Lives interactive debates: How to choose a haemodynamic monitoring system in shock? (Vincent, De Backer, Teboul)

Expectations of haemodynamic monitoring in shock:

De Backer:  additional information besides clinical history

Vincent:  if you only measure, but not interpret/treat à monitoring doesn’t help – so: measure – interpret –apply!

Teboul: shock is complex; haemodynamic monitoring helps to identify which component is important in an individual patient and to identify the optimal therapy combination

Vincent: Better than speaking about the “4 types of shock”: speak about the 4 pathophysiologic alterations/ 4 mechanisms: hypovolemic – cardiac – obstructive – distributive

De Backer: clinical signs are helpful but not enough

Teboul: echocardiography + central venous catheter – the initial basic monitoring for the shock patient

 

Diastolic BP: very important, because it tells us about the vascular tone

Pulse pressure: gives information about arterial compliance

 

Arterial catheter is mandatory in these patients – but where to put it?

  • Vincent: radial site (infections at femoral site?)
  • Teboul: femoral: close to aorta – for an idea of the central blood pressure
  • De Backer: brachial

 

De Backer: Differentiate between impaired cardiac function (does not necessarily require Dobutamine) and impaired CO (good indication for dobutamine)

 

Vincent: avoid hypotension at all times; Teboul: you cannot restore vascular tone with fluids only à you will need vasopressors anyway and if you start earlier you can discontinue earlier!

 

Vincent: Consider measuring CO and see if it increases during a fluid challenge. Teboul: Decisions based on parameters always depend on the individual patients (organ impairment?)

Vincent: Pulmonary artery catheter use: only appropriate if it is routinely used. If you are using it less than one a week, that’s a problem.

 

..and always question the measured parameters of your haemodynamic monitor.

 

References: 

Consensus on shock and haemodynamic monitoring

 

By Dr Julia Wagner