Vincent et al.

Critical Care 2011, 15:229

http://ccforum.com/content/15/4/229

REVIEW

Clinical review: Update on hemodynamic

monitoring - aconsensus of 16
Jean-Louis Vincent1*, Andrew Rhodes2, Azriel Perel3, Greg S Martin4, Giorgio Della Rocca5, Benoit Vallet6,
MichaelRPinsky7, Christoph K Hofer8, Jean-Louis Teboul9, Willem-Pieter de Boode10, Sabino Scolletta11,
AntoineVieillard-Baron12, Daniel De Backer1, Keith R Walley13, Marco Maggiorini14 and Mervyn Singer15

or low oxygen delivery (DO2) early, enabling timely

Abstract corrective therapy to be initiated.
Hemodynamic monitoring plays a fundamental role in Although microcirculatory changes are believed to play
the management of acutely ill patients. With increased a major role in the development of organ dysfunction and
concerns about the use of invasive techniques, multiple organ failure and there is increasing interest in
notably the pulmonary artery catheter, to measure new techniques to monitor the microcirculation, these
cardiac output, recent years have seen an influx of are not yet available for clinical practice, and hemo-
new, less-invasive means of measuring hemodynamic dynamic monitoring, therefore, still focuses on the macro-
variables, leaving the clinician somewhat bewildered circulation. Current hemodynamic monitoring therefore
as to which technique, if any, is best and which he/she includes measurement of heart rate, arterial pressure,
should use. In this consensus paper, we try to provide cardiac lling pressures or volumes, cardiac output, and
some clarification, offering an objective review of the mixed venous oxygen saturation (SvO2). Although not
available monitoring systems, including their specific perfect, the pulmonary artery catheter (PAC) has long
advantages and limitations, and highlighting some been considered the optimal form of hemodynamic
key principles underlying hemodynamic monitoring in monitoring, allowing for the almost continuous,
critically ill patients. simultaneous recording of pulmonary artery and cardiac
lling pressures, cardiac output and SvO2. However,
although the incidence of complications with the PAC is
Introduction relatively low, the technique is still quite invasive and
Hemodynamic monitoring plays an important role in the there is no clear evidence for improved outcomes asso-
management of todays acutely ill patient. Essentially, ciated with its insertion and use to guide therapy [1]. As a
hemodynamic monitoring can be helpful in two key result, interest in alternative monitoring systems has
settings. The rst is when a problem has been recognized; surged in recent years.
here, monitoring can help to identify underlying patho- There are now many dierent monitoring systems
physiological processes so that appropriate forms of available, and physicians may feel somewhat confused by
therapy can be selected. A typical scenario is the patient the multiple possibilities. These systems can be easily
in shock for whom options are to give more uids or to listed in order of degree of invasiveness, from the highly
give a vasopressor or an inotropic agent, depending on invasive PAC to the completely non-invasive bioimpedance/
the hemodynamic evaluation. The second setting is more bioreactance technique and transthoracic echo-Doppler.
preventative, with monitoring allowing preemptive Classifying them according to how accurate (closeness of
actions to be performed before a signicant problem measured values to the true value, expressed as the bias)
arises. A typical scenario here is the perioperative patient or precise (variability of values due to random errors of
in whom monitoring can be used to detect hypovolemia measurement) [2] they are is more dicult, in part
because of the lack of a perfect gold standard for com-
parison. Most devices have been evaluated by comparing
their results with those obtained by intermittent thermo-
*Correspondence: [email protected]
1
Department of Intensive Care, Erasme Hospital, Universit Libre de Bruxelles,
dilution from the PAC as the reference, although this
808route de Lennik, 1070-Brussels, Belgium technique has its own limitations and may not represent
Full list of author information is available at the end of the article the best choice of comparator [2].
Our purpose in this consensus article is not to review
2010 BioMed Central Ltd 2011 BioMed Central Ltd the technology or modus operandi of the various systems
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Table 1. Examples of available methods to measure cardiac output

