HEMODYNAMIC MONITORING - SElECTING THE

RIGHT TOOL FOR THE RIGHT PATIENT

Azriel Perel' 315

Anesthesia, surgery and criticat illness are often associated with siqniflcant
hemodynamic changes which have the potential to cause organ dysfunction
and death. It is therefore that hemodynamic monitoring has become an
elementary and essential tool for the proper management of anesthetized
and crincallv tll patients. Such monitoring allows the early reccqninon of
hemodynamic derangements, and the choice and follow-up of treatment
modalities,

Dur ever-growing physiological understanding coupled with significant

technological innovations have resulted in the development of many bed-
sde monitors which are able to measure a multitude of phvsioloqrcal pa-
rameters. The use of such monitoring modalities is often associated with
mcreased rnvasiveness and cost. and necessitates specific theoretical and
practicat knowledge. In addrtion, the use of more, and even less, advanced
morutorinq technologies is not supported as a rule by strong evidence for
Improved outcome. This lack of evidence stands however In contradistinc-
tion to the expert clinician knowledge that no intelliqent decisions can be
madewithout the mformation supplied by hemodynamic monitoring. The
challenge therefore is to select the right monitor for the right patient,

Ihrs problem is well illustrated by the measurement of cardiac output

leo) which is the main determinant of oxygen delivery. It IS well known that
physicalexamination and vital signs alone often fail to reflect signlficanl
derangements In CO, and yet manv of our therapeutic efforts are aimed al
:DepartIIlCII/ oI Allestl,c.\iolo!1Y allli !lItrllsil'r COlt', . 'i/lt'bo AlediclI! CCllter, Tel AI'a
'.Ilil'rr>ity. Tel Allill 5262/ ISRAEL III'rc1I1D@.I!IlII1II1I't

TilJlişoara 20 J /
 incre~sing the CO. The monitoring of CO is therefcre very useful for proper
de.clslon-making in critically ill and high-risk surgical patients. The fact that
this statement is not supporied by evidence-based medicine (EBM) tehs us
more about the shortcominqs of EBM than those of the measurement of CO
Measuring CO should be compared to the technological developments and
imp:ovements that have made driving and flying much safer. For example,
the intrcduction of the speedometer into cars did not entail any randomized
control trials. It is therefore natural to assume that in the future CO will be
measured as a standard just like any other vital sign.

In the meantime, in our low-risk patients at least, we continue to assess

316
CO indirectly by vital signs and, not of ten enough, by capnography. Howe-
ver, in the medium- and high-risk patients we have a growing possibility of
using new devices that offer serni- or non-invasive continuous real-time CO
measurement. The accuracy of these devices may not always be as perfect as
we would like it to be, however, the continuity of the CO measurement that
they provide should not be underestimated. Intermittent thermodilution CO
measurement may indeed be more accurate but has a well known limited
reproducibility. This limitation makes it inferior to continuously measured
real-tirne ca in assessing the response to therapeutic or diagnostic events
with short time constants (e.g., fluid loading, passive leg raising and respon-
se to inotropes). Such techniques are especially suitable for perioperative
optimization. In the more complex patients, the measurement of CO alone
may not suffice, and should be complemented by the monitoring of preload,
fluid responsiveness and extra-vascular lung water.