Hemodynamic Monitoring

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Michael R. Pinsky
Jean-Louis Teboul
Jean-Louis Vincent
Editors

Hemodynamic
Monitoring
Editors
Michael R. Pinsky Jean-Louis Teboul
Critical Care Medicine Dept. Bicetre University Hospital
University of Pittsburgh Paris South University
Pittsburgh, PA Le Kremlin-Bicêtre
USA France

Jean-Louis Vincent
Department of Intensive Care
Erasme University Hospital
Brussels
Belgium

ISSN 2522-5928     ISSN 2522-5936 (electronic)

Lessons from the ICU
ISBN 978-3-319-69268-5    ISBN 978-3-319-69269-2 (eBook)
https://doi.org/10.1007/978-3-319-69269-2

Library of Congress Control Number: 2019930093

© European Society of Intensive Care Medicine 2019

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recita-
tion, broadcasting, reproduction on microfilms or in any other physical way, and transmission or infor-
mation storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar
methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publica-
tion does not imply, even in the absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this
book are believed to be true and accurate at the date of publication. Neither the publisher nor the
authors or the editors give a warranty, express or implied, with respect to the material contained herein
or for any errors or omissions that may have been made. The publisher remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
 V

The editors wish to dedicate this volume to all our teachers who through hard work and
dedication mentored us through our careers, our colleagues who have been with us always on
this journey of shared patient care, and to our patients, for whose optimal care and comfort is
our never-ending goal.
Foreword

Critical illness often presents problems of such complexity that the bedside clinician is
forced to integrate information from many data streams into the management deci-
sion. As the ‘evidence-based’ investigational paradigm gained traction and eventual
dominance in medicine, initial hope was entertained by many intensivists that solid
evidence from trials, together with advanced imaging and the laboratory data, would
generate effective ‘rules’ to guide practice. In fact, well-designed and conducted clini-
cal trials (RCTs) do characterize general behaviors and may provide defensible starting
points for making some choices, especially if positive. To this point however, we have
been disappointed by RCT output; fundamentally, such problems are too imprecisely
defined, complicated, interactive, and labile to allow RCTs, ‘snapshot’ imaging, and
biomarkers – even considered together – to reliably direct the next best step for the
individual patient.

Effective life support needs a more ‘personalized’ approach that adheres to established
principles aimed at supporting the patient’s own efforts to recover homeostasis and
viability. Our decisions must remain flexible; within the physical boundaries of the
ICU, the principles of therapeutic challenge, frequent reassessment, continual re-eval-
uation, and timely mid-course correction remain fundamental elements of the inten-
sivist’s art. Moment-by-moment access to key information relevant to the patient’s
status is central to well-timed interventions. Successful management still depends
upon having a firm grasp of the physiology of critical illness, coupled with the ability
to expertly integrate and act upon monitored information from key indicators that
reflect cardiopulmonary functioning. A few foundational elements of critical care
physiology share precedence over the others, but none is more important than the
circulation.

This important volume, written by the foremost experts of our field and directed
toward bedside management, is a wide-ranging compendium of in-depth chapters that
address essential cardiovascular physiology as well as the pragmatics of diagnosing,
monitoring, and supporting the circulatory system. The mechanistic basis for clinical
decision making is emphasized throughout. Cardio-respiratory management of the
critically ill has advanced rather impressively in recent decades, and such progress is
clearly evident in the attention given to such up-to-date topics as bedside ultrasound,
assessment of the microcirculation and perfusion adequacy, advanced monitoring
options, and extracorporeal circulatory assistance and gas exchange. The chapters of
this book are not meant to be read sequentially from cover to cover (even though such
an exercise might prove highly rewarding), but rather to be accessed in a focused man-
ner as specific clinical issues arise in patient care or when knowledge gaps need to be
filled.

In this current exciting age of rapidly expanding knowledge of genetic and molecular
sciences, exhaustive statistical analyses, empirical evidence gathering, RCTs and meta-
analysis, it sometimes seems that our attention as practitioners has been diverted from
 VII
Foreword

understanding the ‘why?’ to the ‘what and how’?. I congratulate the editors and authors
for addressing both in admirable fashion. It is refreshing and most welcome to see a
definitive work based upon the often neglected but invaluable middle ground of applied
pathophysiology. Mastery of physiology will always be needed to unravel our most dif-
ficult clinical challenges and remains the foundation of intelligent critical care.

