SCCMPod-569: From Monitoring to Personalized Medicine

Dr. McLaughlin: Hello, and welcome to the 2026 Congress edition of the Society of Critical Care Medicine podcast. I'm your host, Diane McLaughlin. Today, I'm speaking with Dr. Michael R. Pinsky, MD, FAPS, MCCM, about the Max Harry Weil Honorary Lecture, The Effective Management of Shock, Moving from Physiology to Guidelines to Precision Medicine and Ultimately Personalized Medicine. Dr. Pinsky is a professor of critical care medicine, bioengineering, and anesthesiology at the University of Pittsburgh. He's also a doctor honoris causa at the University of Rene Descartes.

Dr. Pinsky: University of Paris, Rene Descartes. So it's a sort of all.

Dr. McLaughlin: Ah, okay. Very impressive. So you're going to teach me French too, right?

So in 2012, you became one of the first 20 critical care physicians to receive Master of Critical Care Medicine. You are also currently an emeritus honorary attending at UPMC, vice chair emeritus department of critical care medicine, as well as faculty member of the Center for Critical Care Nephrology and Center for Military Medicine Research. You have time for us, thank you! So welcome.

And before we start, do you have any disclosures to report? And I remember seeing a little list, so pick your favorites here.

Dr. Pinsky: Really, I'm a consultant or have been in the past every now and you and I laundering company. And back in the days of the sepsis discoveries to all the drug companies, that's the drug company. Things have kind of fallen away, but I'm still a consultant and I help with the evaluation of new monitoring devices. And when I see them, I talk to them and that's all of them. Edwards, which has now been Dixon, Massimo that was just eaten last week by some other company. And this is happening.

And when they want me to evaluate something, I tell them I start this with this. When we had our initial meeting in Brussels on functional hemodynamic monitoring, for which we wrote a textbook, and I brought in all these experts from around the world that had their own special monitoring devices and things to measure. And I said, we all must agree on one thing before we start this symposium.

I said, no monitoring device, no matter how accurate or insightful its data will improve patient outcome, unless coupled to a treatment, which itself improves patient outcome. So you might be able to tell me very accurately that someone is going to die, but I don't need deathometers. I need things to predict how I'm going to make a patient better and then make them better.

And so the focus on all monitoring should be to prevent further deterioration and to optimize the recovery back to health.

Dr. McLaughlin: So that's actually a great way to get started. It feels like we have all of these buzz terms that are coming around. And when I first heard precision medicine, to me, that seemed a little bit obvious.

Isn't everything that we're trying to do to help somebody supposed to be somewhat precise? What is precision medicine and how do we use the tools we have to achieve that?

Dr. Pinsky: Well, let's take a step back to the first thing you said, which is wrong. You think that everything we do is precise and that's absolutely not true. The original Surviving Sepsis guidelines had this ridiculous statement that you had to give 30 mls per kilogram to every patient.

Your circulating blood volume is 45 milligrams per kilogram, mls per kilogram. So you're basically giving two thirds of the blood volume right back to a person. Okay.

And number two, you're treating vasoplegia in sepsis, which is increasing unstressed volume. The management should be vasopressors. Yes, they need some fluids, but you want to restore the normal vasomotor tone.

And if you just get fluids to do it, I assure you, you'll get volume over them. So to start with the first statement, there's a lot of things we do that are not precise.

Dr. McLaughlin: Should they be?

Dr. Pinsky: Yes.

Dr. McLaughlin: Okay.

Dr. Pinsky: As your colleague said, who knew me when he was a fellow, not only do I love to teach at the bedside because you're teaching on a specific patient to treat that patient specifically, but you're looking at the same time at their response to therapy. I'm not so arrogant as to tell you what the patient's going to do, but I am observant enough to watch how they respond. And if I realize I've done the wrong thing to stop it, and this is an important part of precision medicine, it's the titration of care.

And I give as an analogy, a person driving a car. And if all you saw were the person's hands on the wheel and feet on the brakes and the gas, you'd say, what is this person doing? They're stepping on the gas.

