European Heart Journal: Acute Cardiovascular Care (2024) 13, 802–809 EDUCATIONAL PAPER

[Link] General Intensive Care

The microcirculation in cardiogenic shock

Mara Schemmelmann1, Malte Kelm 1,2
, and Christian Jung 1,2
*
1
Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine-University Duesseldorf, Moorenstrasse 5, Duesseldorf D-40225, Germany; and
2
CARID, Cardiovascular Research Institute Duesseldorf, Duesseldorf 40225, Germany

Received 30 August 2024; revised 27 October 2024; accepted 5 November 2024; online publish-ahead-of-print 7 November 2024

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Cardiogenic shock is a life-threatening condition characterized by inadequate cardiac output, leading to end-organ hypoperfusion and associated
mortality rates ranging between 40 and 50%. The critical role of microcirculatory impairments in the progression of organ failure during shock
has been highlighted in several studies. Traditional therapies have often focused on stabilizing macrocirculation, neglecting microcirculatory dysfunc­
tion, which can result in persistent tissue hypoxia and poor outcomes. This review highlights the importance of assessing microcirculation in car­
diogenic shock, including parameters such as skin perfusion, sublingual microcirculation, and lactate dynamics. Integrating microcirculatory
assessments into clinical practice remains challenging due to the complexity of the methods and limited therapeutic options targeting microvascular
perfusion. While advances in microcirculation-guided therapies hold promise for improving outcomes in cardiogenic shock, further research is
needed to establish effective protocols.
-Keywords
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Microcirculation • Cardiogenic shock • Intravital microscopy • Hand-held video microscopes • Critically ill

Introduction and maintaining fluid balance. Organ functions are there for critically de­
pendent on the integrity of the microcirculatory network.5
Cardiogenic shock is characterized by end-organ hypoperfusion result­
ing from a significant decrease in cardiac output.1 This condition leads
to insufficient delivery of oxygen and nutrients to peripheral tissues, po­ Microcirculatory alterations in shock
tentially resulting in multi-organ failure if not promptly treated. Despite Cardiogenic shock arises from primary cardiac dysfunction, leading to
advancements in medical care, the mortality rate for cardiogenic shock an inadequate cardiac output and a decrease in perfusion pressure.
remains high, ranging from 40 to 50%.2 Over the past decades, there This results in reduced peripheral tissue blood flow causing a mismatch
has been increasing recognition of the critical role that impaired micro­ between oxygen supply and demand in peripheral tissue.6 Tissue hyp­
circulation plays in the progression of organ failure in shock. Modern oxia is a common finding in cardiogenic shock.7 The exchange of oxygen
understanding of shock encompasses not only macrocirculatory distur­ and nutrients between blood and peripheral tissues occurs in the capil­
bances but also microcirculatory impairments, as recently highlighted in lary bed. Under physiological conditions, flow within the capillary bed is
a review by Merdji et al.3 The goal of this review is to provide an over­ primarily governed by the haemodynamic pressure gradient between
view of the assessment of microcirculation in cardiogenic shock and its the arteriolar pressure and post-capillary venules, known as the micro­
current clinical application. circulatory driving pressure (Figure 1).8 Arteriolar pressure is a key de­
terminant of systemic vascular resistance (SVR) and cardiac afterload.
Terminal arteries and arterioles contribute ∼45–55% to the SVR, play­
Relevance of microcirculation in ing a key role in regulating blood pressure and flow distribution. In these
arteriolar resistance vessels, there is a significant decrease in pressure,
cardiogenic shock establishing the capillary microcirculation as a low-pressure environ­
ment (see Figure 2).8 Mean capillary pressure is significantly influenced
Definition by downstream venous pressure, making central venous pressure a
Microcirculation refers to the network of small blood vessels, including critical determinant of capillary microcirculation.9 In cardiogenic shock,
arterioles, capillaries, and venules. The microcirculatory network ac­ the resultant increase in capillary hydrostatic pressure contributes to
counts for ∼90% of the total vascular surface area, playing a pivotal microcirculatory stasis reflecting convective microcirculatory impair­
role in maintaining tissue perfusion. It facilitates the exchange of gases, nu­ ments (Type 3 microcirculatory alterations, see Figure 3).10 Cellular
trients, and waste products between blood and tissues.4 Defined as ves­ hypoxia triggers a cascade of pathological processes, including endothe­
sels ≤100 µm, this network is crucial for oxygenation, decarboxylation, lial damage and dysfunction, microvascular obstruction, inflammatory

* Corresponding author. Tel: 02118118800, Email: [Link]@[Link]

© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@[Link] for
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Microcirculation in cardiogenic shock 803

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Figure 1 Loss of hemodynamic coherence in cardiogenic shock. MAP mean arterial pressure.

