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The ideal circulatory monitoring system would be noninvasive, cost-effective and easy to use.
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As understanding of hemodynamics and critical illness has evolved, more sophisticated circulatory monitoring technologies have been developed.
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The primary hemodynamic goal in the management of critically ill patients includes the assessment and manipulation of the circulatory system to ensure adequate tissue delivery of oxygen and essential metabolic substrates.
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Current monitoring devices should continue
Hemodynamic Assessment in the Contemporary Intensive Care Unit: A Review of Circulatory Monitoring Devices
Section snippets
Key points
Clinical methods for hemodynamic assessment
Detailed physical examination along with other clinical data provide a framework for assessment of the underlying pathophysiology of the patient against which all information obtained from hemodynamic monitors can be interpreted. These methods are used to infer data about the two major parameters of the circulatory system: intravascular volume and tissue perfusion.
PAC
Following its introduction into clinical practice in the 1970s, bedside PAC using flow-directed balloon-tipped catheters gradually became a standard of care for critically ill patients. During the PAC era, its widespread use significantly improved the understanding of the physiologic responses and pathophysiologic changes in various conditions. Despite the criticism for the use of PAC generated by the lack of evidence supporting an outcome benefit,32, 33, 34, 35, 36 particularly after the
Minimally invasive hemodynamic monitoring and imaging
The major reservations and concerns about the use of PAC given its level of invasiveness and the lack of evidence supporting improved outcomes, as well as the decreased familiarity and training in PAC, have triggered the search for less invasive hemodynamic monitoring methods. As a result, many imaging modalities and minimally invasive monitors have surfaced as potential alternatives to invasive catheterization.
Esophageal Doppler monitor
EDM was initially introduced in 1971 by Side and Gosling and subsequently modified by Singer in 1998. An esophageal Doppler monitor is a minimally invasive hemodynamic device that evaluates the CO and fluid status based on the assessment of descending aortic blood flow.79, 80, 81 Using a Doppler probe inserted into the esophagus, the velocity of the descending aortic blood flow can be determined by the frequency shift as the waves get reflected of the moving red blood cells. The spectral
Pulse contour analysis or pulse wave analysis
Newly emerging technologies based on pulse wave analysis (PWA) can be helpful in the measurement and optimization of flow. These devices have gained attention because they are relatively less invasive. They are all based on a similar basic principle of continuously estimating SV by analyzing arterial pressure waveforms but they use different techniques with varying proprietary algorithms. Understanding the physiology and technology used in PWA is important for the correct measurement and
Thoracic electrical bioimpedance or impedance cardiography
Impedance cardiography (thoracic electrical bioimpedance [TEB]) in the measurement of cardiovascular performance was introduced in the late 1960s.90 Its appeal was that is was the least invasive method to continuously monitor SV and CO. It is based on the measurement of changes in the thoracic impedance to an electrical current that is produced by the fluctuations in thoracic blood volume with each cardiac cycle.
Depending on the equation used, the theory behind impedance cardiography models the
Future directions for hemodynamic monitoring in the ICU
Despite all the controversy regarding the use of PAC, there has been no argument against the limitations of physical examination in critically ill patients and the need for better hemodynamic assessment to provide a better understanding of the underlying pathophysiologic state and, as important, help in the development of goal-directed management strategies. To achieve these goals and to overcome the perceived limitations of PAC, alternative hemodynamic assessments have evolved. These new
References (146)
- et al.
Cardiac output measurement with an esophageal Doppler in critically ill Emergency Department patients
J Emerg Med
(2000) - et al.
Physical examination, central venous pressure and chest radiography for the prediction of transpulmonary thermodilution-derived hemodynamic parameters in critically ill patients: a prospective trial
J Crit Care
(2011) - et al.
Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares
Chest
(2008) - et al.
The use of respiratory variations in right atrial pressure to predict the cardiac output response to PEEP
J Crit Care
(2001) - et al.
Relationship between B-type natriuretic peptides and pulmonary wedge pressure in the intensive care unit
J Am Coll Cardiol
(2005) - et al.
Lack of equivalence between central and mixed venous oxygen saturation
Chest
(2004) - et al.
Comparison of central venous to mixed venous oxygen saturation in patients with low cardiac index and filling pressures after coronary artery surgery
J Cardiothorac Vasc Anesth
(2008) - et al.
