Hemodynamic monitoring over the past 10 years

Changes in hemodynamic monitoring over the past 10 years have followed two paths. First, there has been a progressive decrease in invasive monitoring, most notably a reduction in the use of the pulmonary artery catheter because of a presumed lack of efficacy in its use in the management of critically ill patients, with an increased use of less invasive monitoring requiring only central venous and arterial catheterization to derive the same data. Second, numerous clinical trials have documented improved outcome and decreased costs when early goal-directed protocolized therapies are used in appropriate patient populations, such as patients with septic shock presenting to Emergency Departments and high-risk surgical patients before surgery (pre-optimization) and immediately after surgery (post-optimization). Novel monitoring will be driven more by its role in improving outcomes than in the technical abilities of the manufacturers

Toward a better ventilation strategy for patients with acute lung injury

Ventilator-induced lung injury is a major outcome determinant of the acute respiratory distress syndrome (ARDS). Ventilatory strategies that limit ventilator-induced lung injury should improve outcome from ARDS. The ARDSnet trial showed improved survival in subjects ventilated with a lower tidal volume. Although this trial developed and tested a rigorous clinical protocol, it did not define the limits to which tidal volume reduction would benefit outcome. It is also not at all clear if it is the reduction in tidal volume or the reduction in plateau airway pressure that confers this benefit. Finally, ventilator-induced lung injury occurs more commonly from repetitive collapse and re-expansion of injured lung units rather than from the overdistention of persistently aerated lung units. This was not addressed in the trial design. Thus, further study using targeted open-lung strategies are also needed

Evidence-based review of the use of the pulmonary artery catheter: impact data and complications

The pulmonary artery catheter (PAC) was introduced in 1971 for the assessment of heart function at the bedside. Since then it has generated much enthusiasm and controversy regarding the benefits and potential harms caused by this invasive form of hemodynamic monitoring. This review discusses all clinical studies conducted during the past 30 years, in intensive care unit settings or post mortem, on the impact of the PAC on outcomes and complications resulting from the procedure. Although most of the historical observational studies and randomized clinical trials also looked at PAC-related complications among their end-points, we opted to review the data under two main topics: the impact of PAC on clinical outcomes and cost-effectiveness, and the major complications related to the use of the PAC