• Kyle J. Gunnerson
  • Emanuel P. Rivers


Evolving knowledge of critical illness has greatly influenced our understanding of shock and how we define it. The first century Roman savant Aulus Cornelius Celsus made the following observation, “When much blood is lost, the pulse becomes feeble, the skin extremely pale, the body covered with a malodorous sweat, the extremities frigid, and death occurs speedily.” In 1737, French surgeon, Le Dran, introduced the term “choc” to describe a severe impact or jolt, which was later adapted by Clarke, an English physician who used the term “shock” to describe the rapid physiological deterioration of a badly injured trauma victim. Historic advances in medicine, specifically the ability to measure blood pressure, changed the meaning of the term “shock” to denote arterial hypotension associated with hemorrhage. Later in the first part of the twentieth century, great physiologists such as Keith, Cannon, Blalock, and Cournard introduced the notion that tissue hypoperfusion, rather than isolated arterial hypotension, was the key feature of hemorrhagic shock. The contemporary understanding of shock is generally regarded as a syndrome precipitated by a systemic derangement of perfusion (global tissue hypoperfusion) that leads to widespread cellular dysoxia and vital organ dysfunction. Furthermore, by acknowledging that acquired derangements in mitochondrial function can impair cellular energetics, shock can be even more broadly defined as an acute physiological derangement resulting from the inadequate production of adenosine triphosphate (ATP) by cells in many organs of the body.


Spinal Cord Injury Right Ventricular Mean Arterial Pressure Cardiogenic Shock Hemorrhagic Shock 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Pinsky MR. Cardiovascular issues in respiratory care. Chest. 2005;128:592S–597S.PubMedCrossRefGoogle Scholar
  2. 2.
    Beyar R, Halperin HR, Tsitlik JE, et al. Circulatory assistance by intrathoracic pressure variations: optimization and mechanisms studied by a mathematical model in relation to experimental data. Circ Res. 1989;64:703–720.PubMedCrossRefGoogle Scholar
  3. 3.
    Crowell JW. Oxygen debt as the common parameter in irreversible hemorrhagic shock. Fed Proc. 1961;20:116.Google Scholar
  4. 4.
    Crowell JW, Smith EE. Oxygen deficit and irreversible hemorrhagic shock. Am J Physiol. 1964;206:313.PubMedGoogle Scholar
  5. 5.
    Dunham CM, Siegel JH, Weireter L, et al. Oxygen debt and metabolic acidemia as quantitative predictors of mortality and the severity of the ischemic insult in hemorrhagic shock. Crit Care Med. 1991;19:231–243.PubMedCrossRefGoogle Scholar
  6. 6.
    Rixen D, Siegel JH. Metabolic correlates of oxygen debt predict posttrauma early acute respiratory distress syndrome and the related cytokine response. J Trauma. 2000;49:392–403.PubMedCrossRefGoogle Scholar
  7. 7.
    Rixen D, Raum M, Holzgraefe B, et al. A pig hemorrhagic shock model: oxygen debt and metabolic acidemia as indicators of severity. Shock. 2001;16:239–244.PubMedCrossRefGoogle Scholar
  8. 8.
    Shippy CR, Appel PL, Shoemaker WC. Reliability of clinical monitoring to assess blood volume in critically ill patients. Crit Care Med. 1984;12:107–112.PubMedCrossRefGoogle Scholar
  9. 9.
    Shoemaker WC, Appel PL, Kram HB. Tissue oxygen debt as a determinant of lethal and nonlethal postoperative organ failure. Crit Care Med. 1988;16:1117–1120.PubMedCrossRefGoogle Scholar
  10. 10.
    Reilly PM, Wilkins KB, Fuh KC, Haglund U, Bulkley GB. The mesenteric hemodynamic response to circulatory shock: an overview. Shock. 2001;15:329–343.PubMedCrossRefGoogle Scholar
  11. 11.
    Chien S. Role of the sympathetic nervous system in hemorrhage. Physiol Rev. 1967;47:214–288.PubMedGoogle Scholar
  12. 12.
