Methods of Monitoring Shock

Ednan K. Bajwa; Atul Malhotra; B. Taylor Thompson

doi:10.1055/s-2004-860986

Seminars in Respiratory and Critical Care Medicine, Table of Contents

Semin Respir Crit Care Med 2004; 25(6): 629-644
DOI: 10.1055/s-2004-860986

Methods of Monitoring Shock

Ednan K. Bajwa¹ , Atul Malhotra² , B. Taylor Thompson¹

¹Massachusetts General Hospital, Pulmonary and Critical Care Unit, Boston, Massachusetts
²Brigham & Women's Hospital, Boston, Massachusetts

Abstract

ABSTRACT

Intensive monitoring is a crucial component of the management of shock. However, there is little consensus about optimal strategies for monitoring. Although the pulmonary artery catheter has been widely used, conflicting data exist about the utility of this device. A variety of other techniques have been developed in hopes of providing clinically useful information about myocardial function, intravascular volume, and indices of organ function. In addition, there is evolving evidence that targeting and monitoring certain physiological goals may be most important early in the course of shock. In this chapter, we examine many of the available monitoring techniques and the evidence supporting their use.

KEYWORDS

Shock - monitoring - critical illness - intensive care unit - pulmonary artery catheter

Full Text

References

REFERENCES

1 Zeni F, Freeman B, Natanson C. Anti-inflammatory therapies to treat sepsis and septic shock: a reassessment. Crit Care Med. 1997; 25 1095-1100
2 Bernard G R, Vincent J L, Laterre P F et al.. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. 2001; 344 699-709
3 Dellinger R P. Cardiovascular management of septic shock. Crit Care Med. 2003; 31 946-955
4 LeDoux D, Astiz M E, Carpati C M, Rackow E C. Effects of perfusion pressure on tissue perfusion in septic shock. Crit Care Med. 2000; 28 2729-2732
5 Dalen J E, Bone R C. Is it time to pull the pulmonary artery catheter?. JAMA. 1996; 276 916-918
6 Rivers E, Nguyen B, Havstad S et al.. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001; 345 1368-1377
7 Parrillo J E, Parker M M, Natanson C et al.. Septic shock in humans: advances in the understanding of pathogenesis, cardiovascular dysfunction, and therapy. Ann Intern Med. 1990; 113 227-242
8 Schwartz D R, Malhotra A, Fink M. Cytopathic hypoxia in sepsis: an overview. Sepsis. 1998; 2 279-289
9 Fink M. Cytopathic hypoxia in sepsis. Acta Anaesthesiol Scand Suppl. 1997; 110 87-95
10 Gattinoni L, Brazzi L, Pelosi P et al.. A trial of goal-oriented hemodynamic therapy in critically ill patients. SvO2 Collaborative Group. N Engl J Med. 1995; 333 1025-1032
11 Vincent J L, Dufaye P, Berre J et al.. Serial lactate determinations during circulatory shock. Crit Care Med. 1983; 11 449-451
12 Rame J E, Dries D L, Drazner M H. The prognostic value of the physical examination in patients with chronic heart failure. Congest Heart Fail. 2003; 9 170-175 178
13 Thomas J T, Kelly R F, Thomas S J et al.. Utility of history, physical examination, electrocardiogram, and chest radiograph for differentiating normal from decreased systolic function in patients with heart failure. Am J Med. 2002; 112 437-445
14 Kaplan L J, McPartland K, Santora T A, Trooskin S Z. Start with a subjective assessment of skin temperature to identify hypoperfusion in intensive care unit patients. J Trauma. 2001; 50 620-627; , discussion 627-628
15 Joly H R, Weil M H. Temperature of the great toe as an indication of the severity of shock. Circulation. 1969; 39 131-138
16 Connors Jr A F, McCaffree D R, Gray B A. Evaluation of right-heart catheterization in the critically ill patient without acute myocardial infarction. N Engl J Med. 1983; 308 263-267
17 Poelaert J I, Trouerbach J, De Buyzere M, Everaert J, Colardyn F A. Evaluation of transesophageal echocardiography as a diagnostic and therapeutic aid in a critical care setting. Chest. 1995; 107 774-779