Method System Limitations
Thermodilution PAC Invasiveness - training required

Transpulmonary PiCCO Decreased accuracy?

indicator dilution Need for dedicated arterial catheter
LiDCO Decreased accuracy?
Need for lithium injection
Interference by non-depolarizing muscle relaxants; inaccurate in case of
hyponatremia
COstatus Decreased accuracy?
VolumeView Decreased accuracy?
Need for dedicated arterial catheter

Arterial-pressure PiCCO, LiDCO, Vigileo, Decreased accuracy, need for optimal arterial pressure tracing
waveform-derived MostCare

Esophageal Doppler CardioQ, WAKIe TO Training required, intermittent measurement

Suprasternal Doppler USCOM Difficult in some patients

Echocardiography Vivid, Sonosite MicroMaxx, Training required, intermittent measurement

Philips CX50, and so on

Partial CO2 rebreathing NiCO Less reliable in respiratory failure

Bioimpedance Lifegard, TEBCO, Hotman, Less reliable in critically ill patients, not applicable in cardiothoracic surgery
BioZ, and so on

Bioreactance NICOM Validated in only one study in critically ill patients

PAC, pulmonary artery catheter.

in any detail, not to provide readers with a shopping list, over the previous 10 minutes. The averaged values have
nor to identify one system that would be suitable in all the advantage of eliminating variability in the presence of
patients; rather, we will briey review the advantages and arrhythmias, but the disadvantage of not being real-time
limitations of each system, and propose ten key principles values, thus limiting the usefulness of this approach for
to guide choice of monitoring system(s) in todays acutely assessing rapid hemodynamic changes in unstable
ill patients. patients.
The PAC has a key advantage over many other systems
Available systems for monitoring cardiac output in that it provides simultaneous measurements of other
Examples of the main systems that are available for hemodynamic parameters in addition to cardiac output,
estimating cardiac output are listed in Table 1. including pulmonary artery pressures, right-sided and
left-sided lling pressures, and SvO2.
Thermodilution (pulmonary artery catheter)
The intermittent thermodilution technique, in which Transpulmonary or ultrasound indicator dilution
boluses of ice-cold uid are injected into the right atrium The PiCCO (Pulsion Medical Systems, Munich, Germany),
via a PAC and the change in temperature detected in the LiDCO (LiDCO Ltd, London, UK), VolumeView
blood of the pulmonary artery used to calculate cardiac (Edwards Life Sciences), and COstatus (Transonic Systems
output, is still widely considered as the standard method Inc., Ithaca, NY, USA) systems allow cardiac output to be
of reference. Adaptation of the PAC to incorporate a investigated less invasively, using a central venous (to
thermal lament (Vigilance, Edwards Life Sciences, allow calibration) and an arterial catheter, rather than
Irvine, CA, USA) or thermal coil (OptiQ, ICU Medical, needing to introduce a catheter into the pulmonary
San Clemente, CA, USA) that warms blood in the artery. The PiCCO and recently launched VolumeView
superior vena cava and measures changes in blood systems require a femoral artery catheter. These devices
temperature at the PAC tip using a thermistor, provides a use the same basic principles of dilution to estimate the
continuous measure of the trend in cardiac output, with cardiac output as with PAC thermodilution. PiCCO and
the displayed values representing an average of the values VolumeView use injections of ice cold intravenous uid
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as the indicator, measuring change in temperature down- Echocardiography and echo-Doppler

