CARDIOPULMONARY MONITORING: Edited by Anthony S. McLeanWhat should I use next if clinical evaluation and echocardiographic haemodynamic assessment is not enough?Messina, Antonio; Greco, Massimiliano; Cecconi, MaurizioAuthor Information Department of Anaesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center – IRCCS, Rozzano, Milan, Italy Correspondence to Maurizio Cecconi, Department of Anaesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center – IRCCS, Via Alessandro Manzoni, 56, 20089 Rozzano, Milan, Italy. Tel: + 39 0 2 8224 8282; e-mail: [email protected] Current Opinion in Critical Care: June 2019 - Volume 25 - Issue 3 - p 259-265 doi: 10.1097/MCC.0000000000000603 Buy Metrics Abstract Purpose of review To provide an integrated clinical approach to the critically ill patients in shock. Recent findings The complexity behind shock mechanism has improved in the last decades; as consequence, conventional generalized practices have been questioned, in favour of different approaches, titrated to patient's individual response. Bedside clinical examination has been demonstrated to be a reliable instrument to recognize the mismatch between cardiac function and peripheral oxygen demand. Mottling skin and capillary refill time have been recently proposed using a semi-quantitative approach as reliable tool to guide shock therapy; lactate, ΔCO2 and ScVO2 are also useful to track the effect of the therapies overtime. Critical care echocardiography is useful to assess the source of the shock, to choice the correct the therapy and to customize the therapy. Finally, a more sophisticated and invasive calibrated monitoring should be promptly adopted in case of refractory or mixed shock state to titrate the therapy on predefined goals, avoiding the inappropriate use of fluids and vasoactive drugs. Summary Bedside haemodynamic assessment in critically ill patients should be considered an integrated approach supporting the decision-making process and should be based on clinical examination and critical care echocardiography. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.