Mark Wefers Bettink

Mind the mitochondria! 2 29 Table 1 The COMET different measurement types. Single measurement One measurement per activation of the touchscreen non physical button. Interval measurement The COMET will measure in a set interval: At the start of the interval a measurement is done, and the interval time can be chosen (60 min, 20 min, 5 min, 1 min) Dynamic measurement The COMET can conduct a series of up to 120 measurements, one measurement per second. Hemodynamic coherence Resuscitating critically ill patients from different states of shock is key and remains a challenge in critical care. Currently, the main focus is on administration of fluids and vasoactive medication, targeting the normalization of systemic hemodynamic parameters such as blood pressure, cardiac output and venous saturation. However, many randomized trials have failed to show a consistent difference between patient groups that were compared based on interventions directed at these systemic hemodynamic variables (62-66). This could be due to the trial design and trial execution, the intervention, or the heterogeneity of the population. Alternatively, our interventions aimed at improving cellular oxygen delivery might fail to do so or cells were not able to use the delivered oxygen appropriately. Therefore, to further our knowledge about which intervention most benefits the patient, we will need a more physiological, mechanistic and comprehensive approach. Shock is a condition in which oxygen delivery to the cells and mitochondria is insufficient to sustain cellular activity and thus organ function. We therefore should add targeting microcirculatory and mitochondrial function to our conventional resuscitation targets (i.e. systemic variables). Particularly, we should study whether the condition of shock is already a condition in which systemic andmicrocirculatory and cellular measures diverge. We also have to study whether our interventions aimed at improving the systemic hemodynamic parameters of a patient are actually improving or maybe worsening our patients microcirculatory and mitochondrial function. Therefore, we should focus on and study this coherence of the macro- and micro and cellular situation with respect to diagnosis and effect of therapeutic interventions. Hemodynamic coherence is thecoherencebetween themacrocirculation,microcirculation and the parenchymal cells, in which resuscitation procedures aimed at the correction of hemodynamic variables are effective in correction of regional and microcirculatory