ICU · Cardiovascular
Advanced haemodynamic monitoring in the ICU
Also known as Haemodynamic monitoring · Pulmonary artery catheter (PAC) · Arterial line · PiCCO/LiDCO · Echocardiography in ICU · Transpulmonary thermodilution · Pulse contour analysis · Fluid responsiveness · Central venous pressure
Haemodynamic monitoring guides resuscitation in critically ill patients. From basic (clinical examination, urine output, arterial line, CVP line) to advanced (invasive cardiac output monitoring). Levels: (1) Basic: arterial line (BP, blood sampling, waveform), CVP line (right atrial pressure — a POOR predictor of fluid responsiveness). (2) Intermediate: echocardiography (non-invasive, qualitative + quantitative — the most versatile ICU tool), lactate, ScvO2. (3) Advanced: pulmonary artery catheter (PAC — gold standard but invasive, declining use after FACTT/PAC-Man/ESCAPE), transpulmonary thermodilution (PiCCO/TPTD — GEDV, ITBV, EVLW, PVPI), lithium dilution (LiDCO), pulse contour analysis (arterial line-derived CO). Fluid responsiveness must be assessed with DYNAMIC tests (passive leg raise, fluid challenge, SVV/PPV) not static markers (CVP). Choose monitoring based on the clinical question, not routinely.
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Red flags
- CVP is a POOR predictor of fluid responsiveness — do NOT use alone to guide fluid therapy (AUC ~0.56, Marik 2013 meta-analysis)
- Pulmonary artery catheter: no proven mortality benefit (PAC-Man, FACTT, ESCAPE trials), increased complications — use selectively for complex shock, pulmonary HTN, RV failure, MCS titration
- Fluid responsiveness: use DYNAMIC tests (passive leg raise, fluid challenge, SVV/SPV) not static markers (CVP)
- Echocardiography is the most versatile ICU monitoring tool — non-invasive, rapid, qualitative + quantitative
- Arterial line MAP is preserved in both under- and over-damping — trust MAP, distrust the systolic when the square-wave test is abnormal
- SVV/PPV are INVALID in atrial fibrillation, spontaneous breathing, low tidal volume ventilation, right heart failure, and open chest
- PA catheter in a patient with pre-existing LBBB risks complete heart block (transient RBBB during RV transit) — have pacing available
- EVLW (extravascular lung water) predicts mortality and guides fluid strategy — a low or falling EVLW is the target in ARDS/septic shock
Meet the patient
A 68-year-old woman with pneumonia and septic shock has had 30 mL/kg of crystalloid. Her central venous pressure reads 12, the registrar wants to give another bolus "because the CVP is only 12," and she is still mottled and cold with a lactate of 3.1. The monitor is showing you a number — the question is whether it answers the question you are actually asking.[2]
The whole field turns on one discipline: define the question first, then choose the least invasive monitor that answers it, and remove line moment it stops changing management. "Do not monitor what you cannot interpret" is the rule that prevents a ward full of unused pulmonary artery catheters.[13]
References15ShowHide
- [1]Marik PE, Cavallazzi R, Vasu T, et al. Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature Crit Care Med, 2009.PMID 19602972
- [2]Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense Crit Care Med, 2013.PMID 23774337
- [3]Monnet X, Marik PE, Teboul JL. Prediction of fluid responsiveness: an update Ann Intensive Care, 2016.PMID 27858374
- [4]Chaves RCF, Barbas CSV, Queiroz VNF, et al. Assessment of fluid responsiveness using pulse pressure variation, stroke volume variation, plethysmographic variability index, central venous pressure, and inferior vena cava variation in patients undergoing mechanical ventilation: a systematic review and meta-analysis Crit Care, 2024.PMID 39217370
- [5]Harvey S, Harrison DA, Singer M, et al. Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised controlled trial Lancet, 2005.PMID 16084255
- [6]Binanay C, Califf RM, Hasselblad V, et al. Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial JAMA, 2005.PMID 16204662
- [7]Wheeler AP, Bernard GR, Thompson BT, et al. Pulmonary-artery versus central venous catheter to guide treatment of patients with acute lung injury N Engl J Med, 2006.PMID 16714768
- [8]Connors AF Jr, Speroff T, Dawson NV, et al. The effectiveness of right heart catheterization in the initial care of critically ill patients. SUPPORT Investigators JAMA, 1996.PMID 8782638
- [9]De Backer D, Vincent JL. The pulmonary artery catheter: is it still alive? Curr Opin Crit Care, 2018.PMID 29608456
- [10]Monnet X, Teboul JL. Transpulmonary thermodilution: advantages and limits Crit Care, 2017.PMID 28625165
- [11]Gavelli F, Shi R, Teboul JL, et al. Extravascular lung water levels are associated with mortality: a systematic review and meta-analysis Crit Care, 2022.PMID 35794612
- [12]Menger J, Mora B, Skhirtladze K, et al. Accuracy of Continuous Cardiac Output Measurement With the LiDCOplus System During Intra-Aortic Counterpulsation After Cardiac Surgery J Cardiothorac Vasc Anesth, 2016.PMID 26718662
- [13]Scheeren TWL, Ramsay MAE. New Developments in Hemodynamic Monitoring J Cardiothorac Vasc Anesth, 2019.PMID 31279355
- [14]Pearse RM, Harrison DA, MacDonald N, et al. Effect of a perioperative, cardiac output-guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: a randomized clinical trial and systematic review JAMA, 2014.PMID 24842135
- [15]Beurton A, Gavelli F, Teboul JL, et al. Changes in the Plethysmographic Perfusion Index During an End-Expiratory Occlusion Detect a Positive Passive Leg Raising Test Crit Care Med, 2021.PMID 33332814