1. Hemodynamic Monitoring in
operating Room and Intensive care
unit
Dr Minati Choudhury
Professor
Cardiothoracic Sciences Centre
AIIMS
New Delhi

2. What I intend to discuss
• Why to monitor?
• What to monitor?
• How to monitor
• What is the evidence that what we are
doing actually makes a difference

3. 3
Can’t I look at my patient and
tell if they are OK?
NO! Physical Assessment is often inaccurate,
slow to change and difficult to interpret

4. Why to monitor?
• Respiration and circulation ..Essential for sustaining
life
• Oxygen ,,,,,, the real necessity for organ function
• To gather information that will indicate whether the
conditions that are required to maintain tissue
perfusion are adequately maintained.

5. To assure the adequacy of perfusion
Early detection of inadequacy of perfusion
To titrate therapy to specific hemodynamic end point
To differentiate among various organ system
dysfunctions

6. Why hemodynamic monitoring?
• Preoptimization for high-risk surgery patients
treated in the operating room
• EGDT (< 12 h) resuscitation in septic patients treated
in the emergency department reduce morbidity,
mortality, and resource use.
• The closer the resuscitation is to the insult, the
greater the benefit.
• Focus of these monitoring protocols .......... to
establish a mean arterial pressure > 65 mm Hg and
then to increase DO2 to 600 mL/min/m2 within the
first few minutes to hours of presentation.

7. Adequate Oxygen Delivery?
ConsumptionDemand

8. Oxygen Delivery
Arterial Blood
Gas
Hemoglobin
PaO2
Oxygen
Content
Oxygen
Delivery
Cardiac
Output
Oxygen
Content= X
Hemodynamic Monitors

9. Oxygen Consumption
Oxygen
Delivery
Oxygen
Consumed
Remaining
Oxygen to
Heart
= +
Oxygen Uptake
by Organs &
Tissues
Oxygen Content
in CVP & PA

10. Hemodynamic Monitoring
Truth
•No monitoring device, no matter
how simple or complex, invasive or
non-invasive, inaccurate or precise
will improve outcome
•Unless coupled to a treatment,
which itself improves outcome
Pinsky & Payen. Functional Hemodynamic Monitoring,
Springer, 2004

11. Different Environments Demand
Different Rules
Emergency Department
Trauma ICU
Operation Room
ICU & RR
Rapid, invasive, high specificity
Somewhere in between ER and OR
Accurate, invasive, high specificity
Close titration, zero tolerance for complications
Rapid, minimally invasive, high sensitivity

12. Traditional Monitoring
 Electrocardiography
• HR, dysrhythmnias, HR variability
 Pulse oxymetry
 NIBP
 Arterial blood pressure
 Central venous pressure

13. Pulse Oxymetry
• ABSORBTION SPECTRO PHOTOMETRY
• BEER LAMBERT LAW
• LAMBERT’S LAW states that when a light falls on a homogenous
substance,intensity of transmitted light decreases as the distance through
the substance increase
• BEER’S LAW states that when a light is transmitted through a clear
substance with a dissolved solute ,the intensity of transmitted light
decreases as the concentration of the solute increases
Uses two lights of wavelengths
• 660nm –deoxy Hb absorbs ten times as oxy hb
• 940 nm – absorption of oxyHb is greater
• Lab oximeters use 4 wavelengths to measure 4 species of haemoglobin
• It =I o e –Ecd [Ecd –absorbance]

15. Oxygen desaturation
• Saturation is defined as is a relative measure
of the amount of oxygen that is dissolved or
carried in a given medium(percentage).
• Desaturation leads to Hypoxemia – a relative
deficiency of O2 in arterial blood. PaO2 <
80mmHg – hypoxemia
• Oxygen saturation will not decrease until
PaO2 is below 85mmHg.
• Rough guide for PaO2 between saturation of
90%-75% is,, PaO2 = SaO2 - 30.
• SaO2< than 76% is life threatening.