They're stepping on the brake. They're turning right. They're turning left.

All I told them was I want to go from here to school and they're changing everything. And the person looks at you and they say, every second, the condition we're dealing is changing and I have to adapt to it or we're going to have a car accident. That is no different than a patient.

So if you do continually the same thing in every patient, you're going to have a lot of car accidents.

Dr. McLaughlin: So a lot of our care is algorithmic or based on protocols. Based upon what you just said, do you think the time for that, we're past that and we need to be thinking more about how each individual responds?

Dr. Pinsky: Well, if you recall in my last summary slide, I said that protocolized care simplifies what's going on. If you don't know what you're doing, use a protocol because the protocol is something that very smart people have developed. And though it won't be individual, it will be pretty good.

And so for example, when you have very junior people or the example that Phil Dellinger gave me when he first posed with others, the Surviving Sepsis guidelines, and I railed against what he was saying. And he said, Michael, we didn't write them for you. You know what you're doing. It's for the emergency room doctor that sees two septic shock patients a year and you want to give them an immediate thing to do. No, it is of course not right for all of them. But what happened is, is they get codified and almost like written by the hand of God and you get punished if you don't do them the right way, when in fact you're punishing people for thinking sometimes.

And so to get back to that point, we should always be titrating care to the response of the patient to the pathology and the causes of disease to make them better. In the operating room, anesthesiologists do this all the time with the level of anesthesia they give. They don't give the same level of isoflurane to every single patient. And that would kill a lot of people. And so they titrate their anesthesia and the LGs and everything else relative to the stress of the patient, where they are in the operation, et cetera, depending on the type of operation, what may happen later, especially cardiac surgery or bypass and things like that. So the titration of care is a fundamental part of acute care medicine.

And the reason why intensive care units were invented wasn't for us. It was for nurses to allow them to titrate the care that needed to be done at the bedside, because it often needed to be done on a moment-to-moment basis. We're just window dressing.

It's the nurses that are taking care of the patients. And so we have to make sure, and I always include nurses on rounds and have for the last 45 years. They didn't like it initially because they said, leave us alone. We're doing our stuff. And I said, this is your patient. Join us in rounds. You know your patient better than anyone in this room. Stay here for this. And they would contradict us when we said we're doing this. No, we're not. We're doing that. Thank you.

Dr. McLaughlin: That's great.

Dr. Pinsky: It's a team effort. Later, and by the way, there was pushback initially by nurses. And when we tried to get a pharmacist to join us, there was major pushback from the pharmacy because they have other things to do.

I was trying multidisciplinary rounds from the very beginning, not because I was trying to be a visionary. It was just the right thing to do.

Dr. McLaughlin: That everybody had their own points that they could add.

Dr. Pinsky: And they're professionals. Nobody goes into the hospital and says, today, I'm going to practice bad medicine.

Dr. McLaughlin: Nobody.

Dr. Pinsky: But if you do something wrong, it's often because you have incomplete information or even misunderstanding of what you're doing. And to the extent that we can minimize that, and one of the things that protocols do is that minimizes random behavior. And I understand the logic of that.

But what we really want to do is to train intensivists to understand the pathophysiologic basis of what they're treating. And then the titrates, the care that they see, the response based on that foundation, but understanding that this patient may quote, like a CVP of four or mean arterial pressure of 80. There's no book I can write that will tell me what title volume they like.

And so on rounds, when you were given someone else was recruiting to you, they will say, this patient likes that. In other words, their physiology is such that that's what they want. And that's because you're an observant doctor.

And the example that I gave in my lecture was that Manny Rivers, who had been one of our fellows, went back to Detroit after he'd been trained by Jim Snyder, the late Dr. Jim Snyder. And he said, when he came back as an honorary alumni lecturer, he said, I just did what Jim Snyder and Michael Pinsky told me. If a patient is in shock, get them out of shock and as fast as you can, which was true.

He says, when we had patients in the emergency room, we diagnose the stuff, start antibiotics, give them a liter, in those days, saline, which was wrong, but we didn't know, and call the health staff on the floor, and they go on to the next patient. And we would come back and look at them. And two hours later, they're still sitting in the emergency room, in a back room, nobody looking at them, in septic shock.

