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Why Advanced Hemodynamic Monitoring?

Topic
Intensive Care
Operating Room
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Topic
Intensive Care
Operating Room

The lives of critically ill patients with hemodynamic instability depend on the right decision regarding the next therapeutic step. Advanced hemodynamic monitoring helps to identify targeted and patient-individualized therapy.

Limitations of Basic Monitoring

Monitoring physiological parameters of cardiovascular function is a decisive factor for a goal-directed management of critically ill patients.

Basic monitoring reaches its limits in cases of hemodynamic instability caused by organ failure or major surgical procedures. In such situations, a patient's condition can deteriorate rapidly within a very short time. For a differentiated assessment of the circulatory situation, standard parameters such as ECG, blood pressure measurement, and pulse oximetry are no longer sufficient to reliably evaluate cardiac output (CO) and oxygen transport for targeted, individualized therapy. 

More differentiated assessment through advanced hemodynamic monitoring

Advanced hemodynamic monitoring provides additional and significantly more precise information about the cardiovascular system, such as blood flow, volume status, vascular tone, and cardiac function. Through the continuous monitoring and analysis of the shape and the area under the arterial pressure curve (pulse contour analysis), the structural and mechanical properties of the vascular system, and the physical properties of the blood, a differentiated assessment of the circulatory situation can be performed at any time, and targeted therapy can be initiated.
In addition, the extravascular lung water index (ELWI) enables bedside assessment of pulmonary edema, allowing early therapeutic intervention [1] [2] [3].

Advanced hemodynamic monitoring enables answers to the following questions:

  • What is the current cardiovascular status?
  • What are the cardiac preload and afterload?
  • Will an increase in preload result in higher cardiac output (does the patient respond to fluid administration)?
  • Should fluids or catecholamines be administered?
  • Is there a risk of fluid overload?
  • Is the patient developing pulmonary edema?

By using advanced hemodynamic monitoring, clinicians are continuously informed about changes in the patient’s condition. As a result, treatment can be adjusted immediately and in a targeted manner, and patient-specific therapy can be carried out with optimal use of fluids, inotropes, and vasoactive substances. Clinical evidence has long shown that hemodynamic optimization as part of a goal-directed therapy approach (“Early Goal-Directed Therapy,” EGDT) reduces complications and morbidity, shortens length of stay, and saves costs. [4] [5] [6].

Indications

Typical indications for the use of advanced hemodynamic monitoring in both intensive care and anesthesia include:

  • Septic shock
  • Acute respiratory distress syndrome (ARDS)
  • Cardiogenic shock
  • Severe burns
  • Polytrauma
  • Pancreatitis
  • High-risk surgical procedures

The principles of transpulmonary thermodilution and arterial pulse contour analysis enable the calculation of these advanced hemodynamic parameters and have been clinically tested and established for more than 20 years [7] [8].

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Intensive Care

  1. 1. Brown LM, Calfee CS, Howard JP, Craig TR, Matthay MA, McAuley DF. Comparison of thermodilution measured extravascular lung water with chest radiographic assessment of pulmonary oedema in patients with acute lung
    injury. Ann Intensive Care 2013; 3(1): 25.

  2. 2. Saugel B, Ringmaier S, Holzapfel K, Schuster T, Phillip V, Schmid RM, Huber W. 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; 26(4): 402-10.

  3. 3. Sakka S. G. et al., Assessment of cardiac preload and extravascular lung water by single transpulmonary thermodilution. Intensive Care Med 2000, 26(2): 180-187.

  4. 4. Salzwedel et al. Perioperative goal-directed hemodynamic therapy based on radial arterial pulse pressure variation and continuous cardiac index trending reduces
postoperative complications after major abdominal surgery: a multi-center, prospective, randomized study. Critical Care 2013;17:(191).

  5. 5. Grocott et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane systematic review. British Journal of Anaesthesia. 2013;111(4):535-48.

  6. 6. Manecke, G.R., Asemota, A. & Michard. Tackling the economic burden of postsurgical complications: Would perioperative goal-directed fluid therapy help. Critical Care. 2014;18:(5):1–8.

  7. 7. Michard F. et al., Global end-diastolic volume as an indicator of cardiac preload in patients with septic shock. Chest 2003, 124(5): 1900-1908.

  8. 8. Adler C. et al., Fluid therapy and acute kidney injury in cardiogenic shock after cardiac arrest. Resuscitation 2013, 84(2): 194-199

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