Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, Département d'Anesthésie-Réanimation, Université Paris Sud XI, Le Kremlin-Bicêtre, France.
Curr Opin Crit Care. 2011 Jun;17(3):303-7. doi: 10.1097/MCC.0b013e3283466ba0.
The ultimate goals of hemodynamic therapy in acutely unwell patients are to restore effective tissue perfusion and oxygen delivery to maintain cellular metabolism. Optimization of systemic hemodynamics may improve the time course of microcirculatory dysfunction and eventually the patient's outcome. However, relationships between systemic hemodynamics and microcirculatory changes during resuscitation are complex and underperfused microcirculation may persist, despite restored macrohemodynamics. Thus, targeting the microcirculation is a logical goal to obtain an adequate resuscitation.
The impact of systemic interventions such as fluid resuscitation, vasopressor therapy, and transfusion has been evaluated on microcirculatory perfusion in septic-shock patients. It demonstrated inconstant improvement according to time-course evolution of the underlying pathology with interindividual variability. Thus, therapy targeting the microcirculation should be adapted to individual microcirculatory monitoring. Specific therapy with nitroglycerin did not promote microcirculation in septic shock but was associated with microcirculatory improvement in cardiogenic shock.
Microcirculatory hemodynamics have to be restored as soon as possible during the early phase of the management of acutely unwell patients. Future trials should test whether microcirculation-guided strategy could better improve organ dysfunction than global hemodynamic-guided strategy. An optimal resuscitation has to restore the systematic hemodynamics and make sure of the quality of the microcirculation.
急性疾病患者血流动力学治疗的最终目标是恢复有效的组织灌注和氧输送，以维持细胞代谢。优化全身血流动力学可能会改善微循环功能障碍的时间过程，并最终改善患者的预后。然而，在复苏过程中全身血流动力学与微循环变化之间的关系很复杂，尽管宏观血流动力学已经恢复，但可能仍然存在灌注不足的微循环。因此，针对微循环进行治疗是获得充分复苏的合理目标。
已经评估了全身性干预措施（如液体复苏、血管加压素治疗和输血）对感染性休克患者微循环灌注的影响。根据潜在病理的时间过程演变，其改善情况不一致，具有个体间的可变性。因此，针对微循环的治疗应该根据个体的微循环监测进行调整。在感染性休克中，使用硝酸甘油的特定治疗并没有促进微循环，但在心源性休克中与微循环改善相关。
在急性疾病患者管理的早期阶段，应尽快恢复微循环血流动力学。未来的试验应该测试微循环指导策略是否比全身血流动力学指导策略能更好地改善器官功能障碍。优化复苏既要恢复系统性血流动力学，又要确保微循环的质量。
