Best Practice & Research Clinical Anaesthesiology 28 (2014) 477e488

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Hemodynamic monitoring devices: Putting it all together Bhiken I. Naik, M.B.B.Ch, Assistant Professor *, Marcel E. Durieux, M.D., Ph.D., Professor Department of Anesthesiology, University of Virginia, Charlottesville, VA 22908, USA

Keywords: macro-hemodynamic microcirculation goal-directed hemodynamic treatment cost analysis

Perioperative hemodynamic optimization of the high-risk surgical patient is associated with reduced postoperative morbidity and mortality. The hemodynamic parameters to be optimized (using goal-directed algorithms) encompass preload, contractility, afterload, volume responsiveness, and end-organ perfusion. Current hemodynamic monitors facilitate multi-modal monitoring of these macro-hemodynamic targets. This review focuses on the variety of invasive, minimally invasive, and noninvasive hemodynamic monitors available to the clinician. © 2014 Elsevier Ltd. All rights reserved.

Background Hemodynamic monitoring and manipulation of the cardiovascular system remains the cornerstone of therapy for the perioperative high-risk surgical and critically ill patient. The key principle governing hemodynamic management is the optimization of oxygen delivery commensurate with current tissue metabolic requirements. Achieving this goal requires monitoring of blood pressure, intravascular volume, cardiac output, organ-specific autoregulation, and tissue microcirculation. Monitoring each of these facets adds a “piece” to the complex hemodynamic puzzle that clinicians are faced with on a daily basis. Increasing evidence suggests that this multi-modal approach using goal-directed treatment algorithms is associated with reduced morbidity and mortality in the high-risk surgical patient [1,2]. For the interested reader, a consensus statement on hemodynamic monitoring was published by Vincent et al., in 2011 [3]. Whereas other articles in this volume describe individual measurement techniques in detail, this article will review macro-hemodynamic and microcirculation monitoring devices and discuss the cost

* Corresponding author. PO Box 800710, Charlottesville, VA 22908, USA. Tel.: þ1 434 924 2283 (office); Fax: þ1 434 982 0019. E-mail address: [email protected] (B.I. Naik).

http://dx.doi.org/10.1016/j.bpa.2014.09.004 1521-6896/© 2014 Elsevier Ltd. All rights reserved.

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B.I. Naik, M.E. Durieux / Best Practice & Research Clinical Anaesthesiology 28 (2014) 477e488

implications of their use in the setting of goal-directed treatment. The purpose is to help guide the clinician in choosing the appropriate and most cost-effective approach to circulation monitoring.

Macro-hemodynamic monitors Blood pressure monitoring Blood pressure measurement is an American Society of Anesthesiologists (ASA) standard of care during anesthesia, and of vital importance in the critically ill patient. Interestingly, limited consensus exists on acceptable blood pressure ranges for patients with sepsis, or for the surgical patient during the perioperative period. A recent open-label trial by Asfar et al., comparing high (80e85 mmHg) versus low (65e70 mmHg) mean arterial pressure (MAP) targets in septic shock, found no difference in mortality between the two groups [High-MAP (43.8%) vs. Low-MAP (42.3%), hazard ratio in the hightarget group, 1.07; 95% confidence interval [CI], 0.84 to 1.38; P ¼ 0.57] [4]. It should be realized, however, that even the “low” pressure group was maintained at a fairly substantial MAP. By contrast, emerging evidence suggests that a triad of intraoperative low blood pressure, high blood loss, and elevated heart rate is associated with increased risk of postoperative morbidity and mortality [5]. Furthermore, although challenged by a recent study by Kertai et al., a “triple-low” state of low blood pressure (MAP

Hemodynamic monitoring devices: putting it all together.

Perioperative hemodynamic optimization of the high-risk surgical patient is associated with reduced postoperative morbidity and mortality. The hemodyn...
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