11
Med Intensiva. 2012;36(6):434---444 www.elsevier.es/medintensiva UPDATE IN INTENSIVE CARE MEDICINE: HEMODYNAMIC MONITORIZATION IN THE CRITICAL PATIENT Techniques available for hemodynamic monitoring. Advantages and limitations M.L. Mateu Campos a,, A. Ferrándiz Sellés a , G. Gruartmoner de Vera b , J. Mesquida Febrer b , C. Sabatier Cloarec b , Y. Poveda Hernández c , X. García Nogales b a Servicio de Medicina Intensiva, Hospital Universitario General de Castellón, Castellón, Spain b Área de Críticos, Hospital de Sabadell, Institut Universitari Parc Taulí, Centro de Investigación Biomédica en Red (CIBER) en Enfermedades Respiratorias, Sabadell, Barcelona, Spain c Servicio de Medicina Intensiva, Hospital Santiago Apóstol, Vitoria, Álava, Spain KEYWORDS Hemodynamic monitoring; Cardiac output; Hemodynamic variables Abstract The pulmonary artery catheter has been a key tool for monitoring hemodynamic status in the intensive care unit for nearly 40 years. During this period of time, it has been the hemodynamic monitoring technique most commonly used for the diagnosis of many clinical situations, allowing clinicians to understand the underlying cardiovascular physiopathology, and helping to guide treatment interventions. However, in recent years, the usefulness of pulmonary artery catheterization has been questioned. Technological advances have introduced new and less invasive hemodynamic monitoring techniques. This review provides a systematic update on the hemodynamic variables offered by cardiac output monitoring devices, taking into consideration their clinical usefulness and their inherent limitations, with a view to using the supplied information in an efficient way. © 2012 Elsevier España, S.L. and SEMICYUC. All rights reserved. PALABRAS CLAVE Monitorización hemodinámica; Gasto cardiaco; Parámetros hemodinámicos Técnicas disponibles de monitorización hemodinámica. Ventajas y limitaciones Resumen El catéter de la arteria pulmonar (CAP) ha constituido una herramienta fundamental para la monitorización hemodinámica en las unidades de cuidados intensivos durante los últimos 40 nos. Durante este período de tiempo ha sido ampliamente usado en pacientes críticos para el diagnóstico y como guía del tratamiento, ayudando a los clínicos a entender la fisiopatología de muchos procesos hemodinámicos. Sin embargo, en los últimos nos la utilidad del CAP ha sido sometida a un intenso debate. Paralelamente, los avances tecnológicos han permitido el desarrollo de nuevas técnicas, menos invasivas, para la monitorización cardiovascular. Esta puesta al día pretende dar a los clínicos una visión de los parámetros hemodinámicos que Please cite this article as: Mateu Campos ML, et al. Técnicas disponibles de monitorización hemodinámica. Ventajas y limitaciones. Med Intensiva. 2012;36:434---44. Corresponding author. E-mail address: [email protected] (M.L. Mateu Campos). 2173-5727/$ see front matter © 2012 Elsevier España, S.L. and SEMICYUC. All rights reserved.

Techniques Available for Hemodynamic Monitoring

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  • Med Intensiva. 2012;36(6):434---444

    www.elsevier.es/medintensiva

    UPDATE IN INTENSIVE CARE MEDICINE: HEMODYNAMIC MONITORIZATION IN THE CRITICALPATIENT

    Techniques available for hemodynamic monitoring.Advantages and limitations

    M.L. Ma a, a bJ. Mesq

    a Servicio db rea de Cen Enfermec Servicio d

    KEYWOHemodynmonitoriCardiac Hemodynvariables

    PALABRMonitorihemodinGasto caParmethemodin

    Please ciMed Intensiv

    CorrespoE-mail ad

    2173-5727/$teu Campos , A. Ferrndiz Sells , G. Gruartmoner de Vera ,uida Febrerb, C. Sabatier Cloarecb, Y. Poveda Hernndezc, X. Garca Nogalesb

    e Medicina Intensiva, Hospital Universitario General de Castelln, Castelln, Spainrticos, Hospital de Sabadell, Institut Universitari Parc Taul, Centro de Investigacin Biomdica en Red (CIBER)dades Respiratorias, Sabadell, Barcelona, Spaine Medicina Intensiva, Hospital Santiago Apstol, Vitoria, lava, Spain

    RDSamicng;output;amic

    Abstract The pulmonary artery catheter has been a key tool for monitoring hemodynamicstatus in the intensive care unit for nearly 40 years. During this period of time, it has beenthe hemodynamic monitoring technique most commonly used for the diagnosis of many clinicalsituations, allowing clinicians to understand the underlying cardiovascular physiopathology, andhelping to guide treatment interventions. However, in recent years, the usefulness of pulmonaryartery catheterization has been questioned. Technological advances have introduced new andless invasive hemodynamic monitoring techniques.

    This review provides a systematic update on the hemodynamic variables offered by cardiacoutput monitoring devices, taking into consideration their clinical usefulness and their inherentlimitations, with a view to using the supplied information in an efcient way. 2012 Elsevier Espaa, S.L. and SEMICYUC. All rights reserved.

    AS CLAVEzacinmica;rdiaco;rosmicos

    Tcnicas disponibles de monitorizacin hemodinmica. Ventajas y limitaciones

    Resumen El catter de la arteria pulmonar (CAP) ha constituido una herramienta fundamentalpara la monitorizacin hemodinmica en las unidades de cuidados intensivos durante los ltimos40 anos. Durante este perodo de tiempo ha sido ampliamente usado en pacientes crticos parael diagnstico y como gua del tratamiento, ayudando a los clnicos a entender la siopatologade muchos procesos hemodinmicos. Sin embargo, en los ltimos anos la utilidad del CAP hasido sometida a un intenso debate. Paralelamente, los avances tecnolgicos han permitido eldesarrollo de nuevas tcnicas, menos invasivas, para la monitorizacin cardiovascular. Estapuesta al da pretende dar a los clnicos una visin de los parmetros hemodinmicos que

    te this article as: Mateu Campos ML, et al. Tcnicas disponibles de monitorizacin hemodinmica. Ventajas y limitaciones.a. 2012;36:434---44.nding author.dress: [email protected] (M.L. Mateu Campos).

    see front matter 2012 Elsevier Espaa, S.L. and SEMICYUC. All rights reserved.