I said, we have to do something. And so define, do something. He invented his algorithm, which was the central venous zone to SAT, blood pressure to 165, CVP to 8 to 12, and a hemoglobin greater than 10, because a lot of his inner city people were profoundly anemic.

Well, what he really did is he had a doctor at the bedside seeing the patient. So what they did was less important than the fact that they did what they were supposed to do, whatever it was. So when the ARISE, ProCESS, and I can't remember the third one, clinical trials were done from Australia, England, and centered out of the University of Pittsburgh, Derek Angus and David Huang ran it for our group, but it was a multi-centered study.

They show that all forms of process in a community-acquired pneumonia sepsis in the emergency room, if you had a doctor from the ICU, see him immediately, the results were identically the same, they were all good. So in essence, Manny Rivers won, because he said, what you really want is a doctor at the bedside, observant of the patient and treating them accordingly.

And so I have given several lectures over the last 45 years to the Society of Critical Care Medicine. And if it has to do with resuscitation, almost the first thing I say is nothing I'm going to tell you is going to exclude the importance of having a trained intensivist at the bedside, observing the patient's response to treatment and titrating it to their needs. As I start every lecture, because that is a true statement. And we always forget it when we create protocols and stuff.

And I'm not trying to denigrate the protocols. I'm very impressed with the effort that everyone is doing, because the evidence out there, especially with this explosion of publications, makes it impossible for a hardworking intensivist to keep up to date on all the literature. No one would expect them to.

So that's why the Society of Critical Care Medicine and other societies with their guidelines are so important. But it should never supersede an understanding of pathophysiology at the bedside of observing your patient.

Dr. McLaughlin: And when we're talking about observing the patient, really this titration that occurs is based upon physiologic parameters. Which physiologic parameters do you feel like are the most important or even the most underlooked? Because a lot has come out and then we kind of go the opposite direction, CVP targets, or.

Dr. Pinsky: One of the things that has bothered me is people say, Dr. Pinsky told me CVP is useless. Dr. Pinsky never said CVP is useless. I said CVP cannot assess volume status or volume responsiveness.

From guiding physiology, it has nothing to do with those. It does tell you you have right heart failure. And if it's high, it tells you you've got venous hypertension, and that's terrible.

So those two things it’s good for. And in fact, for example, we've shown and others that if you're giving fluid bolus and the CVP goes up by two millimeters of mercury, you should stop, reassess the patient, because what it's showing is the right heart can't handle that volume, or at least not that fast. So let's go back to what you said about monitoring.

I said you had to observe the patient. Well, I left my x-ray vision goggles at home. I don't have them with me.

And I don't bring them usually into the ICU, the nurses get upset. So the point is, how do I look at the patient independent of just my eyes? And this is where the stethoscope, ultrasound, and hemodynamic monitoring come in.

And the advantage of hemodynamic monitoring is it's continuous. The mantra should always be continuous, metabolic, noninvasive. To the extent that we can do all three of those things, there's less complications and more chance to pick up things early on.

We often can't get away with the noninvasive, because certain things can't be measured otherwise. For example, pulmonary hypertension, right heart failure, ARDS oftentimes, you're really stuck. You need to have a central line, even a pulmonary catheter or a transpulmonary catheter. And we publish that in guidelines.

But for most patients, they come in. I can be very minimal. I like to have a continuous arterial pressure waveform from an arterial catheter or a cuff or whatever you have, if it's reliable, because the information you get on it is more than mean arterial pressure. Pulse pressure is a surrogate for stroke volume, because from one heartbeat to the next, the only determinant of a change in pulse pressure is a change in stroke volume, period. Because none of the other things, the impedance, resistance, viscosity, but the change between one heartbeat to the next.

And that's the reason why changes in pulse pressure and systolic pressure were discovered by Socrates and the other people as a method of determining tamponade. They called it Pulse's Paradoxes. And that was done in antiquity.

