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78
B.M. Howard and D.B. Christie III
III. Sounds again become crisper and louder.
IV. Sounds are muffl ed, less distinct, and softer.
V. Sounds disappear completely (diastolic pressure).
The systolic blood pressure corresponds to the pressure at
which the sounds fi rst appear at phase I. The diastolic blood
pressure corresponds to the pressure at which the sounds disappear at phase V [
limit the intensity of audible sound and can lead to falsely
depressed systolic blood pressure recordings.
7 , 8 ]. Low-fl ow states or hypotension can
Considerations: Oscillometric/Automated Method
Oscillometric measurements have been reported to be consistently inaccurate when compared to invasive or direct
blood pressure recording modalities. The disparity may be in
part to mal-fi tting cuffs or individual manufacturer device
variation [ 9 , 10 ]. Calcifi c arterial structures also impede the
device’s capture of arterial oscillation amplitude resulting in
falsely depressed blood pressure values. Automated oscillometric devices are quite accurate when capturing blood
pressure values in normotensive patients but seem to overestimate values in hypotensive states (i.e., systolic blood pressure less than 80 mmHg) and are consistently lower than
direct blood pressure measurements achieved by arterial
catheterization [ 9 , 10 ].
Gastric pH Monitoring
Tonometry is the measurement of the partial pressure of a
gas in a fl uid or intravascular medium. Gastric tonometry
measures luminal CO2 and mucosal CO2 partial pressures
(pCO2) as they become equalized across a semipermeable
membrane [ 8 ]. The general tenet of gastric pH monitoring
projects that a decreased mucosal pH implies either an
increase in anaerobic metabolic efforts or a low systemic
fl ow state leading to tissue hypoperfusion and, subsequently,
an ischemic insult.
Two general methods have been described to perform
gastric pH monitoring, conventional gastric tonometry and
air-semicontinuous gastric tonometry. Conventional gastric
tonometry is the more commonly described technique and
involves a transorally inserted catheter or tube with a salinefi lled balloon often composed of silicon or latex polymers, as
these agents are permeable to CO2. The saline PCO2 and the
gastric mucosal PCO2 come to equilibrium. The PCO2
within the saline-fi lled balloon is now considered physiologically representative of the gastric mucosal CO2 and is measured using a blood gas analyzer. Utilizing the
Henderson-Hasselbalch equation, and assuming that the par-
tial pressure of the stomach mucosa and atrial bicarbonate
are equal, the intramucosal pH (pHi) can be calculated and
perfusion trends established [ 11 ].
The air-semicontinuous gastric tonometry uses an airfi lled CO2 permeable balloon and rapidly equilibrates with
luminal and mucosal PCO2. This is directly measured in a
semicontinuous manner, by an infrared sensor.
Considerations
The luminal and mucosal PCO2 generally equilibrate in
approximately 30 min, although equilibration times up to
90 min have been reported [ 12 ]. A pHi of <7.32 represents
mucosal acidosis and can be trended over time. Studies have
found that H2 blockers have not been shown to infl uence luminal PCO2, luminal pH, and pHi in the shock state [ 13 , 14 ].
Two major assumptions enter into the calculation of pHi
8 , 11 ]. It is assumed that the PCO2 measured through gas-
[
tric tonometric techniques approximates that of intramucosal
PCO2. Secondly, it is assumed that intramucosal and arterial
HCO3 measurements are the same. Animal studies exist that
support the notion that no differences exist between luminal
and mucosal CO2 measurements; however, arterial HCO3
measurements are likely an overestimation of the mucosal
HCO3 in the ischemic or shock state [
Clinical investigators have shown that guiding resuscitations with gastric tonometry compared to traditional resuscitation techniques do not yield improved outcomes in either
overall survival rates or development rates of multi-organ
system failure [ 15 , 16 ]. At one point, gastric tonometry
seemed poised to evolve into a monitoring technique for the
prevention of mesenteric ischemia insults during prolonged
vasopressor use in the setting of refractory shock [ 8 ]; how-
ever, consistent clinical application of the technique is
lacking.
11 ].
Sublingual Capnography
Similar to gastric PCO2 monitoring, sublingual PCO2
(PslCO2) is measured against the arterial PCO2 in order to
defi ne a PslCO2 gap. Interestingly, investigators have demonstrated that the PslCO2 correlates closely with those
obtained in the stomach during low-fl ow states [ 17 – 19 ].
Sublingual capnography does not directly refl ect the perfusion quality to the splanchnic vasculature, however; the sublingual mucosal vascular bed shares similar characteristics
with the splanchnic circulation, including a rich vascular
supply and parasympathetic neural input.
