IMANCUAGEMENT & PRACTICE Intensive care - Emergency - Anaesthesiology VOLUME 19 - ISSUE 1 - spring 2019

SPECIAL SUPPLEMENT in the ICU Innovation Protecting ward patients: the case for continuous , F. Michard, T.J. Gan, R. Bellomo Innovations in ICU ventilation: the future delivered, F. Gordo, A. Abella, B. Lobo-Valbuena Data-driven management for intensive care units, F. J. da Silva Ramos, J. I. F. Salluh Technology innovations in delivering accurate nutrition: preventing malnutrition and enforcing nutritional guidelines, P. Singer, L. Elia The business of research, J. B. Ochoa Gautier

PLUS The role of disruptive and hybrid The establishment and provision The need to humanise the ICU, technologies in acute care, of an acute kidney injury service S. East T. Kyprianou at a tertiary renal centre, S. Fray Noninvasive technologies for Extravascular lung water as a Communication myths of personalised haemodynamic target for intensive care, M. Kirov, anaesthetists, S. Watson monitoring: advanced V. Kuzkov, L. Bjertnaes The role of the haemodynamic monitoring Managing delirium in the ICU Assistant in critical care, methods, B. Saugel with sleep guardians, C. Irwin, V. Bakshi S. Parkinson ©For personal and private use only. Reproduction must be permitted by the copyright holder. Email to [email protected]. must be permitted use only. Reproduction and private ©For personal

icu-management.org @ICU_Management 60 INTERVIEW

N o n i n v a s i v e t e c h n o l o g i e s for personalised haemodynamic monitoring Advanced haemodynamic monitoring methods

Bernd Saugel, MD, EDIC is a Professor of and works as a consultant in the Department of Anesthesiology, Center of Anesthesiology and , University Medical Center Hamburg-Eppendorf, Hamburg, Germany. Prof. Saugel is a specialist in anaesthesiology, intensive care medicine, and and holds a European Diploma in Intensive Care Medicine. His primary field of research is the haemodynamic management of high-risk patients having and critically ill patients. Prof. Saugel is particularly interested in the concept of personalised haemodynamic management using advanced innovative haemodynamic monitoring methods in anaesthesiology and intensive care medicine. Is noninvasive cardiac monitoring and the "true" value under study conditions. (By patients having surgery. However, in our optimisation reliable, accurate and precise the way, a measurement of a haemodynamic University Medical Center, we still use these enough yet? variable is always uncertain). On the other innovative noninvasive monitoring technolo- It depends. There are numerous different hand, I could easily show you studies for each gies almost exclusively in clinical studies. technologies for continuous noninvasive of the mentioned technologies showing poor monitoring of , stroke volume/ agreement between these innovative methods What do you see as the most promising cardiac output, and derived haemodynamic and invasive reference methods. The challenge noninvasive haemodynamic monitoring variables such as pulse pressure or stroke is to have a differentiated view on these valida- technology? volume variation. These technologies include tion studies and to exactly analyse the study My personal take on this challenging question bioimpedance/bioreactance, pulse wave transit protocols and study settings before drawing is that –at the moment– pulse wave analysis time, carbon dioxide re-breathing, Doppler, definite conclusions if a novel monitoring using finger-cuff methods is the most promis- pulse wave analysis, and many more (Saugel et technology can be considered "reliable" or not. ing approach for noninvasive monitoring of al. 2018; Saugel et al. 2015). These technolo- blood pressure and cardiac output in perioper- gies are based on different physical measure- What has been your clinical experience of ative and intensive care medicine. However, the ment principles and, therefore, have different using noninvasive monitoring methods? field of cardiovascular and respiratory monitor- advantages and limitations with regard to their In clinical practice, we started using noninva- ing is rapidly evolving and we, for sure, can measurement performance and applicability in sive finger-cuff technologies that allow expect that new technologies using highly clinical routine. For all technologies, different continuous monitoring of both blood innovative sensor materials will be proposed validation studies comparing the innovative test pressure and stroke volume/cardiac output in the near future. These future technologies method with an established reference method using pulse wave analysis. We don't use these will use ultra-small and highly sensitive sensors showed contradicting results – depending on the technologies to replace the arterial catheter or to make monitoring systems "wearable and patient population, clinical setting, and reference advanced haemodynamic monitoring methods wireless" and to allow "integrated monitor- method (Joosten et al. 2017). All methods in high-risk surgical patients or critically ill ing," i.e. monitoring of various cardiovascular have been shown to be able to provide reliable patients treated in the ICU, but to monitor and respiratory signals with one sensor and measurements i.e. accurate and precise measure- blood pressure continuously instead of only analysing a combination of different haemody- ments with a good ability to indicate changes in intermittently in low- or intermediate risk namic signals. ©For personal and private use only. Reproduction must be permitted by the copyright holder. Email to [email protected]. must be permitted use only. Reproduction and private ©For personal ICU Management & Practice 1 - 2019 61 INTERVIEW