16. • PaO2 [mmHg] SaO2 [%]
• Normal 97 to ≥80 97 to ≥95
• Hypoxia < 80 < 95
• Mild 60-79 90-94
• Moderate 40 – 59 75 – 89
• Severe <40 < 75

17. Cardiovascular response to
hypoxemia
SPO2% HR BP Stroke
volume
SVR Response
>80    No
change
Reflex
60-80   No
change
 Direct
<60     Direct

18. Limitations
 Shivering patient -motion artefacts
 High intensity ambient light
 Perfusion of the patient
ear probe may be more reliable
 Abnormal pulses –erratic perfomance
 Carboxy Hb – Produces SpO2 > than true O2 saturation (10-
20% in heavy smokers)
 Methaemoglobinemia – absorbs equal amount of red
&infra red light (SpO2 to move towards 85%)
Endo / exogenous dyes interfere
 Blue ,Black ,Green nail polishes
Diathermy leads to disturbance in monitor

19. Problems
• False positives and negatives
• Burn injury
• Pressure injuries

20. Invasive Arterial pressure

21. Normal arterial wave form

22. Dampened trace
Arterial catheter Fling
Air bubble/blood in line
Clot
Disconnect/loose tubing
Underinflated pressure bag
Catheter tip against wall
Compliant tubing

25. ARTERIAL LINE MONITORING SITES
• Radial
– Low complications
– Allen’s test
– Poss median n damage b/o dorsiflexion
• Ulnar
– Primary source hand flow
– Low complications
– Poss median n. damage

26. ARTERIAL LINE MONITORING SITES
• Brachial
– Medial to biceps tendon
– Potential median n damage
• Axillary
– At junction pectoralis major & deltoid
– Safer than brachial
– Low thromboembolic issues

27. ARTERIAL LINE MONITORING SITES
• Femoral
Easy access in shock states
Potential hemorrhage
(local/retroperitoneal)
Requires longer catheter
• Doralis Pedis
Post tibial collateral circ
Estimates systolic higher
Contraind in DM & PVD

28. ALLEN’S TEST
• OCCLUDE ulnar and radial arteries
• Have pt clench fist until hand blanches
• Release ulnar a with hand open
• Color return within 5 sec = adequate
collateral circ

29. MODIFIED ALLEN’S TEST
• Elevate arm above heart
• Have pt open and close fist several
times
• Tightly clench fist
• Occlude radial and ulnar a
• Lower hand, open fist, release ulnar a
• Color return within 7 sec = OK

30. RELATIVE CONTRAINDICATIONS
• Inadequate circulation
• Infection at the site
• Recent cannulation same artery
• Peripheral vascular disease

31. COMPLICATIONS ARTERIAL LINE
• Thrombosis/embolus
• Hematoma
• Infection
• Nerve damage/palsy
• Disconnect=blood loss
• Fistula
• Aneurysm
• Digital ischemia

32. mlr/2007
LOSS OF WAVEFORM
• Stopcock in wrong position
• Monitor not on correct scale
• Nonfunctioning monitor
• Nonfunctioning transducer
• Kinked/clotted catheter
• Asystole

33. Patient effect on arterial pressure
Tachycardia
Hypotension
Atrial fibrillation
Wave form quality
Crisp: sharp, clear lines,
flowing
◦ideal
Dampened: blunted, smooth
◦Low flow states, air in line
Hyperdynamic: spikes
◦Pinched, compliant tubing

34. Patient effect on arterial pressure
Upstroke of wave
• Related to velocity of blood ejected
• Slowed upstroke
 AS
 LV failure
• Inc sharp vertical in hyperdynamic states
 Anemia
 Hyperthermia
 Hyperthyroidism
 SNS
 Aortic regurg

35. CENTRAL VENOUS PRESSURE
MONITORING
 Usually put in coditions where…….
 Rapid administration of fluids and blood
products in patients with any form of shock
 Administration of vasoactive and caustic drugs
 Administration of parenteral nutrition,
electrolytes or hypertonic solutions
 Venous access for monitoring CVP and
assessing the response to fluid or vasoactive
drug therapy
 Insertion of transvenous pacemaker
 Lack of accessible peripheral veins
 Hemodynamic instability

36. CVP ACCESS
RIJ (OR)
EJ
Subclavian(ICU)
Antecubital
Femoral

37. mlr/2007
CVP ACCESS

38. Central venous pressure
monitoring kit

39. Typical CVP wave form

40. Elevations in Central venous
pressure
• Hypervolemia
• Right ventricular infarction
• Impaired RV contraction
• Pulmonary hypertension
• Pulmonic stenosis
• Left to right shunts
• Tricuspid valve disease
• Cardiac tamponade

