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Monitoring and Testing the Critical Care Patient

by Soumitra R. Eachempati, MD

Some monitoring is manual (ie, by direct observation and physical examination) and intermittent, with the frequency depending on the patient’s illness. This monitoring usually includes measurement of vital signs (temperature, BP, pulse, and respiration rate), quantification of all fluid intake and output, and often daily weight. BP may be recorded by an automated sphygmomanometer; a transcutaneous sensor for pulse oximetry is used as well.

Other monitoring is ongoing and continuous, provided by complex devices that require special training and experience to operate. Most such devices generate an alarm if certain physiologic parameters are exceeded. Every ICU should strictly follow protocols for investigating alarms.

Blood Tests

Although frequent blood draws can destroy veins, cause pain, and lead to anemia, ICU patients typically have routine daily blood tests to help detect problems early. Placement of a central venous catheter (see Vascular Access : Central Venous Catheterization) or arterial catheter (see Vascular Access : Arterial Catheterization) can facilitate easy blood sampling without the need for repeated peripheral needle sticks, but the risk of complications must be considered. Generally, patients need a daily set of electrolytes and a CBC. Patients with arrhythmias should also have Mg, phosphate, and Ca levels measured. Patients receiving TPN need weekly liver enzymes and coagulation profiles. Other tests (eg, blood culture for fever, CBC after a bleeding episode) are done as needed.

Point-of-care testing uses miniaturized, highly automated devices to do certain blood tests at the patient’s bedside or unit (particularly ICU, emergency department, and operating room). Commonly available tests include blood chemistries, glucose, ABGs, CBC, cardiac markers, and coagulation tests. Many are done in < 2 min and require < 0.5 mL blood.

Cardiac Monitoring

Most critical care patients have cardiac activity monitored by a 3-lead system; signals are usually sent to a central monitoring station by a small radio transmitter worn by the patient. Automated systems generate alarms for abnormal rates and rhythms and store abnormal tracings for subsequent review.

Some specialized cardiac monitors track advanced parameters associated with coronary ischemia, although their clinical benefit is unclear. These parameters include continuous ST segment monitoring and heart rate variability. Loss of normal beat-to-beat variability signals a reduction in autonomic activity and possibly coronary ischemia and increased risk of death.

Pulmonary Artery Catheter Monitoring

Use of a pulmonary artery catheter (PAC) is becoming less common in ICU patients. This balloon-tipped, flow-directed catheter is inserted via central veins through the right side of the heart into the pulmonary artery. The catheter typically contains several ports that can monitor pressure or inject fluids. Some PACs also include a sensor to measure central (mixed) venous O 2 saturation. Data from PACs are used mainly to determine cardiac output and preload. Preload is most commonly estimated by the pulmonary artery occlusion pressure (see Pulmonary artery occlusion pressure (PAOP)). However, preload may be more accurately determined by right ventricular end-diastolic volume, which is measured using fast-response thermistors gated to heart rate.

Despite longstanding use, PACs have not been shown to reduce morbidity and mortality. Rather, PAC use has been associated with excess mortality. This finding may be explained by complications of PAC use and misinterpretation of the data obtained. Nevertheless, some physicians believe PACs, when combined with other objective and clinical data, aid in the management of certain critically ill patients. As with many physiologic measurements, a changing trend is typically more significant than a single abnormal value. Possible indications for PACs are listed in Potential Indications for Pulmonary Artery Catheterization.

Potential Indications for Pulmonary Artery Catheterization

Cardiac disorders

Acute valvular regurgitation

Cardiac tamponade

Complicated heart failure

Complicated MI

Ventricular septal rupture

Hemodynamic instability*

Assessment of volume status

Shock

Hemodynamic monitoring

Cardiac surgery

Postoperative care in critically ill patients

Surgery and postoperative care in patients with significant heart disease

Pulmonary disorders

Complicated pulmonary embolism

Pulmonary hypertension

*Particularly if inotropic drugs are required.

Procedure

The PAC is inserted through a special catheter in the subclavian or internal jugular vein with the balloon deflated. Once the catheter tip reaches the superior vena cava, partial inflation of the balloon permits blood flow to guide the catheter. The position of the catheter tip is usually determined by pressure monitoring (see Table: Normal Pressures in the Heart and Great Vessels for intracardiac and great vessel pressures) or occasionally by fluoroscopy. Entry into the right ventricle is indicated by a sudden increase in systolic pressure to about 30 mm Hg; diastolic pressure remains unchanged from right atrial or vena caval pressure. When the catheter enters the pulmonary artery, systolic pressure does not change, but diastolic pressure rises above right ventricular end-diastolic pressure or central venous pressure (CVP); ie, the pulse pressure (the difference between the systolic and diastolic pressures) narrows. Further movement of the catheter wedges the balloon in a distal pulmonary artery. A chest x-ray confirms proper placement.

