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.