41. Low Central venous pressure
• Hypovolemia
• Dehydration
• Poor vascular tone
• Peripheral vasodilation
• Hemorrhage
• Addisonian crisis
• Sepsis
• Regional anesthesia
• Polyuria
• Sympathetic dysfunct

42. Contraindication
• Coagulopathies or bleeding disorders
(monitor platelet count, PT, PTT)
• Current or recent use of fibrinolytics or
anticoagulants
• Insertion sites that are infected or burned, or
where previous vascular surgery has been
performed, or involve catheter placement
through vascular grafts
• Patients with suspected or confirmed vena
cava injury

43. Central venous
pressure
• Limitations.....
• Evaluate as a trend
• Systemic vasoconstriction
can present a CVP
elevated despite
hypovolemia
• Mechanical ventilation
 Positive pressure
ventilation ↑ thoracic and
central venous pressures
 Measure at end-expiration
Complication………
• Arterial puncture
– Hematoma
– False aneurysm
– Fistula
• Catheter position during
placement
 Wall perf/tamponade
 Dysrhythmias
• Catheter shear
• Brachial plexus injury
• Thoracic duct injury

44. Direct monitoring of Cardiac
output
Invasive
PA catheter
 Fick’s
method
 Dye dilution
 Thermo
dilution
Non-invasive and semi invasive
Echocardiography
 Oesophageal doppler
Aortovelography
Transthoracic impedance
Arterial pulse contour
analysis (PiCCO)
Arterial pulse power analysis
(LiDCO)
 Flotrac-vigileo

45. PA Catheter
Swan-Ganz Catheter
Swan

46. Use in…
MI with complications
 CHF
 Pulmonary HTN
 Respiratory failure
 Shock
 Sepsis
 Trauma
 Hemodynamic instability
 High risk cardiac surgery
 Peripheral vascular
surgery
 Aortic surgery
 Neuro surgery
DO NOT USE INCASE OF
Tricuspid or pulmonary valve
mechanical prosthesis
Right heart mass (thrombus and/or
tumor)
Tricuspid or pulmonary valve
endocarditis

47. PA Catheter on float

48. Waveforms during PAC insertion and distance
from skin insertion

49. Proximal port in Right atrium

50. Right ventricular port (orange)

51. Distal port (yellow)
Normal values
PA systolic pressure = 20-
30 mm Hg
PA diastolic pressure = 8-
12 mm Hg
Mean PAP=12-15 mmHg

52. Measurements that can be done
from PA catheter
CVP
Rt ventricular pressure
PAP
PCWP
CO
CI = CO/BSA, L/min/m2
Stroke volume= CO/HR 1,000, mL/min
Stroke index = stroke volume/BSA, mL/m2
LV stroke work= stroke volume (MAP- Ppao), mL
mm Hg
LV stroke work index= LV stroke work/BSA, mL
mm Hg/m2

53. Derived Hemodynamic Parameters From
Hemodynamic Monitoring*
Systemic vascular resistance= (MAP-
Pra)/CO× 80,dyne s/cm5
RV stroke work = stroke volume × (MPAP-
Pra), mL mm Hg
RV stroke work index= RV stroke
work/BSA, mL mm Hg/m2
Pulmonary vascular resistance= [(MPAP –
Ppao)/CO] × 80,dyne s/cm5

54. Derived Hemodynamic Parameters From
Hemodynamic Monitoring*
Global Do2† = CO× (Sao2 - Svo2) × Hb ×
1.36 × 1,000, mL oxygen/min
Global Do2 index†= CI × (Sao2- Svo2) ×
Hb × 1.36, mL oxygen/min
Global V˙ o2† = CO × Sao2 × Hb × 1.36
1,000, mL oxygen/min
Global V˙ o2 index† = CI × Sao2 × Hb ×
1.36 × 1,000, mL oxygen/min

55. Normal values
Directly measured
• CVP 2-4 mm Hg
• PA 25/10
• PAOP 8-12
• SvO2 60-75%
• Cardiac output 4-8 L/m
• Cardiac index 2.5-4.0
L/min/M2
Calculated
• SVR 900-1200 dynes
sec/cm5
• PVR 50-140
• SV 50-100mL
• SV index 25-45