Figure 2 Schematic representation of the relationship between pressure and total cross-sectional area across different vascular segments. The great­
est drop in pressure occurs in terminal arteries and arterioles. The total cross-sectional area is largest in the capillaries (∼3000 cm²), corresponding to a
marked reduction in blood flow velocity, facilitating optimal nutrient and gas exchange. This inverse relationship between cross-sectional area and vas­
cular resistance is a key determinant of haemodynamic regulation. Adapted from Physiologie des Menschen mit Pathophysiologie, by R. Brandes (2019),
p. 225, Springer Berlin Heidelberg. R, resistance; A, total cross-sectional area.
804 M. Schemmelmann et al.

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Figure 3 Illustration of different types of microcirculatory alterations in shock. Type 1: Heterogeneous microvascular flow, characterized by uneven
blood distribution, primarily seen in septic shock. Type 2: Haemodilution, reducing oxygen-carrying capacity due to fluid resuscitation or autotransfu­
sion. Type 3: Reduced microvascular flow caused by arteriolar constriction (increased resistance) or venous congestion (elevated pressure). Type 4:
Oedema increases oxygen diffusion distances, impairing tissue oxygenation. P, pressure; R, resistance (adapted from Ince10).

response, and oxidative stress. Endothelial damage results in capillary for incorporating microcirculatory assessment into clinical shock man­
leak syndrome including increasing vascular permeability and a resultant agement.21 A more holistic approach is needed as microcirculatory
perivascular oedema which impairs oxygen diffusion (Type 4 microcir­ impairments are important predictors of clinical outcome in cardio­
culatory alterations, see Figure 3).10 This condition is further exacer­ genic shock.10,22,23
bated by the loss of SVR, commonly observed in sepsis and septic
shock.5 The impairment of both, convection and diffusion of oxygen,
critically compromises tissue oxygenation, contributing to the overall Assessment of microcirculation
severity of cardiogenic shock.
Skin perfusion
During circulatory compromise, the activation of the sympathetic ner­
Loss of haemodynamic coherence vous system leads to reduced skin blood flow via vasoconstriction to
Traditionally, shock therapy has been based on the assumption that sta­ prioritize the perfusion of vital organs. Clinical parameters of cutaneous
bilizing macrocirculation ensures adequate peripheral perfusion and tis­ hypoperfusion and microcirculatory impairments include pallor, cool­
sue oxygenation.10 Thus, the success of shock therapy is often gauged ness, mottling, cyanosis, and decreased skin turgor.24 Clinical scores
by improvements in macrocirculatory parameters.11 However, despite to describe and quantify cutaneous microcirculatory impairments in­
advancements in the management of cardiogenic shock that target clude the Mottling score and capillary refill time (CRT).24–26 These as­
macro-haemodynamics mortality remains high.12 Efforts to improve sessments are simple to perform at the bedside without specialized
macrocirculatory haemodynamics, particularly through temporary tools. Capillary refill time, measured by pressing on a patient’s nail
mechanical circulatory support, have not consistently translated into bed or skin until it turns white and observing the time for colour to re­
improved clinical outcomes.13,14 For instance, it has been demon­ turn, is a reliable and reproducible measure when performed correctly.
strated that the use if intra-aortic balloon pump (IABP) did not improve Prolonged CRT (>3 s) indicates poor peripheral perfusion in shock.26 It
microcirculatory impairments in patients with cardiogenic shock com­ correlates with higher SOFA scores and hyperlactatemia.24 Merdji
plicating myocardial infarction.15 In fact, some studies have shown a et al.27 demonstrated the prognostic value of CRT assessment in car­
paradoxical worsening of microcirculation under IABP circulatory sup­ diogenic shock based on a two-centre observational cohort study in­
port.16 Additionally, increasing mean arterial pressure using norepin­ cluding 59 patients. A prolonged CRT was associated with early
ephrine was not associated with improvements in microcirculation,17 prediction of 90-day mortality or need for mechanical support in car­
underscoring the dissociation between macro- and microcirculation. diogenic shock, enhancing risk discrimination when added to the
Even after restoring stable macrocirculation, patients with shock can CardShock score. Cutaneous mottling, defined as patchy skin discolor­
still develop significant end-organ damage.18 Ince10 described the lim­ ation typically around the knees, can predict organ failure severity
ited relationship between macro- and microcirculation as a loss of and mortality in septic shock patients. Cutaneous mottling correlates
haemodynamic coherence. This loss of haemodynamic coherence has with microcirculatory impairment. Improvements in the Mottling
been demonstrated in several clinical studies.19,20 Failure to improve score within the first 6 h of resuscitation correlates with a significantly
tissue perfusion despite good macrocirculation highlights the need better prognosis in septic shock.25 Merdji et al.’s28 findings from the
Microcirculation in cardiogenic shock 805