Normal Pressures in the Heart and Great Vessels

Type of Pressure

Average (mm Hg)

Range (mm Hg)

Right atrium

3

0–8

Right ventricle

Peak-systolic

25

15–30

End-diastolic

4

0–8

Pulmonary artery

Mean

15

9–16

Peak-systolic

25

15–30

End-diastolic

9

4–14

Pulmonary artery occlusion

Mean

9

2–12

Left atrium

Mean

8

2–12

A wave

10

4–16

V wave

13

6–12

Left ventricle

Peak-systolic

130

90–140

End-diastolic

9

5–12

Brachial artery

Mean

85

70–150

Peak-systolic

130

90–140

End-diastolic

70

60–90

Adapted from Fowler NO: Cardiac Diagnosis and Treatment , ed 3. Philadelphia, JB Lippincott, 1980, p. 11.

The systolic pressure (normal, 15 to 30 mm Hg) and diastolic pressure (normal, 5 to 13 mm Hg) are recorded with the catheter balloon deflated. The diastolic pressure corresponds well to the occlusion pressure, although diastolic pressure can exceed occlusion pressure when pulmonary vascular resistance is elevated secondary to primary pulmonary disease (eg, pulmonary fibrosis, pulmonary hypertension).

Pulmonary artery occlusion pressure (PAOP)

With the balloon inflated, pressure at the tip of the catheter reflects the static back pressure of the pulmonary veins. The balloon must not remain inflated for > 30 sec to prevent pulmonary infarction. Normally, PAOP approximates left atrial pressure, which in turn approximates left ventricular end-diastolic pressure (LVEDP). LVEDP reflects left ventricular end-diastolic volume (LVEDV). The LVEDV represents preload, which is the actual target parameter. Many factors cause PAOP to reflect LVEDV inaccurately. These factors include mitral stenosis, high levels of positive end-expiratory pressure (> 10 cm H 2 O), and changes in left ventricular compliance (eg, due to MI, pericardial effusion, or increased afterload). Technical difficulties result from excessive balloon inflation, improper catheter position, alveolar pressure exceeding pulmonary venous pressure, or severe pulmonary hypertension (which may make the balloon difficult to wedge).

Elevated PAOP occurs in left-sided heart failure. Decreased PAOP occurs in hypovolemia or decreased preload.

Mixed venous oxygenation

Mixed venous blood comprises blood from the superior and inferior vena cava that has passed through the right heart to the pulmonary artery. The blood may be sampled from the distal port of the PAC, but some catheters have embedded fiberoptic sensors that directly measure O 2 saturation.

Causes of low mixed venous O 2 content (SmvO 2 ) include anemia, pulmonary disease, carboxyhemoglobin, low cardiac output, and increased tissue metabolic needs. The ratio of SaO 2 to (SaO 2 − SmvO 2 ) determines the adequacy of O 2 delivery. The ideal ratio is 4:1, whereas 2:1 is the minimum acceptable ratio to maintain aerobic metabolic needs.

Cardiac output

Cardiac output (CO) is measured by intermittent bolus injection of ice water or, in new catheters, continuous warm thermodilution. The cardiac index divides the CO by body surface area to correct for patient size (see Normal Values for Cardiac Index and Related Measurements).

Other variables can be calculated from CO. They include systemic and pulmonary vascular resistance and right ventricular stroke work (RVSW) and left ventricular stroke work (LVSW).

Normal Values for Cardiac Index and Related Measurements

Measurement

Units ± SD

O 2 uptake

143 ± 14.3 mL/min/m 2

Arteriovenous O 2 difference

4.1 ± 0.6 dL

Cardiac index

3.5 ± 0.7 L/min/m 2

Stroke index

46 ± 8.1 mL/beat/m 2

Total systemic resistance

1130 ± 178 dynes-sec-cm -5

Total pulmonary resistance

205 ± 51 dynes-sec-cm -5

Pulmonary arteriolar resistance

67 ± 23 dynes-sec-cm -5

SD = standard deviation.

Adapted from Barratt-Boyes BG, Wood EH: Cardiac output and related measurements and pressure values in the right heart and associated vessels, together with an analysis of the hemodynamic response to the inhalation of high oxygen mixtures in healthy subjects. Journal of Laboratory and Clinical Medicine 51:72–90, 1958.

