Towards integrative physiological monitoring of the critically ill: from cardiovascular to microcirculatory and cellular function monitoring at the bedside

Abele Donati, Dick Tibboel, Can Ince

Current hemodynamic monitoring of critically ill patients is mainly focused on monitoring of pressure-derived hemodynamic variables related to systemic circulation. Increasingly, oxygen transport pathways and indicators of the presence of tissue dysoxia are now being considered. In addition to the microcirculatory parameters related to oxygen transport to the tissues, it is becoming increasingly clear that it is also important to gather information regarding the functional activity of cellular and even subcellular structures to gain an integrative evaluation of the severity of disease and the response to therapy. Crucial to these developments is the need to provide continuous measurements of the physiological and pathophysiological state of the patient, in contrast to the intermittent sampling of biomarkers. As technological research and clinical investigations into the monitoring of critically ill patients have progressed, an increasing amount of information is being made available to the clinician at the bedside. This complexity of information requires integration of the variables being monitored, which requires mathematical models based on physiology to reduce the complexity of the information and provide the clinician with a road map to guide therapy and assess the course of recovery. In this paper, we review the state of the art of these developments and speculate on the future, in which we predict a physiological monitoring environment that is able to integrate systemic hemodynamic and oxygen-derived variables with variables that assess the peripheral circulation and microcirculation, extending this real-time monitoring to the functional activity of cells and their constituents. Such a monitoring environment will ideally relate these variables to the functional state of various organ systems because organ function represents the true endpoint for therapeutic support of the critically ill patient.