56. Mean PAP
↑MPAP
•Volume infusions
•Low CO states(LV failure
,RV failure)
•Peripheral
vasoconstriction
•Hypothermia
•Vasopressors
•Alpha adrenergic agents
•Increased blood
viscosity
↓MPAP
•Diuretics
•Vasodilators
•Peripheral vasodilation
•Inotropic therapy(PDIII
inhibitor)
•Hyperdynamic phase of
sepsis
•Loss of vasomotor tone

57. PVR
↑PVR
•Hypoxia
•Hypercarbia
•PEEP
•Pulmonary edema
•Pulmonary hypertension
•ARDS
•Sepsis
•Pulmonary emboli
•Valvular heart disease
•Congenital heart defects
↓ PVR
•Vasodilator therapy
•Prostaglandins
•Correction of hypoxia
•Prostacyclin

58. Systemic vascular resistance
↑SVR
•Volume infusion
•Decreased LV contractility
•Hypervolemia
•Hypoxia
•Pulmonary vasoconstriction
•Pulmonary hypertension
•COPD
↓ SVR
•Hypovolemia
•Diuretics
•Inotropic therapy
•Pulmonary vasodilation
•Pulmonary vasodilators

59. Pulmonary capillary wedge pressure
 Normal mean value: 8-12 mm Hg
 Low (< 8 mm Hg):Hypovolemia
 High (>12 mm Hg):Hypervolemia
Low
Sepsis
Cirrhosis
anemia
High
LV failure
Overload
Mitral v. issues
Tamponade
Pericardial
effusion
Stiff LV
PPV

60. Complications due to PA catheter
• Dysrhythmias
• RBBB/CHB in pt with LBBB
• PA/RA/RV rupture
• Knot/kink/coil catheter
• Infection
• Balloon rupture
• Thrombus
• Air embolus
• Pneumothorax
• Phrenic n. block
• Horner’s
– R/T stellate ganglion damage
– Eyelid ptosis

61. Transesophageal echocardiography
• Measurement of LVOT
diameter
• Measurement of LVOT
area=(∏×LVOT dia2 )/4
• Measurement of LVOT
VTI from signal’s
envelope

62. Transesophageal
echocardiography
Cardiac output (l/min) = Stroke volume
x Heart Rate
Pit falls….. Irregular rhythm→false
measurement

63. Esophageal doppler CO
A small probe is inserted into the esophagus of
mechanically-ventilated patients, usually during
anesthesia
The probe is introduced orally and advanced
gently until its tip is located approximately at
the mid-thoracic level, and then rotated so that it
faces the descending aorta.

64. Esophageal doppler CO
• The tip of the probe contains a Doppler transducer
which transmits an ultrasound beam (4 MHz
continuous-wave or 5 MHz pulsed-wave).
• The change in frequency of this beam as it reflects
off a moving object allows measurement of blood
flow velocity in the descending aorta. This
measurement, when combined with an estimate of
the cross-sectional area of the aorta, allows
calculation of hemodynamic variables including
stroke volume and cardiac output.

65. Esophageal doppler CO,potential
complications
• Operator dependency, occasional
difficulties in probe placement
• Difficulty interpreting the signal during
periods of arrhythmia

66. CO measurement from expired
gas...Indirect Fick’s principle

67. CO measurement from expired
gas...Indirect Fick’s principle
• Continuous cardiac output
•
• Principle: Differential CO2 Fick’s partial
rebreathing method
• CO= VCO2/ CvCO2-CaCO2
• To estimate CvCO2 , 150 ml of dead space is
added to the ventilator circuit by opening a
rebreathing valve

68. CO measurement from expired
gas...Indirect Fick’s principle
• Cardiac output is computed on breath-by-breath
measurements of CO2 elimination.
• Rebreathing measurements are made every three
minutes for 35 seconds.
• Cardiac output is proportional to the change in CO2
elimination divided by the change in end tidal CO2
resulting from a brief rebreathing period.
• These measurements are accomplished and
measured by the proprietary NICO Sensor, which
periodically adds a rebreathing volume into the
breathing circuit.

