Functional Hemodynamic Monitoring, 1st Edition
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VI Contents
Pulmonary Artery Occlusion Pressure:
Measurement, Significance, and Clinical Uses . . . . . . . . . . . 111
J.J. Marini and J. W. Leatherman
Cardiac Output by Thermodilution
and Arterial Pulse Contour Techniques . . . . . . . . . . . . . . . 135
J.R.C. Jansen and P.C.M. van den Berg
Clinical Value of Intrathoracic Volumes
from Transpulmonary Indicator Dilution . . . . . . . . . . . . . 153
A.B.J. Groeneveld, R.M.B.G.E. Breukers, and J. Verheij
Methodology and Value
of Assessing Extravascular Lung Water . . . . . . . . . . . . . . . 165
A.B.J. Groeneveld and J. Verheij
Arterial Pulse Contour Analysis:
Applicability to Clinical Routine . . . . . . . . . . . . . . . . . . . 175
D.A. Reuter and A.E. Goetz
Arterial Pulse Power Analysis: The LiDCOTMplus System . . . . 183
A. Rhodes and R. Sunderland
Esophageal Doppler Monitoring . . . . . . . . . . . . . . . . . . . 193
M. Singer
Splanchnic Blood Flow . . . . . . . . . . . . . . . . . . . . . . . . . 205
J. Creteur
Measurement of Oxygen Derived Variables and Cardiac Performance
Microcirculatory Blood Flow: Videomicroscopy . . . . . . . . . . 223
D. De Backer
Mixed Venous Oxygen Saturation (SvO2) . . . . . . . . . . . . . . 233
J. B. Hall
Central Venous Oxygen Saturation (ScvO2) . . . . . . . . . . . . . 241
K. Reinhart and F. Bloos
DO2/VO2 Relationships . . . . . . . . . . . . . . . . . . . . . . . . 251
J.L. Vincent
Cardiac Preload Evaluation
Using Echocardiographic Techniques . . . . . . . . . . . . . . . . 259
M. Slama
Contents VII
Right Ventricular End-Diastolic Volume . . . . . . . . . . . . . . 269
J. Boldt
Assessment of Fluid Responsiveness
Fluid Therapy of Tissue Hypoperfusion . . . . . . . . . . . . . . . 285
R.P. Dellinger
The Use of Central Venous Pressure
in Critically III Patients . . . . . . . . . . . . . . . . . . . . . . . . 299
S. Magder
Arterial Pressure Variation
during Positive-pressure Ventilation . . . . . . . . . . . . . . . . 313
A. Perel, S. Preisman, and H. Berkenstadt
Arterial Pulse Pressure Variation during Positive Pressure
Ventilation and Passive Leg Raising . . . . . . . . . . . . . . . . . 331
J.-L. Teboul, X. Monnet, and C. Richard
Development of Treatment Algorithms
Standardization of Care by Defining Endpoints
of Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
M. Mythen, H. Meeran, and M. Grocott
Protocolized Cardiovascular Management Based
on Ventricular-arterial Coupling . . . . . . . . . . . . . . . . . . . 381
M. R. Pinsky
Cost Eeffectivness of Monitoring Techniques . . . . . . . . . . . 397
J. Wendon
Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415
List of Contributors
Bennett D Calzia E
Department of Intensive Care Division of Pathophysiology
St George’s Hospital and Process Development
Blackshaw Road in Anesthesia
London SW17 0QT Dept of Anesthesiology
United Kingdom University Clinic
Parkstrasse 11
Berkenstadt H 89073 Ulm
Department of Anesthesiology Germany
and Intensive Care
Sheba Medical Center Carlesso E
Tel Aviv University Institute of Anesthesiology
52621 Tel Hashomer and Intensive Care
Israel Ospedale Maggiore Policlinico-IRCCS
Via Francesco Sforza 35
Bloos F 20122 Milan
Department of Anesthesiology Italy
and Intensive Care Medicine
Klinikum der Friedrich-Schiller- Creteur J
Universität Department of Intensive Care
Bachstrasse 18 Erasme University Hospital
07743 Jena Route de Lennik 808
Germany 1070 Brussels
Belgium
Boldt J
Department of Anesthesiology De Backer D
and Intensive Care Medicine Department of Intensive Care
Klinikum der Stadt Ludwigshafen Erasme University Hospital
Bremserstrasse 79 Route de Lennik 808
67063 Ludwigshafen 1070 Brussels
Germany Belgium
Breukers RMBGE Dellinger RP
Department of Intensive Care Section of Critical Care Medicine
Vrije Universiteit Medical Centre Cooper University Hospital
De Boelelaan 1117 One Cooper Plaza
1081 HV Amsterdam Dorrance Building, Suite 393
Netherlands Camden, NJ 08103
USA
X List of Contributors
Gattinoni L Iványi Z
Institute of Anesthesiology Semmelweis Egytem AOK
and Intensive Care Kütvölgyi ut 4
Ospedale Maggiore Policlinico-IRCCS 1125 Budapest
Via Francesco Sforza 35 Hungary
20122 Milan
Italy Jansen JRC
Department of Intensive Care, H4-Q
