[Hemodynamic management of septic shock. From a global approach to a gastrointestinal approach]

Oxygen uptake and increased metabolic requirements are characteristic of the acute state resulting from septic shock. One therapeutic approach to improving hemodynamics is to increase oxygen delivery in an attempt to overcome tissue oxygen debt. Recent randomized trials have suggested that systematically increasing oxygen supply is not necessarily the ideal strategy. It might be better, for each patient, to reach an optimal oxygen supply. This requires identification of parameters capable of indicating the optimal level, a rather difficult task. Currently, focus has been placed on the importance of the splanchnic circulation in severe septic shock. Hypoxia resulting from hypoperfusion of the intestinal mucosa occurs early in sepsis and could, via intermediary bacterial and/or endotoxinic translocation, maintain the septic syndrome and favor development of multiple organ failure. Since the drugs used to restore hemodynamics have vasoactive properties, measuring their effect on relevant indicators of splanchnic perfusion and oxygenation such as PCO2 or pH within the gastric mucosa using tonometric gastric probes might be a means of determining optimal oxygen level. With this approach, it would be possible to avoid sacrifying the perfusion of the gastrointestinal mucosa by using drugs which appear to favor the microcirculation in this territory.