69. CO measurement from
expired gas...Indirect Fick’s
principle
ADVANTAGES
 Noninvasive
 No infection risks
 Automated and
continuous
 Not technique
dependent
 Extremely simple
to set up and use
 Can be used in
AF.
LIMITATIONS
Assumption about CvCO2
Accurate only if PaCO2 >
30mmHg
Any change in ventilation
parameters will change the
CO
Requires an intubated
patient
No parameter to monitor
intravascular volume status

70. THORACIC ELECTRICAL
BIOIMPEDANCE
• Bioimpedance monitoring (1965) , NASA...... to estimate
cardiac output non-invasively in astronauts
• Impedance ....... the resistance to alternating current
• Theory of technique
• The technique depends on the change in bio impedance of the
thoracic cavity during systole
• The bioimpedance monitors apply a small (3 mA) high-
frequency current to the thorax and use an array of
thoracic electrodes to measure the resulting potential
changes to give an impedance-time or dZ/dt trace
• Cardiac output is estimated from the 0.5% variation in
impedance that occurs with the cardiac cycle,

71. THORACIC ELECTRICAL BIOIMPEDANCE
Stroke Volume / Index (SV / SI)
Cardiac Output / Index (CO / CI)
Systemic Vascular Resistance / Index (SVR / SVRI)
Systolic Time Ratio (STR)
Pre-ejection Period (PEP)
LV Ejection Time (LVET)
Velocity Index (VI)
Acceleration Index (ACI)
Thoracic Fluid Content (TFC)

72. THORACIC ELECTRICAL BIOIMPEDANCE
LIMITATIONS
Physical
Height: Between 4
feet and 7 feet, 8
inches
Weight: Between 67
lbs. and 341 lbs.
 Warning
 Pacemakers,
 thoracotomy,
 emphysema
 PE
 ARDS
Precautions
HR > 250 bpm
Septic Shock (End stage
sepsis)
Severe Aortic Valve
Regurgitation
Extremely High Blood
Pressure (MAP > 130)
Intra-Aortic Balloon
Pump

73. THORACIC ELECTRICAL BIOIMPEDANCE
INTRAOPERATIVE LIMITATIONS
Electrocautery
Mechanical ventilation
Changes in volume in chest
Surgical manipulation
Assumption of hemodynamic
stability
Loose electrodes during
rewarming
Acute change in tissue water, pulm
edema, chest wall edema
VET from QRS: Arrythmias

74. LiDCO
• Principle: Indicator dilution
• A small dose of lithium chloride (0.15 -0.30
mmol) is injected via a central or peripheral
venous line; the resulting arterial lithium
concentration-time curve is recorded by
withdrawing blood past a lithium sensor
attached to the patient’s existing arterial
line.

75. 1) A bolus of Lithium is
flushed through a
central or venous line
2) A Lithium sensitive sensor, attached to a
peripheral arterial line, detects the concentration
of Lithium ions in the arterial blood
4) This value is then used to calibrate the LiDCOplus
to give continuous cardiac output and derived
variables from arterial waveform analysis.
L i D C O ™
The LiDCOplus - Lithium Indicator Dilution
16
3) The Lithium indicator dilution ‘wash-out’
curve on the LiDCOplus provides an
accurate absolute cardiac output value

76. LiDCO
Cardiac Output = (Lithium Dose x 60)/(Area
x (1-PCV))

77. LiDCO
 ADVANTAGES
 Provides an absolute cardiac output value
 Requires no additional invasive catheters to insert into
the patient
 Is safe – using non-toxic bolus dosages
 Is simple and quick to set up
 Is not temperature dependent

78. Pulse Contour analysis
FloTrac
• PRINCIPLE – PCA
• Flow is determined by a pressure gradient along a
vessel and the resistance to that flow (F=P/R).
• The FloTrac algorithm uses a similar principle to
measure pulsatile flow by incorporating the effects
of both vascular resistance and compliance through
a conversion factor known as Khi

79. Pulse Contour analysis (Flo Trac)
• The FloTrac algorithm analyzes the pressure waveform at one
hundred times per second over 20 seconds, capturing 2,000 data
points for analysis.
• These data points are used along with patient demographic
information to calculate the standard deviation of the arterial
pressure(σAP).

