REVIEW

CURRENT
OPINION Monitoring: from cardiac output monitoring
to echocardiography
Mathieu Jozwiak a,b, Xavier Monnet a,b, and Jean-Louis Teboul a,b

Purpose of review
Hemodynamic exploration is mandatory in patients with shock to identify the type of shock, to select the
best therapeutic strategy, and to assess the efficacy of the selected therapy. In this review, we summarize
the characteristics of the main available hemodynamic monitoring systems and emphasize on how to select
the most appropriate ones in patients with circulatory shock.
Recent findings
Over the past decade, hemodynamic monitoring techniques have progressively evolved from intermittent
toward real-time measurements and from invasive toward less invasive approaches. Nowadays,
echocardiography is recommended as the first-line modality of hemodynamic evaluation in patients with
shock. Current guidelines recommend reserving advanced hemodynamic monitoring systems for patients
not responding to the initial therapy and/or for complex conditions such as combination of shock with
acute respiratory distress syndrome. Invasive and noninvasive uncalibrated cardiac output monitors, as well
as esophageal Doppler, could find their place in the perioperative context rather than in patients with
shock.
Summary
The use of echocardiography should be encouraged at the initial period of shock to identify main involved
mechanisms and to select the appropriate therapy. The use of more invasive monitoring systems should be
discussed on an individualized basis.
Keywords
cardiac output, echocardiography, hemodynamic monitoring

INTRODUCTION discuss their relative place in patients with circula-

In patients with shock, hemodynamic monitoring
techniques can be used for identifying the type of
shock, selecting the therapeutic intervention, and
&&
evaluating the patients response to therapy [1 ].
Several techniques are available and differ in terms
of invasiveness, and the number and nature of the
provided hemodynamic variables [2]. Monitoring of
arterial blood pressure (ABP) using an artery catheter
is the simplest hemodynamic monitoring system,
&&
used in most cases of shock states [1 ]. It not only
provides measurements of ABP in real time, but also
enables continuous monitoring of pulse pressure
variation (PPV), which is a dynamic marker of pre-
load responsiveness [3]. A further step is to measure
and monitor cardiac output (CO). Finally, some
advanced hemodynamic monitoring systems pro-
vide the measurements of other variables, which
could be helpful in complex cases. In this article,
we review the available hemodynamic monitoring
techniques in light of recent clinical studies. We also
tory shock.
THE AVAILABLE HEMODYNAMIC
MONITORING TECHNIQUES
Invasive uncalibrated arterial pulse contour
analysis monitors
The FloTrac/Vigileo system (Edwards LifeSciences,
Irvine, California, USA), ProAQT/PulsioFlex system
a
Hopitaux universitaires Paris-Sud, Hopital de Bicetre, service de rean-
imation medicale and bINSERM UMR S 999, Univ Paris-Sud, Le Kremlin-
Bicetre, France
Correspondence to Professor Jean-Louis Teboul, Service de reanimation
medicale, Hopitaux universitaires Paris-Sud, Hopital de Bicetre, 78 rue du
General Leclerc, Le Kremlin-Bicetre, F-94270 France.
Tel: +33 145213543; e-mail: jean-louis.teboul@aphp.fr
Curr Opin Crit Care 2015, 21:395401
DOI:10.1097/MCC.0000000000000236

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Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.

Cardiovascular system
KEY POINTS

Over the past decade, hemodynamic monitoring
techniques have continuously evolved toward less
invasiveness and real-time hemodynamic variable
measurements.

Although it is not a continuous monitoring technique,
echocardiography is recommended to be the first-line
modality of hemodynamic evaluation in every patient
with shock.

It is currently not recommended to use advanced
hemodynamic monitoring systems in patients with
shock, who quickly respond to the initial therapy, on
the basis of clinical evaluation and echocardiography.

Advanced hemodynamic monitoring is recommended
to be used in patients with shock who do not respond
to the initial therapy and/or in complex conditions.
Transpulmonary thermodilution devices should be
reserved for patients with shock and acute respiratory
distress syndrome. Pulmonary artery catheter should be
reserved for patients with refractory shock and right
ventricular dysfunction.

