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Review Article Monitoring in the Intensive Care Hindawi Publishing Corporation Critical Care Research and Practice Volume 2012, Article ID 473507, 20 pages doi:10.1155/2012/473507 Review Article Monitoring in the Intensive Care Eric Kipnis,1 Davinder Ramsingh,2 Maneesh Bhargava,3 Erhan Dincer,3 Maxime Cannesson,2 Alain Broccard,3 Benoit Vallet,1 Karim Bendjelid,4, 5 and Ronan Thibault6 1 Department of Anesthesiology and Critical Care, Lille University Teaching Hospital, Rue Michel Polonowski, 59037 Lille, France 2 Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA 92697, USA 3 Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA 4 Geneva Medical School, 1211 Geneva 14, Switzerland 5 Centre de Recherche en Nutrition Humaine Auvergne, UMR 1019 Nutrition Humaine, INRA, Clermont Universit´e, Service de Nutrition Clinique, CHU de Clermont-Ferrand, 63009 Clermont-Ferrand, France 6 Intensive Care Division, Geneva University Hospitals, 1211 Geneva 14, Switzerland Correspondence should be addressed to Karim Bendjelid, [email protected] Received 7 May 2012; Accepted 21 June 2012 Academic Editor: Daniel De Backer Copyright © 2012 Eric Kipnis et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In critical care, the monitoring is essential to the daily care of ICU patients, as the optimization of patient’s hemodynamic, ventilation, temperature, nutrition, and metabolism is the key to improve patients’ survival. Indeed, the decisive endpoint is the supply of oxygen to tissues according to their metabolic needs in order to fuel mitochondrial respiration and, therefore, life. In this sense, both oxygenation and perfusion must be monitored in the implementation of any resuscitation strategy. The emerging concept has been the enhancement of macrocirculation through sequential optimization of heart function and then judging the adequacy of perfusion/oxygenation on specific parameters in a strategy which was aptly coined “goal directed therapy.” On the other hand, the maintenance of normal temperature is critical and should be regularly monitored. Regarding respiratory monitoring of ventilated ICU patients, it includes serial assessment of gas exchange, of respiratory system mechanics, and of patients’ readiness for liberation from invasive positive pressure ventilation. Also, the monitoring of nutritional and metabolic care should allow controlling nutrients delivery, adequation between energy needs and delivery, and blood glucose. The present paper will describe the physiological basis, interpretation of, and clinical use of the major endpoints of perfusion/oxygenation adequacy and of temperature, respiratory, nutritional, and metabolic monitorings. 1. Central Hemodynamic Monitoring various patient populations (sepsis, cardiovascular surgery, trauma, and other critical illnesses) have challenged the 1.1. Introduction. In critical care, the optimization of notion that these indicators accurately predict volume status patient’s hemodynamic and temperature is the key to [1–7]. These “static” pressure-derived values do not accu- improve patient morbidity and mortality. The goal of hemo- rately identify a position on the Starling curve and, therefore, dynamic monitoring is to provide data that aids in the poorly predict whether volume will improve hemodynamics. optimization of end organ tissue oxygenation and effectively In fact a recent meta analysis showed no positive association combats global tissue hypoxia, shock, and multiorgan failure. between PAC use for fluid management and survival [8]. Traditional, noninvasive methods of hemodynamic monitor- Recently, however, technologic advancements in this ing pertained solely to physical examination, and invasive area have introduced new methods of noninvasive and methods included central venous and pulmonary artery less invasive hemodynamic monitoring. Generally, this data catheterization mostly. These pressure-derived preload val- provides insight into the fluid status of the patient by ues have been used extensively in the management of fluid indicating where the patient is on the Frank-Starling curve resuscitation and titration. However, numerous studies of (preload) and may also provide insight into cardiac output, 2 Critical Care Research and Practice myocardial contractility, systemic vascular resistance, and studies, are all central to this issue. Newer FloTrac software more novel parameters related to the pulmonary vascular versions have improved the accuracy of the system’s ability to system. This chapter seeks to provide an overview of these determine CO. new technologies and its implication in the critical care setting. 