    Cumming AD, Driedger AA, McDonald JW, et al. Vasoactive hormones in the renal response to systemic sepsis. Am J Kidney Dis. 1988;11:23–32.PubMedGoogle Scholar
  13. 13.
    Marik PE, Zaloga GP. Adrenal insufficiency in the critically ill: a new look at an old problem. Chest. 2002;122:1784–1796.PubMedCrossRefGoogle Scholar
  14. 14.
    Givertz MM. Manipulation of the renin-angiotensin system. Circulation. 2001;104:E14–E18.PubMedCrossRefGoogle Scholar
  15. 15.
    Jan Danser AH. Local renin-angiotensin systems: the unanswered questions. Int J Biochem Cell Biol. 2003;35:759–768.CrossRefGoogle Scholar
  16. 16.
    Zingg H, Bourque C, Bichet D. Vasopressin and oxytocin: molecular, cellular and clinical advances. New York: Plenum Press; 1998.CrossRefGoogle Scholar
  17. 17.
    Normon AW, Litwack G. Hormones. 2nd ed. San Diego: Academic Press; 1997.Google Scholar
  18. 18.
    Landry DW, Oliver JA. The pathogenesis of vasodilatory shock. N Engl J Med. 2001;345:588–595.PubMedCrossRefGoogle Scholar
  19. 19.
    Gann DS, Carlson DE, Byrnes GJ, Pirkle JC Jr, Allen-Rowlands CF. Role of solute in the early restitution of blood volume after hemorrhage. Surgery. 1983;94:439–446.PubMedGoogle Scholar
  20. 20.
    Bond RF, Johnson G III. Vascular adrenergic interactions during hemorrhagic shock. Fed Proc. 1985;44:281–289.PubMedGoogle Scholar
  21. 21.
    Szabo C, Billiar TR. Novel roles of nitric oxide in hemorrhagic shock. Shock. 1999;12:1–9.PubMedCrossRefGoogle Scholar
  22. 22.
    Patel JP, Beck LD, Briglia FA, Hock CE. Beneficial effects of combined thromboxane and leukotriene receptor antagonism in hemorrhagic shock. Crit Care Med. 1995;23:231–237.PubMedCrossRefGoogle Scholar
  23. 23.
    Salzman AL, Vromen A, Denenberg A, Szabo C. K(ATP)-channel inhibition improves hemodynamics and cellular energetics in hemorrhagic shock. Am J Physiol. 1997;272:H688–H694.PubMedGoogle Scholar
  24. 24.
    Szabo C, Salzman AL. Inhibition of ATP-activated potassium channels exerts pressor effects and improves survival in a rat model of severe hemorrhagic shock. Shock. 1996;5:391–394.PubMedCrossRefGoogle Scholar
  25. 25.
    Landry DW, Oliver JA. The ATP-sensitive K+channel mediates hypotension in endotoxemia and hypoxic lactic acidosis in dog. J Clin Invest. 1992;89:2071–2074.PubMedCrossRefGoogle Scholar
  26. 26.
    Palmer RMJ. The discovery of nitric oxide in the vessel wall: a unifying concept in the pathogenesis of sepsis. Arch Surg. 1993;128:396–401.PubMedCrossRefGoogle Scholar
  27. 27.
    Szabo C. Alterations in nitric oxide production in various forms of circulatory shock. New Horiz. 1995;3:2–32.PubMedGoogle Scholar
  28. 28.
    Zingarelli B, Day BJ, Crapo JD, Salzman AL, Szabo C. The potential role of peroxynitrite in the vascular contractile and cellular energetic failure in endotoxic shock. Br J Pharmacol. 1997;120:259–267.PubMedCrossRefGoogle Scholar
  29. 29.
    Elbers PW, Ince C. Mechanisms of critical illness – classifying microcirculatory flow abnormalities in distributive shock. Crit Care. 2006;10:221.PubMedCrossRefGoogle Scholar
  30. 30.