In surgical patients, use of noninvasive hemodynamic
monitoring integrated in an early goal-directed therapy
approach during and after surgery is associated with a
decreased mortality and postoperative complications.
(Pulsion Maquet, Munich, Germany), and LiD-
COrapid monitor (LiDCO, Ltd., London, UK) pro-
vide real-time CO measurements by deriving ABP
waveform recorded from an artery catheter. They
use different proprietary algorithms that analyze the
characteristics of the ABP waveform along with
patient-specific anthropometric and demographic
data. These devices can be used either with a radial
or a femoral artery catheter. The main advantage of
these systems is their simplicity to provide continu-
ous and real-time CO measurements without any
calibration. They can be used to assess the short-term
CO response to diagnostic tests such as passive leg
raising (PLR) [4] or to therapies such as fluid infusion.
However, their reliability has been seriously ques-
tioned in cases of acute changes in vascular tone,
in particular, during septic shock with use of vaso-
&
pressors [5,6 ], during cardiac surgery [7], and during
liver transplantation [8]. Moreover, these systems do
not provide other hemodynamic variables, such as
cardiac filling pressures or volumes, cardiac systolic
function indices, and extravascular lung water. This
represents an important disadvantage compared
with advanced monitoring systems such as the pul-
monary artery catheter (PAC) or the transpulmonary
thermodilution systems. Nevertheless, uncalibrated
CO monitors can calculate and display in real time
396 www.co-criticalcare.com
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
the value of PPV and/or stroke volume variation
(SVV). Thus, these uncalibrated devices could be
suitable for predicting fluid responsiveness (PPV,
SVV, CO, response to PLR) and for evaluating the
response to fluid administration, in particular, in
patients without septic shock or not receiving
vasopressors.
The MostCare monitor (Vygon Health, Padua,
Italy) uses the pressure-recording analytical method
(PRAM) to provide real-time CO monitoring from
the analysis of the ABP waveform without external
calibration. Its proprietary algorithm does not use
the area under the systolic part of the ABP curve,
but uses the physics theory of perturbation [9].
This device can be used either with a radial or a
femoral artery catheter. Although a good agreement
between PRAM CO and thermodilution CO was
found in patients without shock [10], contradictory
results were found in severe sepsis patients [11,12].
Noninvasive uncalibrated cardiac output
monitors
The ClearSight device
The ClearSight (ex-Nexfin) device (Edwards Life-
Sciences) provides a real-time CO measurement by
deriving the finger ABP waveform, which is recorded
noninvasively thanks to an inflatable cuff wrapped
around the middle phalange of a finger. This tech-
nique uses the volume-clamp principle, a transfer
correction, and a pulse contour method based on
the systolic pressure area and a physiological three-
element Windkessel model. It seems to be valuable
to track the CO changes [1316] in the perioperative
context, although poor results even for trending
ability were reported in cardiac surgery patients
receiving vasopressors [17,18]. The reliability of this
device is questionable in patients with shock and/or
receiving vasopressors [1921], even for tracking
changes in CO induced by fluid infusion [19,20].
One potential advantage of this device is to provide
PPV and SVV noninvasively. However, one study in
cardiac surgery patients showed that PPV and SVV
obtained from this device could not predict fluid
responsiveness very well [17].
Applanation tonometry cardiac output
device
The radial applanation tonometry has been recently
proposed to monitor CO in real time and non-
invasively. The T-line system (Tensys, San Diego,
California, USA) uses the ABP waveform continu-
ously recorded by a sensor located in a bracelet
placed around the patients wrist to derive CO using
a proprietary autocalibrating algorithm. A clinical
Volume 21
Number 5
October 2015
 From cardiac output monitoring to echocardiography Jozwiak et al.
study performed in patients after cardiac surgery
(40% receiving norepinephrine) showed promising
results in terms of trending ability compared to
pulmonary artery thermodilution [22]. Additional
confirmation studies are required.
Esophageal Doppler
The esophageal Doppler continuously calculates the
