [24-33]%, P = 0.386. CONCLUSION: Recruitment maneuver improved PaO2/FiO2 ratio by ≥20% in 50% of patients ventilated in CPAP/PS mode.

Goal-Directed Resuscitation Aiming Cardiac Index Masks Residual Hypovolemia: An Animal Experiment.

The aim of this study was to compare stroke volume (SVI) to cardiac index (CI) guided resuscitation in a bleeding-resuscitation experiment. Twenty six pigs were randomized and bled in both groups till baseline SVI (T bsl) dropped by 50% (T 0), followed by resuscitation with crystalloid solution until initial SVI or CI was reached (T 4). Similar amount of blood was shed but animals received significantly less fluid in the CI-group as in the SVI-group: median = 900 (interquartile range: 850-1780) versus 1965 (1584-2165) mL, p = 0.02, respectively. In the SVI-group all variables returned to their baseline values, but in the CI-group animals remained underresuscitated as indicated by SVI, heart rate (HR) and stroke volume variation (SVV), and central venous oxygen saturation (ScvO2) at T 4 as compared to T bsl: SVI = 23.8 ± 5.9 versus 31.4 ± 4.7 mL, HR: 117 ± 35 versus 89 ± 11/min SVV: 17.4 ± 7.6 versus 11.5 ± 5.3%, and ScvO2: 64.1 ± 11.6 versus 79.2 ± 8.1%, p < 0.05, respectively. Our results indicate that CI-based goal-directed resuscitation may result in residual hypovolaemia, as bleeding caused stress induced tachycardia "normalizes" CI, without restoring adequate SVI. As the SVI-guided approach normalized most hemodynamic variables, we recommend using SVI instead of CI as the primary goal of resuscitation during acute bleeding.

Monitoring Microcirculatory Blood Flow with a New Sublingual Tonometer in a Porcine Model of Hemorrhagic Shock.

Tissue capnometry may be suitable for the indirect evaluation of regional hypoperfusion. We tested the performance of a new sublingual capillary tonometer in experimental hemorrhage. Thirty-six anesthetized, ventilated mini pigs were divided into sham-operated (n = 9) and shock groups (n = 27). Hemorrhagic shock was induced by reducing mean arterial pressure (MAP) to 40 mmHg for 60 min, after which fluid resuscitation started aiming to increase MAP to 75% of the baseline value (60-180 min). Sublingual carbon-dioxide partial pressure was measured by tonometry, using a specially coiled silicone rubber tube. Mucosal red blood cell velocity (RBCV) and capillary perfusion rate (CPR) were assessed by orthogonal polarization spectral (OPS) imaging. In the 60 min shock phase a significant drop in cardiac index was accompanied by reduction in sublingual RBCV and CPR and significant increase in the sublingual mucosal-to-arterial PCO2 gap (PSLCO2 gap), which significantly improved during the 120 min resuscitation phase. There was significant correlation between PSLCO2 gap and sublingual RBCV (r = -0.65, p < 0.0001), CPR (r = -0.64, p < 0.0001), central venous oxygen saturation (r = -0.50, p < 0.0001), and central venous-to-arterial PCO2 difference (r = 0.62, p < 0.0001). This new sublingual tonometer may be an appropriate tool for the indirect evaluation of circulatory changes in shock.

The multimodal concept of hemodynamic stabilization.

Hemodynamic instability often leads to hypoperfusion, which has a significant impact on outcome in both medical and surgical patients. Measures to detect and treat tissue hypoperfusion early by correcting the imbalance between oxygen delivery and consumption is of particular importance. There are several studies targeting different hemodynamic endpoints in order to investigate the effects of goal-directed therapy on outcome. A so-called multimodal concept putting several variables in context follows simple logic and may provide a broader picture. Furthermore, rather than treating population based "normal" values of certain indices, this concept can be translated into the individualized patient care to reach adequate oxygen supply and tissue oxygenation in order to avoid under, or over resuscitation, which are equally harmful. The purpose of this review is to give an overview of current data providing the basis of this a multimodal, individualized approach of hemodynamic monitoring and treatment.