stream to calculate cardiac output, whereas LiDCO uses Echocardiography allows measurement of cardiac output
minute amounts of lithium chloride as the indicator and using standard two-dimensional imaging or, more com-
measures levels using a lithium-selective electrode. monly, Doppler-based methods. The main interest in
COstatus calculates cardiac output by using ultrasound echocardiography in general is that it can be used not
technology to measure changes in blood ultrasound only for measurement of cardiac output but also for the
velocity and blood ow following an injection of warm additional assessment of cardiac function. Echocardio-
saline solution. graphy is particularly useful as a diagnostic tool because
Cardiac output values measured using transpulmonary it allows the visualization of cardiac chambers, valves and
or ultrasound indicator dilution techniques correlate well pericardium. Small ventricles (kissing ventricles) may
with those measured using PAC thermodilution [3-6] incite uid administration whereas a poorly contractile
and may show less respiratory phase-dependent variation myocardium may suggest that a dobutamine infusion is a
[4]. The PiCCO and the VolumeView systems provide better choice. Right ventricular dilatation may orient
variables in addition to cardiac output, such as global towards the diagnosis of massive pulmonary embolism or
end-diastolic volume and measurements of extravascular myocardial infarction whereas the presence of pericardial
lung water. The COstatus system also provides some uid may suggest a diagnosis of pericardial tamponade.
derived variables, including total end diastolic volume Severe valvulopathy can also be recognized promptly.
index. However, echocardiography instruments and expertise
may not be readily available everywhere; in some
Arterial pressure trace-derived estimation of cardiac institutions, this is still the domain of the cardiologists
output and they need to be called to do the procedure.
In addition to the intermittent indicator dilution cardiac If an ultrasound beam is directed along the aorta using a
output measurements discussed above, the PiCCO and probe, part of the ultrasound signal will be reected back
LiDCO systems can also estimate cardiac output on a by the moving red blood cells at a dierent frequency. The
continuous basis from the arterial pressure waveform resultant Doppler shift in the frequency can be used to
with (PiCCO2 and LiDCOplus) or without (LidCOrapid) calculate the ow velocity and volume and hence cardiac
the need for recalibration when changes in vascular com- output. Echo-Doppler evaluation can provide reasonable
pliance may have occurred. The PiCCO system uses a estimates of cardiac output, but again is operator-
pulse contour analysis and the LiDCO system a pulse dependent and continuous measurement of cardiac
power analysis. In addition to these, Vigileo (Edwards output using this technique is not possible. Echo-Doppler
Life Sciences) and MostCare (Vytech, Padova, Italy, evaluation may be applied either transthoracically or
using the Pressure Recording Analytical Method (PRAM)) transesophageally. However, transthoracic techniques do
systems have been developed for arterial waveform not always yield good images and transesophageal
analysis without external calibration. Each of these techniques are more invasive such that some sedation,
systems contains a proprietary algorithm for converting a and often endotracheal intubation, is required in order to
pressure-based signal into a ow measurement. The obtain reliable measurements. Moreover, the esophageal
specic algorithms have individual characteristics and probe is uncomfortable in non-intubated patients,
make dierent assumptions - for example, related to although may be better tolerated if inserted nasally, and
arterial compliance (Vigileo) or pressure (MostCare) - should be used cautiously in patients with esophageal
which can make them more or less accurate depending lesions. The signal produces dierent waveforms that can
on the clinical circumstances. The level of accuracy and be used to distinguish to some extent changes in preload,
precision of each device needs to be understood as the afterload and left ventricular contractility. Doppler ow
data cannot be superimposed from one system to studies focusing on the descending thoracic aorta may not
another. The advantages of these arterial pressure-based provide a reliable measurement of the total cardiac output
cardiac output monitoring systems over PAC-derived (for example, with epidural use), and are invalid in the
measurements is primarily their less invasive nature. presence of intra-aortic balloon pumping. Echo-Doppler
The major weakness of all these devices is the drift in cardiac output estimates vary considerably for several
values whenever there is a major change in vascular reasons, including diculty in assessment of the velocity
compliance, as, for example, in vascular leak syndrome time integral, calculation error due to the angle of
with increased vessel wall edema leading to decreased insonation, and problems with correct measurement of
arterial compliance. Aortic valve regurgitation may the cross-sectional area. Some training is required when
further decrease the accuracy of these techniques. Over- using these techniques. Esophageal-Doppler techniques
or under-damped arterial pressure waveforms will also have been shown to be useful for optimizing uid
decrease the precision of these monitors. administration in high risk surgical patients [7,8].
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Simplied transesophageal Doppler techniques can be monitoring device must be suciently accurate to be able