blood flow in the ascending aorta from the aortic
blood velocity (Doppler probe), the aortic diameter,
and the heart rate. The aortic diameter is either
measured (M-mode echo) or estimated from
morphologic data. Finally, from the descending
aorta blood flow, the esophageal Doppler devices
estimate CO, based on the hypothesis that the blood
flow in the descending thoracic aorta represents
70% of the systemic blood flow. This technique is
more suitable for the operating room than for the
ICU because the probe can move easily into the
esophagus when the patient is moving [23]. The
esophageal Doppler can assess changes in cardiac
preload using the flow time corrected for heart rate
and changes in contractility using the mean accel-
eration and the peak of velocity of the systolic aortic
blood flow [24]. Aortic blood flow variations can
serve as predictors of fluid responsiveness in
mechanically ventilated patients [25].
Bioreactance
Bioreactance (Nicom, Cheetah Medical, Boston,
Massachusetts, USA) monitors CO in real time and
is totally noninvasive. It is based on the frequency
and phase modulation of the output voltage in
response to a high-frequency electrical current
delivered by skin surface electrodes placed on the
patients chest and neck. The output current is
recorded by other electrodes on the skin surface,
with a time delay called a phase shift, which
depends on the stroke volume. The main limits of
this technique are overweight patients, increased
intrathoracic volume (pulmonary edema, pleural
effusion), and cardiac arrhythmias. Validation
studies in critically ill patients showed a poor agree-
ment between CO values provided by bioreactance
&
and by thermodilution [26,27 ].
Lithium dilution monitor
The lithium dilution provides intermittent CO
measurements after injection of a small amount
of lithium in a central venous vein and detection
of changes in lithium concentration in a radial
artery using a catheter equipped with a lithium-
selective sensor (LiDCOplus monitor, LiDCO Ltd.,
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Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
London, UK). This technique has been validated
against pulmonary artery thermodilution [28]. It
is also used to calibrate a pulse power algorithm
of the arterial waveform that provides a continuous
estimate of CO. The agreement between the lithium
dilution CO and the pulse power CO remains accept-
able for up to 4 h after calibration in ICU patients
[29].
Transpulmonary thermodilution
At present, two transpulmonary thermodilution sys-
tems are available: the PiCCO/PulsioFlex system
(Pulsion Maquet) and the VolumeView/EV1000 sys-
tem (Edwards LifeSciences). The transpulmonary
thermodilution technique consists of injecting a
bolus of cold saline in a vein of the superior vena
cava territory and to measure the resulting changes
in temperature in a femoral artery with thermistor-
tipped arterial catheter. The mathematical analysis
of the thermodilution curve allows CO calculation.
The measurement of CO by transpulmonary ther-
modilution has been demonstrated to be not only
accurate but also precise [30]. The reliability is not
altered in patients with renal replacement therapy,
even at high blood flows [31]. The analysis of the
thermodilution curve also provides other hemody-
namic variables. The global end-diastolic volume
(GEDV) is a marker of cardiac preload. The cardiac
function index (CFI) and the global ejection fraction
(GEF) are markers of cardiac systolic function. The
extravascular lung water (EVLW) is a quantitative
measure of pulmonary edema and the pulmonary
vascular permeability index (PVPI) is a marker of the
permeability of the alveolo-capillary barrier. The
EVLW and PVPI are markers of severity in acute
respiratory distress syndrome [32]. Transpulmonary
thermodilution also serves to calibrate the femoral
artery pulse contour analysis, which provides real-
time CO, SVV, and/or PPV. Because of a potential
drift with time, frequent recalibration is mandatory
&&
[1 ], in particular, in patients with septic shock,
who are receiving vasopressors [33]. Use of these
devices is contraindicated in patients with femoral
artery occlusive disease and is inefficient in patients
with extracorporeal membrane.
Pulmonary artery catheter
The PAC provides intermittent measurements of CO
after injection of a cold bolus of saline in the right
atrium through the proximal port of the catheter.
This method is considered as the gold standard to
&&