1.2.3. LiDCO Plus System. This system also uses analysis of pulse contour from an arterial line to determine stroke 1.2. Macrocirculation Monitoring. Identification of patients volume and CO. However, the main difference is that who are on the steep part of frank starling curve and there- this system uses a lithium-based dye-dilution technique to fore are fluid responsive is a core principle of hemodynamic calibrate its pulse contour analysis algorithm, referred to monitoring and aids in the determination of the extent that as Pulse CO. After calibration, the LiDCO plus system can circulatory homeostasis can be maintained with fluids alone, generate CO measurements using pulse contour analysis; versus the need for inotropes or vasopressors. Similarly however recalibration is recommended every 8 hours. the continuous assessment of cardiac output, myocardial contractility, and vascular tone is crucial to the diagnosis and 1.2.4. The PiCCO System. Like the LiDCO and FloTrac management of critically ill patients, and this has long been systems, this device provides CO through pulse contour solely provided by the PAC catheter. Recently, however there analysis of the arterial waveform. It also requires an external are new technologies that may provide this information in a calibration (cold saline) for this analysis. The PiCCO mon- less invasive or completely noninvasive manner. itor provides several other measurements as well including global end-diastolic volume measurements of all four heart 1.2.1. Pulse Contour Analysis. The concept of pulse contour chambers as well as extravascular lung water measurements. analysis is a method of ascertaining the cardiac output One of the limitations of this technology is the requirement from analyzing of the pulse pressure waveform. It is known for proximal artery catheterization with a thermistor-tipped that the pulse pressure is directly proportional to stroke catheter [10]. As with the other pulse contour technologies volume and inversely related to vascular compliance. Also previously described, periods of significant hemodynamic it is known that the pulse pressure waveform depicts the instability result in potentially intolerable inaccuracies in changes in stroke volume that occur with positive pressure CO measurement requiring frequent recalibration [11]. ventilation. Specifically, during the inspiratory phase of Once again, small single center studies, different settings, positive pressure ventilation, intrathoracic pressure increases and different standards of reference make generalizations passively, increasing right atrial pressure and causing venous difficult. return to decrease, decreasing right ventricular output, and ff after two or three heart beats a ecting left ventricular 1.2.5. Esophageal Doppler. TheesophagealDopplerisaflex- output. Monitoring this stroke volume variation has shown ible probe that has a Doppler transducer (4 MHz continuous to accurately predict patients who are fluid responsive [9]. wave or 5 MHz pulsed wave, according to manufacturers) A large pulse pressure/stroke volume variation (10% to at the tip that is placed in the esophagus to obtain an 15%) is indicative of hypervolemia and predictive of volume aortic velocity signal in the descending aorta. The technology responsiveness. allows one to gain insight into preload by looking at the flow There are several technologies that use pulse contour time of the velocity time integral (VTI) of the aortic flow analysis; these include the FloTrac, PiCCO, and LiDCO plus (normal = 330–360 msec), with states of decreased preload ff systems. These systems di er in their modality to assess for shortening the flow time. Also it quantifies myocardial vascular tone their requirements for invasive monitoring and contractility by assessing the peak velocity of the aortic need for external calibration for CO measurements. A short VTI signal (normal > 70 cm/sec). Finally, this technology discussion of each of these devices is in the following. derives vascular tone by analysis of the VTI waveform. A meta-analysis Dark and Singer demonstrated an 86% corre- 1.2.2. The Vigileo/FloTrac System. The FloTrac has a pro- lation between cardiac output as determined by esophageal prietary software algorithm that analyzes characteristics Doppler and PAC [12]. Clinical studies comparing TED of the arterial pressure waveform and uses this analysis, guided protocols to conventional approaches of volume along with patient-specific demographic information, to replacement (guided by clinical assessment and/or central determine continuous CO, systemic vascular resistance, and venous pressure) conclusively report beneficial effects in the dynamic parameter of stroke
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