A variety of commercially available devices have been
manufactured and proved reliable in clinical application.
One of the more widely used devices employs a specifi c CO2
sensing optode consisting of a CO2-permeable silicone bag
with a buffering solution and a fl uorescent dye solvent. The
8 Hemodynamic Monitoring in Surgical Critical Care
79
silicone bag is attached to a light source that captures the
changes in wavelengths of the fl uorescent solvent as it is
acted upon by the pH of the buffering solution. This is converted to the measurement of PslCO2. A key to accurate
measurement capture is that the patient’s mouth must be
closed around the monitor [ 8 , 20 ].
Considerations
Initial research of sublingual capnography was predominately with animal models, but consistent correlations
between rising PslCO2 and systemic markers such as arterial
lactate were identifi ed [ 17 ]. Comparative animal studies
where gastric tonometry and sublingual capnography were
performed noted parallel increases in both measured gastric
PCO2 and PslCO2 gap [ 18 ]. Later identifi ed was that PslCO2
values greater than 70 mmHg were predictive of hospital survival and that PslCO2 corrected more rapidly than lactate. A
small study found that PslCO2 gap was a better predictor of
survival than lactic acid. A recent study has also found correlation between hemorrhage in penetrating trauma and rise
in PslCO3, coinciding with increases in pre-resuscitation
base defi cit and lactate levels [ 21 – 23 ].
infl uenced by volume status but by fl uctuations of venous
tone, presence of tricuspid regurgitation, congestive heart failure, right-sided diastolic dysfunction, pulmonary embolism,
pulmonary hypertension, acute respiratory distress syndrome,
chronic obstructive pulmonary disease, and mechanical ventilation with positive end-expiratory pressure.
A zero reference point exists for central venous pressures
in the thorax located at a point on the external thorax where
the fourth intercostal space intersects the midaxillary line,
the phlebostatic axis. This anatomical landmark corresponds
to the position of the right and left atrium when the patient is
in the supine position; therefore, in the lateral position, it is
not a valid reference point and will provide an inaccurate
CVP reading [
More contemporary research has challenged the utility of
CVP as reliable hemodynamic monitoring method fi nding
no association between CVP and circulating blood volume
and identifying that CVP does not predict fl uid responsiveness across a wide spectrum of clinical conditions [ 25 ].
Because of these infl uences, CVP must be interpreted with
concern for variations in measurement with general recommendations encouraging the capture of trends in measurement rather than the absolute value.
1 , 24 ].
Central Venous Pressure Monitoring
Central venous pressure (CVP), as a measure of pressure in
the superior vena cava, allows for the extrapolation of rightsided ventricular fi lling pressure and has been used to estimate intravascular volume and determine fl uid requirements
in critically ill or injured patients for decades. CVP became
rather ubiquitous as a hemodynamic monitoring modality
due to its ease of insertion and seemingly straightforward
measurement parameters.
While CVP provides the ability to estimate right-sided
cardiac fi lling pressures, it is not a direct assessment of cardiac performance or output, nor a refl ection of end-organ
perfusion adequacy. CVP can be measured from three sites
of central venous access: the internal jugular vein, subclavian vein, and the femoral vein. However, the femoral vein is
deemed less optimal as proper catheter positioning calls for
the catheter tip to be situated at the atriocaval junction, a
position unachievable with most commercially available
catheters through femoral vein access. Furthermore, it should
be noted that increases in intra-abdominal pressure or pressure of the accessed extremity from injury, edema, or infl ammation can erroneously elevate values.
Considerations
Normal CVP in a critical care patient is estimated to range
from 0 to 9 mmHg with a standard waveform being composed
of three waves (a, c, and v) and two descents (x and y) (Fig.
8 ]. As a measure of intravascular volume, CVP is not only
[
8.1 )
Pulmonary Catheter Monitoring
Pulmonary artery catheters (PACs) have historically been the
defi nitive clinical tool for assessing hemodynamic performance and responsiveness to therapeutic interventions. PACs
were introduced into clinical practice in the 1970s predominately as a monitoring method for patients with acute cardiac
insults and transitioned to use as a monitoring instrument for
complex resuscitation scenarios, shock states, severe cardiovascular dysfunction, respiratory failure, and intraoperative
fl uid management.
The PAC allows for the capture of hemodynamic data that
assists in defi ning the cardiovascular status of a systemic insult
through the generation of physiologic profi le.