measure CO [1 ]. A modified PAC equipped with a
proximal thermal filament provides semicontinu-
ous CO measurements, which, however, cannot
www.co-criticalcare.com 397
Cardiovascular system
Table 1. Compared analysis of strengths and drawbacks of hemodynamic monitoring devices
Invasiveness
Pulmonary artery catheter
Transpulmonary thermodilution systems
Lithium dilution monitor
Uncalibrated arterial pulse contour analysis
Noninvasive arterial pulse contour analysis 0
Esophageal Doppler
Bioreactance 0
CO, cardiac output.
track in real time abrupt changes of CO. The PAC
provides some other important variables such as
pulmonary artery pressure (PAP), pulmonary artery
occlusion pressure (PAOP), mixed venous carbon
dioxide pressure (PvCO2), and mixed venous
oxygen saturation (SvO2) a variable which can
also be monitored in real time when a fiberoptic
probe is included in the catheter.
Table 1 lists the main strengths and drawbacks
of the main hemodynamic monitoring systems.
ECHOCARDIOGRAPHY
Echocardiography is not a hemodynamic monitor-
ing technique, as it cannot provide continuous
hemodynamic measurement. Nevertheless, a recent
study has shown that a new single-use miniaturized
transesophageal echocardiography probe could be
left in place for up to 72 h in critically ill patients
with a good tolerance and could be useful for hemo-
dynamic management of mechanically ventilated
patients with shock [34]. At present, echocardiog-
raphy is still considered today as the first step of the
cardiovascular exploration in patients with shock,
in particular, to initially evaluate the type of shock
and to sequentially evaluate the cardiac function
&&
[1 ]. Its two main advantages are noninvasiveness
and ability to assess cardiac function far better than
any other method. The left ventricular ejection
fraction (LVEF) is one of the most important vari-
ables provided by echocardiography. Since it
depends on both left ventricular contractility and
afterload, LVEF must be interpreted in function of
the systolic ABP. This is particularly important
during shock when left ventricular afterload can
change markedly over a short period [1 ]. The
&&
stroke volume can be estimated by echocardiogra-
phy from the product of the velocitytime integral
(VTI) of the subaortic flow and the area of the left
ventricular outflow tract. The VTI represents the
distance travelled by red blood cells during one
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Reliability in Ease Ability to monitor Ability to measure
ICU patients of use CO in real-time other variables than CO
/
systole and is measured by drawing the outline of
the subaortic flow in pulsed Doppler. The area of the
left ventricular outflow tract is calculated from its
diameter. It is noteworthy that even a small error in
the subaortic diameter measurement may result in a
marked error in the CO value. Nevertheless, because
the aortic annulus is fibrous, the area of the left
ventricular outflow tract does not change over a
short time. Thus, the relative changes in CO can
be estimated by the relative changes in VTI, whose
measure is easier and less subject to errors.
Echocardiography can also assess the left heart
diastolic function. Combination of tissue Doppler
imaging of the mitral annulus and pulsed Doppler of
transmitral flow allows a semiquantitative esti-
mation of left ventricular filling pressures [35].
Echocardiography can also predict fluid responsive-
ness using analysis of the respiratory variations of
the subaortic maximal velocity [36] or of the inferior
vena cava diameter [37], and using the response of
the subaortic VTI to PLR [38]. Finally, echocardiog-
raphy is useful to evaluate the right ventricular
function. In particular, it is the gold standard to
detect acute cor pulmonale [39].
Echocardiography has the disadvantage to be
operator-dependent and to require a period of train-
ing for the operator before being skilled enough, in
particular, to deal with complex cardiac diseases or
when the transesophageal approach is used. How-
ever, acquiring basic critical care transthoracic echo-
cardiography skills requires only a limited period of
training [40].
How to choose a hemodynamic monitoring
device in patients with shock?
Hypovolemia, depressed vascular tone, and cardiac
dysfunction are the main cardiovascular disorders
potentially involved during shock. These disorders
can be either isolated or combined in different
ways. Evaluation of cardiac function and preload
Volume 21
Number 5
October 2015

