Hemodynamic Monitoring

Hemodynamic monitoring is a mainstay in the care of critically ill patients and remains a valuable
adjunct to physical examination and diagnostics in the assessment, diagnosis, and management of shock
(Rali et al., 2022). It involves using invasive and non-invasive methods to provide information about
pump effectiveness, vascular capacity, blood volume, and tissue perfusion. The precise data obtained
from hemodynamic monitoring helps to identify the type and severity of shock (cardiogenic,
hypovolemic, distributive, or obstructive). When paired with clinical evaluation, hemodynamic
monitoring is helpful in guiding the administration of fluids, in selecting and titrating vasoactive drugs,
and in deciding when mechanical support might be necessary to treat refractory shock and allows for
evaluation of the effectiveness of treatment in real time.

The Cardiac Cycle & Key Definitions

A thorough understanding of the cardiac cycle and key definitions provide a foundation for the
interpretation of hemodynamics.

The Cardiac Cycle

Diastole
 Diastole begins when the musculature of the atria and ventricles relax. During this period,
all four cardiac valves are closed.
 During diastole, blood returns to the atria from the venous system. The inferior vena cava
and superior vena cava fill the right atrium with blood returning from the body and the four
pulmonary veins fill the left atrium with blood returning from the lungs.
 The increasing pressure inside the filling atria push the atrioventricular (AV) valves open,
allowing for passive ventricular filling. At this point in the cardiac cycle, the semilunar
valves remain closed.
 At the end of diastole, the atria contract to forcibly fill the ventricles with extra volume of
blood. Contraction of the atria is referred to as atrial systole.

Systole
 Shortly after atrial systole, ventricular systole begins. During ventricular systole, the ventricles
contract, pushing the AV valves closed and forcing the semilunar valves open.
 Blood is ejected from the ventricles through the semilunar valves. The right ventricle
moves blood into the pulmonary artery and the left ventricle pushes blood to the body.

Key Definitions
Definition Clinical Considerations
Stroke volume (SV) The volume of blood Normal range is 60-90 mL.
pumped out of the left
ventricle with each Calculation
contraction SV = End-diastolic volume (EDV) – end-systolic
volume (ESV)

End diastolic volume Volume of blood in the Normal is about 120 mL.
(EDV) right ventricle (RV) or
 LV at the end of
diastole (filling)

End systolic volume Volume of blood in Normal is about 50 mL.

(ESV) the RV or LV at the
end of systole
(contraction)

Preload The amount of Also known as the left ventricular end-diastolic

ventricular stretch at pressure (LVEDP)
the end of diastole

Afterload The amount of Also known as the systemic vascular resistance (SVR)
resistance the heart
must overcome to
open the aortic valve
and push the blood
volume out into the
systemic circulation

Contractility The ability of the heart

to contract and
generate force and
blood flow

Measuring Hemodynamics
Hemodynamic instability causes a mismatch between oxygen demand and delivery, ultimately leading to
organ failure. Hemodynamic instability can typically be managed with clinical examination and
monitoring of vital signs (heart rate, blood pressure, oxygen saturation, and respiratory rate) and urine
output. However, when the patient does not improve, or deteriorates further, invasive hemodynamic
monitoring is often needed to guide fluid management and vasopressor/inotropic support.

Clinical Assessment
A clinical examination is the fastest and least invasive hemodynamic monitor available.
 A patient with inadequate global perfusion often presents with signs of end organ dysfunction,
such as tachypnea, tachycardia, confusion, weak peripheral pulses, skin mottling, and oliguria.
 Capillary refill time (CRT), which can be rapidly tested, is the time required for blood flow to
return to the distal capillaries. CRT is measured by compressing and blanching the nailbed of a
patient’s fingertip for ten seconds, then releasing the pressure. The amount of time required for
color to return to the nailbed is documented as CRT. The upper limit of a normal CRT is three
seconds in adults. A longer CRT indicates reduced capillary perfusion and decreased peripheral
blood flow.
Non-invasive Monitoring
Electrocardiogram (ECG)
 Heart rate is an important determinant of cardiac output (CO) (CO = HR X SV).
 A 12-lead ECG confirms cardiac rhythm and provides baseline information on ST segments and T
waves.
 Continuous monitoring of heart rate, cardiac rhythm, and ST segments allow for
early recognition of hypovolemia and myocardial ischemia.
 Tachyarrhythmias are a common finding in certain shock states. Bradycardia and/or heart block
may indicate cardiogenic shock.