18 Slama M A, Novara A, Van de Putte P et al.. Diagnostic and therapeutic implications of transesophageal echocardiography in medical ICU patients with unexplained shock, hypoxemia, or suspected endocarditis. Intensive Care Med. 1996; 22 916-922
19 Sohn D W, Shin G J, Oh J K et al.. Role of transesophageal echocardiography in hemodynamically unstable patients. Mayo Clin Proc. 1995; 70 925-931
20 Goldman A P, Glover M U, Mick W et al.. Role of echocardiography/Doppler in cardiogenic shock: silent mitral regurgitation. Ann Thorac Surg. 1991; 52 296-299
21 Shephard J N, Brecker S J, Evans T W. Bedside assessment of myocardial performance in the critically ill. Intensive Care Med. 1994; 20 513-521
22 Muhiudeen I A, Kuecherer H F, Lee E, Cahalan M K, Schiller N B. Intraoperative estimation of cardiac output by transesophageal pulsed Doppler echocardiography. Anesthesiology. 1991; 74 9-14
23 Keyl C, Rodig G, Lemberger P, Hobbhahn J. A comparison of the use of transoesophageal Doppler and thermodilution techniques for cardiac output determination. Eur J Anaesthesiol. 1996; 13 136-142
24 Vieillard-Baron A, Prin S, Chergui K, Dubourg O, Jardin F. Hemodynamic instability in sepsis: bedside assessment by Doppler echocardiography. Am J Respir Crit Care Med. 2003; 168 1270-1276
25 Singer M, Clarke J, Bennett E D. Continuous hemodynamic monitoring by esophageal Doppler. Crit Care Med. 1989; 17 447-452
26 Singer M, Bennett E D. Noninvasive optimization of left ventricular filling using esophageal Doppler. Crit Care Med. 1991; 19 1132-1137
27 Cariou A, Monchi M, Joly L M et al.. Noninvasive cardiac output monitoring by aortic blood flow determination: evaluation of the Sometec Dynemo-3000 system. Crit Care Med. 1998; 26 2066-2072
28 Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ. 1997; 315 909-912
29 Birman H, Haq A, Hew E, Aberman A. Continuous monitoring of mixed venous oxygen saturation in hemodynamically unstable patients. Chest. 1984; 86 753-756
30 Schmidt C R, Frank L P, Forsythe S B, Estafanous F G. Continuous S-vO₂ measurement and oxygen transport patterns in cardiac surgery patients. Crit Care Med. 1984; 12 523-527
31 Cason C L, DeSalvo S K, Ray W T. Changes in oxygen saturation during weaning from short-term ventilator support after coronary artery bypass graft surgery. Heart Lung. 1994; 23 368-375
32 Magilligan Jr D J, Teasdall R, Eisinminger R, Peterson E. Mixed venous oxygen saturation as a predictor of cardiac output in the postoperative cardiac surgical patient. Ann Thorac Surg. 1987; 44 260-262
33 Pearson K S, Gomez M N, Moyers J R, Carter J G, Tinker J H. A cost/benefit analysis of randomized invasive monitoring for patients undergoing cardiac surgery. Anesth Analg. 1989; 69 336-341
34 Lee J, Wright F, Barber R, Stanley L. Central venous oxygen saturation in shock: a study in man. Anesthesiology. 1972; 36 472-478
35 Reinhart K, Rudolph T, Bredle D L, Hannemann L, Cain S M. Comparison of central-venous to mixed-venous oxygen saturation during changes in oxygen supply/demand. Chest. 1989; 95 1216-1221
36 Goedje O, Hoeke K, Lichtwarck-Aschoff M et al.. Continuous cardiac output by femoral arterial thermodilution calibrated pulse contour analysis: comparison with pulmonary arterial thermodilution. Crit Care Med. 1999; 27 2407-2412
37 Buhre W, Weyland A, Kazmaier S et al.. Comparison of cardiac output assessed by pulse-contour analysis and thermodilution in patients undergoing minimally invasive direct coronary artery bypass grafting. J Cardiothorac Vasc Anesth. 1999; 13 437-440
38 Rodig G, Prasser C, Keyl C, Liebold A, Hobbhahn J. Continuous cardiac output measurement: pulse contour analysis vs thermodilution technique in cardiac surgical patients. Br J Anaesth. 1999; 82 525-530
39 Raaijmakers E, Faes T J, Scholten R J, Goovaerts H G, Heethaar R M. A meta-analysis of three decades of validating thoracic impedance cardiography. Crit Care Med. 1999; 27 1203-1213
40 Shoemaker W C, Belzberg H, Wo C C et al.. Multicenter study of noninvasive monitoring systems as alternatives to invasive monitoring of acutely ill emergency patients. Chest. 1998; 114 1643-1652