  • Techniques available for hemodynamic monitoring. Advantages and limitations 435

    aportan los distintos mtodos disponibles, considerando que es fundamental comprender tantosu potencial utilidad clnica como sus limitaciones para un uso ecaz de la informacin queproporcionan. 2012 Elsevier Espaa, S.L. y SEMICYUC. Todos los derechos reservados.

    Introduc

    For the pahas been torization (ICU).1 Durin critical to treatmeiopathologHowever, ithe subjecpublicationbe associaIn fact, semortality the same tsible to umonitorizalization of controversbe used to variables in

    In recethe PAC iThese newvery invasintermittenprinciples,dynamic uas better sion, whileparametermeasuremecontributecritical pationed techi.e., noninreproducibcian, accurthe utilizatheir availaprofessiona

    All of tidated by standard, wof the pulm

    The prehemodynamwhich are tial to undand their linformatio

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    thetip iinforles: scul

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    st 40 years, the pulmonary artery catheter (PAC)a fundamental tool in the hemodynamic moni-of patients admitted to the Intensive Care Uniting this period of time, it has been widely usedpatients for diagnostic purposes and as a guident, helping clinicians to understand the phys-y of a broad range of hemodynamic processes.n recent years the usefulness of the PAC has beent of intense debate, fundamentally due to the

    of studies in which its use was not found toted with benets in terms of patient survival.2---7

    veral of these studies reported an increase inassociated with the use of the catheter.2,3 Atime, technological advances have made it pos-se less invasive procedures for cardiovasculartionreinforcing the idea that the systematic uti-the PAC may have come to an end. Despite they, however, there is no doubt that the PAC canobtain unique, valuable and useful hemodynamic

    critically ill patients.8,9

    nt years, new methods have come to replacen the determination of cardiac output (CO).

    technologies are highly diverse, ranging fromive to less invasive or even noninvasive, fromt to continuous, and involving different basic

    methods and costs. Some of the methods offerid response indices, which are currently regardedpredictors of the response to volume expan-

    others allow us to evaluate volumetric preloads or afford continuous central venous saturationnts. All of these variables, together with CO,

    to improve the hemodynamic monitorization oftients.10 However, to date, none of the men-niques exhibit optimum or ideal characteristics,

    vasiveness, continuous measurement, reliability,ility, convenience for both the patient and physi-acy and minimum side effects.11,12 Consequently,tion of each of them fundamentally depends onbility and on the knowledge or aptitudes of thel.hese techniques have been evaluated and val-comparing their results with those of the goldhich continues to be intermittent thermodilutiononary artery.

    sent update aims to offer clinicians a vision of the

    Invas

    Pulmo

    This ca1970. Iside ofdistal offers variabintrava

    MeasuThe mecardiaat a tethermithe fothe mment ovalve iin prev

    MeasuThe PApressutral vearterypulmothe PAcorrespulmoof pulming anfact, emate oboth peffect a seribeen estimaDoppleand pusumingrequireof echic parameters afforded by the different methodscurrently available, considering that it is essen-erstand both their potential clinical usefulnessimitations in order to ensure effective use of then obtained in each case.

    parametersultrasoundthe usefulninition. It hPCWP has lmethods

    y artery or Swan---Ganz catheter

    er was introduced by J.C. Swan and W. Ganz indvanced through a large caliber vein to the right

    heart and into the pulmonary artery, where itss positioned in a branch of the artery. The PACmation referred to three categories of differentmeasurements of blood ow (CO), intrathoracicar pressures, and oximetric parameters.

    nts of blood owement of CO using this catheter is based on trans-rmodilution. After injecting a volume of liquidrature below the temperature of the blood, thedetects the temperature changes over time inf a curve. The area under this curve (AUC) is

    volume. The details referred to the measure-, and the technical limitations involved (tricuspidciency, etc.), have been extensively addressed

    Updates in hemodynamic monitorization.13

    nt of intrathoracic intravascular pressureshen correctly positioned, allows us to record

    n three different locations: right atrium (cen-s pressure, CVP), pulmonary artery (pulmonarysure, PAP) and the pulmonary veins (also calledocclusion or wedge pressure, PWP). Originally,s developed for the measurement of PWP, whichs to the pulmonary venous pressure distal to thecapillary bed (hence the commonly used termry capillary wedge pressure, or PCWP), afford-irect estimate of left atrial pressure (LAP). Inoday PCWP affords the best patient bedside esti-lmonary venous pressure, contributing to assessnary resistances and left atrial preload. To thise is no practical alternative to PCWP. Recently,f pulmonary venous ow measurements haveosed, using Doppler echocardiography, for the

    of PCWP,14 though the variables obtained usingtrasound derived from transmitral ow (TMF)nary venous ow (PVF) are inexact, time con-obtain, cannot be recorded in all patients, andportant experience beyond the basic principlesdiography.15 Nevertheless, in recent years new have been developed, based on tissue Doppler, which afford increased accuracy. In any case,ess of PCWP in the critical patient requires redef-as been repeatedly and consistently shown thatow predictive value in the evaluation of volume

  • 436 M.L. Mateu Campos et al.

    response. As a result, it is not advisable for clinicians to usethe absolute PCWP values at the patient bedside in predict-ing the response to uid administration. In this regard, thevariables obtained from the analysis of the arterial pressurecurve during positive pressure ventilation, such as the vari-ation in pupredict vomeasuremethe origin obetween pgenic) lung