So to answer your question, we need to observe the patient. But to do that, oftentimes, we need to look into beside them. And for that, we need hemodynamic monitoring.

And we need whatever hemodynamic monitoring the patient needs, but no more. So it should always be titrated to the patient's response. A significant number of patients, you just give them a little bit of fluid, because they're slightly hypoglycemic, maybe a touch of norepinephrine, and they normalize.

At that point, you say, let's not turn it off. Let's hold them here, allow the antibiotics to do what they were supposed to do, which is a real treatment for septic shock. But when it's finally cleared and the inflammatory process goes down, because everything will go down eventually if you stop the initiating process, then we can taper them off and they're fine.

And we haven't given them excessive volume, we haven't given them excessive pressures. So that's going to be 80% of the patients who come in in sepsis. But if they progress to organ failure, that septic shock, and in those, the mortality rate goes much higher, and their response to simple things like that aren't so lucky.

And in those patients, you have to have some sort of framework in your own mind, which can be a protocol from the hospital that says, at this point in time, I need more information to titrate care personally to this patient. And that's when the other monitoring, or echo, or x-rays, or whatever it is, or even consultants, are necessary, depending on the specific thing. Trauma, for example, in having a neurosurgeon see a person, because they're having traumatic brain injury, and you're wondering what should be the targets for the cerebral perfusion pressure based on bleeding versus subcutaneous pressure.

So every patient is different. And so to make a single solitary recommendation would be ludicrous.

Dr. McLaughlin: Septic shock is the prime example here. You mentioned in one of your slides yesterday that we have these subtypes of shock that, in theory, would be great if they all lived in isolation. But the truth is, how often does that actually occur?

Dr. Pinsky: Well, the last time I looked, the body didn't read a textbook. So the body does what the body will do. And the human body, or any animal, evolved a healthcare system for itself inside that has to do with immunity, inflammation, coagulation to survive.

And it didn't ever think there were doctors, nurses, medicines, or fluids given to it. You accept that as being true, right? So the body only was able to respond to two things, hypovolemia, which was often trauma, or being bit by a saber-tooth tiger, or minor infections.

So the two things the body does very well is infection control and hypovolemia. If your infection gets so far along, the immune system responses you get become systemic and disruptive, and you are supposed to die. I'll remind you that pneumococcal pneumonia in the 1800s had an 80% mortality rate in elderly people, okay? It was the old man's friend. You were supposed to die from it. And in fact, in animals, it's the same way.

It maintains herd vitality that a sick animal dies quickly, because the natural thing of all animals is to help and protect a sick animal as part of their group. The other thing that the body has absolutely no defense for is venous hypertension. Volume overload is not anything that in evolution the body has ever seen. It has no defense for it. It can only pee out so much fluid at the most, and the massive salt overload we give to patients is why sometimes we have to squeeze it ourselves using diuretics or even dialysis, okay?

And I said one other thing once, and that is that I've never in my life treated a patient for acute lung injury or acute renal failure. I have absolutely no idea how to fix the lungs or the kidney, but I've supported mechanical ventilation and gas exchange, and I've maintained the homeostasis that the blood has or give dialysis, but sometimes that makes the lungs and the kidney respectively worse.

So I've never treated those diseases. I let the body do that. I just try to take away the insults that caused it and hope that the body can make it do better, and usually it does. So another aspect of monitoring is to just do what you're supposed to do and not more, okay? And this is where precision medicine becomes important.

One of the very, very first things we said in our first paper, I'll just go back a step. As you know, pulse pressure variation and stroke flammation are called dynamic parameters, and they predict volume responsiveness extremely accurately, and they've been shown in almost now 1,000 papers, and they're recommended by all the societies, not just SCCM, but Surviving Sepsis, American College of Sepsis, the European Society, all of them. Fine.

All they are is their statement of cardiovascular reserve. If I intubated you right now awake, and we put you here and said, relax, let me give you a 6 ml per kilogram of tidal volume, you would have a pulse pressure variation at 25% because you're a normal person, and that's your cardiovascular reserve. So I said years ago, and we said in the first paper we wrote in 1999, what we're defining is cardiovascular reserve and the response to fluids.