41 Murdaugh H V, Robin E D, Millen J E, Drewry W F. Cardiac output determinations by the dye-dilution methol in Squalus acanthias. Am J Physiol. 1965; 209 723-726
42 Jacobs R R, Heyden W C, Williams B T, Schmitz U T, Schenk Jr W G. Cardiac output in the exercising dog: an evaluation of the dye-dilution method using the electromagnetic flowmeter as a standard. J Surg Res. 1970; 10 25-32
43 Olsson B, Pool J, Vandermoten P, Varnauskas E, Wassen R. Validity and reproducibility of determination of cardiac output by thermodilution in man. Cardiology. 1970; 55 136-148
44 Gust R, Gottschalk A, Bauer H et al.. Cardiac output measurement by transpulmonary versus conventional thermodilution technique in intensive care patients after coronary artery bypass grafting. J Cardiothorac Vasc Anesth. 1998; 12 519-522
45 Sakka S G, Reinhart K, Meier-Hellmann A. Does the optimization of cardiac output by fluid loading increase splanchnic blood flow?. Br J Anaesth. 2001; 86 657-662
46 Swan H J, Ganz W, Forrester J et al.. Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter. N Engl J Med. 1970; 283 447-451
47 Eidelman L A, Pizov R, Sprung C L. Pulmonary artery catheterization: at the crossroads?. Crit Care Med. 1994; 22 543-545
48 Dalen J E. Bedside hemodynamic monitoring. N Engl J Med. 1979; 301 1176-1178
49 Gore J M, Goldberg R J, Spodick D H, Alpert J S, Dalen J E. A community-wide assessment of the use of pulmonary artery catheters in patients with acute myocardial infarction. Chest. 1987; 92 721-727
50 Zion M M, Balkin J, Rosenmann D et al.. Use of pulmonary artery catheters in patients with acute myocardial infarction: analysis of experience in 5,841 patients in the SPRINT Registry. SPRINT Study Group. Chest. 1990; 98 1331-1335
51 Connors Jr A F, Speroff T, Dawson N V et al.. The effectiveness of right heart catheterization in the initial care of critically ill patients. SUPPORT Investigators. JAMA. 1996; 276 889-897
52 Richard C, Warszawski J, Anguel N et al.. Early use of the pulmonary artery catheter and outcomes in patients with shock and acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2003; 290 2713-2720
53 Sandham J D, Hull R D, Brant R F et al.. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med. 2003; 348 5-14
54 Ganz W, Donoso R, Marcus H S, Forrester J S, Swan H J. A new technique for measurement of cardiac output by thermodilution in man. Am J Cardiol. 1971; 27 392-396
55 Jansen J R. The thermodilution method for the clinical assessment of cardiac output. Intensive Care Med. 1995; 21 691-697
56 Heerdt P M, Pond C G, Blessios G A, Rosenbloom M. Comparison of cardiac output measured by intrapulmonary artery Doppler, thermodilution, and electromagnetometry. Ann Thorac Surg. 1992; 54 959-966
57 Heyland D K, Cook D J, King D, Kernerman P, Brun-Buisson C. Maximizing oxygen delivery in critically ill patients: a methodologic appraisal of the evidence. Crit Care Med. 1996; 24 517-524
58 Tuchschmidt J, Fried J, Astiz M, Rackow E. Elevation of cardiac output and oxygen delivery improves outcome in septic shock. Chest. 1992; 102 216-220
59 Meredith J H, Little J M, Egle Jr J L. A comparison of simultaneous cardiac output measurements by two methods: the oxygen-Fick principle and the electromagnetic flowmeter. Am Surg. 1967; 33 949-952
60 de Abreu M G, Quintel M, Ragaller M, Albrecht D M. Partial carbon dioxide rebreathing: a reliable technique for noninvasive measurement of nonshunted pulmonary capillary blood flow. Crit Care Med. 1997; 25 675-683
61 Fein A M, Goldberg S K, Walkenstein M D et al.. Is pulmonary artery catheterization necessary for the diagnosis of pulmonary edema?. Am Rev Respir Dis. 1984; 129 1006-1009
62 Schriger D L, Baraff L J. Capillary refill: is it a useful predictor of hypovolemic states?. Ann Emerg Med. 1991; 20 601-605
63 McGee S, Abernethy III W B, Simel D L. The rational clinical examination: is this patient hypovolemic?. JAMA. 1999; 281 1022-1029