Complications and precautions

PACs may be difficult to insert. Cardiac arrhythmias, particularly ventricular arrhythmias, are the most common complication. Pulmonary infarction secondary to overinflated or permanently wedged balloons, pulmonary artery perforation, intracardiac perforation, valvular injury, and endocarditis may occur. Rarely, the catheter may curl into a knot within the right ventricle (especially in patients with heart failure, cardiomyopathy, or increased pulmonary pressure).

Pulmonary artery rupture occurs in < 0.1% of PAC insertions. This catastrophic complication is often fatal and occurs immediately on wedging the catheter either initially or during a subsequent occlusion pressure check. Thus, many physicians prefer to monitor pulmonary artery diastolic pressures rather than occlusion pressures.

Noninvasive Cardiac Output

Other methods of determining CO, such as thoracic bioimpedance and the esophageal Doppler monitor, are being developed to avoid the complications of PACs. Although these methods are potentially useful, neither is yet as reliable as a PAC.

Thoracic bioimpedance

These systems use topical electrodes on the anterior chest and neck to measure electrical impedance of the thorax. This value varies with beat-to-beat changes in thoracic blood volume and hence can estimate CO. The system is harmless and provides values quickly (within 2 to 5 min); however, the technique is very sensitive to alteration of the electrode contact with the patient. Thoracic bioimpedance is more valuable in recognizing changes in a given patient than in precisely measuring CO.

Esophageal Doppler monitor (EDM)

This device is a soft 6-mm catheter that is passed nasopharyngeally into the esophagus and positioned behind the heart. A Doppler flow probe at its tip allows continuous monitoring of CO and stroke volume. Unlike the invasive PAC, the EDM does not cause pneumothorax, arrhythmia, or infection. An EDM may actually be more accurate than a PAC in patients with cardiac valvular lesions, septal defects, arrhythmias, or pulmonary hypertension. However, the EDM may lose its waveform with only a slight positional change and produce dampened, inaccurate readings.

Hand-held echocardiography

Assessment of LV function is particularly important because decreased cardiac contractility is a common cause of hemodynamic instability in critically ill patients, including those with sepsis. Bedside transthoracic echocardiography (TTE) provides rapid and noninvasive assessment of cardiac function in critically ill patients, but delays can result if an experienced sonographer or cardiologist is not immediately available.

Intensivists who have completed brief training in the use of hand-held sonographic equipment that is now available can provide point-of-care, bedside TTE when formal TTE is not immediately available. Unlike formal TTE, the limited examination focuses primarily on assessment for hemodynamically significant pericardial effusions and impaired global LV function, which can affect treatment. Results of such limited bedside TTE by intensivists have been shown to be highly concordant with results of formal TTE.

Intracranial Pressure Monitoring

Intracranial pressure (ICP) monitoring is standard for patients with severe closed head injury and is occasionally used for some other brain disorders, such as in selected cases of hydrocephalus and pseudotumor cerebri or in postoperative or postembolic management of arteriovenous malformations. These devices are used to optimize cerebral perfusion pressure (mean arterial pressure minus intracranial pressure). Typically, the cerebral perfusion pressure should be kept > 60 mm Hg.

Several types of ICP monitors are available. The most useful method places a catheter through the skull into a cerebral ventricle (ventriculostomy catheter). This device is preferred because the catheter can also drain CSF and hence decrease ICP. However, the ventriculostomy is also the most invasive method, has the highest infection rate, and is the most difficult to place. Occasionally, the ventriculostomy becomes occluded due to severe brain edema.

Other types of intracranial devices include an intraparenchymal monitor and an epidural bolt. Of these, the intraparenchymal monitor is more commonly used. All ICP devices should usually be changed or removed after 5 to 7 days because infection is a risk.

Other Types of Monitoring

Sublingual capnometry uses a similar correlation between elevated sublingual P co 2 and systemic hypoperfusion to monitor shock states using a noninvasive sensor placed under the tongue. This device is easier to use than gastric tonometry and responds quickly to perfusion changes with resuscitation.

Tissue spectroscopy uses a noninvasive near infrared (NIR) sensor usually placed on the skin above the target tissue to monitor mitochondrial cytochrome redox states, which reflect tissue perfusion. NIR may help diagnose acute compartment syndromes (eg, in trauma) or ischemia after free tissue transfer and may be helpful in postoperative monitoring of lower-extremity vascular bypass grafts. NIR monitoring of small-bowel pH may be used to gauge the adequacy of resuscitation.

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