The value of pulmonary artery catheter and central venous monitoring in patients undergoing abdominal aortic reconstruction surgery: a comparative study of two selected, randomized, groups
J Vasc Surg
(1990) - et al.
Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomized controlled trial
Lancet
(2005) - et al.
Transthoracic echocardiography to identify or exclude cardiac cause of shock
Chest
(2004)
Recommendations for chamber quantification: a report from the American society of echocardiography’s guidelines and standards committee and the chamber quantification writing group
J Am Soc Echocardiogr
Unreliability of hemodynamic indexes of left ventricular size during cardiac surgery
Ann Thorac Surg
Does inferior vena cava size predict right atrial pressures in patients receiving mechanical ventilation?
J Am Soc Echocardiogr
Goal-directed transesophageal echocardiography performed by intensivist to assess left ventricular function: comparison with pulmonary artery catheterization
J Cardiothorac Vasc Anesth
Multiplane transesophageal echocardiographic Doppler imaging accurately determines cardiac output measurements in critically ill patients
Chest
The use of echocardiography in the critical care setting
Crit Care Clin
Assessment of left ventricular function and hemodynamics with transesophageal echocardiography
Crit Care Clin
Echocardiographic pattern of acute cor pulmonale
Chest
Comparison of several noninvasive methods for estimation of pulmonary artery pressure
J Am Soc Echocardiogr
Diagnostic usefulness and impact on management of transesophageal echocardiography in surgical intensive care units
Am J Cardiol
Usefulness of transesophageal echocardiography in the treatment of critically ill patients
Chest
Evaluation of transesophageal echocardiography as a diagnostic and therapeutic aid in a critical care setting
Chest
Feasibility and potential clinical utility of goal directed transthoracic echocardiography performed by noncardiologist intensivists using a small hand-carried device (SonoHeart) in critically ill patients
J Cardiothorac Vasc Anesth
How useful is hand-carried bedside echocardiography in critically ill patients?
J Am Coll Cardiol
Bedside ultrasonography in the ICU: Part 1
Chest
A review of impedance cardiography
Heart Lung
The use of the oesophageal Doppler Monitor in the intensive care unit
Crit Care Resusc
Noninvasive versus invasive assessment of cardiac output after cardiac surgery: clinical validation
J Cardiothorac Vasc Anesth
A comparison of hemodynamic data derived by pulmonary artery flotation catheter and the esophageal Doppler monitor in preeclampsia
Am J Obstet Gynecol
Noninvasive monitoring of blood pressure in the critically ill: reliability according to the cuff site (arm, thigh or ankle)
Crit Care Med
Interaction between respiration and systemic hemodynamics. Part I: basic concepts
Intensive Care Med
Cardiopulmonary interactions and volume status assessment
J Clin Monit Comput
The role of venous return in critical illness and shock: part II-shock and mechanical ventilation
Crit Care Med
Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure
Am J Respir Crit Care Med
Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature
Crit Care Med
Does this patient have abnormal central venous pressure?
JAMA
Does the central venous pressure predict fluid responsiveness. An updated meta-analysis and a plea for some common sense
Crit Care Med
Prediction of volume responsiveness in critically ill patients with spontaneous breathing activity
Curr Opin Crit Care
How to use central venous pressure measurements
Curr Opin Crit Care
Cardiovascular response to elevation of intra-abdominal hydrostatic pressure
Am J Physiol
Radionuclide assessment of peripheral intravascular capacity: a technique to measure intravascular volume changes in the capacitance circulation in man
Circulation
Passive leg raising predicts fluid responsiveness in the critically ill
Crit Care Med
Comparable increase of B-type natriuretic peptide and amino-terminal pro-B-type natriuretic peptide levels in patients with severe sepsis, septic shock and acute heart failure
Crit Care Med
The interpretation of brain natriuretic peptide in critical care patients; will it ever be useful?
Crit Care
Lactate clearance vs. central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial
JAMA
Lactate as a hemodynamic marker in the critically ill
Curr Opin Crit Care
Early lactate clearance is associated with improved outcome in severe sepsis and septic shock
Crit Care Med
Lactate clearance in cardiogenic shock following ST elevation myocardial infarction: a pilot study
Acute Card Care
Lactate clearance as a target of therapy in sepsis: a flawed paradigm
OA Crit Care
Are central venous lactate and arterial lactate interchangeable? A human retrospective study
Anesth Analg
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