    Garrison RN, Spain DA, Wilson MA, Keelen PA, Harris PD. Microvascular changes explain the “two-hit” theory of multiple organ failure. Ann Surg. 1998;227:851–860.PubMedCrossRefGoogle Scholar
  31. 31.
    Groner W, Winkelman JW, Harris AG, et al. Orthogonal polarization spectral imaging: a new method for study of the microcirculation. Nat Med. 1999;5:1209–1212.PubMedCrossRefGoogle Scholar
  32. 32.
    De Backer D, Hollenberg S, Boerma C, et al. How to evaluate the microcirculation: report of a round table conference. Crit Care. 2007;11:R101.PubMedCrossRefGoogle Scholar
  33. 33.
    Harlan JM, Winn RK. Leukocyte–endothelial interactions: clinical trials of anti-adhesion therapy. Crit Care Med. 2002;30:S214–S219.PubMedCrossRefGoogle Scholar
  34. 34.
    Parent C, Eichacker PQ. Neutrophil and endothelial cell interactions in sepsis. The role of adhesion molecules. Inf Dis Clin North Am. 1999;13:427–447.CrossRefGoogle Scholar
  35. 35.
    Poraicu D, Sandor S, Menessy I. Decrease of red blood cell filterability seen in intensive care. II. Red blood cell crenellation “in vivo” as morphological evidence of increased red blood cell viscosity in low flow states. Resuscitation. 1983;10:305–316.PubMedCrossRefGoogle Scholar
  36. 36.
    Astiz ME, DeGent GE, Lin RY, Rackow EC. Microvascular function and rheologic changes in hyperdynamic sepsis. Crit Care Med. 1995;23:265–271.PubMedCrossRefGoogle Scholar
  37. 37.
    Kirschenbaum LA, Astiz ME, Rackow EC, Saha DC, Lin R. Microvascular response in patients with cardiogenic shock. Crit Care Med. 2000;28:1290–1294.PubMedCrossRefGoogle Scholar
  38. 38.
    Korbut R, Gryglewski RJ. The effect of prostacyclin and nitric oxide on deformability of red blood cells in septic shock in rats. J Physiol Pharmacol. 1996;47:591–599.PubMedGoogle Scholar
  39. 39.
    Shires GT III, Peitzman AB, Illner H, Shires GT. Changes in red blood cell transmembrane potential, electrolytes, and energy content in septic shock. J Trauma. 1983;23:769–774.PubMedCrossRefGoogle Scholar
  40. 40.
    Chaudry IH, Clemens MG, Baue AE. Alterations in cell function with ischemia and shock and their correction. Arch Surg. 1981;116:1309–1317.PubMedCrossRefGoogle Scholar
  41. 41.
    Eastridge BJ, Darlington DN, Evans JA, Gann DS. A circulating shock protein depolarizes cells in hemorrhage and sepsis. Ann Surg. 1994;219:298–305.PubMedCrossRefGoogle Scholar
  42. 42.
    Borchelt BD, Wright PA, Evans JA, Gann DS. Cell swelling and depolarization in hemorrhagic shock. J Trauma. 1995;39:187–192.PubMedCrossRefGoogle Scholar
  43. 43.
    Mayer B, Oberbauer R. Mitochondrial regulation of apoptosis. News Physiol Sci. 2003;18:89–94.PubMedGoogle Scholar
  44. 44.
    Fink MP. Bench-to-bedside review: cytopathic hypoxia. Crit Care. 2002;6:491–499.PubMedCrossRefGoogle Scholar
  45. 45.
    Boulos M, Astiz ME, Barua RS, Osman M. Impaired mitochondrial function induced by serum from septic shock patients is attenuated by inhibition of nitric oxide synthase and poly(ADP-ribose) synthase. Crit Care Med. 2003;31:353–358.PubMedCrossRefGoogle Scholar
  46. 46.
    Brealey D, Brand M, Hargreaves I, et al. Association between mitochondrial dysfunction and severity and outcome of septic shock. Lancet. 2002;360:219–223.PubMedCrossRefGoogle Scholar
  47. 47.
