COMMENTARY
Year : 2022 | Volume
: 4 | Issue : 1 | Page : 16-
Four Principles of Hemodynamic Monitoring: Early, Optimal, Combined, and Sequential
Hui Wang, Jun Duan
Department of Intensive Care Medicine, China-Japan Friendship Hospital, Beijing, China
Correspondence Address:
Dr. Jun Duan
Department of Intensive Care Medicine, China-Japan Friendship Hospital, No.2, Yinghua East Street, Chaoyang District, Beijing 100029
China
How to cite this article:
Wang H, Duan J. Four Principles of Hemodynamic Monitoring: Early, Optimal, Combined, and Sequential.J Transl Crit Care Med 2022;4:16-16
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How to cite this URL:
Wang H, Duan J. Four Principles of Hemodynamic Monitoring: Early, Optimal, Combined, and Sequential. J Transl Crit Care Med [serial online] 2022 [cited 2023 Mar 29 ];4:16-16
Available from: http://www.tccmjournal.com/text.asp?2022/4/1/16/356709 |
Full Text
Preface
Hemodynamic monitoring technology is not only an important diagnostic tool for critically ill patients with circulatory failure but also a vital tool for guiding treatment and evaluating response after treatment. The introduction of pulmonary artery (PA) floating catheter is a milestone in the development of clinical hemodynamic monitoring. Technologic advances preceding the PA catheter generally could not be used at the bedside and required patients to be stable enough to be taken to the catheterization laboratory.[1],[2] However, for the early unstable hemodynamic state, it is difficult to identify in our clinical work, such as the compensatory period of low blood volume or heart failure.[3],[4] The invention of PA floating catheter and hemodynamic monitoring technologies can clearly and accurately identifying the type of shock, guiding the selection of the best treatment, and evaluating the effect after treatment.
In recent years, hemodynamic monitoring technology has developed from incoherent to continuous, from noninvasive to invasive, and then back to minimally invasive,[5],[6] from simple arterial blood pressure monitoring to accurate monitoring of cardiac output (CO), extravascular lung water (EVLW), and other parameters; various monitoring technologies are being updated daily. At the same time, the continuous development of these monitoring technologies also brings many challenges to clinicians, such as when to start, what method to choose, how to guide treatment through these multiple technologies, how to apply them into hemodynamic management, and when to evacuate monitoring.
The concept of early, optimal, combined, and sequential hemodynamic monitoring can provide some ideas for clinicians to choose hemodynamic monitoring technology and clinical application. Timely selection of appropriate monitoring methods, evaluation of hemodynamic status, and guidance of hemodynamic treatment can also reduce unnecessary harm.
Early Stage
The initial clinical assessment in the early stages of shock has important implications for the patient's hemodynamic status, such as peripheral tissue hypoperfusion, reduced arterial pressure, changed central venous pressure, and decreased vascular tension, are important hemodynamic parameters.[7],[8] However, the professional sources of intensive care unit (ICU) physicians are complex, the examination of critically ill patients is limited, the involvement and interaction of multiple organs, the combination of vasoactive drugs, and other treatment measures affect the accuracy of clinical evaluation. Subsequently, the development of various hemodynamic monitoring technologies has enabled clinicians to obtain parameters that more deeply and directly reflecting the pathophysiological mechanism of patients, such as CO, EVLW, and so on.[9] It is because of the emergence of these monitoring means that our treatment has entered a goal-directed treatment mode, from “shooting while aiming” to “aiming before shooting.” Collectively, for patients with early shock or perioperative hypotension, if these direct hemodynamic indexes can be obtained early, it will be of great help to guide the treatment and improve the prognosis of patients.[10],[11],[12]
Hemodynamic monitoring should be carried out as soon as possible for critically ill patients, especially for those with hemodynamic instability. Due to the need for immediate monitoring, the most suitable and convenient monitoring methods were considered, including point-of-care ultrasound and noninvasive or minimally invasive hemodynamic monitoring technologies.[4],[13] These monitoring techniques can calculate CO, stroke volume variability, and other parameters in real time without harming the patient, especially suitable for those high-risk perioperative patients, who with unstable hemodynamic states,[14],[15] or those patients at the early stage of shock.