    Mixed venOxygen sator mixed vbest isolattransport (remaining the tissues(SvcO2) haing SvO2, fdifferent creects SvOcritical patSvO2 valueculate globVO2, respeand the oxtricular sep

    Advantag

    The PAC apent forms obstructiveparametertry. The usdirect meaus to estabment respobeen one patients inization tooignored or sspecic anfor the lackin differen

    Anothertion of theto interprefor examplthe lack ovariables oclinical setsystem canmation it pthat effect

    In contshown theto improvestrategies

    obtained with the PAC, such as DO2, the cardiac index (CI)or SvO2, signicant reductions have been recorded in hos-pital stay, with improved patient survival.22---24 It thereforeseems that the PAC is a useful tool, capable of improvingsurvival when associated to a treatment algorithm with spe-

    ysiod pa

    the tg rese had bentrate

    studremedditphas

    PAC,iden, ths havserthe iner, tctiombo

    s to h wio imed thor no

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    tray ofo-betionothennul

    the

    mealyz(Pure

    es, Ited

    dilution

    c/Vtionlse pressure or the variation in systolic volume,lume response much more reliably.16 However,nts of PCWP remain very useful in diagnosingf pulmonary hypertension, and in distinguishing

    rimary (non-cardiogenic) and secondary (cardio- edema.

    ous saturation and other oximetric variablesuration measured at distal pulmonary artery levelenous oxygen saturation (SvO2) is probably theed indicator of the adequacy of global oxygenDO2), since it represents the amount of oxygenin the systemic circulation after passing through. The use of central venous oxygen saturations been proposed as a simple method, replac-or assessing the adequacy of global perfusion inlinical scenarios. However, the fact that SvcO22 has been strongly debated, particularly in theient. Moreover, based on the recorded CO ands and the arterial oxygenation values, we can cal-al oxygen transport and consumption (DO2 and

    ctively), as well as the pulmonary oximetric shuntimetric gradient in situations of acute interven-tal rupture.

    es and inconveniences

    pears ideal for identifying and monitoring differ-of circulatory shock (hypovolemic, cardiogenic,

    and distributive), with the determination of keys in any of these scenarios: CO, PCWP and oxime-e of these three measurements, associated tosurements of mean blood pressure (MBP), allowslish the origin of shock and to monitor the treat-nse.17 Based on these arguments, the PAC has

    of the cornerstones in the management of our the ICU, being used as a systematic monitor-l. However, the data obtained have been largelyimply used to assess patient stability. This scantlyd indiscriminate use is at least partly responsible

    of efcacy (in terms of patient survival) reportedt studies.18---20

    contributing factor is the repeated conrma- scant knowledge clinicians have when it comesting the information obtained with the PAC, ase in the analysis of PCWP wave morphology, andf adequate comprehension of the physiologicalbtained when transferring the information to theting.21 Clearly, no hemodynamic monitorization

    improve the patient prognosis, unless the infor-rovides is associated to a choice of treatmentively serves to improve patient survival.raposition to the above, several studies have

    use of the PAC in objective-guided treatment the patient prognosis. When the resuscitationhave been guided by hemodynamic variables

    cic phselecteusing guidindamagyieldement sFACCTmeasu

    In asis, emof theuse. Evcedurestudiefrom infrom tHowevof infeto throwell a(thougand ndeducment when,used.

    Minim

    In recent comethothe anto a cume f(the WThe exway ofphologbeat-tcalibrawhile rial caand incase.

    Thefor anPiCCO

    MostCascienccalibralithiumconvenFloTracalibralogical goals or objectives, applied in adequatelytients. No benets have been documented whenechnique in low surgical risk populations or inuscitation in late stage disease, once organics been established.25 Likewise, the PAC has notets when comparing volume expansion manage-gies guided by PCWP versus CVP, as in the recenty,7 since neither of the variables used are reliablents of preload or volume response.ion to the debate referred to the patient progno-is has been placed on the potential complications

    as a reinforcement of the arguments against itstly, and in the same way as with any invasive pro-ere are potential risks and complications. Manye shown that the local complications resultingion of the PAC are no different from those derivedsertion of any other central venous catheter.26

    he PAC has been related to an increased riskns (incidence of bacteremia of 0.7---1.3%)30 andtic phenomena during prolonged use (>48 h), asan increased risk of arrhythmias during insertionth a minimum incidence of serious arrhythmias,pact upon the prognosis). It therefore can beat the contribution of PAC use to the improve-t of the patient prognosis will depend on how,re and in what type of patient the catheter is

    y invasive methods

    years we have seen the introduction of differ-rcial systems, involving new and less invasiver quantifying CO. Most of them are based on

    is of arterial pulse wave morphology accordingal model allowing estimation of the stroke vol-variations in the morphology of the pulse waveessel model described by Otto Frank in 1899).27

    g systems differ in a number of aspects: in thensforming the information provided by the mor-

    the arterial pressure into systolic volume andat CO; in the algorithms used in each case; in the

    employed (since some require manual calibrationrs require no external calibration); in the arte-ation site involved; in the parameters analyzed;

    accuracy with which CO is determined in each

    thods and systems available on the marketing pulse wave morphology are the following:lsion), PulseCO (LiDCO), Modelow (TNO/BMI),(Vygon) and FloTrac/Vigileo (Edwards Life-

    rvine, CA, USA). Of these systems, the PiCCO isby transpulmonary thermodilution, the LiDCO bytion, and the Modelow by means of three or foural thermodilution measurements. In contrast, theigileo system and MostCare require no external.