    Hubbard WJ, Bland KI, Chaudry IH. The role of the mitochondrion in trauma and shock. Shock. 2004;22:395–402.PubMedCrossRefGoogle Scholar
  48. 48.
    Rhee P, Langdale L, Mock C, Gentilello LM. Near-infrared spectroscopy: continuous measurement of cytochrome oxidation during hemorrhagic shock. Crit Care Med. 1997;25:166–170.PubMedCrossRefGoogle Scholar
  49. 49.
    Taylor JH, Beilman GJ, Conroy MJ, et al. Tissue energetics as measured by nuclear magnetic resonance spectroscopy during hemorrhagic shock. Shock. 2004;21:58–64.PubMedCrossRefGoogle Scholar
  50. 50.
    Chaudry IH. Use of ATP following shock and ischemia. Ann NY Acad Sci. 1990;603:130–140.PubMedCrossRefGoogle Scholar
  51. 51.
    Van WC III, Dhar A, Morrison DC, Longorio MA, Maxfield DM. Cellular energetics in hemorrhagic shock: restoring adenosine triphosphate to the cells. J Trauma. 2003;54:S169–S176.Google Scholar
  52. 52.
    Blalock A. Shock: further studies with particular reference to the effects of hemorrhage. Arch Surg. 1937;29:837.CrossRefGoogle Scholar
  53. 53.
    Babaev A, Frederick PD, Pasta DJ, et al. Trends in management and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock. J Amer Med Assoc. 2005;294:448–454.CrossRefGoogle Scholar
  54. 54.
    Fox KA, Anderson FA Jr, Dabbous OH, et al. Intervention in acute coronary syndromes: do patients undergo intervention on the basis of their risk characteristics? The Global Registry of Acute Coronary Events (GRACE). Heart. 2007;93:177–182.PubMedCrossRefGoogle Scholar
  55. 55.
    Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock. N Engl J Med. 1999;341:625–634.PubMedCrossRefGoogle Scholar
  56. 56.
    Urban P, Stauffer JC, Bleed D, et al. A randomized evaluation of early revascularization to treat shock complicating acute myocardial infarction. The (Swiss) Multicenter Trial of Angioplasty for Shock-(S)MASH. Eur Heart J. 1999;20:1030–1038.PubMedCrossRefGoogle Scholar
  57. 57.
    Wei JY, Hutchins GM, Bulkley BH. Papillary muscle rupture in fatal acute myocardial infarction: a potentially treatable form of cardiogenic shock. Ann Intern Med. 1979;90:149–152.PubMedCrossRefGoogle Scholar
  58. 58.
    Jacobs AK, Leopold JA, Bates E, et al. Cardiogenic shock caused by right ventricular infarction: a report from the SHOCK registry. J Am Coll Cardiol. 2003;41:1273–1279.PubMedCrossRefGoogle Scholar
  59. 59.
    Brookes C, Ravn H, White P, et al. Acute right ventricular dilatation in response to ischemia significantly impairs left ventricular systolic performance. Circulation. 1999;100:761–767.PubMedCrossRefGoogle Scholar
  60. 60.
    Wood KE. Major pulmonary embolism: review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest. 2002;121:877–905.PubMedCrossRefGoogle Scholar
  61. 61.
    Ionescu A, Wilde P, Karsch KR. Localized pericardial tamponade: difficult echocardiographic diagnosis of a rare complication after cardiac surgery. J Am Soc Echocardiogr. 2001;14:1220–1223.PubMedCrossRefGoogle Scholar
  62. 62.
    Fowler NO. Cardiac tamponade. A clinical or an echocardiographic diagnosis? Circulation. 1993;87:1738–1741.PubMedCrossRefGoogle Scholar
  63. 63.
    Brown AF. Therapeutic controversies in the management of acute anaphylaxis. J Accid Emerg Med. 1998;15:89–95.PubMedCrossRefGoogle Scholar
  64. 64.