convenient as the probe is smaller than for standard to inuence therapeutic decision making; the data
esophageal echocardiography techniques. Simplied trans- obtained from the monitoring system must be relevant to
thoracic Doppler systems allow estimation of aortic blood the patient being monitored; and changes in management
ow and may be even less invasive; however, although these made as a result of the data obtained need to be able to
techniques can be simple to perform in healthy volun- improve outcomes. If the data are interpreted or applied
teers, access to good images may be more dicult in incorrectly, or the therapies themselves are ineective or
critically ill patients. Moreover, there is a fairly prolonged harmful, the resultant change in management will not
learning curve for correct use of this system [9]. These improve patient status and may be deleterious.
methods need further validation in critically ill patients. If these three conditions are not met, monitoring is
unlikely to be associated with improved outcomes, and
CO2 rebreathing this may account for the lack of evidence of improved
CO2 rebreathing systems, based on the Fick principle, use outcomes in acutely ill patients with use of any
a CO2 sensor, a disposable airow sensor and a disposable monitoring device, not only the PAC [12].
rebreathing loop. CO2 production is calculated from
minute ventilation and its CO2 content, and the arterial Principle 2: monitoring requirements may vary over time
CO2 content is estimated from end-tidal CO2. Partial re- and can depend on local equipment availability and
breathing reduces CO2 elimination and increases the training
end-tidal CO2. By combining measurements taken during The optimal monitoring system will depend on the
and without rebreathing, venous CO2 content can be individual patient, the problem already present or
eliminated from the Fick equation. However, intra- potentially arising for which the monitoring is required,
pulmonary shunting of blood and rapid hemodynamic and the devices and expertise available at the institution
changes aect the accuracy of the measurement, so that in question.
this technique is not considered to be reliable in acutely For initial evaluation of the critically ill patient, an
ill patients. invasive approach is still often needed, which includes
insertion of an arterial catheter and a central venous
Bioimpedance and bioreactance catheter; this is because of the need for secure
Bioimpedance is based on the fact that the conductivity intravenous and arterial access in such patients and the
of a high-frequency, low-magnitude alternating current presumed increased accuracy of measurements based on
passed across the thorax changes as blood ow varies direct pressure monitoring. The data provided can
with each cardiac cycle. These changes can be measured already guide initial treatment. Analysis of the arterial
using electrodes placed on a patients chest and used to pressure trace can identify uid responsiveness in
generate a waveform from which cardiac output can be mechanically ventilated patients, although there are some
calculated. Bioreactance has developed out of bio- limitations to this technique, including adaptation to the
impedance and measures changes in the frequency of the respirator (often with high doses of sedative agents and
electrical currents traversing the chest, rather than even paralysis), need for absence of arrhythmias, and use
changes in impedance, potentially making it less sensitive of relatively large tidal volumes. Response to passive leg
to noise. These techniques are non-invasive and can be raising can be used if beat-by-beat measurements of
applied quickly. They have been used for physiological stroke volume are monitored. Once stabilized, less
studies in healthy individuals and may be useful in invasive monitoring techniques should be employed.
perioperative applications [10], but are less reliable in Importantly, monitoring systems are not necessarily
critically ill patients [11]. Electrical interference may also mutually exclusive and can sometimes be used to
occur in the ICU environment. complement each other. For example, echocardiography
can provide additional information in the early assess-
Key principles of hemodynamic monitoring ment of critically ill patients (Figure 1).
Having briey discussed some of the advantages and There is still a place for the PAC (Swan-Ganz), which
limitations of the available systems, we now consider has the advantage of allowing measurement of cardiac
some key principles than can help when considering lling pressures and pulmonary artery pressures, cardiac
which hemodynamic monitoring system to use. output and SvO2 (and now also extravascular lung water).
However, although in the past a PAC was inserted early
Principle 1: no hemodynamic monitoring technique can in all critically ill patients, today its insertion is no longer
improve outcome by itself necessary during initial resuscitation, but should rather
Hemodynamic monitoring can only improve outcomes if be reserved for complex cases, for example, patients with
three conditions are met: the data obtained from the right ventricular dysfunction, dicult assessment of
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PAP
Hemodynamicinstability
RAP PAOP
EKG
arterial catheter End-diastolic
central venous catheter volumes
Heart rate
Arterialpressure
Fluid responsiveness ?
CO
Microcirculation
(low CVP ?) (OPS, NIRS, ) Urine output
Mental status
PgCO2 Cutaneousperfusion
present absent
Sublingual capnometry
Lactate
echocardiography CO2 gap SvO2