  • Techniques available for hemodynamic monitoring. Advantages and limitations 437

    All of these methods are based on the morphology ofthe arterial pressure curve. It is therefore important toobtain a precise curve morphology. Buffering of the arterialcurve and insufcient zeroingcommon problems in clinicalpractice---must be avoided in order to obtain a signal validfor the calmias and treduce thethe analysiperiods of rapid chanand in case

    The PiCC

    The PiCCOMunich, Geable monitto measurvenous lineical patienand intrava

    MeasuremCardiac oucurve usindeterminetion) is injfrom that venous catis located.the tip of variations,surements system. Inand whenetion of thean analysispulse waveusing the ssis of strokpulse pres(SVV), usedresponse to

    MeasuremAnother adculate diffpressure aextravascuon two padiastolic voof blood inblood volumin the four None of thetion. The mquanties llation of thBoth PPV tus of vent

    parameters, and indicate the point of the patient on theFrank---Starling curve, and whether there will be a responseto uid expansion or not.

    Recent studies indicate that PiCCO measurements aremore consistent and are not inuenced by the respiratory

    come thar syfferere nelitylues.nicalermevascremeis, aoeal c

    mengesemetive iuretile m

    the er-resculapseu

    iDCO

    ay sic Oum a

    inddilueat-e stose centrentra

    con of ttratulserom orache Pave tageerape obnce (tter suesn patutionuntshiuminatculation of CO. The presence of severe arrhyth-he use of an intraaortic counterpulsation balloon

    precision of the CO measurements. Furthermore,s of pulse pressure is of limited accuracy duringhemodynamic instability, as for example in theges in vascular resistance found in septic patientss of liver dysfunction.

    O system

    (PiCCO System, Pulsion Medical Systems AG,rmany) is currently the only commercially avail-or using transpulmonary thermodilution (TPTD)e CO. It requires only an arterial line and a, which in any case are necessary in most crit-ts. The system offers information on blood owsscular volumes.

    ents of blood owtput is calculated from the analysis of the TPTDg the Stewart---Hamilton equation. In order to

    CO, an indicator (normally isotonic saline solu-ected as a bolus dose at a temperature differentof the blood through the lumen of the centralheter in which the external temperature sensor

    Once within the bloodstream, the thermistor inthe arterial catheter detects the temperature

    generating the thermodilution curve. Three mea-are recommended for initial calibration of the

    addition, calibrations must be made every 8 h,ver needed according to the hemodynamic condi-

    patient. Parallel to the thermodilution process, is made of the systolic portion of the arterial

    morphology, to determine aortic compliance. Bytudy of the pulse pressure wave for the analy-e volume (SV), we can also calculate percentagesure variation (PPV) or stroke volume variation

    to guide uid therapy and evaluate the patient such therapy.

    ent of volumesvantage of this technique is its capacity to cal-erent intravascular compartment volumes (nots in the case of the PAC), as well as pulmonarylar uid. Cardiac preloading is estimated basedrameters: (a) the measurement of global end-lume (GEDV), dened as the sum of the volume

    the four heart cavities; and (b) the intrathoracice index (ITBV), regarded as the volume of blood

    heart cavities and in the pulmonary vascular bed.se parameters are altered by mechanical ventila-easurement of extravascular lung water (EVLW)

    ung edema and vascular permeability, with calcu-e pulmonary vascular permeability index (PVPI).and SVV offer information on the volemia sta-ilated patients. These are very sensitive preload

    cycle, pensatvasculthe ditions ainstabiCO vaent cliPAC thnary rmeasustenoscorpor

    Theto chamanagvasoacwith d

    Whway ascathetand vaity, or

    The L

    In a wCardiaCO frolithiumthermouous bof pulsbolus dinto a in a clithiumtrationconcenfrom ption. FintrathAs in tsure wpercenuid thbles, wresistaThe lathe tistions ithe dildiac shand litdetermpared with the PAC. However, in order to com-e inter-individual variations that can occur instem compliance and resistance, as a result ofnt clinical situations, frequent manual calibra-ededparticularly in situations of hemodynamicin order to secure increased precision of the

    28 This technique has been validated in differ- situations in critical patients, comparing it withodilution, including patients subjected to coro-ularization surgery.29,30 TPTD can yield inexactnts in patients with intracardiac shunts, aorticrtic aneurysms, and in those subjected to extra-irculation.asurement of volumes with this system can lead

    in treatment strategy, allowing more precisent of uid resuscitation and the optimization ofdrug use, as well as guiding depletion therapyics or dialysis.inimally invasive, the PiCCO system---in the samePAC---can give rise to complications, which are alllated, including infection, thrombosis, bleedingr damage secondary to ischemia of the extrem-doaneurysms.

    plus system

    milar to the PiCCO device, the Lithium Dilutiontput system (LiDCO plus, London, UK) measureslithium chloride dilution wave using a peripheralicator sensor to generate a curve similar to thetion curve, which in turn is used for the contin-by-beat calibration of CO, based on the analysisrength. Calibration is carried out by injecting aof the lithium chloride tracer (0.002---0.004 M/kg)al or peripheral venous line. An electrode placedl or peripheral arterial line detects the bloodcentration and the time elapsed from adminis-he tracer, calculating CO using the area under theion---time curve. The stroke volume is calculated

    strength after calibration with the lithium solu-the lithium mean transit time (MTt) we obtain theic blood volume (ITBV) as an indicator of preload.iCCO system, using the study of the pulse pres-for the analysis of SV also allows us to calculate

    PPV or SVV in predicting the patient response toy. With the manual introduction of certain varia-tain the systemic or peripheral vascular index orSVRI/SVR) and the oxygen transport index (IDO2).may contribute to maximize oxygen supply to, with optimization of the hemodynamic condi-ients at risk. In the same way as with the PiCCO,

    curve can be altered in patients with intracar-. The use of non-depolarizing muscle relaxants

    salt treatments also give rise to errors in theion of CO.

  • 438 M.L. Mateu Campos et al.

