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Novel tools for hemodynamic monitoring in critically ill patients with shock

Mark E Mikkelsen, MD, MSCE
David F Gaieski, MD
Nicholas J Johnson, MD
Section Editor
Scott Manaker, MD, PhD
Deputy Editor
Geraldine Finlay, MD


Central venous and pulmonary artery catheters (PAC) are invasive tools that have traditionally been used for hemodynamic monitoring in patients who present with shock. However, these tools have drawbacks and inaccuracies. Thus, several, less invasive, novel technologies are available or being investigated for use to assess parameters such as cardiac output, intravascular volume status, responsiveness to intravenous fluid administration, and tissue perfusion. They can potentially be used in the emergency department, intensive care unit, and operating room when caring for patients with shock or hypovolemia.

This topic will discuss novel techniques for hemodynamic monitoring. The evaluation and treatment of shock, central venous pressure and PAC monitoring are discussed separately. (See "Evaluation and management of suspected sepsis and septic shock in adults" and "Evaluation of and initial approach to the adult patient with undifferentiated hypotension and shock" and "Pulmonary artery catheterization: Interpretation of hemodynamic values and waveforms in adults".)


Deficiencies of standard techniques — For many years, the gold standard for hemodynamic monitoring was the pulmonary artery catheter (PAC). However, several studies have demonstrated that the PAC fails to improve outcome in critically ill patients and may be associated with harm. In the late 1990s central venous pressure (CVP) monitoring via central venous catheterization (CVC) emerged as a less invasive alternative that was incorporated into guideline management of sepsis; however, this practice has also been questioned [1-3]. (See "Pulmonary artery catheterization: Indications, contraindications, and complications in adults" and "Evaluation and management of suspected sepsis and septic shock in adults".)

CVP and PAC monitoring suffer from the following inadequacies:

Inconsistent prediction of fluid responsiveness – Both CVP and pulmonary alveolar occlusion pressure have been shown to have poor predictive value for predicting fluid responsiveness (arbitrarily defined as an increase of at least 15 percent in cardiac output [CO] in response to a 500 mL bolus fluid challenge, as measured by PAC) [3-6]. Furthermore, CVP is affected by a number of other physiologic derangements, including valvular regurgitation, right ventricular dysfunction, pulmonary hypertension, and variation in intrathoracic pressure with respiration.


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Literature review current through: Sep 2016. | This topic last updated: Sep 29, 2016.
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