hypovolemialikely smallchambers tamponade Figure 2. Factors influencing the interpretation of cardiac output
large ventricles RV dilation (CO). EKG, electrocardiogram; NIRS, near-infrared spectral imaging;
poor contractile state (obstructive) OPS, orthogonal polarization spectral imaging; PAOP, pulmonary
fluidchallenge valvulopathy artery occlusion pressure; PAP, pulmonary artery pressure; PgCO2,
(cardiogenic)
gastric intramucosal carbon dioxide partial pressure; RAP, right atrial
Figure 1. Diagnostic algorithm based on use of pressure; SvO2, mixed venous oxygen saturation.
echocardiography. CVP, central venous pressure; RV, right
ventricular.

and blood lactate levels (Figure 2). Alarms should thus be

optimal uid management, or specic cases of cardiac individualized for each patient and reevaluated regularly.
failure.
Principle 4: we need to combine and integrate variables
Principle 3: there are no optimal hemodynamic values that Any variable on its own provides relatively little informa-
are applicable to all patients tion - it is just one piece of a large puzzle. We need rather
Although it may be appealing to have some simple to integrate all the available data from multiple sources.
targets, such as keeping the mean arterial pressure above For example, a hypotensive patient with a low cardiac
65 mmHg, the central venous pressure (CVP) above output will present dierent diagnoses (hypovolemia,
8mmHg, or DO2 above 600mL/minute/M, such targets decreased contractility or obstruction) and hence require
are overly simplistic and may even be potentially dierent treatments to a hypotensive patient with a high
dangerous. For example, the acceptable minimal arterial cardiac output (decreased vascular tone). Likewise, as
pressure may be very dierent in a young individual discussed earlier, correct interpretation of a low cardiac
without co-morbidity compared to an elderly athero- output involves consideration of many factors (Figure 2),
sclerotic, previously hypertensive patient. Likewise, the including some assessment of cardiac lling (pressures or
CVP may remain low in adequately resuscitated patients dimensions) to assess ventricular preload.
or may be high at baseline in patients with pulmonary
hypertension due to underlying chronic lung disease. Principle 5: measurements of SvO2 can be helpful
Similarly, it is dicult to dene an optimal level of SvO2 reects the balance between oxygen consumption
cardiac output as cardiac output is an adaptative para- (VO2) and DO2 and thus provides an indication of the
meter for which there is no single normal value, but only adequacy of tissue oxygenation. If there is no PAC in situ,
normal ranges. Since the purpose of the cardiovascular the oxygen saturation in the superior vena cava (ScvO2)
system is to match blood ow to metabolic demand, and can be measured using a central venous catheter and has
this demand may vary widely even over short time been proposed as a surrogate for SvO2. Importantly,
intervals, targeting a specic cardiac output or even ScvO2 represents just an approximation of the SvO2 [13]
sustaining a threshold value may be inappropriate. For and the absolute values of ScvO2 and SvO2 are not
example, keeping a cardiac output above 5 or 6 liters per interchangeable. The dierence between these two para-
minute in an adult would be like driving constantly at meters is inuenced by the sampling site of central
80 km/h, whether in a small town or on the freeway. In venous blood, the presence of left-to-right shunts, in-
the critically ill, cardiac output increases in sepsis, as in complete mixing of venous blood, oxygen extraction in
anemia, but may be reduced with sedation or anesthesia. the renal and the splanchnic beds, redistribution of blood
Multiple factors therefore need to be considered when ow through the upper and lower body, level of con-
determining whether cardiac output is optimal for a sciousness (anesthesia) and myocardial VO2. The relia-
particular patient, including the degree of tissue bility of ScvO2 is also dependent on the position of the tip
perfusion as estimated from a careful clinical examination of the catheter, with right atrial measurements closely
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oxygen extraction, rather than adequate perfusion, such