    The LiDCO technique offers acceptable accuracy whenfrequently recalibrated, and is less invasive that the PiCCOsystem, since it requires no central venous access (catheter-ization of the radial artery is sufcient). On the other hand,calibration is rapid and with few complications, and offerscontinuousmeasuremevalidated continuouswave has astability---nertheless, a substantipatient, pasupport me

    In the cation has bein vivo datasame pulseThis systemoffer reliabguided uithe LiDCO assessing t

    The FloTr

    In contrastsystem (Edthe FloTracrial pulse wcalibrationdepend onpometric mheight). Thsure (the dis proporticomplianceused in marequires notion of a lais needed.

    In additoffers inforof a centracan also m

    DifferenFloTrac/Vigwith PAC tof the Flopatients (bgreater thaation of arLikewise, twith diminbeen increand with ishows accelution and patients.37

    The determination of SVV with this system has revealedaccuracy similar to that afforded by the PiCCO,38 with goodperformance during objective-guided uid therapy, fewercomplications, and a shorter hospital stay.39

    A new hemodynamic monitorization device has recentlyplacrds ulmoay

    TPTitionV, S

    etricg edgh ted t.40

    ostC

    ostCys tha mois ofn artionl pretics,re cupedae pris foown t baratethe nt ccanAM m

    hempatifectetiverizaiac

    by aramrdiov. Th

    r stu

    ode

    odelandlectble uouse w

    syst information on a range of variables. The COnt obtained through lithium dilution has been

    in comparison with PAC thermodilution.31 The measurement of CO obtained from the pulselso been validated,32,33 in the same way as itso recalibration being needed for up to 24 h.34 Nev-recalibration is recommended whenever there isal change in the hemodynamic condition of therticularly after modications in the hemodynamicasures.se of the more recent LiDCO rapid, lithium dilu-en replaced by a normogram derived from the

    to estimate CO on a continuous basis. It uses the pressure algorithm as the LiDCO plus (PulseCO).

    is simple and easy to use, and was designed tole parameters of use in application to objective-d therapy. A number of studies have made use ofrapid as a guide for uid administration and forhe blood pressure response to such treatment.

    ac/Vigileo system

    to the above two devices, the FloTrac/Vigileo

    wards LifeSciences, Irvine, CA, USA), comprising sensor and the Vigileo monitor, analyzes arte-ave morphology without the need for external

    . The latter is replaced by correction factors that the mean blood pressure (PAM) and on anthro-easurements (patient age, gender, weight and

    e system is based on the principle that pulse pres-ifference between systolic and diastolic pressure)onal to SV and inversely proportional to aortic. In contrast to the indicator dilution methodsnual calibration, the FloTrac/Vigileo system

    central or peripheral venous access, or cannula-rge caliber artery; only a radial arterial catheter

    ion to continuous CO monitorization, the systemmation on SV, SVV and SVR. With the implantationl venous catheter equipped with ber optics, weonitor SvcO2.t studies have reported good reliability with theileo in different clinical scenarios comparedhermodilution.35 However, the percentage errorTrac/Vigileo compared with the PAC in obeseody mass index (BMI) > 30 kg/m2) proved slightlyn in patients of normal weight, due to the alter-terial compliance observed in these individuals.he accuracy of the results is lower in patientsished SVR.36 The precision of the system hasased as a result of successive software upgrades,ncorporation of the latest algorithm version itptable correlation with intermittent thermodi-continuous thermodilution in post-heart surgery

    been (Edwatranspsame wing theIn addmine Svoluming lunAlthouobtainsystem

    The MItaly)

    The Memplousing analysonly aproporarteriaacterispressutic imuses thics. Ththe knby-beaheart date, differea signithe PRtion inseptic not afvasoacmonitoor cardformedThis pthe calibriumfurthe

    The M

    The MNetherphotoeinatacontinof pulsof theed on the market: the VolumeView systemLifeSciences, Irvine, CA. USA), which usesnary thermodilution for calculating CO. In theas the PiCCO system, CO is calculated by analyz-D curve, using the Stewart---Hamilton equation.

    to continuous CO, the system allows us to deter-VR and SVV. From the dilution curve it derives

    parameters such as EVLW, PVPI (for quantify-ema), GEDV and global ejection fraction (GEF).he experience gained is still limited, the resultso date are comparable to those of the PiCCO

    are system (Vygon) (Vytech, Padova,

    are system (Vygon)(Vytech, Padova, Italy)e pressure recording analytical method (PRAM),died version of the Wesselings algorithm for

    the arterial pulse wave. The system requiresterial catheter (e.g., radial artery). The SV isal to the area under the diastolic portion of thessure wave divided by the aortic impedance char-

    obtained from the morphological data of therve, without the need for calibration. The aor-nce is determined by means of a formula thatinciples of quantum mechanics and uid dynam-rmula is completely different from those of allmethods. Stroke volume is calculated on a beat-sis, and CO is obtained by multiplying SV by. CO is reported as the mean of 12 beats.11 Tosystem has been validated in animal models inlinical scenarios.41 Recent studies have revealedt correlation between the values obtained withethod and those obtained through thermodilu-odynamically unstable patients,42 as well as in

    ents, where the good correlation to TPTD wasd by the changes in vascular tone induced by

    drugs.43 The MostCare system has an exclusivetion parameter, the cardiac cycle efciency (CCE)stress index, which corresponds to the work per-the heart divided by an energy expenditure ratio.eter reects the energy expenditure needed forascular system to maintain a hemodynamic equi-e MostCare system requires validation throughdies.

    low-Nexn system

    low-Nexn system (FMS, Amsterdam, Thes) analyzes pulse pressure noninvasively usingric plethysmography in combination with annger cuff. Cardiac output is calculated through

    monitorization of arterial pressure and analysisave morphology, based on the study of the areaolic pressure wave and on the Windkessel triple

  • Techniques available for hemodynamic monitoring. Advantages and limitations 439

    elements model individualized for each patient (Modelowmethod). The measurements obtained include continuousCO, SV, SVR and a left ventricle contractility index. Somestudies, carried out in different clinical situations, suggestgood correlation to thermodilution.44

