Perioperative Hemodynamic Monitoring

•The aim of hemodynamic management is to optimize the amount oxygen delivered tissues.•Because direct monitoring remains difficult, variables are monitored instead.•Hemodynamic itself does not improve patient outcomes and needs be combined with treatment protocols.•Pressures, from arterial blood pressure through pulmonary artery occlusion pressure, can measured using invasive catheters, but subject artifacts (e.g. over- underdamping, movements) should zeroed correctly before adequate measurements obtained.•Flow, that cardiac output, mostly obtained by indicator dilution techniques or pulse wave analysis. The evidence for other noninvasive techniques, example transit time, bioimpedance bioreactance, limited. word “hemodynamic” derived Greek words haima dunamikós. Hemodynamic monitoring, therefore, freely translates into observing motion blood. As itself, originates ancient times: Feeling was first described in 2600 BCE myth a Mesopotamian king whose friend had died, “touching” his heart, he realized it did beat any more,1Dalley S. Myths Mesopotamia: creation, flood, Gilgamesh others. Oxford University Press, (England, UK)1989Google Scholar demonstrating at time mankind understood heart beating its pulsations could felt. Two thousand years later, Hippocrates characteristics during different states disease, while Praxagoras (born around 340 BCE) one use indication disease.2Ghasemzadeh N. Zafari A.M. A brief journey history pulse.Cardiol Res Pract. 2011; 2011: 164832Crossref PubMed Scopus (42) Google actual circulation William Harvey seventeenth century, this considered greatest contributions field cardiovascular science.3Bolli R. Discovery Circulation Blood.Circ Res. 2019; 124: 1169-1171Crossref (2) Further development measuring took until 1733, when Stephen Hales pioneered intra-arterial horses4Esunge P.M. From hypertension: research.J R Soc Med. 1991; 84: 621PubMed discovery followed “Stromuhr” 1867 Carl Ludwig, device able quantify flow perfused organs.5Neil E. Ludwig His Pupils.Circ 1961; IX: 971-978Crossref there on forward, important discoveries more rapidly, including systolic cuff-based version mercury sphygmograph Riva Rocci 1896.6Roguin A. Scipione Riva-Rocci men behind sphygmomanometer.Int J Clin 2006; 60: 73-79Crossref (39) In 1905, Nicolai Korotkoff sounds auscultating brachial deflating cuff.7Wesseling K. century non-invasive measurement: form Marey Peñáz Finapres.Homeost Heal Dis. 1995; 36: 50-66Google This way, became possible also determine diastolic pressure. Around same 1901, Willem Einthoven invented electrocardiograph which later (1924) received Nobel Prize.8Einthoven W. Un nouveau galvanomètre.Arch Neerl Sc Ex Nat. 1901; 6: 625-633Google Scholar,9Burnett J. origins as clinical instrument.Med Hist. 1985; : 53-76Crossref (9) foundation modern laid. Arterial measured.7Wesseling Currently, available continuous intermittent perioperative period. catheterization gold standard continuously.10Saugel B. Sessler D.I. Perioperative Blood Pressure Management.Anesthesiology. 2021; 134: 250-261Crossref (7) catheter placed superficial (mostly radial artery) connected via fluid filled tube transducer pressurized bag fluids creates counterpressure pressure.11Saugel Kouz Meidert A.S. et al.How measure an catheter: systematic 5-step approach.Crit Care. 2020; 24: 172Crossref (20) transforms mechanical electrical signal, used depict waveform monitor. result interaction between left ventricle systemic arteries. sensor right atrium level against atmospheric obtain reliable measurements. Over- underdamping underestimate overestimate Additionally, influenced movement patient’s arm kink system.10Saugel Scholar,11Saugel limited owing risk complications costs associated catheterization.12Handlogten K.S. Wilson G.A. Clifford L. al.Brachial catheterization: assessment patterns complications.Anesth Analg. 2014; 118: 288-295Crossref (18) Scholar,13Scheer B.V. Perel Pfeiffer U.J. Clinical review: factors peripheral catheters haemodynamic anaesthesia intensive care medicine.Crit 2002; 198-204Crossref Frequently alternative oscillometry volume clamp method.14Roach J.K. Thiele R.H. monitoring.Best Pract Anaesthesiol. 