have shown coherence between sublingual microcirculation and that of

other organs, such as the intestines and kidneys.33
De Backer et al.23 first described sublingual microcirculatory impair­
ments and their prognostic relevance in cardiogenic shock based on a
study involving 40 patients with cardiogenic shock or severe heart fail­
ure. Notably, the microvascular density of small vessels (<20 µm) was
significantly lower in non-survivors compared with survivors, with a
strong correlation observed between reduced microvascular density
and survival. The second consensus paper on assessment of sublingual
microcirculation recommends combining variables of diffusive capacity
(e.g. total vessel density) with variables of convective blood flow [e.g.
microcirculatory flow index or proportion of perfused vessels (PPV)]
to comprehensively quantify microcirculatory impairments in cardio­
genic shock.32 A CULPRIT-SHOCK trial substudy34 examined sublin­
gual microcirculation in 66 patients with cardiogenic shock following

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percutaneous coronary interventions, confirming an independent asso­
ciation between both microcirculatory perfusion parameters—density
(perfused capillary density) and convective blood flow (PPV)—and
adverse outcomes.
There are, however, limitations associated with the use of mobile
intravital microvideoscopes. Despite the availability at the patient’s bed­
side, the assessment is time-consuming, taking ∼15 min per patient.35
Obtaining reliable microcirculatory parameters requires proper hand­
ling and training in the use of microvideoscopes, as poor video quality
can lead to overestimation of microcirculatory impairments.32
Highlighting the importance of training, Sallisalmi et al.36 found that
only 30% of analysed videos were of good quality. To ensure a high
video quality, the use of quality scores is recommended during micro­
circulatory assessment.32

Lactate and other biomarkers

Figure 4 Representative image of sublingual microcirculation in a Serum lactate levels are widely used point-of-care-parameters in cardio­
genic shock. Traditionally, elevated lactate levels have been linked to tissue
healthy volunteer (A) and a patient in cardiogenic shock (B) obtained
hypoperfusion, oxygen debt, and anaerobic glycolysis.37 However, current
using sidestream dark field intravital microscopy, own images used
understanding has expanded this concept. Elevated lactate in cardiogenic
with permission.
shock is closely tied to adrenergic stimulation as well as enhanced glucose
metabolism and interpreted as an metabolic state in response to severe
disease.38 Lactate is perceived as a major modulator of bioenergetics un­
der stress.39 Significant determinants of lactate accumulation are mixed
FRENSHOCK registry reveal that skin mottling is a strong predictor of venous oxygen saturation, heart rate, and SVR.40 Additionally, the liver’s
poor outcomes in cardiogenic shock, with the worst prognosis seen in contribution to hyperlactatemia, particularly through mechanisms like he­
patients who develop mottling within the first 24 h of treatment, patosplanchnic ischaemia leading to reduced clearance, may be greater
underscoring its importance in early risk stratification. than previously acknowledged.41 Various iatrogenic factors, such as ex­
Skin perfusion assessment techniques are limited as they evaluate a ogenous catecholamine therapy, ultrafiltration, and certain medications,
relatively large volume of tissue, potentially missing alterations in other can influence lactate levels.42 Lactate is a sensitive but non-specific param­
microcirculatory beds. Further studies are needed to examine the rela­ eter in cardiogenic shock. Elevated lactate levels are associated with higher
tion between markers of skin perfusion and the renal, cardiac, and cere­ mortality rates in patients with cardiogenic shock.43 Monitoring lactate dy­
bral microcirculation and function of these vital organs.29 namics is useful, as a high dynamic indicates are indicative of better out­
comes, whereas persistently elevated lactate levels are linked to an
increased incidence of organ failure and mortality.43,44
Sublingual microcirculation Various biomarkers have been identified over the years to assess sys­
In vivo microcirculation measurements using microvideoscopic techni­ temic status, end-organ function, or inflammation in cardiogenic shock,
ques offer a more detailed and direct assessment of microvascular func­ with the goal to serve as prognostic indicators and even as therapeutic
tion compared with skin perfusion assessment. Technologies such as targets, e.g. adrenomedullin, a key regulator of endothelial function and
orthogonal polarization spectral, sidestream dark field (SDF), and inci­ vascular tone, has been recognized for its prognostic value in impaired
dent dark field imaging allow visualization of superficial blood vessels haemodynamics, showing promise in improving outcomes in sepsis
and microvascular flow by emitting polarized green light absorbed by and myocardial infarction. The adrenomedullin antibody adrecizumab
haemoglobin (see Figure 4).30 These technologies enable real-time assess­ increases circulating adrenomedullin levels in cardiogenic shock patients
ment of tissue perfusion, including a detailed assessment of red blood cell but failed to improve survival rates in the ACCOST-HH trial.45 Research
and leucocyte behaviour.31 Furthermore, the density of the vascular net­ into biomarkers and their underlying pathophysiological processes
work can be examined and quantified.32 While assessing microcirculation enhances our understanding and may lead to targeted therapies.
of various organ surfaces over the past 25 years, the sublingual mucosa However, in clinical practice—despite long established biomarkers
has emerged as the preferred site for microcirculatory assessment in crit­ for organ function such as creatinine or transaminases—lactate is
ically ill patients due to its easy bedside accessibility. Experimental studies predominantly used.
806 M. Schemmelmann et al.