The measurement for Q, or cardiac output, and the calculation of systemic vascular resistance (SVR) was touted to
enable one to distinguish hypotensive states such hypovolemic shock, cardiogenic shock, or a form of distributive shock
(i.e., sepsis). Assessment of pulmonary artery occlusion
pressure (PAOP) potentially provides for the differentiation
between cardiogenic and noncardiogenic pulmonary edema
processes. PAOP may also be used as a guide for fl uid resuscitation efforts, estimating left ventricular preload, while
trending Q theoretically predicts the need for, or appropriate
delivery of, inotropic support. In clinical scenarios of systemic infl ammatory response syndrome or sepsis with endorgan dysfunction, calculations of mixed venous oxygen
saturation and oxygen delivery variables may assist in
80
A-line
ECG
B.M. Howard and D.B. Christie III
P
CVP
Atrial
contraction
Systole
aa
c
V
x
Isovolemic
ventricular
contraction
Ventricular
contraction
y
Passive
Diastole
atrial
filling
Passive
ventricular
filling
Fig. 8.1 A-line, ECG, and CVP tracings with cardiac function
identifying the presence of tissue ischemia and further direct
resuscitation strategies [ 8 ].
Access sites for PAC insertion are similar to those of central venous catheters, but proper positioning of the PAC into
the pulmonary artery can be challenging and is infl uenced by
many factors. Volume-depleted states, aberrant vascular
anatomy, and the diffi culties traversing normal vascular and
cardiac contours can create diffi culty achieving appropriate
catheter placement, which is key to obtaining accurate physiologic readings. The most direct access site is the right internal jugular vein, where the PAC only requires one gentle
curve through the right ventricle to reach the right pulmonary artery. Left and right subclavian vein access requires the
catheter to cross the innominate vein to reach the superior
vena cava. Access through the left internal jugular vein also
requires the catheter to cross the innominate vein and
8 Hemodynamic Monitoring in Surgical Critical Care
81
demands a greater travel distance. Femoral vein sites are
possible alternatives but are often very diffi cult to pass into
the right atrium making this access approach the least desirable and often requiring fl uoroscopic control for placement.
After gaining central venous access, a stepwise approach
is used to ensure proper catheter positioning. The catheter is
fl ushed, zeroed, and advanced with the balloon defl ated to a
distance of 12–15 cm. The PAC balloon is infl ated, the PAC
is advanced, and the pressure waveforms measured at the tip
of the PAC are analyzed. The initial waveform is that of a
CVP and as the catheter is advanced will convert to a right
atrial pressure waveform reading. Within the right ventricle,
a high spiking pressure waveform of 20–30 mmHg is
encountered, representing the systolic right ventricular pressure. Further advancement of the PAC into the pulmonary
artery generates a characteristic step-up in diastolic pressure
and a clear dicrotic notch within the waveform. When the
infl ated balloon reaches a pulmonary arteriolar occlusion
position, the waveform fl attens. At this point, the balloon
should be defl ated to confi rm the reappearance of the pulmonary artery waveform. With the PAC tip now in an appropriate position, an occlusion waveform will be obtained with
balloon infl ation of 1.5 mL of air [
8 ].
Considerations
If the occlusion waveform is obtained with less than 1.5 mL,
the catheter tip is likely too distal and located in an inappropriate branch. With the balloon defl ated to prevent pulmonary artery rupture, the catheter should be withdrawn several
centimeters, followed by reinfl ation of the balloon and readvancement back to the occlusion position. After registering an occlusion pressure, it is safest to pull the catheter back
a few centimeters (with the balloon down), each time
between readings to minimize the natural distal migration of
the catheter [ 8 ]. PAOP is most precisely measured when
there is minimal infl uence from external transmural pressures such as increased intrathoracic pressure. Therefore,
accuracy is best achieved when the lungs return to their most
relaxed volume state at end-expiration [ 8 ].
In review, the lungs are divided into three physiologic
zones, based upon the relationship between the pulmonary
vasculature and alveolar pressures. In lung zones (i.e., West
zones) 1 and 2, the magnitude of alveolar pressure affects the
pressure recordings of the PAC. The ideal intravascular pressure always exceeds the alveolar pressure, best achieved in
zone 3 of the lung. In non-zone 3 circumstances, alveolar
pressures may exceed intravascular pressure; therefore, the
degree of alveolar pressure and PEEP may affect the measurement of PAOP [ 8 ].
