Hemodynamic Evaluation and Monitoring in the ICU - Michael R. Pinsky, MD, FCCP

Hemodynamic monitoring, a cornerstone in the management of the critically ill patient, is used to identify cardiovascular insufficiency, its probable cause, and response to therapy. Still it is difficult to document the efficacy of monitoring because no device improves outcome unless coupled to a treatment that improves outcome. Several clinical trials have consistently documented that preoptimization for high-risk surgery patients treated in the operating room and early (<> 65 mm Hg and then to increase DO2 to 600 mL/min/m2 within the first few minutes to hours of presentation. To accomplish these goals, hemodynamic monitoring focuses more on measures of cardiac output and mixed venous oxygen saturation to access adequacy of resuscitation efforts than on filling pressures. Although these protocols reduce mortality and morbidity is selected high-risk patient groups, the widespread use of monitoring-driven treatment protocols has not yet happened, presumably because all studies have been single-center trials using a single, proprietary blood flow monitoring device. Multicenter trials are needed of early goal-directed therapies for all patients presenting in shock of various etiologies and when the protocol and not the monitoring device is the primary variable.
(CHEST 2007; 132:2020–2029)