Non-Invasive Blood pressure (NiBP)

 The definition of hypotension (low blood pressure) is patient-specific and interpreted in the
context of the patient’s usual BP.
 Hypotension is a common feature of most shock states.
 Blood pressure typically shows the pressures in the systemic vasculature during left ventricular
systole (SBP) and diastole (DBP). It is shown in the format SBP/DBP.
 Mean arterial blood pressure (MAP) is an average of the systolic and two times the diastolic
pressures (the heart spends twice as much time in diastole as it does in systole). MAP can
be used as an approximation of organ perfusion pressure.
 Severely elevated BP, especially if acute, is associated with increased vascular resistance and
may be associated with inadequate tissue perfusion, for example hypertensive
encephalopathy or acute renal failure.

Pulse oximetry (SpO2)

 Continuous SpO2 monitoring enables detection of a reduction in arterial oxygen saturation,
which is an integral part of oxygen delivery.
 The SpO2 signal is often inaccurate in the presence of decreased peripheral perfusion. The
inability to measure SpO2 is itself an indicator of abnormal peripheral perfusion.

Echocardiography
 An echocardiogram provides visualization of the cardiac chambers, valves, pericardium,
and overall cardiac function.
 It allows for measurement of left ventricular ejection fraction (LVEF) and estimation of SV and
CO based on measurement of LV outflow tract (LVOT), LVOT velocity, and heart rate.

Fluid responsiveness
 Fluid resuscitation is a key treatment strategy for hemodynamically unstable patients. Although
rapid optimization of volume status has been shown to improve outcomes, volume overload is
associated with increased morbidity and mortality.
 A fluid challenge is necessary to determine whether fluid administration will benefit the patient.
 Fluid responsiveness is frequently defined as an increase in cardiac output (greater than
or equal to 10% from baseline) with a fluid challenge (250-500 mL administered over 10-
15 minutes).
  An alternative to a fluid challenge is to perform a passive leg raise (PLR) maneuver. This
produces an ‘autotransfusion’ of blood from the venous compartments in the abdomen
and lower limbs. To perform a PLR:
o Position the patient in the semi-recumbent position with the head and torso elevated at
45 degrees.
o Obtain a baseline blood pressure measurement.
o Lower the patient's upper body and head to the horizontal position and raise and hold
the legs at 45 degrees for one minute.
o Obtain subsequent blood pressure measurement.
o A 10% or greater increase in cardiac output (CO) indicates that the patient is fluid
responsive. Note: Although not considered a validated measure, we often use blood
pressure as a surrogate marker of CO in evaluating response to the PLR.
o Only patients who are fluid responsive after a fluid bolus or passive leg raise should
receive additional fluids.

Invasive Monitoring
Intra-arterial blood pressure (ABP)
 Arterial cannulation (usually the radial artery) allows for accurate continuous blood pressure
measurement. Arterial line BP monitoring is the standard of care for patients on
vasopressor/inotrope infusions.
 Arterial lines facilitate frequent blood draws for blood gases or other lab studies.

Central venous pressure (CVP)

 The CVP is the blood pressure in the vena cava/right atrium; normal range is 2-6 mm Hg.
 The CVP reflects venous return to right side of heart, or right ventricular preload, which is a
key component of RV function.
 CVP is measured via a catheter positioned in the vena cava.

Pulmonary artery pressure (PAP)

 PAP is the blood pressure in pulmonary artery. Normal systolic PAP range is 15-30 mm Hg
and normal diastolic PAP is 5-15 mm Hg.
 PAP may be measured during right heart catheterization or via introduction of a catheter into
the pulmonary artery (i.e., Swan Ganz Catheter).

