Cris Polma

🫀🤓Pressure does not move blood. Energy does. This outstanding review challenges one of the most deeply rooted concepts in haemodynamic management: the idea that pressure variables are the primary drivers of circulation. Instead, the authors propose a physiology framework where the heart supplies energy, the vasculature defines constraints, and pressures merely reflect system state. Several concepts deserve special attention for critical care clinicians: • Mean systemic pressure does not “drive” flow • Right atrial pressure is a dependent variable, not a therapeutic target • Venous return depends on inflow acceptance and inlet impedance • Raising pressure without improving flow may worsen congestion • Shock should be interpreted as either impaired venous delivery or impaired cardiac acceptance Clinically, this framework helps explain why: • CVP-guided fluid loading often fails • Vasopressors may normalize MAP without restoring perfusion • Congestion can coexist with preserved arterial pressure • Flow responsiveness matters more than static pressure targets One of the strongest messages of the paper is simple but powerful: “Pressure is not perfusion.” For intensivists, anesthesiologists, and cardiogenic shock teams, this review is worth reading in full. It reconnects bedside haemodynamics with first-principles physiology. Miller A, Anaesthesia. 2026. doi.org/10.1111/anae.70238