    Mink S, Becker A, Sharma S, et al. Role of autacoids in cardiovascular collapse in anaphylactic shock in anaesthetized dogs. Cardiovasc Res. 1999;43:173–182.PubMedCrossRefGoogle Scholar
  65. 65.
    Gavalas M, Sadana A, Metcalf S. Guidelines for the management of anaphylaxis in the emergency department. J Accid Emerg Med. 1998;15:96–98.PubMedCrossRefGoogle Scholar
  66. 66.
    Zipnick RI, Scalea TM, Trooskin SZ, et al. Hemodynamic responses to penetrating spinal cord injuries. J Trauma. 1993;35:578–582.PubMedCrossRefGoogle Scholar
  67. 67.
    Savitsky E, Votey S. Emergency department approach to acute thoracolumbar spine injury. J Emerg Med. 1997;15:49–60.PubMedCrossRefGoogle Scholar
  68. 68.
    Hurlbert RJ. Strategies of medical intervention in the management of acute spinal cord injury. Spine. 2006;31:S16–S21.PubMedCrossRefGoogle Scholar
  69. 69.
    Hurlbert RJ. The role of steroids in acute spinal cord injury: an evidence-based analysis. Spine. 2001;26:S39–S46.PubMedCrossRefGoogle Scholar
  70. 70.
    Bracken MB, Shepard MJ, Holford TR, et al. Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. J Amer Med Assoc. 1997;277:1597–1604.CrossRefGoogle Scholar
  71. 71.
    Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003;31:1250–1256.PubMedCrossRefGoogle Scholar
  72. 72.
    Effect of high-dose glucocorticoid therapy on mortality in patients with clinical signs of systemic sepsis. The Veterans Administration Systemic Sepsis Cooperative Study Group. N Engl J Med. 1987;317:659–665.Google Scholar
  73. 73.
    Sprung CL, Caralis PV, Marcial EH, et al. The effects of high-dose corticosteroids in patients with septic shock. A prospective, controlled study. N Engl J Med. 1984;311:1137–1143.PubMedCrossRefGoogle Scholar
  74. 74.
    Bone RC, Fisher CJ Jr, Clemmer TP, et al. A controlled clinical trial of high-dose methylprednisolone in the treatment of severe sepsis and septic shock. N Engl J Med. 1987;317:653–658.PubMedCrossRefGoogle Scholar
  75. 75.
    Bollaert PE, Charpentier C, Levy B, et al. Reversal of late septic shock with supraphysiologic doses of hydrocortisone. Crit Care Med. 1998;26:645–650.PubMedCrossRefGoogle Scholar
  76. 76.
    Briegel J, Forst H, Haller M, et al. Stress doses of hydrocortisone reverse hyperdynamic septic shock: a prospective, randomized, double-blind, single-center study. Crit Care Med. 1999;27:723–732.PubMedCrossRefGoogle Scholar
  77. 77.
    Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. J Amer Med Assoc. 2002;288:862–871.CrossRefGoogle Scholar
  78. 78.
    Sprung CL, Annane D, Keh D, et al. Hydrocortisone therapy for patients with septic shock. N Engl J Med. 2008;358:111–124.PubMedCrossRefGoogle Scholar
  79. 79.
    Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008;36:296–327.PubMedCrossRefGoogle Scholar
  80. 80.
    Meehan TP, Fine MJ, Krumholz HM, et al. Quality of care, process, and outcomes in elderly patients with pneumonia. J Amer Med Assoc. 1997;278:2080–2084.CrossRefGoogle Scholar
  81. 81.
    Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368–1377.PubMedCrossRefGoogle Scholar
  82. 82.
    Ebihara S, Hussain SN, Danialou G, et al. Mechanical ventilation protects against diaphragm injury in sepsis: interaction of oxidative and mechanical stresses. Am J Resp Crit Care Med. 2002;165:221–228.PubMedCrossRefGoogle Scholar
  83. 83.
    Bridges N, Jarquin-Valdivia AA. Use of the Trendelenburg position as the resuscitation position: to T or not to T? Am J Crit Care. 2005;14:364–368.PubMedGoogle Scholar
  84. 84.