John J. Marini
Minneapolis/St. Paul, MN, USA
Preface

An essential aspect of the care of the critically ill patient is to identify cardiovascular
insufficiency, treat it, and know when to stop over resuscitation while also attending to
the various other aspects of pathology that each patient brings to the clinical environ-
ment. No two patents are alike in their presentation of acute illness, response to therapy,
or potential for a good outcome from the treatment of disease and a minimal amount of
treatment-associated morbidities. Furthermore, most people, if they live long enough,
will experience some acute potentially life-taking process that if not treated correctly and
rapidly will result in death or morbidity before their time. These realities make the prac-
tice of critical care medicine one of the most demanding of all medical specialties, and
also one of its greatest attractions in the recruitment of dedicated and passionate bedside
clinicians.

Within this context, this volume has been crafted to systematically address all aspects of
hemodynamic monitoring-related cardiovascular diagnosis and management. Part I of
this volume addresses the essential aspects of the physiology and pathophysiology of
cardiovascular insufficiency. The authors of these eleven chapters are some of the leading
clinical investigators in the field with many years of bedside clinical experience and an
impressive publication record of clinical trials and basic science companion studies.
Although these chapters are arranged in a progressive sequence to supplement each
other, the reader can pick and choose specific chapters of interest based on their per-
ceived knowledge gaps or focused areas of interest.

Part II of this volume assumes the reader is cognizant of the underlying physiology and
pathophysiology and goes directly into their use in clinical assessment. Because once a
basic understanding of physiology is present, real-time knowledge of the patient allows
diagnosis to become personalized by addressing the unique aspects of each patient as
they face life-threatening disease processes. These five integrated chapters require an
understanding of the underlying physiology but then take that plane and elevate it to
clinical decision making and prognosis. This section in the volume represents a unique
series of chapters relative to other critical care medicine textbooks, and we hope its util-
ity to direct patient care will be innately obvious to the reader.

Part III addresses the specific measures made by various monitoring devices because at
the end of the day hemodynamic monitoring is monitoring with specific devices that
report specific information over time. Thus the focus on specific monitoring modality
and physiologic parameter discussed in these twelve chapters bring the physiology of
Part I and the pathophysiologic assessments in Part II into reality at the bedside.

Part IV addresses the very real question of what to do and why. Targeting specific thera-
peutic end points assumes that their achievement will reduce morbidity and mortality.
But what therapies to give and why? These questions are addressed in these three very
focused chapters.
 IX
Preface

Finally, in Part V, patients usually fit into broad groupings of acute illness based on the
fundamental pathophysiologic processes that initiated their instability. Acute heart fail-
ure, septic shock, ARDS, neurologic emergencies, postoperative problems, and recently
the need for extracorporeal support. They reflect the present-day disease state/processes
commonly seen in the intensive care unit. These chapters serve to solidify the prior chap-
ters into a complete set, leaving the bedside clinician with insight and hopeful perspec-
tive as to what to expect, to monitor, and how to apply that monitoring.

The editors are profoundly grateful to the authors of this book for their excellent contri-
butions and knowledge base that made these chapters what they are; the senior editors of
the European Society of Intensive Care Medicine, who oversaw the creation of this book
within their series; and the publisher, Springer, for their support and dedication to this
very important and clinically relevant opus.

Michael R. Pinsky
Pittsburgh, PA, USA

Jean-Louis Teboul
Le Kremlin-Bicêtre, France

Jean-Louis Vincent
Brussels, Belgium
 XI

Contents

I Physiology and P
­ athophysiology
1 Introduction to “Hemodynamic Monitoring”............................................................... 3
Jukka Takala

2 Shock: Definition and Recognition...................................................................................... 7

Antonio M. Dell’Anna, Flavia Torrini, and Massimo Antonelli

3 Assessing the Adequacy of Cardiac Output.................................................................. 21

Jean-Louis Vincent

4 Determinants of Venous Return............................................................................................ 27

Hollmann D. Aya and Maurizio Cecconi

5 Arterial Blood Pressure Regulation.................................................................................... 39

Alexander Kobzik and Michael R. Pinsky

6 Pulmonary Circulation................................................................................................................. 49
Marco Maggiorini

7 The Pulse: An Essential Vital Sign......................................................................................... 65

Paul E. Marik

8 Autonomic Dysfunction in Shock......................................................................................... 71

Gareth L. Ackland

9 Oxygen Delivery.............................................................................................................................. 81
Eleonora Duscio, Francesco Vasques, Federica Romitti, Francesco Cipulli,
and Luciano Gattinoni

10 Mitochondrial Function.............................................................................................................. 97
Mervyn Singer

11 Perioperative Haemodynamics............................................................................................. 107