An increasing number of patients require precise intraoperative hemodynamic monitoring due to aging and comorbidities. Goal-directed therapy techniques allow for flow monitoring as the standard for perioperative fluid management. Based on the concept of personalized medicine, individual assessment and treatment are more advantageous than uniform interventions. The recent development of minimally and noninvasive monitoring devices makes it possible to apply in broad patient populations, all while reducing adverse complications and promoting early postoperative recovery.[14] Brienza et al. also suggested the use of hemodynamic monitoring devices able to estimate and track stroke volume and CO associated to oxygen delivery calculation in high-risk patients.[16]
At present, there is still a lack of effective and clear evidence for the early diagnosis of various shocks. In the early stage of shock, due to the insufficient effective circulating blood volume, the preload, stroke volume, and average arterial pressure plunged, continuous monitoring of these parameters by noninvasive or minimally invasive methods can timely detect sentinel compensatory shock and exclude the cause in time, thereby preventing the shock from worsening. At the same time, fluid therapy can be guided to avoid fluid overload caused by blind resuscitation. In addition, the application of noninvasive monitoring in the early stages of shock can reduce unnecessary complications such as invasive surgical injury and infection.
Besides, hemodynamic monitoring methods reflecting microcirculation and tissue perfusion should be used as early as possible. By monitoring peripheral perfusion status, clinicians can promptly initiate life-saving therapy and reduce the likelihood of shock-associated death.[8] In addition to the conventional and debated pale, cold and clammy skin, increased capillary filling time, and some new technologies available for peripheral perfusion monitoring have been developed.[8]
Optimality
The three main purposes of hemodynamic monitoring during shock are to first determine the type of shock, guide treatment options, and then assess the patient's response to therapy. However, in many cases, patients often have multiple conditions, such as cardiac tamponade with traumatic blood loss, congestive heart failure with septic shock, or multiple complications in patients with septic shock, which make a diagnosis and hemodynamic situation judgment difficult, and more appropriate hemodynamic monitoring methods, are needed at this time. Moreover, the optimality means that the hemodynamic monitoring methods should be selected on patient-specific pathophysiologic basis, either alone or in combination with other hemodynamic monitors.
The parameters obtained by different monitoring technologies are disparate, and the pro vital monitoring objectives are also individual. The PA catheter (PAC) is able to measure additional hemodynamic variables in addition to CO, such as right atrial pressure and PA pressure (PAP), which make it a valuable tool in the hemodynamic assessment of critically ill patients suspected of circulatory shock with additional right ventricular dysfunction or pulmonary hypertension. Due to the invasive nature of PAC, some studies have also confirmed that patients using PA floating catheters have higher 30-day mortality, higher hospitalization expenses, and longer ICU retention time,[17],[18] so the application has gradually decreased in recent years. However, the PAC is the only hemodynamic monitor capable of continuously monitoring the right ventricle, which makes it the monitor of choice in patients with right heart failure, and which allows assessment of the ventilator settings' impact on right ventricular function.[19],[20]
Compared with PAC, transpulmonary thermodilution is less traumatic, but it still needs the injection of a cold fluid bolus into the superior vena cava and measuring the subsequent temperature difference in the femoral artery. This method can obtain additional hemodynamic variables such as EVLW, pulmonary vascular permeability index (PVPI), and global end-diastolic volume.[21] Continuous and reliable CO measurements, in combination with the additional hemodynamic variables, make the method suitable for monitoring in critically ill patients with acute respiratory distress syndrome (ARDS).[20] Moreover, it was proved that EVLW and PVPI are independent prognostic factors of mortality in patients with ARDS, which makes monitoring of these variables particularly valuable.[22]
In terms of fluid treatment, the best volume management is the cornerstone of hemodynamic treatment for shock patients. Both hypovolemia and hypervolemia will cause various organ damages. The prediction of fluid responsiveness is, obviously, crucial for adequate management of fluid administration and goal-oriented hemodynamic optimization. Goal-directed fluid therapy guided by dynamic variables such as pulse pressure variation (PPV) and stroke volume variation (SVV) has been developed to measure fluid responsiveness.[23] The traditional static variables which only reflect the volume status, predicting volume responsiveness have been shown inaccuracy in multiple studies, such as central venous pressure, PA occlusion pressure, left ventricular end-diastolic dimensions, and B-type natriuretic peptide concentration.[24],[25],[26] Different less-invasive or noninvasive hemodynamic monitoring devices primarily based on pulse wave analysis provide SVV and eventually PPV using heart-lung interaction during positive pressure mechanical ventilation. Moreover, noninvasive assessment of fluid responsiveness based on plethysmographic analysis became recently available.
Nevertheless, the principle of noninvasive monitoring technology is mostly related to peripheral small vessel perfusion, such as noninvasive pulse contour analysis, while the peripheral perfusion of patients with severe shock is very poor and the pulse of small arteries is weak. If a large number of vasoactive drugs are used, the peripheral small vessels will also contract excessively, resulting in a steep discount in the accuracy of pulse contour analysis. The transthoracic bioelectrical reactance method also has many influencing factors, such as a large amount of pleural effusion, severe pulmonary edema, pacemaker implantation, and so on, which will interfere with the electrical signal and affect the accuracy of monitoring. Therefore, for critical illness or when people are accompanied by various influencing factors, noninvasive is not the first choice, but less-invasive transpulmonary thermodilution or invasive PA floating catheter monitoring technology should be given in specific indications.