The clinical application of the hemodynamic data generated from the PAC placement requires careful consideration
of how the information relates to the given clinical circumstance. PAC hemodynamic profi les have been patterned to
suggest several broad clinical scenarios of hemodynamic
aberration. However, in current medical practice, controversy surrounds PAC use as the devices’ safety and reliability have come into question. The popularity of the PAC has
progressively declined over the past decade, as data has
accumulated indicating that PAC-directed care does not
improve outcome and may in fact worsen them [ 26 , 27 ]. PAC
has also been associated with an increased incidence of pulmonary emboli in randomized controlled trials [ 26 ]. The
profi cient and safe utilization of the PAC is directly dependent on the clinicians’ understanding of the measurements
provided, the methods through which the data was derived,
and how to deliver the proper therapeutic adjustments based
on the interpretable data. It is these variables of PAC use that
have come under scrutiny [ 28 , 29 ].
Tissue Oxygenation
The ultimate goal of hemodynamic monitoring is to ensure
adequate tissue perfusion and subsequent oxygen delivery to
end organs in order to optimize performance in the physiologic stressed state; however, there are no monitoring modalities that can directly measure tissue oxygenation. When
cellular metabolic demands for oxygen outpace its supply or
delivery, a condition termed dysoxia results with its clinical
manifestation being that of systemic shock [ 30 ]. Dysoxic
states result from cardiogenic and hypovolemic shock states
as the oxygen supply is insuffi cient or in contrast, with septic
shock where mitochondrial oxygen utilization appears
impaired.
Tissue Oxygenation: VO2
The rate of oxygen uptake from the systemic capillaries
(VO2) is an indirect measure of oxygen availability in the
tissues [ 1 ]. As oxygen is not stored in tissues, the VO2 can
also be interpreted as a measure of tissue O2 consumption.
Monitoring of VO2 has been suggested as a means to assist
in determining the tissue dysoxia that results from hypoperfusion with inadequate oxygen supply to the tissue level.
VO2 = Q × (CaO2 − CvO2).
Considerations
VO2 can be calculated or measured. The calculated VO2 is
captured from a physiologic profi le from an indwelling pulmonary artery catheter. The directly measured VO2 requires
specifi c equipment and staff trained with the modality use and
is not pervasively available in most critical care units, making
this method less practical. An abnormally low VO2 (less than
2
100 ml/min/m
dysoxia due to impaired tissue oxygenation [
) can be the result of hypometabolism or tissue
1 ].
Calculated VO2 cannot be interpreted as a measure of
whole-body VO2 as it does not include the VO2 of the
82
B.M. Howard and D.B. Christie III
lungs. During pulmonary infl ammatory conditions such as
acute respiratory distress syndrome or pneumonia, the VO2
of the lungs has been estimated 20 % of the whole-body
VO2, allowing for signifi cant underestimation of wholebody VO2 [
The derivation of VO2 utilizes four different variables
(cardiac output, concentration of hemoglobin in blood, and
the percent oxyhemoglobin saturation in arterial and mixed
venous blood) and each has its own inherent variability [ 1 ].
The variability of the calculated VO2 is 18 % that is equivalent to the summed variability of its components [ 1 , 32 – 34 ].
The calculated VO2 must change by at least 18 or 20 % for
the change to be considered signifi cant [ 1 ]. Correction of
VO2 defi cits will therefore require discerning clinical data
relative to anemic states, inadequate cardiac output, physiologic hypoxemia, and augmenting these components
appropriately.
VO2 may not appropriately refl ect aerobic metabolism in
the septic clinical scenario as tissue oxygenation is not
impaired in the septic state [ 1 ]. The accelerated activity of
neutrophils and macrophages is accompanied by a marked
increase in cellular oxygen consumption coined the respiratory burst. The exaggerated oxygen consumption in this process is used to generate toxic oxygen intermediates
(superoxide radical and hydrogen peroxide) that are elaborated as part of the infl ammatory process contributing to the
septic state [ 35 ]. Therefore, VO2 will be artifi cially elevated,
through the contribution of the respiratory burst, and inaccurately refl ect metabolic VO2 or the rate of aerobic
metabolism.
1 , 31 ].
Tissue Oxygenation: Mixed Venous O2 Saturation (SvO2)
Mixed venous oxygen saturation of hemoglobin (SvO2) can
be utilized to assess the balance of satisfactory systemic oxygen delivery and effective oxygen uptake. Derived through
the established relationship between the rate of tissue oxygen uptake (VO2) and variations in systemic oxygen delivery
(DO2), extrapolating SvO2 can imply the effi ciency of systemic oxygen delivery [ 1 ]. VO2 = DO2 × (SaO2 − SvO2). The
SaO2 and SvO2 are the oxygen saturation of hemoglobin in
arterial and mixed venous blood, respectively. The difference
in the two variables equates to the degree of oxygen extraction from hemoglobin in capillary blood.