CARDIAC OUTPUT that patients may still deteriorate even with a high SvO2.
In sepsis, a high cardiac output, like a high SvO2, can be
HIGH LOW associated with worse outcomes.

SvO2 SvO2 Principle 7: cardiac output is estimated, not measured

No bedside method is available to directly assess cardiac
HIGH LOW HIGH LOW output, so all values obtained are estimates. As such,
INFLAMMATION
(incl. SEPSIS)
ANEMIA LOW VO2 LOW OUTPUT comparison of measurements obtained with dierent
HYPOXEMIA (anesthesia, SYNDROME
EXCESSIVE
HIGH VO2 hypothermia,...) (hypovolemia,
techniques results in relatively poor agreement and signi-
BLOOD FLOW
(hypervolemia,
heart failure, cant bias. The intermittent thermodilution technique is
pulm. embolism...)
excessive vasoactivetherapy)
generally considered as the reference standard, but has
Figure 3. Diagnostic algorithm based on mixed venous oxygen its own limitations. A measurement obtained by a less
saturation (SvO2) and cardiac output. VO2, oxygen consumption. invasive technique may be preferable if it can be obtained
more rapidly and easily, even if it is slightly less accurate.
Importantly, the accuracy of absolute values may be less
approximating SvO2 and high vena cava measurements important if one is following trends, for example, to track
often deviating substantially from SvO2. In general, SvO2 the short-term eects of therapies, such as uid loading.
is more useful when the value is below normal (see
below), even though in these conditions it may not reect Principle 8: monitoring hemodynamic changes over short
a hemodynamic problem. Simultaneous measurements periods of time is important
of blood lactate levels can be helpful. A diagnostic Monitoring of acute changes in cardiac output can be
algorithm based on SvO2 and cardiac output is shown in important, for example, in patients at risk of acute
Figure3. bleeding or in assessing the response to uid adminis-
tration to separate uid responders from non-responders.
Principle 6: a high cardiac output and a high SvO2 are not Evaluating the response to a dobutamine or to a nitrate
always best infusion is another example of this functional monitoring
Although ICU physicians may like to increase cardiac that may also have sound clinical applications. This
output and SvO2 by giving more uid and inotropic assessment of hemodynamic variations observed during
agents, is this always good? Excessive uid administration the challenge of the cardiovascular system has been
to increase cardiac output may result in uid overload termed functional hemodynamic monitoring [18]. The
with massive edema formation and this may be associated study of slow changes in cardiac output over several days
with worse outcomes [14]; some systems measure may be less relevant in most patients, although can be
extravascular lung water, which can help document this. useful to follow the clinical course of the cardiac patient.
Similarly, excessive doses of dobutamine can be detri- Combining measures of multiple variables and their
mental, compromising myocardial function, especially in dynamic interactions in response to time and specic
patients with coronary artery disease; giving inotropic treatments often increases the sensitivity and specicity of
agents in the presence of coronary artery disease is like these monitoring modalities to identify specic disease
trying to stimulate a tired horse. Using vasoactive agents processes and quantify whether therapy is eective or not.
and uids to increase DO2 to supranormal levels in all
patients may result in excessive mortality rates and this Principle 9: continuous measurement of all hemodynamic
strategy has been abandoned [15]. A high ScvO2 has been variables is preferable
suggested as a target for some high risk patients or in Although there are no data to demonstrate the
shock resuscitation, with Rivers and colleagues [16] superiority of continuous cardiac output measurements
