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The cardiovascular system in critical illness.

DOI:10.1097/MCC.0000000000000348 Delivery of adequate oxygen and metabolic substrates to all body tissues is essential for life. Accordingly, the cardiovascular system is a central consideration in all critically ill patients. Our understanding of basic pathophysiology of the cardiovascular system, and translation of this understanding into clinical practice, has evolved substantially over the past decade with important new aspects arising recently. This section on the cardiovascular system in critical illness reviews this new understanding as it relates to clinical practice. The recent protocol-based care for early septic shock (ProCESS) [1], Australasian resuscitation in sepsis evaluation (ARISE) [2], and protocolized management in sepsis (ProMISe) [3] trials highlight the importance of early resuscitation protocols in reducing mortality from shock states to current, encouragingly low values. Interestingly, resuscitation protocols are so ingrained in current care that even the ‘enrollment’ component of these studies all followed cardiovascular resuscitation protocols and, following this protocolized resuscitation during study enrollment, ‘standard care’ in the control groups was so influenced by protocols that the interventions delivered (e.g., fluid and vasopressors) were nearly indistinguishable from ‘protocolized care’. Goodwin et al. [4] delve into the key concepts surrounding protocolized care for early shock resuscitation. They identify features that lead to successful protocols and highlight the importance of protocolized cardiovascular resuscitation in promoting team-based care, guiding care of less experienced practitioners, providing education, and facilitating continuous quality improvement. A fundamental feature of cardiovascular resuscitation and a central component of all cardiovascular resuscitation protocols is volume administration. Too little volume resuscitation leaves the patient in an inadequately resuscitated shock state and too much volume results in tissue edema, hypoxemia, tissue hypoxia, and leads to adverse outcomes [5]. Boyd and Sirounis [6] tackle this issue. A static central venous pressure measurement is not sufficient unless it is strikingly low or high. Instead, perturbation of the cardiovascular system is the best route towards assessing volemia. In an awake spontaneously breathing patient,apassive leg raise resulting inanimprovement