64 Cook D J, Simel D L. The Rational Clinical Examination: does this patient have abnormal central venous pressure?. JAMA. 1996; 275 630-634
65 Eisenberg P R, Jaffe A S, Schuster D P. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med. 1984; 12 549-553
66 Yazigi A, Madi-Jebara S, Antakly M C. Iliac venous pressure predicts central venous pressure in spontaneously breathing patients. Crit Care Med. 1999; 27 1219
67 Ho K M, Joynt G M, Tan P. A comparison of central venous pressure and common iliac venous pressure in critically ill mechanically ventilated patients. Crit Care Med. 1998; 26 461-464
68 Jacobsohn E, Chorn R, O’Connor M. The role of the vasculature in regulating venous return and cardiac output: historical and graphical approach. Can J Anaesth. 1997; 44 849-867
69 Brengelmann G L. A critical analysis of the view that right atrial pressure determines venous return. J Appl Physiol. 2003; 94 849-859
70 Magder S. More respect for the CVP. Intensive Care Med. 1998; 24 651-653
71 Magder S, Lagonidis D, Erice F. The use of respiratory variations in right atrial pressure to predict the cardiac output response to PEEP. J Crit Care. 2001; 16 108-114
72 Magder S, Georgiadis G, Tuck C. Respiratory variations in right atrial pressure predict response to fluid challenge. J Crit Care. 1992; 7 76-85
73 Morris A H, Chapman R H, Gardner R M. Frequency of technical problems encountered in the measurement of pulmonary artery wedge pressure. Crit Care Med. 1984; 12 164-170
74 Marik P, Heard S O, Varon J. Interpretation of the pulmonary artery occlusion (wedge) pressure: physician's knowledge versus the experts’ knowledge. Crit Care Med. 1998; 26 1761-1764
75 Godje O, Peyerl M, Seebauer T et al.. Central venous pressure, pulmonary capillary wedge pressure and intrathoracic blood volumes as preload indicators in cardiac surgery patients. Eur J Cardiothorac Surg. 1998; 13 533-539 , discussion 539-540
76 Krahmer R L, Fang H K, Vitello J, Rypins E B, Law W R. Pulmonary capillary wedge pressure estimates of left ventricular preload are inaccurate in endotoxin shock: contribution of Starling resistor forces to septic pulmonary hypertension. Shock. 1994; 2 344-350
77 Hansen R M, Viquerat C E, Matthay M A et al.. Poor correlation between pulmonary arterial wedge pressure and left ventricular end-diastolic volume after coronary artery bypass graft surgery. Anesthesiology. 1986; 64 764-770
78 Cheung A T, Savino J S, Weiss S J, Aukburg S J, Berlin J A. Echocardiographic and hemodynamic indexes of left ventricular preload in patients with normal and abnormal ventricular function. Anesthesiology. 1994; 81 376-387
79 Reichert C L, Visser C A, Koolen J J et al.. Transesophageal echocardiography in hypotensive patients after cardiac operations: comparison with hemodynamic parameters. J Thorac Cardiovasc Surg. 1992; 104 321-326
80 Bouhemad B, Nicolas-Robin A, Benois A et al.. Echocardiographic Doppler assessment of pulmonary capillary wedge pressure in surgical patients with postoperative circulatory shock and acute lung injury. Anesthesiology. 2003; 98 1091-1100
81 Loubieres Y, Vieillard-Baron A, Beauchet A et al.. Echocardiographic evaluation of left ventricular function in critically ill patients: dynamic loading challenge using medical antishock trousers. Chest. 2000; 118 1718-1723
82 Vincent J L, Thirion M, Brimioulle S, Lejeune P, Kahn R J. Thermodilution measurement of right ventricular ejection fraction with a modified pulmonary artery catheter. Intensive Care Med. 1986; 12 33-38
83 Diebel L, Wilson R F, Heins J et al.. End-diastolic volume versus pulmonary artery wedge pressure in evaluating cardiac preload in trauma patients. J Trauma. 1994; 37 950-955
84 Cheatham M L, Nelson L D, Chang M C, Safcsak K. Right ventricular end-diastolic volume index as a predictor of preload status in patients on positive end-expiratory pressure. Crit Care Med. 1998; 26 1801-1806
85 Mitchell J P, Schuller D, Calandrino F S, Schuster D P. Improved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterization. Am Rev Respir Dis. 1992; 145 990-998