    Boulain T, Achard JM, Teboul JL, et al. Changes in BP induced by passive leg raising predict response to fluid loading in critically ill patients. Chest. 2002;121:1245–1252.PubMedCrossRefGoogle Scholar
  85. 85.
    Finfer S, Bellomo R, Boyce N, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. 2004;350:2247–2256.PubMedCrossRefGoogle Scholar
  86. 86.
    Kellum JA, Pinsky MR. Use of vasopressor agents in critically ill patients. Curr Opin Crit Care. 2002;8:236–241.PubMedCrossRefGoogle Scholar
  87. 87.
    Rivers EP, Ander DS, Powell D. Central venous oxygen saturation monitoring in the critically ill patient. Curr Opin Crit Care. 2001;7:204–211.PubMedCrossRefGoogle Scholar
  88. 88.
    Reinhart K, Kuhn HJ, Hartog C, Bredle DL. Continuous central venous and pulmonary artery oxygen saturation monitoring in the critically ill. Intensive Care Med. 2004;30:1572–1578.PubMedCrossRefGoogle Scholar
  89. 89.
    Cohn SM. Near-infrared spectroscopy: potential clinical benefits in surgery. J Am Coll Surg. 2007;205:322–332.PubMedCrossRefGoogle Scholar
  90. 90.
    Ward KR, Torres FI, Barbee RW, et al. Resonance Raman spectroscopy: a new technology for tissue oxygenation monitoring. Crit Care Med. 2006;34:792–799.PubMedGoogle Scholar
  91. 91.
    Verdant C, De Backer D. How monitoring of the microcirculation may help us at the bedside. Curr Opin Crit Care. 2005;11:240–244.PubMedCrossRefGoogle Scholar
  92. 92.
    Goedhart PT, Khalilzada M, Bezemer R, Merza J, Ince C. Sidestream Dark Field (SDF) imaging: a novel stroboscopic LED ring-based imaging modality for clinical assessment of the microcirculation. Opt Express. 2007;15:15101–15114.PubMedCrossRefGoogle Scholar
  93. 93.
    Cortez A, Zito J, Lucas CE, Gerrick SJ. Mechanism of inappropriate polyuria in septic patients. Arch Surg. 1977;112:471–476.PubMedCrossRefGoogle Scholar
  94. 94.
    Rady MY, Rivers EP, Nowak RM. Resuscitation of the critically ill in the ED: responses of blood pressure, heart rate, shock index, central venous oxygen saturation, and lactate. Am J Emerg Med. 1996;14:218–225.PubMedCrossRefGoogle Scholar
  95. 95.
    Pinsky MR. Targets for resuscitation from shock. Minerva Anestesiol. 2003;69:237–244.PubMedGoogle Scholar
  96. 96.
    Donati A, Loggi S, Preiser JC, et al. Goal-directed intraoperative therapy reduces morbidity and length of hospital stay in high-risk surgical patients. Chest. 2007;132:1817–1824.PubMedCrossRefGoogle Scholar
  97. 97.
    Pearse R, Dawson D, Fawcett J, et al. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial. Crit Care. 2005;9:R687–R693.PubMedCrossRefGoogle Scholar
  98. 98.
    Neumar R, Ward KR. Adult resuscitation. In: Marx J, Hockberger R, Walls R, editors. Rosen’s emergency medicine: concepts and clinical practice. St. Louis: Mosby; 2002. p. 64–82.Google Scholar
  99. 99.
    Fink M, Gunnerson KJ. Shock and Sepsis. In: Sellke F, del Nido P, Swanson S, editors. Sabiston and Spencer surgery of the chest. Philadelphia: Elsevier Saunders; 2005. p. 793–815.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Kyle J. Gunnerson
    • 1
  • Emanuel P. Rivers
    • 2
  1. 1.Virginia Commonwealth University Medical CenterVCURES LaboratoryRichmondUSA
  2. 2.Department of Emergency Medicine and SurgeryHenry Ford HospitalDetroit1

Personalised recommendations