If you are in shock, and you have a pulse pressure variation greater than 15%, please give that person volume because cardiac output will go up, but normal people have a pulse pressure variation greater than 15%, and you shouldn't be giving them fluids. So the first statement is if you're in shock.

Dr. McLaughlin: Yeah.

Dr. Pinsky: The second is if you're in shock, and your pulse pressure variation is less than that, please don't give them fluids because you'll get no benefit, but you'll get all the detriment of volume. And in the very first paper, we said the most important thing of this paper is to show when you should not give fluids because the patient is not volume responsible. That's what we said in the very first paper in 1999.

And it's a fundamental truth. The last thing we want to do is harm.

Dr. McLaughlin: It's funny, I feel like there was a long period of time, we didn't do a great job listening to that. And it was always more is better. As you have alluded to, it seems to be a motto.

Dr. Pinsky: It's a philosophy of life. Yeah. By the way, that's human nature.

Dr. McLaughlin: Yes.

Dr. Pinsky: I don't know if you have any children, but my wife was always excited when my son and daughter would eat more food and give them more. I said, I'll find a way to get some more food in them. And I'm saying, okay, that's what you want to do.

It's because there's this feeling that, you know, the kids aren't eating, they'll eat more, all the kids grew just fine. But the fact is, it's a normal human desire for people we care about. And we care very much about our patients to do more because we feel more is good.

And the answer is more is not good most of the time. In turn, hyperfeeding, very dangerous in the ICU patient. Well, volume overload, high levels of vasopressors, all these things are very bad. Large tidal volumes make great big breaths, very bad for the lungs.

So what makes you feel good as a doctor, because you think you're doing something healthy for the patient, if you understand the pathophysiology disease, you wouldn't be doing it. This is one of the strengths of guidelines.

By the way, people talk about low tidal volume ventilation, 6 mLs per kilogram. That's a bunch of baloney. A normal tidal volume, right now you're breathing at 6 mLs per kilogram.

You are. That's not low, that's normal. But you yourself right now have got about an 8 or 10 mL per kilogram tidal volume from time to time. And a couple of 2 or 3 mLs, you have a chaotic version of breathing. We all do. You can tolerate big breaths and blow them out and have like a 20 mL per kilogram breath. You didn't die, but you wouldn't want to do that every single breath. So it's relative.

As a matter of fact, one of the forms of ventilation that was tried back in the 90s that worked very well was a form of chaotic ventilation in which they changed the peak level slightly between breaths and tidal volumes between four and eight. And it was done in such a way that the lungs were breathing and they found in human beings that the gas exchange was much better and the cardiovascular output was better because it matched more because you were recruiting units, but then you weren't over-distending, etc.

Dr. McLaughlin: So why don't we do that?

Dr. Pinsky: Because it requires special algorithms on the computers and no one ever got FDA approval to do it. Besides, the difference was minimal.

Dr. McLaughlin: Do you think as we've gotten better at this, where do you draw that line between we can keep a body going indefinitely versus this is your pneumococcal pneumonia and this is your time?

Dr. Pinsky: Well, the natural endpoint of life is death. And as I say to the medical students, and you can put this on the record too, because I published this in Intensive Care Medicine, life is a sexually transmitted terminal disease. I assure you it's sexually transmitted and I assure you, you're patient and you are both going to die.

So if you think you're saving lives, you're merely postponing death. What you're really doing is you're maximizing the quality of life within the context of health. And it's not your definition of quality that matters, it's the patient's.

So at all times, you're a consultant to the patient on maximizing their quality of life within the ability you have as a doctor or nurse or whatever, healthcare professional. So you're always a consultant to them. So there is such a thing as a bad life and there's such thing as a good death.

In most patients, when they get older, amongst their family, whenever they're talking, they say, no, I don't want to be in a ventilator forever if he can't get me off. No, I don't want to be on machines. They're very adamant about it.

