title: The effects of advanced monitoring on hemodynamic management in critically ill patients: a pre and post questionnaire study.
abstract: In critically ill patients, many decisions depend on accurate assessment of the hemodynamic status. We evaluated the accuracy of physicians' conventional hemodynamic assessment and the impact that additional advanced monitoring had on therapeutic decisions. Physicians from seven European countries filled in a questionnaire in patients in whom advanced hemodynamic monitoring using transpulmonary thermodilution (PiCCO system; Pulsion Medical Systems SE, Feldkirchen, Germany) was going to be initialized as part of routine care. The collected information included the currently proposed therapeutic intervention(s) and a prediction of the expected transpulmonary thermodilution-derived variables. After transpulmonary thermodilution measurements, physicians recorded any changes that were eventually made in the original therapeutic plan. A total of 315 questionnaires pertaining to 206 patients were completed. The mean difference (±standard deviation; 95 % limits of agreement) between estimated and measured hemodynamic variables was -1.54 (±2.16; -5.77 to 2.69) L/min for the cardiac output (CO), -74 (±235; -536 to 387) mL/m(2) for the global end-diastolic volume index (GEDVI), and -0.5 (±5.2; -10.6 to 9.7) mL/kg for the extravascular lung water index (EVLWI). The percentage error for the CO, GEDVI, and EVLWI was 66, 64, and 95 %, respectively. In 54 % of cases physicians underestimated the actual CO by more than 20 %. The information provided by the additional advanced monitoring led 33, 22, 22, and 13 % of physicians to change their decisions about fluids, inotropes, vasoconstrictors, and diuretics, respectively. The limited clinical ability of physicians to correctly assess the hemodynamic status, and the significant impact that more physiological information has on major therapeutic decisions, support the use of advanced hemodynamic monitoring in critically ill patients.
authors.affiliation: Department of Anesthesiology and Critical Care, Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Azriel
authors.initials: A
authors.lastname: Perel
authors.affiliation: Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany. bernd.saugel@gmx.de.
authors.forename: Bernd
authors.initials: B
authors.lastname: Saugel
authors.affiliation: Paris-Sud Medical School, Paris-Saclay University, Le Kremlin-Bicêtre, France.|Paris-Saclay University, Le Kremlin-Bicêtre, France.
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Teboul
authors.affiliation: Department of Intensive Care, Ziekenhuis Netwerk Antwerpen, Campus ZNA Stuivenberg, Antwerp, Belgium.
authors.forename: Manu L N G
authors.initials: ML
authors.lastname: Malbrain
authors.affiliation: Department of Anaesthesia and Surgical Critical Care, Hospital Clinico Universitario, Valencia, Spain.
authors.forename: Francisco Javier
authors.initials: FJ
authors.lastname: Belda
authors.affiliation: Neuro-Trauma Intensive Care Unit, University Hospital Virgen de LAS Nieves, Granada, Spain.
authors.forename: Enrique
authors.initials: E
authors.lastname: Fernández-Mondéjar
authors.affiliation: Department of Anaesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia.
authors.forename: Mikhail
authors.initials: M
authors.lastname: Kirov
authors.affiliation: Liver Intensive Care, King's College Hospital, London, UK.
authors.forename: Julia
authors.initials: J
authors.lastname: Wendon
authors.affiliation: Surgical Intensive Care Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland.|Intensive Care Unit of the Institute of Anesthesiology and Intensive Care Medicine, Klinik Hirslanden, Zurich, Switzerland.
authors.forename: Roger
authors.initials: R
authors.lastname: Lussmann
authors.affiliation: Medical Intensive Care Unit of the Department of Internal Medicine, University Hospital Zurich, Zurich, Switzerland.
authors.forename: Marco
authors.initials: M
authors.lastname: Maggiorini
mesh_terms: D000328:Adult; D000368:Aged; D001810:Blood Volume / Q000502:physiology; D002302:Cardiac Output; D016638:Critical Illness; D003657:Decision Making; D005060:Europe; D015633:Extravascular Lung Water; D005260:Female; D006439:Hemodynamics; D006801:Humans; D008168:Lung / Q000502:physiology; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic; D015203:Reproducibility of Results; D011795:Surveys and Questionnaires; D013815:Thermodilution
keywords: Cardiac output; Decision making; Extravascular lung water; Global end-diastolic volume; Hemodynamic monitoring; Transpulmonary thermodilution