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INTRODUCTION

KNOWLEDGE COMPETENCIES

  1. Identify hemodynamic monitoring parameters used in progressive care.

  2. Emphasize advantages of dynamic over static variables in shock resuscitation.

  3. Describe components and means of optimization of tissue perfusion.

  4. Discuss the basic elements of arterial and venous pressure-monitoring equipment and methods used to ensure accurate pressure measurements.

  5. Identify invasive and noninvasive methods of hemodynamic monitoring.

  6. Discuss multimodal individualized approach to shock management in a progressive care population.

The term hemodynamics refers to the interrelationship of blood pressure (BP), blood flow, vascular volumes, heart rate (HR), ventricular function, and the physical properties of the blood. A working knowledge of how to obtain accurate information about a patient’s hemodynamic state, including their responsiveness to fluid resuscitation is a key element of progressive care nursing.

Clinical examination findings such as mental status, urine output, edema, capillary refill, skin color and temperature changes, and jugular venous distension provide some data about a patient’s fluid balance, oxygenation, and blood flow. Additional data can be obtained through invasive, minimally invasive, and noninvasive hemodynamic monitoring and through functional hemodynamic assessment. Parameters such as arterial BP, cardiac output (CO), stroke volume variation (SVV), pulse pressure variation (PPV), and changes in inferior vena cava (IVC) diameter can be directly measured with various hemodynamic monitoring methods. Noninvasive evaluations including daily weights, the passive leg raise (PLR) test, cardiovascular ultrasound, and analysis of changes in the arterial waveforms in both spontaneously breathing patients and those on positive pressure mechanical ventilation can also provide information about the patient’s fluid balance that guides management.

Timely recognition of circulatory failure, or shock, is imperative to prevent end organ damage and improve survival. Early in shock, patients frequently develop sympathetically stimulated compensation such as vasoconstriction and tachycardia; these changes may go unnoticed in an athlete with a baseline low HR. Hypotension is a late sign of hypoperfusion and presents a failure to compensate. On the other hand, presence of hypotension does not always result in shock as evidenced by lack of signs and symptoms of hypoperfusion. Thus, hypotension, even though often present, does not define shock and is a weak predictor of hemodynamic instability. Response to early signs of shock, before the failure of compensatory mechanisms, can improve patient outcome.

This chapter includes a discussion of hemodynamic parameters and markers of resuscitation, applicable to the progressive care setting and supported by the latest evidence, to guide treatment strategies in the state of inadequate tissue perfusion. It describes both invasive and noninvasive methods of hemodynamic monitoring, its advantages, and limitations. It emphasizes the advantage of dynamic over static variables used to guide fluid resuscitation and recommends personalized approach to shock management.

HEMODYNAMIC PARAMETERS

Historically, static parameters like central venous pressure (CVP) and pulmonary artery occlusion pressure (PAOP) were used to judge right ventricular (RV) and left ventricular (LV) preload and guide fluid therapy. However, evidence no longer ...

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