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.
By Dr Julia Wagner