But the family members say, I don't want to leave. And so we're dealing with this dynamic. One of the things that I've always done in patient conferences say, we're all on the same side. I want this person to survive and be happy and accomplish everything they want. And so they'll say, we'll see what we can do. But if we can't, we can't. And if that's the case, we don't want to torture them.

And so I've had very few times where there's been recalcitrant people who have been part of the conversation. The times we've had recalcitrant people is the brother coming in from Denver or something that hadn't been there for three weeks. He comes in and says, or she, whatever, they're coming from someplace else. They hadn't been part of any of these conversations. And they come in as they think the white knight to save their uncle, father, whatever. They can fill in the name. And the point is they weren't part of that process. And so usually we have to take a step back and have them be part of it.

And as long as they realize that we have the exact same goal they do, which is the best we can do for that patient. Because we do.

Dr. McLaughlin: We do.

Dr. Pinsky: I'm not being hypocritical. We do. Then they realize we're on their side too, because we are.

And if we can't do it, the last thing we want to do is hurt them.

Dr. McLaughlin: I think that's a really important point to make as we have more and more precision tools and that we understand physiology better and better and better.

Dr. Pinsky: Well, an example of that, the late Dr. Ake Grenvik was part of the presidential council on identifying brain death. And the other thing Dr. Grenvik did, who was one of the first presidents of SCCM, and he's one of the founding fathers of the Society. And he was a close friend of mine up until the day he died, because he was the University of Pittsburgh. We wrote several papers together. He was an absolutely brilliant, compassionate man.

And he said to me that when we created, and he was part of the group that created mechanical ventilation, all of a sudden people who would have died could live. And we now had to make a decision. Who should we do this for? Because some people are supposed to die. And all we're doing is postponing death and not helping them. And he said, so for the first time, and this is us, this is you and me, the first time we had to make a decision on a moral level. What was the appropriate thing to do for the person?

Now, what we do, as you know, realistically, is we always opt for life if we don't know. And then later come back and say, okay, they didn't want this, and we withdraw. I understand.

And that's what we should do. But he was the first to write that as a critical care doctor, now we actually have a decision to make. And being a person who deals with ECMO and various other forms of CVVH, et cetera, I can keep almost anyone alive, almost indefinitely.

And that's good if they've got reversible stuff. It's terrible if you're trying to torture them to death.

Dr. McLaughlin: So that's a strange note to end on. Do you have any other last pearls of wisdom to anybody listening?

Dr. Pinsky: No, we're probably in, as physicians, nurses, healthcare people, we really have a higher calling within society, because we treat all people and we get personal to them very quickly in a way that no one else in the world would to that person. You would not be that close to your lawyer or person, but if I'm there for your health, you're going to be very honest with me, hopefully, and we're going to be into a personal space very quickly. That is a sacred trust that as healthcare professionals, we cannot violate.

And that means that in critical care medicine, think about it, a large number of doctors and nurses and people are afraid to walk into the ICU. We live there. What is it like if you're a patient's family and you're from, you know, you're doing something else and they're in that ICU, they're scared to death.

We have an obligation to comfort and care for them as well. And so I love patient care conferences because it allows us to help them realize what's happening in this very, very foreign. And so the last thing I would say is that we as healthcare people have an obligation to our patients and their families to allow them to understand what's going on and stewardize, be the stewards of their care, as we go through and to make them feel better as we go through that path, which may end at the end in death.

Dr. McLaughlin: Well, it's been a pleasure talking to you. I feel like we could actually probably do a podcast that lasts, you know, several hours and people would be very interested in hearing. But for now, this will conclude another episode of the Society of Critical Care Medicine podcast. 

If you're listening on your favorite podcast app and you liked what you heard, consider rating and leaving a review. For the Society of Critical Care Medicine podcast, I'm Diane McLaughlin.

Announcer: Diane C. McLaughlin, DNP, AGA, CNP, BC, CCRN, FCCM, is a neurocritical care nurse practitioner at University of Florida Health Jacksonville. She is active within SCCM, serving on both the APP resource and ultrasound committees, and is a social media ambassador for SCCM.

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