Goetz AE University Medical Center
Department of Anesthesiology P.O. Box 9600
University of Munich 2300 RC Leiden
Grosshadern University Hospital Netherlands
Marchioninistrasse 15
81377 Munich Kanoore-Edul VS
Germany Department of Physiology
Academic Medical Center
Grocott M Meibergdreef 9
Centre for Anesthesia 1105 AZ Amsterdam
University College London Netherlands
Room 103 First floor crosspiece
Middlesex Hospital Leatherman JW
Mortimer Street Regions Hospital
London W1 3AA 640 Jackson Street
United Kingdom St. Paul, MN 55101
USA
Groeneveld ABJ
Department of Intensive Care Magder S
Vrije Universiteit Medical Centre Division of Critical Care
De Boelelaan 1117 Department of Medicine
1081 HV Amsterdam McGill University Health Centre
Netherlands 687 Pine Avenue West
Montreal, H3A 1A1
Grounds RM Canada
Department of Intensive Care
Medicine Marini JJ
St George’s Hospital Pulmonary & Critical Care Medicine
Blackshaw Road Regions Hospital
London SW17 0QT 640 Jackson Street
United Kingdom St. Paul, MN 55101
USA
Hall JB
Department of Medicine Meeran H
The University of Chicago Center for Anesthesia
5841 S Maryland Avenue University College London
Chicago, IL 60637 Room 103 First floor crosspiece
USA Middlesex Hospital
Mortimer Street
Ince C London W1 3AA
Department of Physiology United Kingdom
Academic Medical Center
Meibergdreef 9
1105 AZ Amsterdam
Netherlands
List of Contributors XI
Monnet X Radermacher P
Medical ICU Division of Pathophysiology
Paris XI University and Process Development
78, rue du Général Leclerc in Anesthesia
94275 Le Kremlin-Bicêtre Dept of Anesthesiology
France Parkstrasse 11
89073 Ulm
Mythen M Germany
Center for Anesthesia
University College London Reinhart K
Room 103 First floor crosspiece Department of Anesthesiology
Middlesex Hospital and Intensive Care Medicine
Mortimer Street Klinikum der Friedrich-Schiller-
London W1 3AA Universität
United Kingdom Bachstrasse 18
07743 Jena
Payen D Germany
Department
of Anesthesiology & Critical Care Reuter DA
Lariboisiere University Hospital Department of Anesthesiology
Université Paris VII University of Munich
2 Rue Ambroise Paré Grosshadern University Hospital
75010 Paris Marchioninistrasse 15
France 81377 Munich
Germany
Perel A
Department of Anesthesiology Rhodes A
and Intensive Care Department of Intensive Care
Hôpital Pitié-Salpétrière Medicine
47-83 Boulevard de l’Hôpital St George’s Hospital
75651 Paris Blackshaw Road
France London SW17 0QT
United Kingdom
Pinsky MR
Department of Critical Care Medicine Richard C
University Hospital Medical ICU
606 Scaife Hall Paris XI University
3550 Terrace Street 78, rue du Général Leclerc
Pittsburgh, PA 15261 94275 Le Kremlin-Bicêtre
USA France
Preisman S Singer M
Department of Anesthesiology Department of Intensive Care
and Intensive Care University College London
Sheba Medical Center Jules Thorn Building
Tel Aviv University Middlesex Hospital
52621 Tel Hashomer Mortimer Street
Israel London WT 3AA
United Kingdom
XII List of Contributors
Slama M Valenza F
Intensive care Unit, Department Institite of Anesthesiology
of Nephrology and Intensive Care Medicine
CHU Sud Ospedale Maggiore Policlinico-IRCCS
Avenue René Laennec Via Francesco Sforza 35
80054 Amiens 20122 Milan
France Italy
Smith T van den Berg PCM
Department of Intensive Care Department of Intensive Care, H4-Q
Medicine University Medical Center
St George’s Hospital P.O. Box 9600
Blackshaw Road 2300 RC Leiden
London SW17 0QT Netherlands
United Kingdom
Verheij J
Spronk PE Department of Intensive Care
Department of Intensive Care Vrije Universiteit Medical Centre
Medicine De Boelelaan 1117
Gelre Ziekenhuis, locatie Lukas 1081 HV Amsterdam
Albert Schweitzerlaan 31 Netherlands
7334 DZ Apeldoorn
Netherlands Vincent JL
Department of Intensive Care
Sunderland R Erasme University Hospital
Department of Intensive Care Route de Lennik 808
Medicine 1070 Brussels
St George’s Hospital Belgium
Blackshaw Road
London SW17 0QT Weil MH
United Kingdom The Institute of Critical Care Medicine
North Sunrise Way 1695, Bldg. #3
Teboul JL Palm Springs, CA 92262
Medical ICU USA
Paris XI University
78, rue du Général Leclerc Wendon J
94275 Le Kremlin-Bicêtre Liver Intensive Care Unit
France King’s College Hospital
Bessemer Road
London SE5 9RS
United Kingdom
