Functional hemodynamic monitoring

Michael R Pinsky, Didier Payen

Hemodynamic monitoring is a central component of intensive care. Patterns of hemodynamic variables often suggest cardiogenic, hypovolemic, obstructive, or distributive (septic) etiologies to cardiovascular insufficiency, thus defining the specific treatments required. Monitoring increases in invasiveness, as required, as the risk for cardiovascular instability-induced morbidity increases because of the need to define more accurately the diagnosis and monitor the response to therapy. Monitoring is also context specific: requirements during cardiac surgery will be different from those in the intensive care unit or emergency department. Solitary hemodynamic values are useful as threshold monitors (e.g. hypotension is always pathological, central venous pressure is only elevated in disease). Some hemodynamic values can only be interpreted relative to metabolic demand, whereas others have multiple meanings. Functional hemodynamic monitoring implies a therapeutic application, independent of diagnosis such as a therapeutic trial of fluid challenge to assess preload responsiveness. Newer methods for assessing preload responsiveness include monitoring changes in central venous pressure during spontaneous inspiration, and variations in arterial pulse pressure, systolic pressure, and aortic flow variation in response to vena caval collapse during positive pressure ventilation or passive leg raising. Defining preload responsiveness using these functional measures, coupled to treatment protocols, can improve outcome from critical illness. Potentially, as these and newer, less invasive hemodynamic measures are validated, they could be incorporated into such protocolized care in a cost-effective manner.