33: 127-138Crossref most widely method noninvasively oscillometry. Usually, cuff inflated instead sounds, oscillations signal detected.15Forouzanfar M. Dajani H. Groza V. al.Oscillometric estimation: past, present, future.IEEE Rev Biomed Eng. 2015; 8: 44-63Crossref (96) causes maximum closest mean (MAP), pressures mathematically value.16Yelderman Ream Indirect measurement anesthetized patient.Anesthesiology. 1979; 50: 253-256Crossref (126) uses plethysmograph inflatable finger cuff. detects digital arteries subsequently adjusted high frequency keep constant (volume clamp). Subsequently, constructed needed ensure volume.17Kouz Scheeren T.W.L. de Backer D. al.Pulse Wave Analysis Estimate Cardiac Output.Anesthesiology. 119-126Crossref (12) Scholar, 18Saugel Hoppe P. Nicklas J.Y. al.Continuous analysis technologies output medicine: review meta-analysis.Br Anaesth. 125: 25-37Abstract Full Text PDF 19Saugel al.Cardiac estimation analysis-physiology, algorithms, technologies: narrative review.Br 126: 67-76Abstract (13) Calibration periodically performed applying MAP calibrate plethysmography signal.14Roach has been validated obese patients20Rogge D.E. Schön G. patients bariatric surgery: evaluation vascular unloading technique.Anesth 128: 477-483Crossref (22) atrial fibrillation21Berkelmans G.F.N. Kuipers Westerhof B.E. al.Comparing volume-clamp fibrillation admitted medium unit.J Monit Comput. 2018; 32: 439-446Crossref (17) Scholar; however, impaired perfusion, receiving doses vasopressors hypothermia edema.14Roach Scholar,21Berkelmans Other methods include applanation tonometry, hydraulic coupling, decomposition. accuracy these therefore (yet) daily routine.10Saugel central venous (CVP) vena cava near atrium, commonly placing superior internal jugular vein subclavian vein.22Shah Louis Physiology, pressure..in: StatPearls [Internet]. 2020https://www.ncbi.nlm.nih.gov/books/NBK519493/Google then line. CVP determined function return heart,23Magder How measurements.Curr Opin Crit 2005; 11: 264-270Crossref (74) Scholar,24Guyton Determination equating curves response curves.Physiol Rev. 1955; 35: 123-129Crossref (331) traditionally estimate preload status,23Magder Scholar,25Kumar Anel Bunnell al.Pulmonary fail predict ventricular filling volume, performance, infusion normal subjects.Crit Care 2004; 691-699Crossref (602) guide therapy.26Boldt Lenz Kumle al.Volume replacement strategies units: results postal survey.Intensive 1998; 147-151Crossref (117) It assumed that, because obtaining end-diastolic suitable many settings, would surrogate preload.25Kumar However questioned poor correlation status patient25Kumar Scholar,27Michard F. Alaya Zarka al.Global septic shock.Chest. 2003; 1900-1908Abstract (261) 28Hofer C.K. Furrer Matter-Ensner al.Volumetric thermodilution: comparison transoesophageal echocardiography.Br 94: 748-755Abstract (114) 29Marik P.E. Baram Vahid Does responsiveness? Systematic Review Literature Tale Seven Mares.Chest. 2008; 172-178Abstract (1043) no longer assess responsiveness.29Marik Scholar,30Marik Cavallazzi An updated meta-analysis plea some common sense.Crit 2013; 41: 1774-1781Crossref (470) Nonetheless, still frequently might stop resuscitation.31Pinsky Kellum Bellomo Central stopping rule, target resuscitation.Crit Resusc. 17: 56PubMed Although responsiveness, function, example, embolism, failure, after transplantation.29Marik Another advantage possibility taking gas samples saturation.32Van Beest Wietasch T. al.Clinical saturations goal - yet unfinished puzzle.Crit 15: 232Crossref Pulmonary (PAOP) assessed (PAC).33Vincent J.L. catheter.J 2012; 26: 341-345Crossref (23) Scholar,34Bootsma I. Boerma Lange al.The contemporary catheter. Part 1: placement analysis.J https://doi.org/10.1007/s10877-021-00662-8Crossref (5) PAC inserted vein, femoral tip positioned artery.34Bootsma tubing These insertion position tip. contains 2 ports; distal port located proximal CVP.34Bootsma balloon close tip, float PAOP.33Vincent PAOP reflects veins atrium.33Vincent Scholar,35O’Quin Marini pressure: physiology, measurement, interpretation.Br Psychother. 