Further techniques predefined risk factors, lactate-guided patients demonstrated a signifi­

Organ microcirculation can also be monitored using contrast-enhanced cantly reduced ICU length of stay and mortality rates. This study under­
ultrasound (CEUS), which visualizes microcirculation and regional perfu­ scores the importance of lactate levels and dynamics as potent indicators
sion in real-time employing gas microbubbles surrounded by stabilizing of clinical deterioration, while also highlighting the limitations as a marker
envelopes.46 Unlike sublingual microcirculation assessment, CEUS is for therapeutic success and its utility in therapy guidance. On the other
not limited to superficial microcirculation but can directly visualize micro­ hand, the multi-centred randomized ANDROMEDA-SHOCK trial59
circulation in deep organs.46 Renal CEUS has been successfully used to compared a lactate-guided with CRT-based resuscitation in 424 patients
quantify renal microcirculation under various conditions, including renal with septic shock, demonstrating an advantage for the CRT-based ap­
transplantation.47 In a porcine model of lipopolysaccharide-induced sep­ proach. In this study, the goal of achieving a 20% reduction in lactate levels
tic shock, Lima et al.48 used CEUS to evaluate renal microcirculatory im­ every 2 h was pursued. The CRT-based strategy resulted in less organ
pairments associated with acute kidney injury. The study revealed dysfunction at 72 h, reduced intravenous fluid administration, and was
decreased but prolonged contrast enhancement in septic kidneys, re­ likely associated with lower mortality at both 28 and 90 days compared
flecting hypoperfusion and sluggish capillary blood flow. Concomitant with the lactate-guided resuscitation. Studies on lactate-guided therapy in
sublingual microcirculatory assessment mirrored the renal microcircula­ cardiogenic shock remain scarce.