    The NICO

    The NICO

    ford, USA)indicator. Win producta brief reof inconvesurement calculationPaCO2 and PCO2 < 30 min dead spa

    Few valhave been been reporment of Crespect to this systemconstitutesas those su

    Noninvas

    Techniquesesophagearecent yeawell acceplimitations

    The NICOsystem

    Bioimpedatractility fin thoracicvolume duused by thenhead, Beand frequethrough thto bioimpeas electricing, or dispto data ercompared the techniunder the pow and vdeterminatconditions.relation tohumans an

    Area

    Stroke distance (VTI)

    1 Cross-sectional area of the ascending aorta blood distance beat-by-beat = stroke volume (SV).

    er ultrasound (USCOM system)

    SCOM system is a noninvasive technique that usesr technology to obtain the measurements of stroke

    and its derived parameters. All medical deviceson Dwaveod cnsduitteve tginalhenord se oternaximuy val

    tra Baseasurand v

    maltraasiveto u

    is rthe

    dentThee of

    possernachniion

    outring er---teasue obs. Tden

    usly,), ha

    Time (s)

    Figure 2 Doppler wave. system

    system (Novametrix Medical Systems, Walling- is based on the Fick principle, using CO2 asith this method, CO is proportional to the change

    ion of CO2 divided by the end-tidal CO2 after-inhalation period. This system has a numberniences that limit its utilization: small mea-errors give rise to important changes in the

    of CO, due to the scant difference betweenPvCO2---the results not being valid in patients withmHg, and false changes in CO are obtained bothce and ventilation---perfusion alterations.idation studies of this technique versus the PACmade, though a reasonably good correlation hasted. In post-heart surgery patients, the measure-O through re-inhalation is underestimated withthe value obtained with the PAC. In conclusion,

    is presently no replacement for the PAC, but a feasible alternative in certain patients, suchbjected to heart surgery.45,46

    ive methods

    such as transthoracic bioimpedance andl Doppler ultrasound have been developed inrs for the evaluation of CO, and have beented in clinical practice, though with certain.

    M thoracic electrical bioreactance

    nce is used to determine CO, SV and cardiac con-rom continuous measurements of the changes

    impedance caused by uctuation of the bloodring the cardiac cycle. Bioreactance, a methode NICOM system (Cheetah Medical Ltd., Maid-rkshire, UK), analyzes the changes in amplitudency of the electrical impulses as they coursee chest. The advantage in this case with respectdance is a signicant reduction of factors suchal interferences, patient movements or position-lacement of the electrodes, which can give riseror. A better signal-to-noise ratio is obtainedwith bioimpedance. Among the limitations ofque, it should be mentioned that since the areaulse wave is proportional to the product of peakentricle ejection time, the precision of the COions may be adversely affected under low ow

    The readings obtained offer an acceptable cor- the results of CO measured with the PAC, in bothd animals, and in different clinical scenarios.47---49

    Figurecolumn

    Doppl

    The UDopplevolumebased sound red blothe trathe emthe waits oriow. Wwe recthe casuprasthe mamonaroutowrithm.the meindex

    Theto all unoninveasier system

    On depenbasis. the usber ofparastthe tevalidatcarriedcompacathet250 mwith thsystema conPrevio(n = 50oppler ultrasound use a probe that emits ultra-s that are reected from the constantly movingells (they either move closer to or further fromcer), thereby obtaining a measure of ow. Whend wave comes into contact with the red cell,hat is reected towards the transducer changes

    frequency according to the direction of blood the transducer is aligned with the blood ow,a maximum optimum velocity or frequency. Inf the USCOM, the probe is positioned at thel, supraclavicular or parasternal notch, seekingm blood ows at the level of the aortic and pul-ve outow tracts, respectively. The areas of thects are estimated from an anthropometric algo-d on these velocities and areas, we can obtainements of stroke volume, cardiac output, cardiacascular resistances (Figs. 1 and 2).

    in advantages of this method are those commonsound systems. In effect, the technique is totally, and the compact size of the device makes itse at the patient bedside. Learning to use theapid, and no calibration is needed.other hand, the USCOM system is observer-

    and does not afford information on a continuous acoustic window is also a limiting factor in

    the device, despite the existence of a num-ible accesses (suprasternal, supraclavicular andl) that help minimize this limitation. The use ofque is not yet widespread, due to the lack ofstudies. Most of the existing studies have been

    in surgical patients or following heart surgery,the USCOM device with the pulmonary arteryhe results varying greatly. Tom et al.50 comparedrements obtained simultaneously in 89 patients,servation of a poor correlation between the twohe mean difference was 0.09 L/min, but withce interval of between 2.83 and 3.01 L/min.

    Chand et al.,51 in the same type of patientsd recorded an excellent correlation, with a mean

    Velocity (m/s)

  • 440 M.L. Mateu Campos et al.

    difference of 0.03 L/min and with a condence interval ofbetween 0.19 and 0.13 m/min m. A recent study, publishedby Horster et al.,52 has compared the cardiac output mea-surements obtained with the PiCCO and USCOM systems inseptic patients, and describes a good correlation betweenthe USCOMmodilutionshowed a dence inte

    Furtherment this s

    Esophage

    Esophagealin critical rapid, contdynamic mother paramaffording anamic condof a D-shapsound waveis positionewith an incvessel (in twaves are are again danalyzed, avelocity---titracing is tby a blood of the leftand the crous to obtai

    The diffthe markethe CardioQemploys a height to etricle from

    In additlarly intereof the patifrom the a

    Althougevidence iability of Doppler cosurements.supported demonstrapreoperatigical patieof these paerative comDoppler hation tool, iabove. Itstion of paacute respi