86 Sakka S G, Klein M, Reinhart K, Meier-Hellmann A. Prognostic value of extravascular lung water in critically ill patients. Chest. 2002; 122 2080-2086
87 Lichtwarck-Aschoff M, Zeravik J, Pfeiffer U J. Intrathoracic blood volume accurately reflects circulatory volume status in critically ill patients with mechanical ventilation. Intensive Care Med. 1992; 18 142-147
88 Nuckton T J, Alonso J A, Kallet R H et al.. Pulmonary dead-space fraction as a risk factor for death in the acute respiratory distress syndrome. N Engl J Med. 2002; 346 1281-1286
89 Koreny M, Karth G D, Geppert A et al.. Prognosis of patients who develop acute renal failure during the first 24 hours of cardiogenic shock after myocardial infarction. Am J Med. 2002; 112 115-119
90 Chiara O, Pelosi P, Segala M et al.. Mesenteric and renal oxygen transport during hemorrhage and reperfusion: evaluation of optimal goals for resuscitation. J Trauma. 2001; 51 356-362
91 Wilson J X, Young G B. Progress in clinical neurosciences: sepsis-associated encephalopathy: evolving concepts. Can J Neurol Sci. 2003; 30 98-105
92 Bakker J, Coffernils M, Leon M, Gris P, Vincent J L. Blood lactate levels are superior to oxygen-derived variables in predicting outcome in human septic shock. Chest. 1991; 99 956-962
93 Bakker J, Gris P, Coffernils M, Kahn R J, Vincent J L. Serial blood lactate levels can predict the development of multiple organ failure following septic shock. Am J Surg. 1996; 171 221-226
94 James J H, Luchette F A, McCarter F D, Fischer J E. Lactate is an unreliable indicator of tissue hypoxia in injury or sepsis. Lancet. 1999; 354 505-508
95 McNelis J, Marini C P, Jurkiewicz A et al.. Prolonged lactate clearance is associated with increased mortality in the surgical intensive care unit. Am J Surg. 2001; 182 481-485
96 Davis J W. The relationship of base deficit to lactate in porcine hemorrhagic shock and resuscitation. J Trauma. 1994; 36 168-172
97 Davis J W, Parks S N, Kaups K L, Gladen H E, O'Donnell-Nicol S. Admission base deficit predicts transfusion requirements and risk of complications. J Trauma. 1996; 41 769-774
98 Kincaid E H, Miller P R, Meredith J W, Rahman N, Chang M C. Elevated arterial base deficit in trauma patients: a marker of impaired oxygen utilization. J Am Coll Surg. 1998; 187 384-392
99 Husain F A, Martin M J, Mullenix P S, Steele S R, Elliott D C. Serum lactate and base deficit as predictors of mortality and morbidity. Am J Surg. 2003; 185 485-491
100 Nelson D P, Beyer C, Samsel R W, Wood L D, Schumacker P T. Pathological supply dependence of O₂ uptake during bacteremia in dogs. J Appl Physiol. 1987; 63 1487-1492
101 Danek S J, Lynch J P, Weg J G, Dantzker D R. The dependence of oxygen uptake on oxygen delivery in the adult respiratory distress syndrome. Am Rev Respir Dis. 1980; 122 387-395
102 Stratton H H, Feustel P J, Newell J C. Regression of calculated variables in the presence of shared measurement error. J Appl Physiol. 1987; 62 2083-2093
103 Bihari D, Smithies M, Gimson A, Tinker J. The effects of vasodilation with prostacyclin on oxygen delivery and uptake in critically ill patients. N Engl J Med. 1987; 317 397-403
104 Fiddian-Green R G, Baker S. Predictive value of the stomach wall pH for complications after cardiac operations: comparison with other monitoring. Crit Care Med. 1987; 15 153-156
105 Maynard N, Bihari D, Beale R et al.. Assessment of splanchnic oxygenation by gastric tonometry in patients with acute circulatory failure. JAMA. 1993; 270 1203-1210
106 Downing A, Cottam S, Beard C, Potter D. Gastric mucosal pH predicts major morbidity following orthotopic liver transplantation. Transplant Proc. 1993; 25 1804
107 Marik P E. Gastric intramucosal pH: a better predictor of multiorgan dysfunction syndrome and death than oxygen-derived variables in patients with sepsis. Chest. 1993; 104 225-229
108 Roumen R M, Vreugde J P, Goris R J. Gastric tonometry in multiple trauma patients. J Trauma. 1994; 36 313-316