1983; 319-326Google analogy ventricle, predictor preload, turned out unreliable purpose well.25Kumar several (severe) complications,33Vincent benefits have clearly established critically ill patients.36Shah Hasselblad Stevenson al.Impact patients: randomized trials.JAMA. 294: 1664-1670Crossref (515) Scholar,37Rajaram Desai Kalra adult (Review).Cochrane Database Syst 2: CD003408Crossref (166) Therefore, questioned. always specific protocol outcomes.38Harvey Harrison D.A. Singer al.Assessment effectiveness (PAC-Man): randomised controlled trial.Lancet. 366: 472-477Abstract (754) worldwide, particularly surgery, hypertension (suspected known), severe cardiogenic shock, unknown cardiopulmonary disease.39Cohen M.G. Kelly R.V. Kong D.F. acute coronary syndromes: insights GUSTO IIb III trials.Am 482-488Abstract (62) 40Rapoport Teres Steingrub al.Patient ICU organizational influence catheterization.J Am Med Assoc. 2000; 283: 2559-2567Crossref (94) 41Koo K.K.Y. Sun J.C.J. Zhou Q. catheters: evolving rates reasons use.Crit 39: 1613-1618Crossref (70) suggested clinicians gain clear understanding pathophysiology.42Ospina-Tascón Cordioli R.L. Vincent What type shown acutely patients?.Intensive 34: 800-820Crossref (78) Similar catheter, mixed saturation, marker global relation delivery consumption ability tissues extract (Pmsf) equilibrates stops pumping all distributed equally throughout circulation.43Rothe C.F. Mean circulatory meaning measurement.J Appl Physiol. 1993; 74: 499-509Crossref (167) value Pmsf (closer latter size reservoir). chambers (mean pressure). pressure.43Rothe resembles stressed is, exerts walls. unstressed turn blood, held within system without creating ways: (1) inspiratory hold method, stop-flow (3) calculated model.44Maas J.J. Pinsky M.R. Geerts B.F. al.Estimation postoperative surgery three methods.Intensive 38: 1452-1460Crossref (58) Scholar,45Wijnberge Sindhunata D.P. al.Estimating practice: comparing bedside ill.Ann Intensive 73Crossref holds seconds plateau briefly increase CVP. When increases, decreases consequently (CO) well. Multiple maneuvers levels derive pairs CO measurements, correlated extrapolated zero (which state) estimated (Fig. 1). For required.46Maas Van Den Berg P.C.M. curve patients.Crit 2009; 37: 912-918Crossref (85) However, overestimated airway may redistribute circulation.47Fessler H.E. Brower R.G. Wise R.A. al.Effects positive end-expiratory canine curve.Am Respir 143: 19-24Crossref (104) rapidly inflating cuff, occludes flow. intravascular will equilibrate compartment approximately 30 seconds. equilibration Pmsf. only required.44Maas last mathematical model comprises resistance flow, resulting following formula: = aRAP + bMAP cCO, RAP output48Parkin W.G. Leaning M.S. Therapeutic control circulation.J 22: 391-400Crossref (43) b both dimensionless constants (often 0.96, 0.04), reflecting contribution c age, height, weight, resembling resistance.48Parkin accurately status, although quite difficult thus use. minus driving force return.49Guyton Lindsey Abernathy al.Venous various 1957; 189: 609-615Crossref (308) overview found Table 1.Table 1Overview methodsArterial PressureCentral Venous PressurePulmonary Artery PressuresPmsfArterial catheterVolume methodIntermittent oscillometryCentral catheterPulmonary catheterInspiratory methodArm methodCalculated Open table new tab product stroke rate primary determinant organs tissues, being clinically relevant variables. Invasive determining thermodilution (PATD), transpulmonary (TPTD), lithium dilution.50Saugel monitoring: how choose optimal individual patient.Curr 165-172Crossref (31) All modified versions Stewart Hamilton equation CO.51Monnet X. Teboul Transpulmonary advantages limits.Crit 2017; 21: 147Crossref (91) based fact if temperature concentration injected known, change downstream related CO, follows: CO=TemperatureofindicatorAreaunderthetemperaturecurve PATD requires PAC, cold bolus changes thermistor. Because artery, actually measures output.50Saugel Scholar,51Monnet Newer generation PACs incorporate electric heating elements continuously differences and, thus, CO.52Reuter Huang C. Edrich indicator-dilution techniques: basics, limits, perspectives.Anesth 2010; 110: 799-811Crossref (183) TPTD proximity heart.51Monnet Using technique, difference circulation, CO. Unlike PATD, ventilatory cycle.52Reuter