Volume 18
Number 5
Dec 2014
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Review
A. Lima

The early descriptions of abnormalities in the peripheral circulation date back to the 18th century during the American Civil War when the British surgeon Jordan Furneaux wrote what is considered to be one of the first elaborate descriptions of abnormalities in the peripheral circulation during shock. However, one of the earliest references to the dynamic component of the peripheral vascular bed is the work of the Danish scientist August Krogh, in the 1920s. His work was followed by a new generation of clinical investigators such as the American physiologist Carl John Wiggers, who introduced the term ‘peripheral circulation failure’ in his experimental studies of haemorrhagic shock. The introduction of the mercury sphygmomanometer in 1896 and the first performance of right heart catheterisation in 1929 contributed to a great extent to the understanding of the pathophysiology of shock and the associated haemodynamic changes. Over time, pathogenic theories have evolved, providing a better understanding of regulatory mechanisms for the central and peripheral circulation during the state of shock. The connection between hypotension and peripheral vasodilatation in ‘vasodilatory shock’ was first published in a review by Gilbert in 1960, who was the first to provide evidence of heterogeneous distribution of peripheral blood flow in sepsis. With his experiments in the 1960s, physiologist Arthur Clifton Guyton described the behaviour pattern between peripheral circulation within organs and systemic circulation during acute shock. In the early 1970s, critical care medicine emerged and sophisticated haemodynamic methods of monitoring were introduced, which allowed physicians to understand the relationship between changes in the peripheral circulation and the prognosis of shock. The introduction of gastric tonometry in the 1990s signalled the ability to measure gastric perfusion, and opened a window to systematically assess regional perfusion in patients with shock, proving the concept that the peripheral circulation is the first to deteriorate and the last to reperfuse during cardiovascular collapse. During the last few years, studies have focused on monitoring other vascular beds also susceptible to hypoperfusion, such as skin, subcutaneous tissue and muscle. Progression in the understanding of the role of peripheral circulation in haemodynamic regulation during shock has led to the application of different investigative techniques to continually monitor peripheral circulation in the critically ill patient.


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