Dynamic CPC-I (mild coupling) reflects a perfusion improvement (ie, a range of improved tissue perfusion of 0%–15%/0–2 SD over baseline) that is not significant but has not become worse. We suggest that dynamic CPC should be reevaluated with caution after 1 to 2 h. If the expected perfusion targets improve and reach the level of dynamic CPC-II, the current treatment might continue, with careful monitoring. However, if the expected perfusion targets do not change or perhaps worsen, the therapeutic direction should be changed. Moreover, other unchecked factors that result in persistent impaired microcirculatory perfusion should be suspected, such as new-onset sepsis, an occult infection source, profound ischemia-reperfusion injury, or an undetermined etiology of the circulatory shock.
The dynamic CPC degree is suggested to evaluate the dynamic relationship between the Macro and tissue perfusion in the procedure of resuscitation, and the RI classification is suggested to determine where coherence is lost. It is necessary to evaluate the combined effect of colloids on Macro and Micro for correctly interprete the role of colloids in the shock resuscitation. The first expected aim of the recovery of the Macro is the Micro, and the expected aim of the improved Micro is improved cellular oxygen metabolism. In theory, stepwise targets should be proposed to interpret the dynamic CPC. However, the relationship between the Micro and cellular oxygen metabolism is difficult to quantitatively analyze, and impaired Micro always accompanies poor cellular oxygen metabolism in clinical practice. Thus, it might be difficult in clinical practice to divide tissue perfusion into microcirculatory perfusion and cellular oxygen metabolism using a dynamic CPC degree scale. Recent studies supported the P(v-a)CO2 might be a potential indicator of sublingual microcirculation. Furthermore, studies indicated that perfusion-related variables exhibited different normalization rates in septic shock survivors.[52,53] Here, we emphasize using serial and dynamic parameters in multimodal monitoring strategies for the abovementioned three domain (Macro, Micro, and cell) parameters to assess the loss of coherence and dynamic CPC. We believe that the concepts of resuscitation coherence and dynamic CPC may provide meaningful information to assess the effect of shock resuscitation and determine further therapeutic directions. In summary, a conceptual protocol of the use of dynamic CPC and RI is shown in Figure 4.
The concepts of resuscitation coherence and dynamic CPC may provide meaningful information to interpret shock resuscitation. These clinical findings should be considered for the management of circulatory shock. Moreover, these concepts require further study for validation in clinical practice.
This work was supported by a grant from the Fundamental Research Funds for the Central Universities (No. 3332018010).
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