The holistic view on perfusion monitoring in septic shock

To review recent evidence concerning the interactions between hemodynamic and perfusion parameters during septic shock resuscitation, and to propose some basic foundations for a more comprehensive perfusion assessment.

Several recent studies have expanded our knowledge about the physiologic determinants and limitations of currently used perfusion parameters such as central venous oxygen saturation and lactate. Macrohemodynamic, metabolic, peripheral and microcirculatory parameters tend to change in parallel in response to fluid loading during initial resuscitation. In contrast, perfusion markers are poorly correlated in patients who evolve with a persistent circulatory dysfunction. Therefore, assessment of perfusion status based solely on a single parameter can lead to inaccurate or misleading conclusions.

All individual perfusion parameters have extensive limitations to adequately reflect tissue perfusion during persistent sepsis-related circulatory dysfunction. A multimodal approach integrating macrohemodynamic, metabolic, peripheral and eventually microcirculatory perfusion parameters may overcome those limitations. This approach may also provide a thorough understanding on the predominant driving forces of hypoperfusion, and lead to physiologically oriented interventions.