Hemodynamic Support in the Critically Ill Patient

Circulatory shock is a leading cause of tissue hypoperfusion and multiple organ dysfunction in critically ill patients. An appropriate cardiovascular support is required when circulatory shock occurs, in order to limit cellular hypoxia by increasing the oxygen delivery. The optimization of the different components involved in cellular oxygenation requires accurate monitoring, and represents the target for pharmacological and mechanical hemodynamic support therapies in critically ill patients with shock.Both invasive and non-invasive systems for hemodynamic monitoring allow the physician to identify the pathophysiological mechanisms sustaining shock, to target therapy delivery on the pathogenesis of the disease, and to evaluate the effects of treatments over time. The hemodynamic monitoring systems have their own advantages and limitation, and the most appropriate system will depend on the individual patient, on device and on local expertise available at each institution.A personalized pharmacological treatment with fluids and vasoactive/inotropic drugs, guided by appropriate monitoring, is crucial in the management of hemodynamic instability. Many drugs administered to critically ill patients have both cardiac and vascular effects depending on the dose and on density and distribution of their target receptors, e.g. catecholamines, vasopressin, inhibitors of phosphodiesterase type III or calcium sensitizer.When the pharmacologic vasoactive and inotropic therapy, even at maximal doses, is insufficient to prevent tissue hypoxia and organ damage, or patients ae becoming refractory to ongoing drug administration due to the prolonged illness, mechanical circulatory support (MCS) can be considered.