Why do you think that validation studies of in the perioperative period) are associated will have an arterial catheter anyway, not only noninvasive methods have shown contra- with postoperative morbidity in terms of for haemodynamic monitoring but also for dictory results? complications and organ failure (Sessler et arterial blood gas analysis. We should not only There are several reasons that might explain al. 2017; Walsh et al. 2013), there are good think about "replacing the arterial catheter"; the contradictory results of validation studies. reasons to aim for continuous blood pressure we should think about improving the quality First, as mentioned earlier, the validation monitoring. In some intermediate-risk of care and outcome in patients who are studies have been performed in very differ- patients, using these technologies will make now monitored intermittently, e.g. almost all ent patient populations and clinical settings it unnecessary to place an arterial catheter. low- and intermediate-risk surgical patients, (Joosten et al. 2017). It makes a huge differ- Second, in intermediate-risk surgical patients patients undergoing diagnostic procedures ence if we evaluate a noninvasive test method additional noninvasively assessed haemody- such as endoscopy, patients in emergency in surgical patients having namic variables such as cardiac output and departments and on normal wards (Wagner or in patients treated in the ICU with septic dynamic cardiac preload parameters may and Saugel 2015). I think identifying patient shock. A general problem is that the patients help to titrate fluids and vasoactive agents populations and clinical settings in which we include in method comparison or valida- (goal-directed haemodynamic ). continuous monitoring instead of intermit- tion studies to test these innovative technolo- In high-risk surgical patients and critically tent monitoring can help to improve the gies are usually not the patients in whom ill patients treated in the ICU, however, arterial quality of care or identify haemodynamic we aim to use these technologies in clinical catheters and invasive advanced haemody- alterations earlier is a key challenge in this practice; nobody would suggest using a namic monitoring methods will still be the field (Saugel and Scheeren 2017). noninvasive device in a patient having cardiac standard of care in the foreseeable future. surgery. We simply use those high-risk patient How best to personalise haemodynamic populations to perform method comparison management of the perioperative patient? studies because –for obvious reasons– patients future technologies In contrast to intensive care medicine, we need to be equipped with invasive reference will use ultra-small and highly have the unique opportunity in periopera- monitoring methods for clinical indications tive medicine that we can assess an individual unrelated to the study. Last but not least, we sensitive sensors to make patient's baseline haemodynamic status. This need a consensus on how to design valida- monitoring systems wearable includes the patient's normal blood pressure tion studies and –of utmost importance– how profile, cardiac function, and metabolic status. to perform statistical analyses in method and wireless and to allow These baseline haemodynamic variables can comparison studies to assess "clinically integrated monitoring then be used to guide haemodynamic optimi- acceptable agreement." sation strategies in the intra- and postopera- tive period (Saugel et al. 2017). When do you expect such technologies to In your article with Dr. Meidert, you say come into routine use in the OR and ICU? that the question “is whether continu- When should advanced haemodynamic I think that innovative noninvasive technol- ous noninvasive devices need to replace monitoring be used in shock? ogies for haemodynamic monitoring will the direct measurement or rather fill In patients with circulatory shock a) if the come into routine use in the OR during the monitoring gap for patients who are type of shock cannot be easily identified, b) the next 5-10 years. There will be two main insufficiently monitored by intermittent if the patient does not respond to the initial indications. First, noninvasive technologies measurements only." Please comment. therapeutic interventions, and c) if circulatory will be used for continuous blood pressure This statement refers to the ongoing discus- shock is complicated by failure of other organ monitoring (Michard et al. 2018). Having sion about the place continuous noninvasive systems [ARDS, right failure, or liver the advantage of allowing continuous and not monitoring technologies should have in the failure,...](Saugel and Vincent 2018; Teboul only intermittent blood pressure monitor- future. et al. 2016). ing these technologies may be used as an My US colleague Robert Thiele wrote alternative to oscillometric upper arm cuff already in 2015: "It is only a matter of time Would you agree that routine use of the measurements [By the way, although used as until volume clamp devices [i.e. finger- pulmonary artery catheter should be "clinical