Common Abbreviations
ARDS Acute respiratory distress syndrome
COPD Chronic obstructive pulmonary disease
CVP Central venous pressure
DO2 Oxygen delivery
EKG Electrocardiogram
EVLW Extravascular lung water
FRC Functional residual capacity
ICU Intensive care unit
LVEDA Left ventricular end-diastolic area
MAP Mean arterial pressure
NO Nitric oxide
PAOP Pulmonary artery occlusion pressure
PEEP Positive end-expiratory pressure
PPV Pulse pressure variation
RVEDP Right ventricular end-diastolic pressure
RVEDV Right ventricular end-diastolic volume
RVEF Right ventricular ejection fraction
SPV Systolic pressure variation
SvO2 Mixed venous oxygen saturation
SVR Systemic vascular resistance
SVV Stroke volume variation
VO2 Oxygen consumption
Introduction
Functional Hemodynamic Monitoring:
Foundations and Future
M. R. Pinsky and D. Payen
Introduction
Hemodynamic monitoring is one of the major diagnostic tools available in the
acute care setting to diagnose cardiovascular insufficiency and monitor changes
over time in response to interventions. However, in recent years, the rationale and
efficacy of hemodynamic monitoring to affect outcome has come into question.
We now have increasing evidence that outcome from critical illness can be im-
proved by focused resuscitation based on existing hemodynamic monitoring,
whereas non-specific aggressive resuscitation impairs survival. Thus, the stage is
set to frame hemodynamic monitoring into a functional perspective wherein
hemodynamic variables and physiology interact to derive performance and physi-
ological reserve estimates that drive treatment.
Any discussion on the utility of hemodynamic monitoring must start from the
perspective of one scientific truth that is often forgotten when discussing the
efficacy of new diagnostic tests or monitoring devices. Namely, that no monitoring
device, no matter how simple or sophisticated, will improve patient-centered
outcomes useless coupled to a treatment which, itself, improves outcome. Thus,
hemodynamic monitoring needs to be considered within the context of clinical
condition, pathophysiological state, and sites within the acute care delivery system
wherein this monitoring takes place.
Rationale for Hemodynamic Monitoring
A reasonable progression of arguments can be developed to defend the use of
specific types of monitoring techniques. At the basic level, the specific monitoring
technique can be defended based on historical controls. At this level, prior experi-
ence using similar monitoring showed it to be beneficial. Clearly, the mechanism
by which the benefit is achieved need not be understood or even postulated. The
next level of defense comes through an understanding of the pathophysiology of
the process being treated, such as heart failure or hypovolemic shock. Most of the
rationale for hemodynamic monitoring lies at this level and, regrettably, is of less
secure foundations than would otherwise be assumed. The implied assumption of
this level of argument is that knowledge of how a disease process creates its effect
and, thus, the ability to prevent the process from altering measured bodily func-
4 M. R. Pinsky and D. Payen
tions, should prevent disease progression and promote recovery. It is not clear
from recent clinical studies that this argument is valid, primarily because knowl-
edge of the actual process is often inadequate. The ultimate level of defense of a
therapy or monitoring process comes from documentation that the monitoring
device, by altering therapy in otherwise unexpected ways, improves outcome in
terms of survival and quality of life. In reality, few therapies in medicine can claim
this benefit. Thus, we are left with the physiologic rationale as the primary defense
of monitoring of critically ill patients. Although defendable at the present time,
potentially new information about process of illness or outcome may come to
light, negating any aspect of the proposed monitoring paradigms. More than
likely, it is through our use of monitoring to direct therapies, defining specific
physiological conditions requiring specific treatments with defined end-points of
treatment with proven benefits, achieved in a timely fashion, that the benefit of
hemodynamic monitoring in any form will be realized.