80. Pulse Contour analysis
FloTrac
The vigileo (c) and Flotrac Sensor (B) for
measurement of cardiac output from area
under the curve (A)

81. Pulse Contour analysis
FloTrac
LIMITATIONS
Paed. Patients
Cardiac shunts
AR
Artherosclerosis
Atrial fibrillation
Elderly patients with altered compliance of artery
 The FloTrac sensor level is continually maintained.
 Intra aortic balloon pump creates artificially high diastolic
pressure
 Non-Invasive Blood Pressure cuff on same arm as
FloTrac™ sensor may cut arterial pressure signal off
intermittently when cuff is inflated.
 Long, flexible femoral catheters may be more predisposed
to arterial pressure artifact

82. Pulse Contour analysis
FloTrac
ADVANTAGES
PCA method which does not require
calibration
Accounts for changes in compliance
Accuracy in changing hemodynamics
Parameters of fluid responsiveness (SVV)

83. FloTrac set up
Accurate Height, Weight, Sex and Age of the Patient
If patient’s BSA changes by more than 0.1 m2----------------
------check and re-enter the patient’s weight. (esp… for
patients with rapid changes in weight eg.renal
failure/dialysis, acute severe burns, etc.
When taking sample data, ensure. . .
Patient is not agitated or coughing
Radial line or femoral line waveform artifact maybe introduced
through constant movement.
Ensure stable waveforms prior to taking the data samples.
Other procedures deferred during sample taking (turning patients,
bathing, suctioning, etc)
Patient preferably in supine position

84. FloTrac: Waveform fidelity
The accuracy and fidelity of the FloTrac sensor is of
importance as the cardiac output is calculated from
pressures measured and waveform assessment
 No “T”ing of arterial lines with other devices
 System is free of bubbles
 Pressure bag for flush is pressurized to and
maintained at 300 mmHg
 Accurate zero referencing and calibration
 Accurate leveling of FloTrac™ sensor relevant
to patient’s Phlebostatic Axis must be
maintained at all times

85. Case scenarios, case I
• 55 yr old, post op whipples procedure
• Post op 5th hr SpO2 100%,HR 130/min,BP
110/46mmHg,CVP 2 mmHG,Hb 8.5
• ABG N
Management????????

86. Case scenarios, case I
• Analgesic
• Blood transfusion 1U
• 6%HES 1U
• HR 82/min,BP 113/58mmHg,CVP 5 mmHg

87. Case scenarios, case II
• 65 yr old,FUC bronchial asthma admitted to
ICU with severe respiratory distress
• Irritable,SpO2??,HR 120/min,BP 140/90,ECG
sinus tachy
• ABG with mask O2 ...... PH 7.2,PO2 40,PCO2
105, BE -4.5, HCO3 20 , Na 130, K 4.2, Hb 14.5
• Intubated........ Bronchial hyegine........
Improved.... Gradual weaning.....Extubated
D3 .... Calm, cooperative

88. Case scenarios, case II
• ABG in room air....... ...... PH 7.39,PO2
65,PCO2 43,BE -2.3, HCO3 22 , Na 132, K 3.8,
Hb 12.8
• HR 110,BP 105/50,RA13,SVV 15%, CO
4.6L/min
Is any Therapy needed???

89. Case scenarios, case II
• Transfusion of 1U RL....... Improve
hemodynamic
• HR 78, BP 130/63, RA 14 CO 4.5 L/min, SVV
8%

90. Case scenarios, case III
• 35 year old,TVD, CABG following ACS.......
• Normal intraopertive course
• Exubation 5th hr, normal ABG and
hemodynamics
• D1 ...... ABG (N) HR 80/min,BP 75/50,RA 14,
SVV 6, CO 2.5 L/min
Management??????

91. Case scenarios, case III
• Fluid challenge 100 ml RL.... No response
• Adr 0.5µkg/hr,Douta 5µ kg/hr,NTG
0.5µkg/hr
• 5th hr................ ABG (N) HR 90/min,BP
105/58,RA 8, SVV 7, CO 3.9 L/min

92. • Tachycardia is never a good thing.
• Hypotension is always pathological.
• There is no normal cardiac output.
• CVP is only elevated in disease.
• A higher mortality was shown in
patients with right ventricular
dysfunction and an increase of
pulmonary vascular resistance.
The Truths in Hemodynamics

93. The Truths in Hemodynamic
Monitoring
• Monitors associate with inaccuracies,
misconceptions and poorly documented benefits.
• A good understanding of the pathophysiological
underpinnings for its effective application across
patient groups is required.
• Functional hemodynamic monitors are superior
to conventional filling pressure.
• The goal of treatments based on monitoring is to
restore the physiological homeostasis.

94. ANY IDEAL SYSTEM?
Ideal
• Non invasive
• Accurate
• Reliable
• Continuous
• Compatible in paed. Pts.
• Reproducible
• Fast response
• Operator independent

95. Questions?
???????????
??