the previous issue of critical care includes a report of a multicenter study in which cardiac index and gastric mucosal ph targets were compared during resuscitation of patients with septic shock . similar to all other hemodynamic variables with the exception of central venous oxygen saturation , the value of a cardiac index target in the resuscitation of patients in septic shock has not been established . in contrast , achievement of other goals in the treatment of septic patients ( for instance , early and adequate antibiotic treatment ) has been associated with improved outcomes . because ' normal ' systemic hemodynamics do not necessarily guarantee adequate tissue oxygen supply , monitoring organ perfusion or function it has been shown that persistent microcirculatory alterations are associated with organ failure and mortality in patients with septic shock . gastric mucosal ph ( phi ) is an interesting parameter that has been shown to predict outcome in many patient groups . phi is a composite variable that reflects not just adequacy of local perfusion but also systemic metabolic acid - base homeostasis and ventilation . the interaction of the components of phi and their response to treatment may confound the interpretation and prognostic relevance of gastric mucosal acidosis . in the study conducted by palizas and coworkers , resuscitation to a phi goal conceptually , there are four interpretations of these findings : the tested variables ( cardiac index and phi ) are not relevant to survival ; the defined targets were not adequate ; the targets were relevant but only in combination with the achievement of other goals ; and finally , the efforts to achieve the goals were not adequate , and the goal therefore was not achieved . cardiac output determines tissue oxygen delivery and is certainly an important variable with respect to the resolution of septic shock . however , other variables contribute to tissue oxygen transport , and the demands may also vary . in that sense , as the authors state themselves , a goal representing a presumed adequate relationship between oxygen delivery and consumption ( for example , mixed venous oxygen saturation ) would have been preferable . its strong association with mortality makes phi an ideal target variable for improving outcomes . in the study reported by palizas and coworkers , the target cardiac index was achieved at baseline in nearly 90% of patients . because the mortality was 30% , it is clear that the target should have been higher , if increasing cardiac index is believed to be beneficial . it is a relatively common practice to increase minute ventilation in order to normalize arterial ph when bicarbonate is low . whether a ( normal ) phi of 7.32 can be achieved at all during the early phase of septic shock is questionable . the use of vasoconstrictors can decrease mesenteric perfusion , and metabolic effects of adrenaline ( epinephrine ) may increase pco2 further . there is no information on how other aspects of septic shock treatment were addressed ( antibiotics , source control , ventilator settings , and so on ) the authors indicate that crystalloids and colloids were given , but in their protocol only saline is listed . although colloids can be harmful in sepsis , normal saline ( or colloids in saline ) can cause hyperchloremic metabolic acidosis and thereby decrease mucosal phi . adrenaline ( epinephrine ) , noradrena - line ( norepinephrine ) , dopamine , and dobutamine were used to improve blood pressure and flow . although adrenaline can impair splanchnic perfusion in septic shock , dobutamine appears to be able to reverse these changes , at least in part . phi was measured every 6 hours , and no data are given on the frequency of cardiac index assessments . four daily assessments of the treatment 's influence on the target variable may be too few , especially in view of the fact that splanchnic blood flow is highly variable in septic patients . it would have been interesting to see how the individual therapeutic interventions influenced the target variables . without this information , nevertheless , the work by palizas and coworkers   reminds us that mucosal acidosis persists in the majority of patients who ultimately will die after resuscitation from septic shock . monitoring and treating cardiac output determines tissue oxygen delivery and is certainly an important variable with respect to the resolution of septic shock . however , other variables contribute to tissue oxygen transport , and the demands may also vary . in that sense , as the authors state themselves , a goal representing a presumed adequate relationship between oxygen delivery and consumption ( for example , mixed venous oxygen saturation ) would have been preferable . in the study reported by palizas and coworkers , the target cardiac index was achieved at baseline in nearly 90% of patients . because the mortality was 30% , it is clear that the target should have been higher , if increasing cardiac index is believed to be beneficial . in contrast , the incidence of low phi was high . however , the variable is influenced by arterial carbon dioxide tension ( pco2 ) . it is a relatively common practice to increase minute ventilation in order to normalize arterial ph when bicarbonate is low . thus , the mucosalarterial pco2 gradient would have been a better choice . whether a ( normal ) phi of 7.32 can be achieved at all during the use of vasoconstrictors can decrease mesenteric perfusion , and metabolic effects of adrenaline ( epinephrine ) may increase pco2 further . there is no information on how other aspects of septic shock treatment were addressed ( antibiotics , source control , ventilator settings , and so on ) the authors indicate that crystalloids and colloids were given , but in their protocol only saline is listed . although colloids can be harmful in sepsis , normal saline ( or colloids in saline ) can cause hyperchloremic metabolic acidosis and thereby decrease mucosal phi . adrenaline ( epinephrine ) , noradrena - line ( norepinephrine ) , dopamine , and dobutamine were used to improve blood pressure and flow . although adrenaline can impair splanchnic perfusion in septic shock , dobutamine appears to be able to reverse these changes , at least in part . phi was measured every 6 hours , and no data are given on the frequency of cardiac index assessments . four daily assessments of the treatment 's influence on the target variable may be too few , especially in view of the fact that splanchnic blood flow is highly variable in septic patients . it would have been interesting to see how the individual therapeutic interventions influenced the target variables . without this information , nevertheless , the work by palizas and coworkers   reminds us that mucosal acidosis persists in the majority of patients who ultimately will die after resuscitation from septic shock . monitoring and treating the department of intensive care medicine at inselspital has or has had research contracts and/or collaboration contracts with edwards lifescience , ge healthcare , pulsion , orion pharma , berna biotech and b. braun medical .