    Maacce

    Flow

    Peak velocity

    3 le ej

    emeon ogenicropoclic assivle 1 tem

    COAddnt s

    sys

    havo hen dif

    maent

    comhere

    h syhoiceced tics s reld to the monitoring system that must be taken intoeration are its availability, the setting in which it isused, and the cost of the device. In turn, aspectsd to the clinician are knowledge of the technique,or experience, ease of use and interpretation of the, and dependency or not upon the operator. In manythe time factor leads to the choice of less invasiveques that can be applied on an immediate basis. Gen-nsiderations, in relation to the characteristics of thet, include particularly the fact that the more seri-

    patient condition, the greater the required precision hemodynamic parameters obtained. At least for theeing, this requirement in the context of continuousrization is satised by the invasive techniques. Thes which we have described as being less invasive, and the reference technique based on ther- (PiCCO). Seventy measurements in 70 patientsmean difference of 0.36 L/min, with a con-rval of 0.99 L/min.

    research is needed to fully validate and imple-ystem at the patient bedside in the ICU.

    al Doppler ultrasound

    Doppler ultrasound began to be used in the 1990spatients, with the purpose of allowing precise,inuous and especially minimally invasive hemo-onitorization, with the measurement of CO andeters of established clinical usefulness---thereby

    sufciently comprehensive view of the hemody-ition of the patient.53 Briey, the device consistsed Doppler probe that continuously emits ultra-s at a xed frequency (generally 4---5 MHz), andd in the esophagus (via the nasal or oral route)lination of 45 with respect to the explored bloodhis case the descending aorta). The ultrasoundreected from the circulating red blood cells andetected by the transducer. The signal received isnd the monitor displays the corresponding waveme tracings. The area under the velocity---timehe systolic distance, i.e., the distance traveledcolumn through the aorta with each contraction

    ventricle. The product of the systolic distancess-sectional area of the aorta at that point allown the stroke volume.erent esophageal Doppler monitors available ont use a variety of principles. As an example,

    (Deltex Medical, Chichester, West Sussex, UK)normogram referred to patient age, weight andstimate the total stroke volume of the left ven-

    the ow measured in the descending aorta.ion to SV and CO, this technique affords particu-sting information on the cardiovascular conditionent (preload, contractility and afterload), drawnnalysis of the velocity---time curves (Fig. 3).h few studies have been made, the existingn the medical literature suggests good reli-the CO measurements obtained by esophagealmpared with the classical thermodilution mea-

    There is a large body of scientic evidence,by numerous randomized prospective studies,ting the usefulness of esophageal Doppler in theve optimization of volemia in the high risk sur-nt54---56---with clear improvement in the prognosistients (shorter hospital stay and fewer postop-plications). In the critical patient, esophageal

    s been postulated as an interesting monitoriza-n view of the characteristics already commented

    use has been described in the monitoriza-tients during lung recruitment maneuvering inratory distress syndrome,57 for the hemodynamic

    Figureventric

    managmizaticardiobeen pthe cywith p

    Tabthe sysmatingthem. differe

    What

    As weused tthem ito theinstrumfewer etc.---tstay.

    EacThe cinuenacterisfactorreferreconsidto be referreoperatresultscases technieral copatienous theof thetime bmonitosystemximumleration

    LVET

    Cardiac cycle

    Time

    Components of an ideal aortic ow wave. LVET: leftection time.

    nt of potential organ donors,58 and even for opti-f the pacemaker pacing mode in patients with

    shock.45 More recently, esophageal Doppler hassed as a tool for evaluating volume response inchanges induced by mechanical ventilation ande leg elevation maneuvering.59,60

    describes the different techniques available ands most commonly used in critical patients for esti-, with the advantages and limitations of each ofitional hemodynamic variables afforded by theystems are also specied.

    tem or method should we choose?

    e seen, different monitorization tools can belp clinicians to evaluate a diagnosis and to guideferent treatment strategies, particularly referrednagement of uids and drugs. In turn, theses can improve the results obtained in terms ofplications, lesser time on mechanical ventilation,by improving morbidity-mortality and hospital

    stem has its advantages and inconveniences. of one monitorization technique or other isby different factors, fundamentally the char-of the system, patient-related parameters, andated to the clinician using the system. Aspects

  • Techniques available for hemodynamic monitoring. Advantages and limitations 441

    Table 1 Techniques available for estimating cardiac output (CO) in the critical patient.

    System Advantages Disadvantages Additional variables

    Static Dynamic

    Pulmonary arterycatheter

    Fully validated technique Invasive system CVPInformation on ow variables(gold standard for CO),intrathoracic pressures and tissueperfusion (SvO2).

    Less invasive alternatives for mostdata provided

    PAP

    Allows calculation of oximetricvariables (DO2, VO2)

    Lack of knowledge in interpretingthe data

    PCWP

    Increased incidenceof complications

    A) PiCCO Continuous informationon multiple variables.

    Invasive CVP SVV

    Measurement of volumes Requires larger caliber vascularaccesses

    GEDV PPV

    Measures of lung edemaand permeability

    Requires recalibrationin situations of instability

    EVLW

    Allows ner hemodynamicmanagement

    PVPI

    GEFB) LiDCO Scantly invasive Invasive system ITBV SVV

    Any arterial or venous line Interference of lithium salts andnon-depolarizing muscle relaxants

    PPV

    Validated techniqueContinuous informationon multiple variables

    C) FloTrac Continuous Requires validation in patientswith diminished systemic vascularresistance

    SVV

    Requires no external calibration Not validated in patientswith ventricular assist devicesor intraaortic counterpulsationballoon

    Minimally invasive Aortic insufciencyPeripheral vascular access

    D) Volume View Continuous informationon multiple variables

    Few validation studies to date EVLW SVV

    Measurement of volumes PVPIMeasurement of lung edemaand permeability

    GEDV

    GEFE) Most care Requires no manual calibration Few validation studies to date SVV

    Monitors cardiac cycle efciency(CCE)

    PPV

    F) Nexn Noninvasive (requires no arterialor venous access)

    Scantly validated

    Bioimpedance(BET)

    Noninvasive Scantly validatedLimited in critical patients, majorsurgery and chest alterationsSusceptible to environmentalchanges (noise), patientmovements and electrodeplacement

  • 442 M.L. Mateu Campos et al.