Considerations
Normal values for SaO2 and SvO2 are 95 % and 70 %,
respectively, implying a satisfactory O2 extraction of 25 %
or, alternatively, that 25 % of the hemoglobin molecules have
desaturated as they traverse the capillaries and microvasculature of end-organ targets. A decrease in SvO2 below 70 %
indicates that systemic O2 delivery is impaired (or utilization
is increased) while a SvO2 below 50 % indicates a global
state of tissue hypoperfusion or impending dysoxia. The possible sources of impaired O2 delivery are identifi ed by determinants of DO2 DO Q Hgb SaO2134 2=´ ´ ´
in DO2 can be the result of a low cardiac output (Q), anemia
(Hgb), or hypoxemia (SaO2) [ 1 ]. Increased O2 utilization is
related to hypermetabolism.
The measurement of SvO2 historically required a pulmonary artery catheter as blood from the pulmonary artery is
considered to be admixed with venous blood from all tissue
beds. A PAC equipped with an infrared sensor at the distal
catheter tip was later developed that provided the enhanced
feature of performing continuous measurements of the
SvO2 in the pulmonary artery blood. Continuous monitoring
of SvO2 with this more specialized pulmonary artery catheter has revealed a spontaneous variation that averages 5 %
but can be as high as 20 % [ 1 , 36 ]. In general, a greater than
5 % change in SvO2 that persists longer than 10 min is considered a signifi cant change [ 1 , 37 ].
Central venous catheters were subsequently developed
that allowed for SvO2 for continuous monitoring but have
fallen out of favor as the utility of SvO2 as a reliable resuscitation measure has come into question. More recently,
transcutaneous devices have been engineered to measure
radial artery and ipsilateral digital artery pressures and
extrapolate SvO2 through computerized computation methods providing a noninvasive option for capturing this hemodynamic data.
()
.
. A decrease
Tissue Oxygenation: Central Venous O2 Saturation (ScvO2)
Central venous O2 saturation (ScvO2) has become an acceptable alternative to SvO2 for monitoring tissue oxygen delivery and utilization as the modality does not require a PAC
and can be drawn from central venous catheter. The two
methods are reported to correlate well with an estimated
variation up to 5 % if multiple measurements are aggregated
[ 38 ]. However, if comparing single measurements, ScvO2
can differ from SvO2 by as much as 10 % implying that
establishing a trend in measurements of ScvO2 is prudent
prior to delivery diagnostic and therapeutic decisions [ 1 ].
The ScvO2 became an acceptable substitute measure of
mixed venous O2 saturation because it precludes the
expense and technical challenges associated with the
PACs. Previously established guidelines for the management of patients with severe sepsis and septic shock have
included achieving an ScvO2 of greater than 70 % as a
therapeutic end point [ 39 ]. One should note that the foun-
dational basis of this value stemmed from the early goaldirected therapy trial whose conclusions have been directly
challenged by three multicenter and randomized trials
demonstrating no specifi c outcome advantage to protocolized as opposed to non- protocolized care for those with
severe sepsis or septic shock.
8 Hemodynamic Monitoring in Surgical Critical Care
83
Direct Perfusion Measurement
Invasive monitoring of arterial pressure was fi rst performed in
1733 with the cannulation of a horse’s left crural artery by
Reverend Stephen Hales [ 8 , 40 ]. In 1865, the fi rst human inva-
sive blood pressure measurement was taken by Dr. Faivre, a
French physician, who cannulated an amputee’s superfi cial
femoral artery [ 8 ]. The routine application of invasive arterial
blood pressure measurement did not become commonplace
until the mid-1960s, associated with the expansion of cardiothoracic and vascular surgery as well as the Angiocath cannulation technique, innovated by Barr in 1961 [ 41 ].
Intra-arterial cannulation with continuous blood pressure
transduction is considered the gold standard for arterial
blood pressure monitoring. While there are many indications
for invasive arterial monitoring, the most common is the
need for continuous blood pressure recordings in a patient at
risk for cardiovascular instability [ 8 , 42 ].
Considerations
Mean arterial pressure is the true driving pressure for peripheral blood fl ow and does not alter as the pressure waveform
migrates distally in a vascular structure, nor is it subject to
distortions generated by recording systems, thus making
mean arterial pressure superior to systolic pressure for arterial pressure monitoring [ 1 ]. In contemporary medical prac-
tices, mean arterial pressure is generally measured, although
estimated values can be achieved. Modern electronic monitoring devices can measure mean arterial pressure by integrating the area under the pressure waveform and dividing
this by the duration of the cardiac cycle (Fig. 8.1 ) [ 1 ].