Combination
In some cases of complicated hemodynamics, a single monitor cannot obtain the underlying cause, the right trigger for intervention, the appropriate hemodynamic target, and the patient's prognosis, requiring a combination of multiple monitor technology. The combination of monitoring can complement the advantages between different hemodynamic monitoring methods and the application of multiple indicators to comprehensively evaluate a certain functional status to evaluate the patient's hemodynamic status.
For example, our patient deteriorated and had to be mechanically ventilated due to hypoxia. An increasing dose of vasopressors had to be administrated. Lactate levels increased and mottling on the knees increased after initial resuscitation. The patient was confirmed to have acute right ventricular dysfunction by critical ultrasound, and a PAC was placed in the jugular vein, which allowed continuous right ventricular function monitoring. This is the exact example of the combination of critical ultrasound and PAC.
Critical ultrasound is known as a “visible stethoscope”, and it can quickly identify the types of shock and formulate treatment strategies rapidly. At present, it has become the first choice for the evaluation of shock patients. However, critical ultrasound still has certain operational limitations, such as the unclear sound shadow of patients after chest surgery, mechanical ventilation, and emphysema, and transthoracic ultrasound is limited. Therefore, it is necessary to combine other hemodynamic monitoring methods based on critical ultrasound. For severe shock patients, most of them are combined with complex clinical conditions, such as cardiogenic pulmonary edema complicated with ARDS and septic shock patients complicated with septic cardiomyopathy. In some patients who are not responding to initial therapy, it is also necessary to combine more advanced monitoring technology to interpret the hemodynamic state and guide the treatment.
Critical illness is usually accompanied by abnormalities in microcirculation and tissue hypoxia. Several studies,[27],[28] based on conventional hemodynamic resuscitation procedures to achieve organ perfusion and decrease morbidity and mortality following conditions of septic shock and other cardiovascular comprise, have been proved the negative results. The loss of hemodynamic coherence between the microcirculation and microcirculation may explain why these studies failed. Hence, evaluating the coherence between macrocirculation and microcirculation in response to therapy seems to be essential in evaluating the efficacy of therapeutic interventions.
Sequential
Invasive monitoring, namely PA floating catheter, can provide more accurate and special monitoring of hemodynamic parameters than minimally invasive/noninvasive monitoring, such as CO, PAP, PA incarceration pressure, and ScvO2. Certainly, the application of invasive monitoring will also bring many complications, such as arrhythmia, PA rupture, bleeding, and thrombosis. Moreover, the PA floating catheter pathway with long-term indwelling is also prone to infection. With the delay of indwelling time, the greater the probability of blood flow infection. Early removal of PA floating catheter is helpful to reduce the occurrence of various complications. Therefore, there is a discrepancy between effective and accurate hemodynamic monitoring and reducing complications such as blood flow infection. For patients whose condition tends to be stable but still needs continuous monitoring, to avoid various complications of invasive monitoring, before removing invasive monitoring, comparing the use of minimally invasive/noninvasive hemodynamic monitoring technology can continue to provide more reliable hemodynamic monitoring for patients and provide guidance for follow-up treatment. This method is invasive minimally invasive or invasive noninvasive sequential hemodynamic monitoring. Of course, when the patient's condition worsens, it can also be transformed into noninvasive invasive or minimally invasive sequential hemodynamic monitoring. As for when to replace invasive monitoring with noninvasive monitoring, it is mainly based on the changes in the patient's condition. As long as the patient's condition tends to be stable, it can be evacuated in time. When advanced monitoring is carried out, it can be replaced with noninvasive monitoring technology as soon as possible.
Epilogue
Hemodynamic therapy focuses on the continuity of treatment. With the change of treatment process, the treatment methods and objectives of each node are different, and the most powerful index to guide the treatment methods of each node is hemodynamic monitoring parameters. With the continuous development and progress of monitoring indicators and technology, hemodynamic therapy is also constantly improving and complete. It will also be the direction of hemodynamic monitoring and treatment to follow the principles of early, optimal, combined, and sequential hemodynamic monitoring and convert the monitoring parameters into treatment methods, to improve the survival rate of patients.
Financial support and sponsorship
Disciplinary construction project of Peking Union Medical College.
Conflicts of interest
There are no conflicts of interest.
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