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Chapter 20. Hemodynamic Monitoring and Shock

Janice L Zimmerman, MD, FCCP
DOI: 10.1378/pulm.26.20
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Sections

Objectives 
  • Understand the indications, complications, and use of pulmonary artery catheterization.

  • Apply hemodynamic information to determine appropriate clinical management.

  • Review techniques of estimating cardiac output.

  • Outline types, characteristic hemodynamic patterns, and management of shock.

Synopsis 

Hemodynamic monitoring is an important tool for monitoring critically ill patients. Pulmonary artery catheterization (PAC) is an invasive technique that has not been demonstrated to improve outcomes in a variety of conditions encountered in the intensive care unit. PAC should be performed by a physician who is skilled in the insertion technique, knowledgeable of complications, and capable of appropriately interpreting and using the data obtained. Changes in juxtacardiac pressure or changes in ventricular compliance alter the interpretation of the pulmonary artery occlusion pressure (PAOP) as an indicator of preload adequacy. Less invasive methods of hemodynamic monitoring include arterial pressure waveform analysis, pulsed Doppler cardiac output devices, CO2 partial rebreathing (applied Fick principle), and bioimpedance. The advantages, disadvantages, and limitations of these techniques must be taken into account when considering their use in critically ill patients. Some of these techniques may use variation in systolic pressure, pulse pressure, or stroke volume to identify patients who respond to fluids with improvement in cardiac output. Shock is a syndrome of impaired tissue oxygenation and perfusion that results from one of the following mechanisms: an absolute or relative decrease in oxygen delivery; ineffective tissue perfusion; or impaired utilization of delivered oxygen. The management of shock requires treatment of the underlying etiology, and the restoration of adequate oxygen delivery and tissue perfusion through appropriate use of fluids and vasoactive agents. Septic shock is a common form of shock encountered in the critically ill patient, and the clinician should be familiar with consensus recommendations and the evidence supporting interventions.

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