Contemporary Review of Hemodynamic Monitoring in the Critical Care Setting

Abstract

Hemodynamic assessment remains the most valuable adjunct to physical examination and laboratory assessment in the diagnosis and management of shock. Through the years, multiple modalities to measure and trend hemodynamic indices have evolved with varying degrees of invasiveness. Pulmonary artery catheter (PAC) has long been considered the gold standard of hemodynamic assessment in critically ill patients and in recent years has been shown to improve clinical outcomes among patients in cardiogenic shock. The invasive nature of PAC is often cited as its major limitation and has encouraged development of less invasive technologies. In this review, the authors summarize the literature on the mechanism and validation of several minimally invasive and noninvasive modalities available in the contemporary intensive care unit. They also provide an update on the use of focused bedside echocardiography.

Hemodynamic monitoring in liver transplantation ‘the hemodynamic system’

“…The PAC is the only monitor that ‘directly’ measures the pulmonary artery pressure (PAP), the pulmonary arterial wedge pressures (PAWP) [3 ▪ ,8 ▪ ,13,20,105], and calculates both the pulmonary vascular resistance (PVR) and the systemic vascular resistance (SVR). Some special PACs can measure right ventricular volume and ejection fraction, which is helpful in patients with right ventricular failure [8 ▪ ,44].…”

“…The ScvO 2 can be used as a surrogate for SvO 2 but is a poor substitute [8 ▪ ,64,79]. There are many less invasive CO devices, but they lack the accuracy of the PAC [8 ▪ ,18,20,34,38,47,64].…”

“…A recent study on liver transplantation patients showed that the PAC alone has better outcomes than the TEE alone [30]. The PAC is still the undisputed gold standard of HDM in critically ill patients including liver transplantation patients [1 ▪▪ ,20,44,63,64,104,105] and is routinely used in about 90% of the liver transplantation programs [63].…”

“…Most of the data included in the algorithm comes from standard patients, and as a result, the CO estimation might be unreliable at extremes of age, weight, and hemodynamic status [7 ▪▪ ,26,40,68 ▪▪ ]. CO measurement by internally calibrated PWA lacks accuracy [18,20,34,38] with a percentage error 23–74% [13]. A meta-analysis showed a mean percentage error of 41% and imprecision of 1.2 l/min [71].…”

Current state of sepsis resuscitation in critical care

“…CO/CI indicates cardiac output/cardiac index; CVP, central venous pressure; MAP, mean arterial pressure; NICOM, noninvasive cardiac output monitor; PAP, pulmonary artery pressure; PAWP, pulmonary artery wedge pressure; RVEDP, right ventricular end-diastolic pressure; SVO 2 , mixed venous oxygen saturation. Reprinted with permission from Rali et al, 58 under CCBY-NC. All permission requests for this image should be made to the copyright holder.…”