reporting that septic patients assigned to an early goal- over intermittent monitoring, there has been a global
directed therapy algorithm had higher ScvO2 values and evolution towards more continuous measurement of
reduced mortality rates. However, this was a strategy for variables. We can now routinely measure various hemo-
early resuscitation of patients with severe sepsis in a dynamic variables continuously, including heart rate,
single institution, and needs further validation in multi- arterial pressure and CVP. Using the thermodilution
center studies, several of which are currently ongoing. technique, one may not wish to go back to intermittent
Importantly, applying the same strategy in general ICU measurements of cardiac output by repeated injections of
patients may not improve outcomes [17]. Indeed, in cold water boluses. It may even be preferable to have real-
patients with sepsis, a high SvO2 may be the result of time (beat-by-beat) continuous cardiac output measure-
maldistribution of peripheral blood ow and altered ment rather than a built-in delay like the semi-continuous
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Table 2. The key properties of an ideal hemodynamic choose devices that have a maximum of these attributes,
monitoring system bearing in mind that there is no one size ts all type of
Provides measurement of relevant variables system and one should, therefore, select the system most
Provides accurate and reproducible measurements appropriate for each patient and, perhaps even more
importantly, for each type of problem. It is important to
Provides interpretable data
be familiar with the technology being used, proting
Is easy to use
from its advantages but recognizing its limitations. Most
Is readily available systems now oer (almost) continuous measurements,
Is operator-independent with the possible exception of echocardiography tech-
Has a rapid response-time niques because it is dicult to leave the probe in place
Causes no harm for prolonged periods. Hemodynamic monitoring can be
particularly helpful in the early stages of resuscitation,
Is cost-effective
but is less useful when organ failure is established. Most
Should provide information that is able to guide therapy
importantly, one must never forget that it is not the
monitoring itself that can improve outcomes but the
cardiac output provided with the Vigilance system. changes in therapy guided by the data obtained.
Systems that are not continuous (for example, echo-
cardiography) or that require calibration (for example, Abbreviations
CVP, central venous pressure; DO2, oxygen delivery; PAC, pulmonary artery
transpulmonary indicator dilution) may not provide the
catheter; ScvO2, central venous oxygen saturation; SvO2, mixed venous oxygen
real-time data needed for optimal acute management of saturation; VO2, oxygen consumption.
unstable critically ill patients, whereas systems that
provide continuous non-calibrated cardiac output measure- Competing interests
J-LV has received grants from Edwards Lifesciences and Pulsion Medical
ments suer from reduced accuracy. Systems. AR has received lecture fees from LiDCO and advisory board fees
from Cheetah and Edwards. AP is a member of the medical advisory board
Principle 10: non-invasiveness is not the only issue of Pulsion Medical Systems and consultant to BMEYE. GSM is a member of
the medical advisory board of Pulsion Medical Systems. GDR has no conflicts
Non-invasiveness is not the only goal. Although it is related to this manuscript. BV is an advisor to, and has received lecture fees
always preferable to be less invasive, being non-invasive from, Edwards. MRP is a paid advisor to LiDCO Ltd, Edwards LifeSciences
is not always possible and may even be counter eective. Inc., and Applied Physiology; he has stock options with LiDCO and Cheetah