109 Silva E, DeBacker D, Creteur J, Vincent J L. Effects of vasoactive drugs on gastric intramucosal pH. Crit Care Med. 1998; 26 1749-1758
110 Meier-Hellmann A, Bredle D L, Specht M, Hannemann L, Reinhart K. Dopexamine increases splanchnic blood flow but decreases gastric mucosal pH in severe septic patients treated with dobutamine. Crit Care Med. 1999; 27 2166-2171
111 Forrest D M, Baigorri F, Chittock D R, Spinelli J J, Russell J A. Volume expansion using pentastarch does not change gastric-arterial CO₂ gradient or gastric intramucosal pH in patients who have sepsis syndrome. Crit Care Med. 2000; 28 2254-2258
112 Frumento R J, Mongero L, Naka Y, Bennett-Guerrero E. Preserved gastric tonometric variables in cardiac surgical patients administered intravenous perflubron emulsion. Anesth Analg. 2002; 94 809-814 , table of contents
113 Gutierrez G, Palizas F, Doglio G et al.. Gastric intramucosal pH as a therapeutic index of tissue oxygenation in critically ill patients. Lancet. 1992; 339 195-199
114 Ivatury R R, Simon R J, Islam S et al.. A prospective randomized study of end points of resuscitation after major trauma: global oxygen transport indices versus organ-specific gastric mucosal pH. J Am Coll Surg. 1996; 183 145-154
115 Gomersall C D, Joynt G M, Freebairn R C et al.. Resuscitation of critically ill patients based on the results of gastric tonometry: a prospective, randomized, controlled trial. Crit Care Med. 2000; 28 607-614
116 Heard S O. Gastric tonometry: the hemodynamic monitor of choice (Pro). Chest. 2003; 123(5 Suppl) 469S-474S
117 Uusaro A, Russell J A, Walley K R, Takala J. Gastric-arterial pCO₂ gradient does not reflect systemic and splanchnic hemodynamics or oxygen transport after cardiac surgery. Shock. 2000; 14 13-17
118 Boyd O, Mackay C J, Lamb G et al.. Comparison of clinical information gained from routine blood-gas analysis and from gastric tonometry for intramural pH. Lancet. 1993; 341 142-146
119 Sato Y, Weil M H, Tang W et al.. Esophageal pCO₂ as a monitor of perfusion failure during hemorrhagic shock. J Appl Physiol. 1997; 82 558-562
120 Nakagawa Y, Weil M H, Tang W et al.. Sublingual capnometry for diagnosis and quantitation of circulatory shock. Am J Respir Crit Care Med. 1998; 157(6 Pt 1) 1838-1843
121 Povoas H P, Weil M H, Tang W et al.. Comparisons between sublingual and gastric tonometry during hemorrhagic shock. Chest. 2000; 118 1127-1132
122 Weil M H, Nakagawa Y, Tang W et al.. Sublingual capnometry: a new noninvasive measurement for diagnosis and quantitation of severity of circulatory shock. Crit Care Med. 1999; 27 1225-1229
123 Marik P E. Sublingual capnography: a clinical validation study. Chest. 2001; 120 923-927
124 Marik P E, Bankov A. Sublingual capnometry versus traditional markers of tissue oxygenation in critically ill patients. Crit Care Med. 2003; 31 818-822
125 Venkatesh B, Meacher R, Muller M J, Morgan T J, Fraser J. Monitoring tissue oxygenation during resuscitation of major burns. J Trauma. 2001; 50 485-494
126 Briers J D. Laser Doppler, speckle and related techniques for blood perfusion mapping and imaging. Physiol Meas. 2001; 22 R35-R66
127 Sair M, Etherington P J, Peter Winlove C, Evans T W. Tissue oxygenation and perfusion in patients with systemic sepsis. Crit Care Med. 2001; 29 1343-1349
128 Hotchkiss R S, Karl I E. The pathophysiology and treatment of sepsis. N Engl J Med. 2003; 348 138-150
129 Vincent J L, Dhainaut J F, Perret C, Suter P. Is the pulmonary artery catheter misused? A European view. Crit Care Med. 1998; 26 1283-1287
130 Nguyen A, Yaffe M B. Proteomics and systems biology approaches to signal transduction in sepsis. Crit Care Med. 2003; 31(1 Suppl) S1-S6
131 Hopf H W. Molecular diagnostics of injury and repair responses in critical illness: what is the future of monitoring in the intensive care unit?. Crit Care Med. 2003; 31(8 Suppl) S518-S523

B. Taylor ThompsonM.D.

Massachusetts General Hospital, Pulmonary and Critical Care Unit

BUL-148, 55 Fruit St.

Boston, MA 02114

Email: tthompson1@partners.org