Central venous catheter
Shock without ARDS
Responders
to initial therapy
Same hemodynaming monitoring
until shock resolution
FIGURE 1. Algorithm to decide how to choose hemodynamic monitoring systems in patients with shock. ARDS, acute
respiratory distress syndrome; RV, right ventricular.
responsiveness is thus essential to identify the main
mechanism of shock, to select the adequate therapy,
and to assess its efficacy. The choice of the appro-
priate hemodynamic monitoring may differ
depending on the phase of shock, the complexity
of shock, and the response to the initial therapy
(Fig. 1).
During the initial phase of shock
In patients with shock, it is most often necessary to
insert a central venous catheter for drugs and fluid
infusion. This also enables us to measure central
venous pressure (CVP), central venous oxygen satur-
ation (ScvO2), and central venous carbon dioxide
pressure (PcvCO2). The CVP is a poor predictor of
fluid responsiveness and can hardly serve to guide
fluid therapy [3]. However, CVP reflects the down-
stream perfusion pressure of most organs, and
measuring it can help in choosing the optimal mean
ABP to target. The ScvO2 is essential to measure in
shock states since a low value (<70%) can identify
the patients for whom elevation of oxygen delivery
to the tissues, in general, through an increase in CO,
should be prioritized [41]. In cases when ScvO2 is
normal or high owing to impairment of oxygen
extraction capacities (e.g. during septic shock),
the difference between PcvCO2 and arterial carbon
dioxide pressure can help in identifying patients in
whom elevation of CO can still be beneficial [42].
Insertion of an arterial catheter is recommended
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Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
From cardiac output monitoring to echocardiography Jozwiak et al.
Patients with shock
Echocardiography Arterial catheter
Shock with ARDS
Transpulmonary thermodilution systems
Nonresponders or
to initial therapy Pulmonary artery catheter
(especially in case of RV dysfunction)
when the patient is not responsive to the initial
&&
therapy and/or when receiving a vasopressor [1 ].
It provides accurate measurements of ABP and, in
particular, of diastolic ABP. As a reliable indicator of
the arterial tone, diastolic arterial pressure helps
clinicians to identify patients who are eligible for
vasopressor therapy. The arterial catheter also allows
calculation of PPV. In addition to clinical assess-
ment and to basic monitoring (central venous and
arterial catheters), echocardiography is proposed as
a first-line modality of hemodynamic evaluation in
&& &&
every patient with shock [1 ,43 ]. Echocardiogra-
phy helps to quickly identify the type of shock and
&& &&
to select an adapted therapeutic strategy [1 ,43 ].
In patients responding to the initial
therapy
Current guidelines do not recommend advanced
hemodynamic monitoring in patients with shock,
who quickly respond to the selected initial therapy
&&
[1 ]. Echocardiography can be used for the sequen-
tial evaluation of cardiac function and preload
responsiveness.
In complex conditions and/or in patients
not responding to the initial therapy
In these cases, it may be difficult to determine with
certainty the degree of each cardiovascular disorder
and to choose an adequate therapy (fluids, vasopres-
sors, and inotropes) without further hemodynamic
www.co-criticalcare.com 399
Cardiovascular system
assessment. Use of transpulmonary thermodilution
monitors or PAC is recommended in such situations,
in particular, in cases of associated acute respiratory
&&
distress syndrome [1 ]. The two advantages of trans-
pulmonary thermodilution systems in these complex
cases are: to allow a valuable assessment of preload
responsiveness (PPV, SVV, pulse contour CO response
to PLR) and to provide values of EVLW and PVPI,
which can serve as safety parameters for fluid admin-
istration [42]. Thus, the benefitrisk ratio of fluid
therapy can be well assessed by these monitoring
systems. In cases of increased EVLW and preload
responsiveness, a therapeutic conflict may exist
and the therapeutic strategy should prioritize the
predominant organ failure. For example, when
hemodynamic and renal failures are predominant,
fluid administration should be prioritized even when
EVLW is increased. On the contrary, when respiratory
failure predominates, vasoactive drugs infusion
should be prioritized, even in case of preload respon-
siveness. The advantage of using PAC is to measure
PAP and PAOP. This latter parameter as a measure of
pulmonary venous pressure should ideally reflect
both the upstream hydrostatic pulmonary capillary
pressure and the downstream left atrial pressure.
However, PAOP is not correlated to the amount of
pulmonary edema [44], especially in cases of
increased capillary permeability, and as a static
marker of preload cannot assess preload responsive-
ness reliably [3,42].
In patients who are not responding to initial
therapy, it is recommended to measure CO to evalu-
&&
ate the response to fluids or inotropes [1 ]. In
patients with refractory shock associated with right
ventricular dysfunction diagnosed with echocar-
diography, a PAC catheter can be inserted in order
&&
to measure PAP in addition to CO [1 ].
It must be underlined that minimal or nonin-
vasive CO monitoring systems such as uncalibrated
pulse contour analysis devices are not recom-
mended in patients with shock, especially those
&&
receiving vasopressors [1 ]. However, some of these
devices might be used to assess the short-term effects
&
of fluid challenge [6 ]. The place of esophageal
Doppler and bioreactance is limited in ICU patients.
The particular case of high-risk surgical
patients
Compared to patients with shock, high-risk surgical
patients most often are far less sick, have less lung
injury, and have less abrupt changes in vascular tone
at the time of surgery. Therefore, advanced hemo-
dynamic monitoring systems are not mandatory in
most of them, and monitoring CO and PPV (or SVV)
should be sufficient. Furthermore, in most cases,
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Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
rather than to obtain an accurate measurement of
CO, it is more important to adequately track any
change in CO in the operating room. Thus, less
invasive hemodynamic monitoring techniques
such as esophageal Doppler, bioreactance, or non-
invasive uncalibrated CO monitors should find their
place in the operating room in high-risk patients. In
cases of high-risk surgery, invasive uncalibrated arte-
rial pulse contour analysis monitors could also be
indicated. Whatever the CO monitoring system, it
could be successfully integrated in a goal-directed
therapy approach during and after surgery to reduce
the mortality rate and the number of complications
&& &&
[1 ,45,46,47 ].
CONCLUSION
Over the past years, hemodynamic monitoring tech-
niques have continuously evolved toward less inva-
siveness and real-time measurements of variables.
Noninvasive hemodynamic monitoring should be
reserved for high-risk surgical patients during and
after surgery. Echocardiography is currently the
first-line evaluation modality in patients with
shock. Advanced hemodynamic monitoring sys-
tems such as transpulmonary thermodilution or
PAC are recommended in patients who do not
respond to the initial therapy and/or with associated
acute respiratory distress syndrome.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
X.M. and J.L.T. are members of Medical Advisory board
of Pulsion/Maquet. M.J. has no conflict of interests to
declare.
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