Intuitively, the electronic measurement is more accurate,
reliable, and preferred to the estimated mean pressure.
Estimated mean arterial pressure is derived as the diastolic
pressure plus one-third of the pulse pressure; a formula is
based on the assumption that diastole represents two-thirds
of the cardiac cycle, which corresponds to a heart rate of 60
beats/min. Therefore, heart rates faster than 60 beats/min,
which are common in critically ill patients, lead to inaccuracies in the estimated mean arterial pressure [ 1 ].
Essentially any peripheral artery can be accessed as a cannulation site. Most commonly used sites include the radial,
femoral, dorsalis pedis, brachial, and axillary arteries. The
appropriate site selection for arterial cannulation is infl uenced by many factors. Typically the radial artery of the nondominant hand is utilized [ 8 ]. When this is unsuitable,
alternate sites are chosen based upon the following four cri-
1 ] the artery should be large enough to accurately
teria: [
refl ect systemic blood pressure [
free of cellulitis or nearby infected or devitalized tissue [ 3 ],
there should be suffi cient collateral fl ow to prevent distal
2 ], the chosen site should be
ischemia, and [
tomic aberrations [
4 ] the artery should be proximal to any ana-
8 ].
Invasive arterial blood pressure monitoring carries two
categories of complications, infectious or mechanical.
The most common mechanical complication is arterial
thrombosis, which may be partial or complete, and has
been noted to occur in 25 % of patients [ 43 ]. However,
despite this seemingly high thrombosis risk, investigators
identifi ed no signifi cant disability or ischemic damage
occurred in most catheter-associated radial artery thrombosis and noted most recanalized within 2–4 weeks after
catheter removal [ 8 ].
Many clinicians recommend performing a modifi ed
Allen’s test prior to radial artery catheter site selection in
order to assess for adequacy of perfusion and collateral fl ow
to the distal extremity. The modifi ed Allen’s test consists of
compression of both the radial and ulnar arteries, clinching
the patient’s fi st until it blanches, then relaxing the fi st and
releasing pressure from the ulnar artery. If the patient’s skin
becomes hyperemic, the collateral fl ow is deemed satisfactory for radial artery cannulation [ 8 ]. While historically rec-
ommended, the Allen’s test has not demonstrated a reduction
in digit ischemia, nor has an abnormal Allen’s test proven to
guarantee distal ischemic changes. However, if a grossly
abnormal Allen’s test is obtained, arterial cannulation should
be sought elsewhere [ 44 ].
Brachial artery cannulation has conventionally been
avoided due to the anatomic consideration of limited collaterals at this level of the upper extremity, theoretically
predisposing to increased risks for thrombosis and extremity loss. While an anatomically sensible consideration,
research has found no increased Doppler evidence of
thrombosis or vascular compromise in a study of brachial
artery cannulations, leading clinicians to consider brachial
artery cannulations as an acceptable risk in the proper clinical scenario [ 45 ]. However, even with this documented sup-
port, it is generally recommended to access the axillary
artery preferentially to the brachial artery due to its generous collateral circulation.
An additional mechanical complication encountered
with arterial cannulation is pseudoaneurysm formation.
Improper technique is believed to contribute to pseudoaneurysm development if the posterior wall of the vessel is
punctured or when multiple passes at the artery are made,
enhancing the risk. Prolong catheter placement and cannulation site infection also predispose to pseudoaneurysm
formation [ 8 ].
Arterial cannulation infection is the second signifi cant
category of complications with the insertion site serving as
the most common access for catheter-associated bacteremia.
Compared to central venous catheters, research has demonstrated that arterial catheter infections do not increase over
time of indwelling, and disciplined aseptic technique on
84
B.M. Howard and D.B. Christie III
insertion, access, and dressing care minimizes the infectious
risk [
46 ]. One should also be cognizant of impedance mis-
match between the patient’s artery and the catheter which
may lead to over- or underestimation of systolic and diastolic
values. Moreover, erroneous placement with partial occlusion may similarly lead to inaccurate pressure measurement.
Therefore, one should always assess the waveform quality, to
look for whip artifact or a dampened waveform before using
the numeric values to trigger intervention.