    Table 1 (Continued)

    System Advantages Disadvantages Additional variables

    Static Dynamic

    BioreactanNICOM

    valund irs, lVADslmonrtic cy asiac sh

    A) EsopDoppler

    se (s on nes avcal cdepe

    B) USCO nuou andepenin sealida

    Partial COre-inhalat(NICO)

    nuouintubwith

    without thbe more ushospital aruation of admission may provecritical caunderlyingbe treatedinvasive teinvolved.

    Thus, tremain moheart failumonary hypechocardioas methodand in thosdiac cathet

    The traintrathoracextravascuchoice in gtion, and iin acute resyndrome.

    In patiemore advissis of arter

    atioce Noninvasive ErroneousLesser operative costs andcapacitation requirements

    External apacemakedevices (L

    Good signal-to-noise ratio Severe puNo variability in relation to bodychanges or electrode positioning

    Severe aoinsufcienalteration

    Continuous, real time data Intracardhageal Minimally invasive Habitual u

    in patientventilatio

    Rapid placement and applicationof the technique

    Few studinon-surgi

    Continuous monitorization Operator-Rapid learning curve

    M Noninvasive Not contiRapid learning curve Operator-

    window-dRequires no calibration Not valid Rapid start of measurements Pending v

    2

    ionMinimally invasive Not contiSimple Requires Frequently repeatable Artifacts

    shunt

    e need for central venous catheterization, could inform

    eful in the Emergency Department or in certaineas for the initial management of patients, eval-their clinical course, and for deciding whetherto the ICU is indicated or not. Likewise, they

    useful in those patients in which admission tore is not considered necessary, in view of the

    disease process, but who nevertheless need to and stabilized. In other cases we resort to morechniques, chosen according to the patient disease

    he PAC and measurements of PCWP appear tore useful in patients with different types ofre, in cardiogenic shock, or in patients with pul-ertension. Provided operator skill is guaranteed,graphy and esophageal Doppler can be regardeds of choice during the evolution of the patients,e cases in which the implantation of an intracar-er is contraindicated.nspulmonary dilution techniques that determineic volumes (global end-diastolic volume andlar lung water) can be regarded as options ofuiding uid management, improving lung func-n reducing the time on mechanical ventilationspiratory failure and acute respiratory distress

    nts with severe sepsis and septic shock, it appearsable to use systems that obtain CO from analy-ial pulse wave morphology. These systems offer

    found, thostages, due

    The systto uid thetranspulmoparameterto volumeand the eindices obsis of pulsin recent phases of used in daric paramelling prespiratory cfrom analyshould be tsince theyventilationfrequency.

    Indepenemployed,vention, itto improveical valuethrough thSvO2/SvcOes in presence of: SVVnternaleft ventricle assist)ary hypertensionor tricuspidnd thoracic aortic

    untsnot exclusive)mechanical

    ailable inritical patientsndent

    s acousticdentvere valve diseasetion studiessated patientintrapulmonary

    n on the phase of shock in which the patient is

    ugh frequent calibration is needed in the initial

    to the alterations in vascular tone.ems and parameters used to assess the responserapy include the cardiac volumes derived fromnary dilution techniques (PPV and SVV are thes that can guide evaluation of the response

    expansion), esophageal Doppler ow velocity,chocardiographic indices, as well as dynamictained from the methods based on the analy-e wave morphology. The greatest controversyyears refers to volume expansion in the earlyshock. Although central venous pressure is stillily practice for volume management, volumet-ters are considered to be more useful thansures, since they are not altered by the res-ycle. Likewise, the dynamic indices obtainedsis of the pulse wave have limitations thataken into account when monitoring the patient,

    are only applicable in controlled mechanical and with a regular heart rhythm of normal61

    dently of the process involved, of the device and of the variables used to guide our inter-

    must be remembered that our objective is tissue perfusion, i.e., to restore physiolog-

    s referred to oxygen transport-consumption,e assessment of lactate concentrations and

    2.62

  • Techniques available for hemodynamic monitoring. Advantages and limitations 443

    Conclusions

    The ultimate purpose of hemodynamic monitorization isreducing mortality in the critically ill patient. At present,we have a range of more or less invasive techniques thatcan be useThe choiceby the folin performtation of tcost-effect

    The setof the patidiagnostic and methocians to momust undeveniences,course the

    It can bpatient mution combithis reviewport and coperfusion a

    Conicts

    The author

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    AJ,inv

    1;201ca Xstimitori1;35:ssugeluatipler . 200a G.nseso8;12:hard

    pat2;121sky Mtor. Pk: Mcina-Ting hientscent olas-ctionopeady. EP---44.r Y, V

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    the scenario best suited to each system, and ofy must be able to interpret the data obtained.e concluded that monitorization of the criticalst be global, with multiparametric monitoriza-ning the hemodynamic parameters described in

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    of interest

    s declare no conicts of interest.

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    Techniques available for hemodynamic monitoring. Advantages and limitationsIntroductionInvasive methodsPulmonary artery or SwanGanz catheterMeasurements of blood flowMeasurement of intrathoracic intravascular pressuresMixed venous saturation and other oximetric variables

    Advantages and inconveniences

    Minimally invasive methodsThe PiCCO systemMeasurements of blood flowMeasurement of volumes

    The LiDCO plus systemThe FloTrac/Vigileo systemThe MostCare system (Vygon) (Vytech, Padova, Italy)The Modelflow-Nexfin systemThe NICO system

    Noninvasive methodsThe NICOM thoracic electrical bioreactance systemDoppler ultrasound (USCOM system)Esophageal Doppler ultrasound

    What system or method should we choose?ConclusionsConflicts of interestReferences