Medical and has received honoraria from Cheetah Medical. CKH has received
For example, continuous monitoring of arterial pressure lecture fees and research grants from Pulsion Medical Systems and Edwards
is more invasive than intermittent monitoring but is Lifesciences. J-LT is a member of the medical advisory board of Pulsion
helpful in hypotensive (or severe hypertensive) states. Medical Systems. W-PdeB has received research grants from Transonic Systems
Inc. and Pulsion Medical Systems. SS has received research grants from Vygon
Likewise, a central venous catheter can be helpful to and Vythec. AV-B has received research grants from General Electric and
monitor the CVP and the ScvO2 (and also facilitates the Maquet. DDeB has received grants and material for studies from Edwards
rapid administration of uids). Whenever possible, we Lifesciences, Pulsion Medical Systems, LiDCO and Vytech and honoraria for
lectures from Edwards Lifesciences and Pulsion Medical Systems. KRW has no
should of course try to be as non-invasive as possible, but conflicts related to this manuscript. MM is a member of the medical advisory
arterial pressure monitoring and CVP monitoring are board of Pulsion Medical Systems. MS is on the Advisory Board for Deltex
still invasive. Echocardiography must be promoted more Medical and Covidien; Deltex Medical provide unrestricted research grants.
for its ability to oer a direct evaluation of cardiac Author details
function than for its non-invasiveness. Even though it is 1
Department of Intensive Care, Erasme Hospital, Universit Libre de
the most invasive method, the PAC is still of value in very Bruxelles, 808 route de Lennik, 1070-Brussels, Belgium. 2Department of
Intensive Care Medicine, St Georges Healthcare NHS Trust, Blackshaw Road,
sick patients with complex problems, for example, London, SW170QT, UK. 3Department of Anesthesiology and Intensive Care,
respiratory failure with shock and oliguria. At the other Sheba Medical Center, Tel Aviv University, Tel Aviv, 52621 Israel. 4Division of
extreme, completely non-invasive bioimpedance has a Pulmonary, Allergy and Critical Care, Emory University School of Medicine,
Grady Memorial Hospital, 615 Michael Street, Suite 205, Atlanta, GA 30322,
place in healthy individuals, but little place in critically ill USA. 5Department of Anesthesia and Intensive Care Medicine, University
patients. Other monitoring systems are of use in patients Hospital, Medical School, University of Udine, P.le S. Maria della Misericordia,
with conditions somewhere between these two extremes. 1533100 Udine, Italy. 6Department of Anesthesiology and Critical Care
Medicine, Ple dAnesthesie Reanimation, Hpital Claude Huriez, rue Michel
The optimal device depends on the type of patient, the Polonoski, CHU Univ Nord de France, 59000 Lille, France. 7Department
question being asked, and the condition being managed of Critical Care Medicine, 606 Scaife Hall, 3550 Terrace Street, Pittsburgh,
or anticipated. PA15261, USA. 8Institute of Anaesthesiology and Intensive Care Medicine,
Triemli City Hospital Zurich, Birmensdorferstr. 497, 8063 Zurich, Switzerland.
9
Service de ranimation mdicale, Centre Hospitalo-Universitaire de Bictre,
Conclusion Assistance Publique-Hpitaux de Paris, EA 4046, Universit Paris Sud, 78
The ideal hemodynamic monitoring system should rue du Gnral Leclerc, 94 270 Le Kremlin-Bictre, France. 10Department of
Neonatology, Radboud University Nijmegen Medical center, PO Box 9101,
comprise all the key factors listed in Table 2; however, 6500 Nijmegen, The Netherlands. 11Department of Anaesthesia and Intensive
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Cite this article as: Vincent JL, et al.: Clinical review: Update on
oesophageal Doppler monitor for fluid replacement in major abdominal
hemodynamic monitoring- a consensus of 16. Critical Care 2011, 15:229.
surgery. Anaesthesia 2008, 63:44-51.