Elsevier

Critical Care Clinics

Volume 23, Issue 3, July 2007, Pages 383-400
Critical Care Clinics

Noninvasive Hemodynamic Monitoring in the Intensive Care Unit

https://doi.org/10.1016/j.ccc.2007.05.002Get rights and content

This article reviews the clinically available devices that have been approved for noninvasive hemodynamic monitoring in critically ill patients. In addition this article reviews some of the surrogate markers that can be used to assess adequacy of cardiac output.

Section snippets

Shock

Shock is best defined as end-organ dysfunction as a result of hemodynamic compromise [15]. While hypotension is an important marker of shock, it is clear that blood pressure alone cannot be used as the sole determinant of shock [16]. Shock models have demonstrated that the body can develop an “oxygen debt” in the setting of normal blood pressure [16]. This concept underscores the importance of evaluating organ function and microcirculatory perfusion in patients with hemodynamic compromise [17],

Upstream hemodynamic monitoring: Measurement of cardiac output

The cardiac output is the most important upstream hemodynamic parameter. Adolph Fick [22] described the first method of cardiac output estimation in 1870. This method was the reference standard by which all other methods of determining cardiac output were evaluated until the introduction of the PAC in the 1970s [8]. Despite its limitations, cardiac output measurement with a PAC using the bolus thermodilution method has become the de facto gold standard for measurement of cardiac output and is

Lactate

The concept that hypoxic tissues can generate a lactic acidosis has been understood since the 1970s [98]. To generate energy, the body must convert glucose into CO2 via the Krebs cycle. In anaerobic environments, the Krebs cycle cannot completely metabolize glucose, so instead a partial metabolic pathway is followed, which generates lactate. The greater the oxygen deficit and with increased metabolic demands, the more lactate is produced. Lactic acidosis is, however, not limited to shock.

Summary

The quest for the holy grail of noninvasive cardiac output assessment methods continues. Although no tool is perfect, a number of noninvasive methods to determine the cardiac output of critically ill patients are now available. It is, however, important to stress that the cardiac output should be interpreted in conjunction with dynamic indices of volume responsiveness and downstream markers of tissue oxygenation. Furthermore, patients cannot be managed by simplistic algorithms or bundles but

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