gold standard" in millions of patients cuff technologies] replace many if not the abandoned (e.g. Youssef and Whitlock throughout the world we should not ignore majority of arterial catheters for the continu- 2017)? that oscillometry has its own limitations ous measurement of blood pressure, arterial More and more people believe that there are regarding the measurement performance respiratory variation, and even noninvasive no routine indications for the PAC. I think and clinical applicability (Wax et al. 2011)]. cardiac output monitoring" (Thiele 2015). that the PAC is still a valuable monitoring With more and more data indicating that even I'm not sure if this really is what we should technique that provides important haemody- short periods of intraoperative (and postop- aim for. Some patients e.g. high-risk surgical namic variables in very specific clinical erative!) hypotension (i.e. low blood pressure patients and critically ill patients in the ICU problems. In patients with circulatory shock ©For personal and private use only. Reproduction must be permitted by the copyright holder. Email to [email protected]. must be permitted use only. Reproduction and private ©For personal ICU Management & Practice 1 - 2019 ©For personal and private use only. Reproduction must be permitted by the copyright holder. Email to [email protected]. Saugel B,Cecconi M,HajjarLA(2018)Noninva- Database ofSystematic Reviews 2:CD003408. adult patientsinintensive care. TheCochrane Rowan K(2013)Pulmonaryartery catheters for Cavanaugh SK,Brampton W,Young D,Harvey S, Rajaram SS, DesaiNK,Kalra A,Gajera M, Intensive Care Med,44:2213-2215. invasive arterial pressure monitoring revisited. Michard F,Sessler DI,SaugelB(2018)Non- Br JAnaesth, 118:298-310. medicine: asystematic review andmeta-analysis. cardiac output monitoring devices in perioperative M (2017)Accuracy andprecision ofnon-invasive Van Obbergh L,Maucort-Boulch D,Cannesson Essiet M, Alexander B,FischerMO,Barvais L, Joosten A,DesebbeO,Suehiro K,MurphyLS, References carefully and benefits needtobalancetherisks erative andpostoperative phase. However, we patients having cardiacsurgery intheintraop- interventions. incertain The sameistrue to monitorthepatient's response tothese help totitrate therapeutic interventionsand failure, heart with right shock thePAC can hypertensionand pulmonary orcirculatory 62 toring: how to choosetheoptimalmethodfor Saugel B,Vincent JL(2018)Cardiac outputmoni- in critical care 2017,23:334-341. ized hemodynamicmanagement.Current opinion Saugel B,Vincent JL,Wagner JY(2017)Personal- of Anaesthesiology, 34:713-715. 'confidence inthe technology.' European Journal impact onpatientoutcome isneeded to gain invasive hemodynamicmonitoring: abeneficial Saugel B,Scheeren TWL(2017)Continuousnon- medicine. BrJAnaesth, 114:562-575. monitoring inperioperative andintensive care (2015) Noninvasive continuous cardiac output Saugel B,Cecconi M,Wagner JY,Reuter DA Vascular Anesthesia. Directions. JournalofCardiothoracic and Surgery Patients: Available MethodsandFuture sive Cardiac OutputMonitoring inCardiothoracic within thereach ofmosthospitalsin Is noninvasive continuous monitoring PAC-derived variables (Rajarametal. 2013). from haemodynamic interventionsguidedby only inthosepatients whoreally canbenefit valuable toolifusedby specialistsandifused method. monitoring of each The PAC isa INTERVIEW Thiele RH(2015)Cardiac bulldozers, backhoes, 42:1350-1359. in critically illpatients.Intensive Care Med, TW (2016)Less invasive hemodynamicmonitoring DA, RhodesA,Squara P,Vincent JL,Scheeren Hofer CK,MonnetX,Perel A,PinskyMR,Reuter Teboul JL,SaugelB,Cecconi M,DeBacker D, Trial. Anesthesiology. infarction anddeath:asubstudy ofthePOISE-2 diac surgery andacomposite ofmyocardial hypotension duringandfor 4 days after noncar- PJ (2017)Period-dependent associations between RM, Duceppe E,RodsethR, Botto F,Devereaux MD, Gossetti B,Walker SA,Premchand RK,Dahl Cavalcanti AB,Parlow JL,Rahate PV,Seeberger Leslie K,Vasquez SM,BalajiP,Alvarez-Garcia J, Sessler DI,Meyhoff CS,ZimmermanNM,MaoG, Care, 24:165-172. the individualpatient.Current OpinioninCritical or patient-centred outcomes. been shown to improve quality of care and/ to invest inany ifithas kindofmonitoring available. But, ofcourse, itonly makes sense haemodynamic are nowadays monitoring Yes, itis. Numerous methodsfor noninvasive middle andhigh-incomecountries? interventions. Anesthesiology ,115:973-978. in measurements andassociated therapeutic blood pressure monitoring: observed differences and concomitant noninvasive intraoperative Wax DB,LinHM,Leibowitz AB(2011)Invasive tion ofhypotension. Anesthesiology, 119:507-515. noncardiac surgery: toward anempirical defini- arterial pressure andclinical outcomes after (2013) Relationshipbetween intraoperative mean A, RodsethRN,CywinskiJ,ThabaneL,Sessler DI Walsh M,Devereaux PJ, Garg AX,KurzA,Turan 29:1-3. Journal ofClinical Monitoring andComputing, monitoring technologies into clinical routine? adopt continuous noninvasive hemodynamic Wagner JY,SaugelB(2015)Whenshouldwe 121:1417-1419. and blood pressure. Anesthesia andAnalgesia,