Direct Visualization Methods
Transthoracic Echocardiography
Transthoracic echocardiography (TTE) has been widely
accepted as an excellent, noninvasive, direct visualization
modality for the assessment of cardiac anatomy and function. Point of care TTE has been utilized successfully in
ICUs for many years, but more recently, intensivists have
strongly advocated for its incorporation as a standard of care
for hemodynamic monitoring purposes [ 47 ]. However, point
of care TTE, or intensivist-performed TTE, should be distinguished from a formal, cardiology-driven TTE in several
respects. Formal cardiology-driven TTE creates a detailed
anatomic report with cardiac functional descriptors relative
to the given moment of the exam. Point of care TTE in the
ICU is a more limited exam anatomically but allows for the
assessment of cardiac fi lling volumes and chamber performances over a continuum of time [ 48 ]. In the critical care
setting, TTE can be quickly applied to assess for cardiac fi lling volumes, chamber functionality, global wall motion
abnormalities, and cardiac responsiveness to therapeutic
efforts. The exam is quick, noninvasive, and repeatable on
demand.
Image Acquisition
Point of care TTE can be performed on any ultrasonographic
device with cardiac penetrance. Most modern critical care
units have access to advanced ultrasonographic equipment
often with exchangeable probes and various examination
modes, such as breast, vascular, or cardiac that adjusts penetration needs based on exam site and type.
TTE transducers have a square surface, as opposed to the
elongated, rectangular-shaped transducer used for vascular
imaging. An inverse relationship exists between sound wave
frequency and depth of penetration, with better resolution
being achieved with high frequency. Higher-frequency,
lower-depth probes are used for vascular imaging with ultrasound. By contrast, an echocardiography transducer emits a
variety of frequencies to provide optimal resolution at a
range of depths. It also uses a high frame rate to capture cardiac motion and display it smoothly [ 49 ].
Examination Views
The views obtainable are essentially those of a standard TTE
and include the parasternal long axis (PLA), parasternal
short axis (PSA), apical four chamber, and subxiphoid windows (Fig. 8.2 ):
• Subxiphoid view: The subxiphoid view allows assessment of the IVC, its diameter, and diameter variation with
respiration.
• Parasternal long-axis view: The PLA is obtained with
prone positioning of the patient between the second and
sixth intercostal spaces with the transducer notch oriented
toward the right shoulder. Through this view the mitral
valve, aortic valve, and left ventricular function can be
assessed.
• Parasternal short-axis view: The PSA view is captured
with prone positioning of the patient between the second
and sixth intercostal spaces with transducer probe now
rotated 90°. Through this window the classic donut view
of the left ventricle is seen along with the right ventricular
chamber. Tilting of the probe allows imaging of the left
ventricle from base to apex revealing the papillary musculature, mitral, and aortic valve.
• Apical four-chamber view: The apical four-chamber view
is visualized with prone positioning of the patient with the
probe placed over the left chest wall at the level of the
cardiac apex. The transducer notch is turned to the bed.
This view allows for visualization of the left and right
ventricular functions.
• Subxiphoid view: The subxiphoid view is obtained by
placing the probe under the xiphoid process with the
patient in supine positioning. The view is the same as that
achieved with a routine assessment with sonography for
trauma exams and allows for visualization of the IVC and
for presence or absence of pericardial effusions. Rotating
the probe counterclockwise opens the view so that the
IVC is in its long axis, allowing assessment of its diameter and collapsibility.
Image Interpretation
The information obtained is to be interpreted as a physiologic assessment relative to a given clinical scenario, allowing for the analysis of cardiac function, preload, afterload,
and cardiac anatomy:
• Cardiac function can be assessed by evaluating ejection
fraction, stroke volume, cardiac output, cardiac index,
diastolic function, and right-sided heart function.
• Preload can be analyzed through the calculation of ventricular cavity size, IVC diameter, and diameter change.
• Afterload is estimated with interpretation of systemic vascular resistance and systolic pulmonary artery pressure.
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Fig. 8.2 Transthoracic echocardiography probe positions and corresponding views
• Cardiac anatomy such as severe valvular dysfunction
resulting in hemodynamic compromise, pericardial fl uid,
or global wall motion abnormalities can be identifi ed.
systole, to be entered whereupon physiologic data such as
CO, CI, EF, SVR, etc., may be generated. IVC diameter
and variation can be measured manually and analyzed.
Alternatively, the skilled echocardiographer can visu-
Software-driven computations provided by manufac-
turers of advanced ultrasound devices are imbedded in
their individual operating systems which allow for exam
fi ndings such as ventricular chamber sized in diastole and
ally assess for chamber size, variation, and responsiveness to therapy in order to estimate hemodynamic status.
The technique of image capture and data point entry for
algorithmic analysis for TTE is beyond the scope of this
86
B.M. Howard and D.B. Christie III
chapter but is readily available in a variety of well-established teaching modules or manufacture device- specifi c
literature.