Tests to Document Effectiveness
of Invasive Hemodynamic Monitoring Procedures [1]
1. Information received cannot be acquired from less invasive and less risky
monitoring.
2. Information received improves the accuracy of diagnosis, prognosis, and/or
treatment based on known physiological principles.
3. The changes in diagnosis and/or treatment result in improved patient outcome
(morbidity and mortality).
4. The changes in diagnosis and/or treatment result in more effective use of health
care resources.
Importantly, hemodynamic monitoring exists within the context of the patient,
pathophysiology, time in the disease process, and area within the healthcare
delivery system where it is used. Furthermore, monitoring technologies progress
from the most simple and non-invasive to the most complex and highly invasive.
As summarized above, the use of increasingly invasive and risky monitoring
devices should be considered with reference to the above four points. The site
where monitoring takes place has a major impact on type of monitoring, its risks
and utility and efficacy. For example, monitoring in the field or in the emergency
department is often less invasive that that seen during major surgery in the
operating room or intensive care unit. And monitoring on the regular hospital
ward can be even less or more invasive depending on the specialized center where
it is occurring (e.g., electrocardiographic monitoring post-myocardial infarction
in a step-down unit or pulse oximetry on a respiratory ward post-endotracheal
extubation). Furthermore, and as alluded to in the previous sentence, the type of
disease and treatment options determine the degree to which the same monitor-
ing will be more or less effective. For example, invasive pulmonary artery
catheterization with continuous monitoring of cardiac output and right ventricu-
lar volumes may be very useful during the intraoperative course of a complex
cardiac surgery patient with pulmonary hypertension, whereas the same monitor-
Functional Hemodynamic Monitoring: Foundations and Future 5
Fig. 1. Schematic representation of the level of intensity of hemodynamic monitoring by place in
the health care delivery system and type of monitoring using an arbitrary scoring system from
zero to thirty to define level of intensity. Pre-op connotes pre-operative optimization for high risk
surgical patients; OR: operating room; ICU: intensive care unit; ER: emergency department; and
floor: regular hospital ward. Special monitoring connotes specialized devices such as echocardiog-
raphy, transcranial Doppler, gastric tonometry and other techniques used in only very specific
conditions and patient subgroups.
ing may not alter care in an otherwise uncomplicated cardiac surgery patient with
normal cardiac contractility. Where, within the course of disease, the monitoring
is used may have profound effects on outcome. Pre-operative optimization of
cardiovascular status using invasive hemodynamic monitoring to define thera-
peutic end-points in high-risk surgery patients (referred to as pre-optimization)
has been shown to reduce morbidity, whereas the same monitoring and treatment
if applied post-operatively or in otherwise unstable patients already receiving
intensive care support does not improve outcome. This point underlies another
fundamental aspect of cardiovascular resuscitation form critical illness. Namely,
the difference between prevention of tissue ischemic injury in patients presenting
in shock and attempts to rescue patients in shock following the development of
the ischemic insult.
Finally, applying protocolized care in the management of critically ill patients
reduces medical errors and practice variation, and can reduce ICU length of stay.
These points are illustrated in a stylized fashion in Figure 1. Hemodynamic moni-
toring exists only within the context of the pathophysiology of the disease and its
associated complications and potential treatments. However, it is only by identify-
ing the fingerprint of hemodynamic variables that characterize specific disease
patterns that one can make specific cardiovascular shock diagnoses and direct
specific treatment.
Acknowledgement: This work was supported in part by NIH grants HL67181-02A1
and HL07820-06
6 M. R. Pinsky and D. Payen
References
1. Bellomo R, Pinsky MR (1996) Invasive hemodynamic monitoring. In Tinker J, Browne D,
Sibbald WJ (eds) Critical Care: Standards, Audit and Ethics. Edward Arnold, London, pp
82–105
Therapeutic goals