Katherine McAndrew, Maurizio Cecconi, and Andrew Rhodes

12 Hemodynamics and Extracorporeal Circulation........................................................ 117

Maxime Coutrot, Alain Combes, and Nicolas Bréchot

II Clinical Assessment and Measurements

13 Clinical Assessment of Hemodynamic Instability..................................................... 131
Jan Bakker
XII Contents

14 Assessment of the Microcirculation................................................................................... 147

Daniel De Backer

15 SvO2/ScvO2.......................................................................................................................................... 157
Zsolt Molnar and Marton Nemeth

16 The PCO2 Gaps................................................................................................................................... 173

Gustavo A. Ospina-Tascón

17 Lactate.................................................................................................................................................... 191
Ricardo Castro, David Carpio, and Glenn Hernández

III The Techniques

18 Cardiac Ultrasound Examination in Shock..................................................................... 205
Guillaume Geri and Antoine Vieillard-Baron

19 Non-cardiac Ultrasound Signs in Shock........................................................................... 215

Becky X. Lou and Paul H. Mayo

20 Central Venous Pressure............................................................................................................. 223

Sheldon Magder

21 Arterial Blood Pressure............................................................................................................... 233

Bernd Saugel, Thomas W. L. Scheeren, and Jean-Louis Teboul

22 Cardiac Output Monitors........................................................................................................... 247

Daniel A. Reuter and Sebastian A. Haas

23 Volumetric Monitoring in Critically Ill Patients........................................................... 253

Manu L. N. G. Malbrain

24 Assessment of Fluid Responsiveness................................................................................. 283

Xavier Monnet and Jean-Louis Teboul

25 Pulmonary Artery Catheter...................................................................................................... 301

Ina Filipović-Grčić and Didier Payen

26 Arterial Pressure Waveform Analysis on Cardiac Output Monitoring......... 313

Manuel Ignacio Monge García and Arnoldo Santos

27 Oesophageal Doppler.................................................................................................................. 323

Jonathan Lacey and Monty Mythen

28 Bioimpedance and Bioreactance.......................................................................................... 339

Lee S. Nguyen and Pierre Squara
 XIII
Contents

IV Basic Goals in Clinical Practice

29 Blood Pressure Targets in the Initial Stabilization.................................................... 359
Julien Demiselle, Peter Radermacher, and Pierre Asfar

30 Lessons from the ICU: Choosing the Right Vasopressor....................................... 367

Francesco Fiorini, David Antcliffe, and Anthony C. Gordon

31 Fluid Resuscitation......................................................................................................................... 379

Peter Buhl Hjortrup and Anders Perner

V Choosing the Right Hemodynamic Therapy

32 Choosing the Ideal Hemodynamic Therapy in Acute Right
and Left Heart Failure.................................................................................................................. 393
Alexa Hollinger and Alexandre Mebazaa

33 Cardiopulmonary Monitoring of Septic Shock........................................................... 411

Claude Martin, Gary Duclos, and Marc Leone

34 In ARDS.................................................................................................................................................. 419

Giacomo Grasselli, Nadia Corcione, and Antonio Pesenti

35 In Neurological Emergencies.................................................................................................. 439

Ilaria Alice Crippa and Fabio Silvio Taccone

36 Perioperative Haemodynamic Optimisation................................................................ 457

Mark R. Edwards and Rupert M. Pearse

37 In a Patient Under ECMO............................................................................................................ 469

Darryl Abrams and Matthieu Schmidt
Contributors

Darryl Abrams Daniel De Backer

Division of Pulmonary, Allergy, and Critical Care Department of Intensive Care
Columbia University College of Physicians CHIREC Hospitals, Université Libre de Bruxelles
and Surgeons/New York-Presbyterian Hospital Brussels, Belgium
New York, NY, USA [email protected]
[email protected]
Jan Bakker, MD, PhD, FCCP, FCCM
Gareth L. Ackland Department of Pulmonary and Critical Care
Translational Medicine and Therapeutics, New York University
William Harvey Research Institute, Barts and New York, NY, USA
The London School of Medicine and Dentistry Division of Pulmonary, Allergy,
Queen Mary University of London and Critical Care Medicine
John Vane Science Centre Columbia University Medical Center
London, UK New York, NY, USA
[email protected] Department of Intensive Care Adults
Erasmus MC University Medical Center
David Antcliffe Rotterdam, The Netherlands
Imperial College London
Department of Intensive Care
London, UK
Pontificia Universidad Católica de Chile
[email protected]
Santiago, Chile
[email protected]
Massimo Antonelli, MD
Department of Anesthesiology Nicolas Bréchot, MD, PhD
and Intensive Care Medicine Medical–Surgical ICU, Hôpital Pitié–Salpêtrière,
Fondazione Policlinico Universitario ­Assistance Publique–Hôpitaux de Paris
A.Gemelli- Università Cattolica Paris Cedex, France
del Sacro Cuore – Roma
INSERM U1050, Centre for Interdisciplinary
Rome, [email protected]
Research in Biology (CIRB), College de France
CNRS, INSERM, PSL Research University
Pierre Asfar
Paris, France
Medical Intensive Care Department
[email protected]
University Hospital of Angers
Angers, France David Carpio, MD
[email protected] Departamento de Medicina Intensiva
Facultad de Medicina, Pontificia Universidad
Hollmann D. Aya Católica de Chile
Critical Care Department Santiago, Chile
St Bartholomew’s Hospital – Heart Center [email protected]
Barts Health NHS Trust
London, UK Ricardo Castro, MD, MPH
[email protected] Departamento de Medicina Intensiva
Facultad de Medicina, Pontificia Universidad
Católica de Chile
Santiago, Chile
[email protected]
 XV
Contributors

