1. BEDSIDE HEMODYNAMIC
MONITORING

2. Bedside Hemodynamic Monitoring
Outline
• Indications and evidence for effectiveness
– Sepsis
– CHF
– Peri-op
• Insertion
• Complications
• Measurement

3. Bedside Hemodynamic Monitoring
Definition
• The use of an indwelling catheter to measure
– pulmonary artery pressure
– pulmonary capillary wedge pressure
– right atrial pressure
– pulmonary artery oxygen saturation
– thermodilution cardiac output
in the intensive care unit.

4. Indications
Summary of ACP/AHA/ACC Expert Panel
• “To help direct management in medical patients in whom
hemodynamics will alter treatment and clinical estimates
are unreliable”
• “To assist management of surgical patients”
• “To establish or assist in establishing specific diagnoses”
– Cardiac vs. non-cardiac pulmonary edema
– VSD vs. MR in acute MI
– Pericardial tamponade
– RV MI
Friesinger et al. JAMA 1990; 15: 1460

5. Evidence for Effectiveness
Decompensated Heart Failure: ESCAPE trial
• Randomized trial of PAC vs. no PAC
– 433 pts hospitalized with CHF and volume overload
– In PAC group: goal PCW 15 and RA 8
– PAC group had greater wt loss (4.0 vs 3.2 kg) but
similar final BUN/creat
– 9 serious adverse events in PAC group (infection,
bleed, catheter knot, VT, pulmonary infarction)
ESCAPE Investigators. JAMA 2005; 294: 1625

6. Evidence for Effectiveness
Decompensated Heart Failure: ESCAPE trial
• For the primary
endpoint, there was
no difference
between intervention
and control groups:
ESCAPE Investigators. JAMA 2005; 294: 1625

7. Evidence for Effectiveness
Decompensated Heart Failure: ESCAPE trial
• For the secondary
endpoints:
– No change in exercise
capacity
– Change in QoL at 1
month only
– Improved patient
assessment of health
state (TTO) at 1 & 6
months
ESCAPE Investigators. JAMA 2005; 294: 1625

8. Evidence for Effectiveness
Medical ICU: PAC-Man trial
• Randomized trial of PAC vs. no PAC
– 1041 pts admitted to ICU who attending thought
needed a PAC. 66% medical. 65% multi-organ
dysfunction.
– Therapy at the discretion of the clinician
– Serious complications occurred in 10% of pts in the
PAC group
Harvey et al. Lancet 2005; 366: 472

9. Evidence for Effectiveness
Medical ICU: PAC-Man trial
• For the primary
endpoint, there was P = 0.381
no difference
between intervention
and control groups:
Harvey et al. Lancet 2005; 366: 472

10. Evidence for Effectiveness
Peri-operative management
Study N Result
Schultz. 1985 70 ↓ mortality in PAC group
Shoemaker. 1988 88 ↓ mortality in PAC group
Isaacson. 1990 102 No differences
Berlauk. 1991 89 No differences
Bender. 1997 104 No differences
Valentine. 1998 120 Borderline ↓ mort in PAC group
Bonazzi. 1992 100 No differences
Sandham. 2003 1994 No differences

11. Evidence for Effectiveness
Meta-analysis
• Quantitative review of
13 RCTs of PAC vs.
no PAC in
– medical
– surgical
– cardiac patients
demonstrated no
mortality benefit:
Combined OR 1.04 (0.90 – 1.20)
PAC better No PAC better
Shah et al. JAMA 2005; 294: 1664

12. Bedside Hemodynamic Monitoring
Indications and Evidence for Effectiveness
• Despite assertions by experts, there is no
demonstrated benefit on mortality or length of
stay associated with bedside hemodynamic
monitoring
• Its use should be limited to “rescue” situations
where all other options have failed, and
diagnostic situations where non-invasive options
have been inconclusive

13. … So if you really feel like you
absolutely have to use it …

14. Bedside Hemodynamic Monitoring
Insertion
Complication rates
• Choose insertion site to
minimize complications
– Subclavian vs femoral: 19.8%
17.3%
18.8%
subclavian preferred
– Subclavian vs IJ:
not tested; likely IJ has > 4.5%
infection rate and < severe Infectious Mechanical
mechanical complications Femoral Subclavian
(except arterial puncture)
– Consider brachial in
patients with coagulopathy Merrer et al. JAMA 2001; 286: 700.
Taupenot et al. NEJM 2002; 348: 12.

15. Bedside Hemodynamic Monitoring
Insertion- complications
• Other potential complications:
– Infection
– Thrombosis and thromboembolism
– Hemorrhage
– Pneumothorax and hemothorax
– Nerve injury
– Pneumomediastinum
– Air embolus
– Foreign body embolus
– RBBB
– Ventricular arrhythmias
– Pulmonary infarction
– Pulmonary artery rupture
– Heparin-induced thrombocytopenia (heparin-bonded catheter)

16. Bedside Hemodynamic Monitoring
Insertion- complications
• Risk factors for complications:
– Insertion site
– Time taken for insertion
– Duration of insertion
– Operator experience (>50 vs <50)
– Site preparation
• Scheduled insertion changes don’t decrease rates of
complications

17. Bedside Hemodynamic Monitoring
Waveform analysis- normal values
Right atrium 0-7 mmHg
Right ventricle 40 (sys) / 9 (end diastolic)
Pulmonary artery 25-40 / 10-20
Pulmonary wedge 2-14
Cardiac index 2.2 – 3.6
Mixed venous O2 saturation 68 – 76%

18. Bedside Hemodynamic Monitoring
Waveform analysis
Right Atrium Pulmonary Artery
Right Ventricle Wedge

19. Bedside Hemodynamic Monitoring
Waveform analysis: Respiratory variation
End-expiratory

20. Bedside Hemodynamic Monitoring
Waveform analysis- diagnosing pathology
“dip & plateau”

21. Bedside Hemodynamic Monitoring
Cardiac Output
• Measured by thermodilution:
– Inject cool saline or warm the blood in the RA
– Measure change in temperature with time in the PA
– Integral of T vs. t curve is used to compute CO
• There are many pitfalls in bedside CO
measurement; be skeptical when the “number”
doesn’t match the clinical data
• Cardiac output is an imperfect indicator of
circulatory function

22. Bedside Hemodynamic Monitoring
Oxygen saturation
• Useful check on accuracy of cardiac output
• Can be used to confirm “wedged” position
• Can be used to diagnose (relatively large)
intracardiac shunts