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tory impairments. Although promising, studies specifically investigating
the use of CEUS in cardiogenic shock are currently lacking. Future chal­ Intravital microvideoscopy-guided
lenges include significant variations in imaging results due to incomplete
understanding of microbubble kinetics and the impact of ultrasound
therapy
settings.49 Addressing microcirculation as a therapeutic target can potentially en­
Other advanced techniques, such as magnetic resonance imaging hance patient outcomes by preventing the progression of organ dys­
(MRI), nailfold videocapillaroscopy, and near-infrared spectroscopy function. The DAMIS trial by Bruno et al.35 was the first RCT to
(NIRS), provide additional insights into microvascular function. attempt integrating real-time microcirculation assessment using mobile
Magnetic resonance imaging offers a detailed analysis of structural intravital videomicroscopes into the clinical decision-making process for
and functional changes in microvasculature.50 However, MRI is not shock patients. The multicentre RCT included 141 patients with various
suitable for bedside use and is impractical for unstable patients.51 types of shock. The study demonstrated that real-time knowledge of the
Magnetic resonance imaging provides a static snapshot rather than a microcirculatory status significantly influenced therapeutic decision-
dynamic assessment of microcirculation. Near-infrared spectroscopy, making but did not result in improved microcirculatory perfusion para­
which assesses deeper tissue microvasculature by measuring total meters after 24 h, nor did it reduce mortality after 30 days. These find­
haemoglobin and tissue oxygen saturation using infrared light,52 is ings sparked a discussion on the role and current limitations of real-time
non-invasive and easy to use but lacks standardization and clear microcirculatory assessment, emphasizing the need for further research
physiological significance.29 Near-infrared spectroscopy metrics, to better understand how to effectively incorporate microcirculatory
which indicate microcirculatory dysfunction by reflecting a patho­ data into clinical practice and therapy. Firstly, the results of the
logical imbalance between oxygen delivery and tissue oxygen extrac­ DAMIS trial suggest challenges in interpreting real-time microcirculatory
tion,52 strongly correlate with the outcome of critical ill patients.53 assessments in clinical settings. The study revealed a significant discrep­
However, NIRS-guided treatment protocols in septic shock have ancy between planned and actual treatment changes.35 In 59.4% of pa­
not shown advantages in tissue oxygenation or patient survival com­ tients, the treating clinician initially intended to modify the therapeutic
pared with standard care, highlighting the prognostic value of NIRS regimen based on the results of the microcirculatory assessment; how­
but limited impact on clinical outcomes.54 In cardiogenic shock, ever, this adjustment was ultimately not implemented over the course of
NIRS metrics can be used to estimate the cardiac index and offer a treatment. The study was conducted with clinicians who were inexperi­
fast and non-invasive assessment of the circulatory status.55 enced in real-time microcirculatory assessment, indicating that clinicians
had difficulties interpreting microcirculatory perfusion parameters or
adjusting the current therapies accordingly.60
Microcirculation in clinical Secondly, targeting the microcirculation with treatment adjustments
presents its own set of problems. While intravital videomicroscopy-
management of cardiogenic shock guided therapy has the potential to improve treatment, it can only be
effective if paired with strategies that specifically target microvascular
Lactate-guided therapy perfusion.35 Common treatments in cardiogenic shock include the
As previously discussed, lactate is a well-established prognostic param­ use of vasopressors, such as norepinephrine or vasopressine.61,62
eter in critically ill patients.43 Despite its predictive power, there is lim­ Norepinephrine primarily stimulates alpha-1 adrenergic receptors of
ited evidence regarding specific therapeutic interventions that might arterioles, leading to vasoconstriction, which increases SVR and raises
benefit patients with elevated lactate levels.42 While dichloroacetate blood pressure but also limits perfused capillary blood flow.21
administration has been shown to reduce lactate levels, it does not im­ Positive inotropic agents are employed to enhance myocardial con­
prove clinical outcomes in critically ill patients.56 Poor clinical outcomes tractility and thus improve cardiac output. Commonly used drugs in­
and high mortality associated with hyperlactatemia are more likely re­ clude dobutamine, levosimendan, and phosphodiesterase-3 inhibitors
lated to the underlying cause than to the hyperlactatemia itself.57 such as milrinone and enoximone.61 However, large-scale studies asses­
Over the years, the impact of resuscitation strategies in shock, aimed sing their effects on microcirculation remain scarce. A small study on
at improving microcirculation by normalizing lactate levels, has been dobutamine therapy revealed no significant improvement in microcir­
evaluated in only a limited number of studies and with mixed results. culation, despite an increase in cardiac index. In contrast, enoximone
On the one hand, a randomized controlled trial (RCT) by Jansen therapy demonstrated a slight improvement in perfused capillary dens­
et al.58 including 348 ICU patients with lactate levels >3 mmol/L inves­ ity in a study involving 10 patients with cardiogenic shock.21 The effect
tigated the effect of lactate-guided therapy compared with a control of levosimendan on microcirculation remains under-researched.
group without serial lactate monitoring. The study found that the target Although preliminary data indicate a potential positive impact in pa­
of a 20% reduction in lactate levels every 2 h was achieved equally in tients with cardiogenic shock, these findings have yet to be validated
both groups. However, patients in the lactate-guided group received through publication in peer-reviewed scientific journals.63 Fluid resusci­
significantly more fluids and vasodilator therapy. After adjustment for tation is primarily recommended in right heart failure, as the right
Microcirculation in cardiogenic shock 807

