Emerging trends in minimally invasive haemodynamic monitoring and optimization of fluid therapy.
BACKGROUND
For decades the pulmonary artery catheter has been the mainstay of cardiac output monitoring in critically ill patients, and pressure-based indices of ventricular filling have been used to gauge fluid requirements with acknowledged limitations. In recent years, alternative technologies have become available which are minimally invasive, allow beat-to-beat cardiac output monitoring and permit assessment of fluid requirements by volumetric means and by allowing assessment of heart-lung interaction in mechanically ventilated patients.


METHODS
A qualitative review of the basic science behind the transpulmonary dilution technique used in the measurement of cardiac output, global end-diastolic volume and extravascular lung water; the basic science and validation of pulse contour analysis methods of real-time cardiac output monitoring; the application and limitations of these technologies to guide rational fluid therapy in surgical and critically ill patients.


RESULTS
Transpulmonary dilution techniques correlate well with pulmonary artery catheter-derived measurement of cardiac output. Volumetric measures of preload appear to be superior to central venous and pulmonary artery occlusion pressures. Dynamic indices of preload responsiveness such as stroke volume variation are more useful than static measures in mechanically ventilated patients.


CONCLUSIONS
In fully mechanically ventilated patients, dynamic measurements of heart-lung interaction such as stroke volume variation are superior to static measures of preload in assessing whether a patient is volume-responsive (i.e. will increase stroke volume in response to a fluid challenge). For patients who are not fully mechanically ventilated, pulse contour analysis allows real-time assessment of increases in cardiac output in response to passive leg-raising.
Benington
Steve
S
Manchester Royal Infirmary, UK. stevebenington@hotmail.com
Ferris
Paul
P
Nirmalan
Mahesh
M
D000818:Animals; D002302:Cardiac Output; D016638:Critical Illness; D005440:Fluid Therapy / Q000379:methods*; D006439:Hemodynamics; D006801:Humans; D012121:Respiration, Artificial / Q000379:methods; D013815:Thermodilution / Q000379:methods