Considerations
The TTE examination can be limited by diffi culty in obtaining clear images in the presence of subcutaneous emphysema,
anasarca or signifi cant edematous states, large patient
body habitus, or presence of abdominal wall or thoracic
bandages.
A variety of physiologic data can be gleaned from a thor-
ough TEE exam; however, guidelines for provider application have yet to be standardized. IVC size and index of
change are currently being applied to hemodynamic monitoring scenarios and studied as a marker for hemodynamic
performance. Many researchers and clinicians alike have
endorsed the analysis of IVC size and variability of change
with therapeutic interventions as a guide for determining
fl uid needs and responsiveness to therapy [
50 – 52 ]. Others
utilize a composite of all views relative to patient performance and base clinical decisions of measurable data such
as computation-derived CO, EF, SVR, as well as other
related variables.
Whether computation-driven measurements or visual
estimation is utilized is a provider or operator preference.
Research is ongoing to identify the validity of both methods
as well as domains of intersection. Specifi c pattern recognition for paradigms of cardiac evaluation relative to shock
management is beyond the scope of this chapter but is available through a variety of references and reviews [ 49 ].
Transesophageal Echocardiography
Transesophageal echocardiography (TEE) is utilized in the
management of the critically ill over the last decade due to its
accuracy and reproducibility as an assessment tool for cardiac anatomy and performance. However, formal multiplane
TEE requires a full-scale TEE module and monitor system,
utilizes relatively bulky probes, requires probe reinsertion
for each exam, and potentially limits the clinicians’ ability to
accurately follow changes in cardiopulmonary performance
over time. Since the US Food and Drug Administration’s
approval for the clinical use of a newly developed, miniaturized TEE probe that may remain indwelling in the esophagus
for up to 72 h, TEE as an application in the critical setting
has become more pervasive. Contemporarily known as
hemodynamic TEE or hTEE, this exam modality has the
unparalleled advantage of allowing for anatomical and functional assessments of the heart and great vessels in real time
for ventilated, critically ill, or injured patients. The ability to
continuously monitor and assess for effects of interventions
facilitates intensivists by guiding complex resuscitations in
order to better tailor therapeutic maneuvers to patient needs
and tolerance [ 53 ].
Image Acquisition and Interpretation
The hTEE probe is approximately 17 French in size, inserted
transorally, and advanced into the stomach. The probe is
slowly retrieved where fl exion, antefl exion, and gentle rotational torque of the probe facilitate image capture.
The views obtainable with hTEE include (Fig. 8.3 ):
• Transgastric view: a short-axis view allowing visualization of both cardiac ventricles, permitting measurement
of LV size, calculation of LV fractional area contraction,
and examination of septal size, shape, and wall motion
abnormalities.
• Four-chamber view: a long-axis view providing visualization of the four cardiac chambers and measurement
opportunity of LV and RV end-diastolic and end-systolic
size and calculation of LV ejection fraction.
• Superior vena cava view: a long-axis view, at the level of
the SVC/right atrial junction where examination of the
variation in the SVC diameter during the respiratory cycle
can be assessed.
Software-driven computations provided by the device
manufacturer are embedded in the operating system which
allow for exam fi ndings such as ventricular chamber sized in
diastole and systole, to be entered whereupon physiologic
data such as CO, CI, EF, SVR, etc., can be generated. SVC
diameter and variation can be manually measured and analyzed. Alternatively, the skilled echocardiographer can visually assess for chamber size, variation, and responsiveness to
therapy in order to estimate hemodynamic status and resuscitation needs. The technique of image capture and data
point entry for algorithmic analysis for hTEE is beyond the
scope of this chapter but is readily available in a variety of
established teaching modules and device manufacturer
literature.
Considerations
The simple yet robust TEE images and cardiac performance
patterns achieved with hTEE have previously been validated
in ventilated patients with septic shock against a more comprehensive and quantitative assessment [ 53 , 54 ]. The hTEE
examination has been demonstrated to provide relevant information for the hemodynamic monitoring of ventilated ICU
patients with cardiorespiratory compromise and has proven to
be therapeutically impactful in several studies and continues
to be applied to various, specifi c clinical scenarios for more
accurate hemodynamic monitoring efforts [
53 – 56 ].
Through the continuous evaluation of the superior vena
cava and the right and LV chambers and their response to
therapeutic maneuvers, hTEE can identify the precise cause
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Fig. 8.3 Hemodynamic transesophageal echocardiography probe position and corresponding image (With permission of ImaCor, Inc.)