Maurizio Cecconi Antonio M. Dell’Anna, MD

IRCCS Istituto Clinico Humanitas Department of Anesthesiology
Rozzano, MI, Italy and Intensive Care Medicine
Humanitas University Fondazione Policlinico Universitario
Pieve Emanuele, MI, Italy A.Gemelli- Università Cattolica del Sacro
[email protected] Cuore – Roma
Rome, Italy
Francesco Cipulli [email protected]
Department of Anesthesiology,
­Emergency and Intensive Care Medicine Julien Demiselle
University of Göttingen Medical Intensive Care Department
Göttingen, Germany University Hospital of Angers
[email protected] Angers, France
[email protected]
Alain Combes, MD, PhD
Medical–Surgical ICU, Hôpital Pitié–Salpêtrière Gary Duclos
Assistance Publique–Hôpitaux de Paris Aix-Marseille Université
Paris Cedex, France Marseille, France
[email protected]
Sorbonne University, UPMC Univ Paris 06,
INSERM, UMRS_1166-iCAN,
Eleonora Duscio
Institute of Cardiometabolism and Nutrition
Department of Anesthesiology,
Paris Cedex, France
­Emergency and Intensive Care Medicine
[email protected]
University of Göttingen
Göttingen, Germany
Nadia Corcione
[email protected]
Fondazione IRCCS Ca’ Granda Ospedale
Maggiore Policlinico
Mark R. Edwards
Milan, Italy
University Hospital Southampton NHS
[email protected]
Foundation Trust and University of Southampton
Southampton, UK
Maxime Coutrot, MD
[email protected]
Medical–Surgical ICU, Hôpital Pitié–Salpêtrière
Assistance Publique–Hôpitaux de Paris
Ina Filipović-Grčić, MD
Paris Cedex, France
Department of Anesthesiology and Intensive Care
[email protected]
European Medical Center-General
Hospital Dubrovnik
Ilaria Alice Crippa, MD
Dubrovnik, Croatia
Department of Intensive Care
[email protected]
Hopital Erasme, Université Libre de
Bruxelles (ULB)
Francesco Fiorini
Brussels, Belgium
Imperial College London
[email protected]
London, UK
[email protected]
XVI Contributors

Manuel Ignacio Monge García Peter Buhl Hjortrup

Unidad de Cuidados Intensivos, Department of Intensive Care
­Hospital SAS de Jerez de la Frontera Copenhagen University Hospital Rigshospitalet
Jerez de la Frontera, Spain Copenhagen, Denmark
[email protected] [email protected]

Luciano Gattinoni Alexa Hollinger

Department of Anesthesiology, Emergency The University Hospital of Basel
and Intensive Care Medicine Basel, Switzerland
University of Göttingen [email protected]
Göttingen, Germany
[email protected] Alexander Kobzik, MD
Department of Critical Care Medicine
Guillaume Geri University of Pittsburgh
Medico-Surgical ICU, Pittsburgh, PA, USA
Ambroise Paré Hospital, APHP [email protected]
Boulogne-­Billancourt, France
Jonathan Lacey
Versailles Saint Quentin University
University College London
INSERM U1018, Team 5
London, UK
Paris, France
[email protected]
[email protected]
Marc Leone
Anthony C. Gordon
Aix-Marseille Université
Imperial College London
Marseille, France
London, UK
[email protected]
[email protected]
Becky X Lou, MD
Giacomo Grasselli Zucker School of Medicine at Hofstra/
University of Milan Northwell Health
Milan, Italy New Hyde Park, NY, USA
[email protected] [email protected]