ventricular function depends on cardiac preload, or to prevent hypo­ optimizing microcirculation. The authors envision a virtual patient mod­
volaemia.61 While fluids may increase microcirculatory flow, they do el based on in vivo monitoring, incorporating macrocirculation and
so at the expense of oxygen diffusion due to haemodilution and an in­ microcirculation, cellular and subcellular components, as well as the im­
creased diffusion distance between red blood cells and tissues.10 mune system and its functions.29 Artificial intelligence has the potential
Additionally, fluids can exacerbate interstitial oedema and venous con­ to assist in the creation of algorithms, allowing clinicians to make more
gestion.9 Den Uil et al.64 demonstrated that administration of nitrogly­ informed therapeutic decisions regarding the therapy of microcircula­
cerine leads to a decrease in SVR and blood pressure but increase in tory impairments.29 The holistic approach of AI-based physiological
cardiac output as well as capillary density reflecting microcirculatory im­ models may provide targets for more effective therapeutic guidance
provement. The potential benefit of SGLT-2 inhibitors in treatment of of critically ill patients, including those suffering from cardiogenic shock.
cardiogenic shock is currently being investigated (EMPASHOCK).
Known for improving endothelial and microcirculatory function, these
inhibitors have shown significant outcome improvements in acute heart Conclusion
failure, including reduced mortality and symptom burden.65 There are
Cardiogenic shock remains a significant clinical challenge, particularly
heterogeneous study results regarding the impact of mechanical sup­
due to its high mortality rate and the critical role of microcirculatory
port systems on microcirculation in cardiogenic shock. Venoarterial

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impairments in its progression. Despite advances in macrocirculatory
extracorporeal membrane oxygenation (vaECMO) has been associated
management, effective integration of microcirculatory assessments in
with increases in PPV and perfused capillary density, among others.66
treatment is limited by current methods’ complexity and accessibility.
However, studies have indicated that increasing vaECMO flow does
not significantly affect microcirculation.67 Notably, a recent pre-clinical
study using an ovine model demonstrated that pulsatile vaECMO can Acknowledgements
improve microcirculation, suggesting that specific configurations of We acknowledge the support of the Susanne-Bunnenberg-Stiftung at
mechanical support may offer additional benefits.68 Recent findings the Düsseldorf Heart Center. Figure 1 was drawn in part using artwork
from the DanGer Shock study69 highlighted the significance of microax­ from Servier Medical Art (Servier, [Link] licensed
ial flow pumps in managing STEMI-related cardiogenic shock. Routine under a Creative Commons Attribution 4.0 Unported License. Figure
use of these pumps, alongside standard care, significantly reduced the 2 created in BioRender. Kanschik, D. (2024) [Link]/d37t800.
risk of all-cause mortality at 180 days compared with standard care
alone. In terms of microcirculation, Lam et al.70 reported that using a
microaxial flow pump in patients with acute heart failure led to in­
Funding
creased perfused capillary density and microvascular flow index, reach­ The authors acknowledge the support of the Deutsche
ing levels comparable to those in healthy individuals, while remaining Forschungsgemeinschaft (DFG, German Research Foundation)—grant
suboptimal in patients without mechanical support. Thus, effective no. 236177352–CRC1116; project B06 and grant no. 397484323–
treatment algorithms for optimizing microvascular tissue perfusion CRC/TRR259. Further institutional support has been received by the
are still lacking. The previously described mismatch between planned German Aerospace Center (DLR) and the German Federal Ministry
and actual treatment changes in the DAMIS trial can be seen more as for Economic Affairs and Energy (#50WB1714 and #50WB1914) as
a failure of the selected interventions than a failure of microcirculatory well as support via the Multi-Omics Data Science (MODS) project
monitoring.35 In the DAMIS trial, treatment decisions were made by the funded from the programme ‘Profilbildung 2020’ (grant no.
treating clinician. There was no fixed study protocol providing treat­ PROFILNRW-2020-107-A, State of North Rhine Westphalia).
ment guidelines tailored to the pathophysiology of the various shock Conflict of interest: None declared.
types. Consequently, the effective therapeutic measures identified in
the above-mentioned studies to improve microcirculation were not
consistently applied. Future efforts should focus on identifying effective Data availability
resuscitation protocols that integrate microcirculatory monitoring There is no data in this manuscript.
alongside standard haemodynamic parameters and standard therapeut­
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