Sebastian A. Haas Sheldon Magder

Department of Anesthesiology Department of Critical Care
and Intensive Care Medicine McGill University Health Centre
Rostock University Medical Center Montreal, QC, Canada
Rostock, Germany [email protected]
[email protected]
Marco Maggiorini
Glenn Hernández, MD, PhD University Hospital Zürich
Departamento de Medicina Intensiva Zürich, Switzerland
Facultad de Medicina [email protected]
Pontificia Universidad Católica de Chile
Santiago, Chile Manu L. N. G. Malbrain
[email protected] Vrije Universiteit Brussel (VUB)
Ixelles, Belgium
[email protected]
 XVII
Contributors

Paul E. Marik, MD, FCCM, FCCP Monty Mythen

Division of Pulmonary and Critical University College London
Care Medicine London, UK
Eastern Virginia Medical School [email protected]
Norfolk, VA, USA
[email protected] Marton Nemeth, MD, PhD
Department of Anesthesiology
Claude Martin and Intensive Therapy
Aix-Marseille Université University of Szeged
Marseille, France Szeged, Hungary
[email protected] [email protected]

Paul H. Mayo, MD Lee S. Nguyen

Zucker School of Medicine at Hofstra/ Critical Care Medicine Department
Northwell Health CMC Ambroise Paré
New Hyde Park, NY, USA Neuilly-sur-­Seine, France
[email protected] [email protected]

Katherine McAndrew Gustavo A. Ospina-Tascón

Department of Intensive Care Medicine Department of Intensive Care Medicine
St George’s University Hospitals NHS Fundación Valle del Lili - Universidad ICESI
Foundation Trust Cali, Colombia
London, UK [email protected]
[email protected]
Didier Payen, MD, PhD
Alexandre Mebazaa University Paris 7 Denis Diderot, Sorbonne Cité
Hôpitaux Lariboisière Saint Louis UMR INSERM 1109, Hôpital Lariboisière, AP-HP
University Hospitals Paris, France
Paris, France [email protected]
[email protected]
Rupert M. Pearse
Zsolt Molnar, MD, PhD Queen Mary’s University of London Barts &
Department of Anesthesiology The London School of Medicine and Dentistry
and Intensive Therapy London, UK
University of Szeged Adult Critical Care Unit, Royal London Hospital
Szeged, Hungary London, UK
[email protected] [email protected]

Xavier Monnet Anders Perner

Medical Intensive Care Unit, Bicêtre Hospital Department of Intensive Care
Paris-Sud University Hospitals Copenhagen University Hospital Rigshospitalet
Inserm UMR_S999, Paris-Sud University Copenhagen, Denmark
Le Kremlin-Bicêtre, France [email protected]
Service de réanimation médicale
Hôpital de Bicêtre Antonio Pesenti
Le Kremlin-Bicêtre, France University of Milan
[email protected] Milan, Italy
[email protected]
XVIII Contributors

Michael R. Pinsky, MD Bernd Saugel

Department of Critical Care Medicine Department of Anesthesiology
University of Pittsburgh Center of Anesthesiology and Intensive Care
Pittsburgh, PA, USA Medicine, University Medical Center
[email protected] Hamburg-Eppendorf
Hamburg, Germany
Peter Radermacher [email protected]
Institut für Anästhesiologische Pathophysiologie
und ­Verfahrensentwicklung Thomas W. L. Scheeren
Universitätsklinikum Department of Anaesthesiology
Ulm, Germany University of Groningen
[email protected] University Medical Center Groningen
Groningen, The Netherlands
Daniel A. Reuter [email protected]
Department of Anesthesiology
and Intensive Care Medicine Matthieu Schmidt
Rostock University Medical Center Medical-Surgical Intensive Care Unit
Rostock, Germany Hôpital Pitié-Salpêtrière, Assistance
[email protected] Publique-Hôpitaux de Paris
Paris, France
Andrew Rhodes Sorbonne University Paris, INSERM
Department of Intensive Care Medicine Institute of Cardiometabolism and Nutrition
St George’s University Hospitals NHS UMRS_1166-ICAN
Foundation Trust Paris, France
London, UK [email protected]
[email protected]
Mervyn Singer
Federica Romitti Bloomsbury Institute of Intensive Care
Department of Anesthesiology, Emergency Medicine, University College London
and Intensive Care Medicine London, UK
University of Göttingen [email protected]
Göttingen, Germany
[email protected] Pierre Squara
Critical Care Medicine Department
Arnoldo Santos CMC Ambroise Paré
CIBER de enfermedades respiratorias (CIBERES) Neuilly-sur-­Seine, France
Madrid, Spain [email protected]
Surgical Sciences Department, Hedenstierna
Laboratory, Uppsala University
Uppsala, Sweden
[email protected]