Mixed venous oxygen saturation (SvO2)

 SvO2 reflects the balance between oxygen delivery and oxygen consumption (VO2).
 It depends on arterial blood saturation (SaO2), the balance between VO2 and CO,
and hemoglobin (Hgb) levels.
o Normal SvO2 is greater than or equal to 70% (drawn from a pulmonary artery catheter).
o Central venous oxygenation (ScvO2) is normally greater than or equal to 65%
(drawn from a central venous catheter).
 Hemodynamic Values
Definition Calculations & Normal Range
Cardiac output (CO) The volume of blood Normal range is 4-8 L/minute.
pumped through the
heart per minute Calculation
(L/min) CO = Stroke Volume (SV) X Heart Rate (HR)

Cardiac index (CI) CO adjusted for body Normal range is 2.8-4.2 L/min/m2.
surface area (BSA)
Calculation
CI = CO/BSA

Central venous The blood pressure in Normal range is 2-6 mm Hg.

pressure (CVP) the vena cava and right
atrial diastolic
pressure; used to
assess preload and
volume status
Mean arterial blood Systolic blood pressure Normal range is 70-105 mm Hg.
pressure (MAP) + (2 x diastolic blood
pressure)/3

Right atrial pressure Reflects venous return Normal range is 0-7 mm Hg.
(RA) to the right atrium and
right ventricular end-
diastolic pressure

Right ventricular Measured during Normal RV systolic pressure is 15-25 mm Hg.

pressure (RV) catheter insertion

Pulmonary artery Used to diagnose Normal PA systolic pressure is 15-25 mm Hg. Normal
pressure (PA) pulmonary artery mean PA pressure is 10-20 mm Hg.
hypertension

Pulmonary capillary Reflects left atrial Normal range is 6-15 mm Hg.

wedge pressure pressure and left
(PCWP) ventricular end-
diastolic pressure (left
ventricular preload)

Systemic vascular The amount of Normal range is 800-1200 dynes-sec/cm-5.

resistance (SVR) resistance the heart
must overcome to
open the aortic valve
and push the blood
volume out into the
systemic circulation
 Pulmonary vascular Reflects the resistance Normal is less than 250 dynes-sec/cm-5.
resistance (PVR) the blood must
overcome to pass into
the pulmonary
vasculature

Novel Cardiac Output Monitoring Devices

Assessment of values obtained from a pulmonary artery catheter is currently considered the gold
standard for monitoring a patient’s hemodynamics and cardiac output). However, there are safety
concerns with pulmonary artery catheters (i.e., infection, pneumothorax, pulmonary artery rupture).
There’s also a lack of evidence to suggest a benefit to mortality.

As an alternative, devices for minimally invasive cardiac output monitoring have been developed. These
devices use arterial pressure and pulse contour or chest bioreactance to assess hemodynamics. Another
alternative, esophageal doppler monitoring, utilizes a flexible trans-esophageal doppler ultrasound
probe to estimate cardiac output and stroke volume. However, these techniques aren’t typically
accurate enough to provide absolute cardiac output values but are more commonly utilized for trending
values.

References:

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Bridges, E. (2013). Using Functional Hemodynamic Indicators to Guide Fluid Therapy. American Journal of Nursing, 113(5),
42-50. https://www.doi.org/10.1097/01.NAJ.0000429754.15255.eb

Clement, R.P., Vos, J.J. & Scheeren, W.L. (2017). Minimally Invasive Cardiac Output Technologies in the ICU: Putting It All
Together. Current Opinion in Critical Care, 23(4), 302-309. https://www.doi.org/10.1097/MCC.0000000000000417

Fleitman, J. (2021, October 18). Pulmonary Artery Catheterization: Interpretation of Hemodynamic Values and
Waveforms in Adults. UpToDate. https://www.uptodate.com/contents/pulmonary-artery-catheterization-interpretation-
of- hemodynamic-values-and- waveforms-in-adults

Kerstens, M.K., Wijnberge, M., Geerts, B. F., Vlaar, A.P., & Veelo, D.P. (2018). Non-invasive cardiac output monitoring
techniques in the ICU. Netherlands Journal of Critical Care, 26(3), 104-110.

Kollef, M. (2017). The Washington Manual of Critical Care (3rd ed.). Wolters Kluwer
Health. https://bookshelf.vitalsource.com/books/9781496398451

Mikkelsen, M.E, Gaieski, D.F., & Johnson, N.J. (2020, September 28). Novel Tools for Hemodynamic Monitoring in Critically Ill
Patients with Shock. UpToDate. https://www.uptodate.com/contents/novel-tools-for-hemodynamic-monitoring-in-critically-
ill-patients- with-shock

Rali, A.S., Butcher, A., Tedford, R.J., Sinha, S.S., Mekki, P., Van Spall, H.G., & Sauer, A.J. (2022). Contemporary Review of
Hemodynamic Monitoring in the Critical Care Setting. US Cardiology Review. https://doi.org/10.15420/usc.2021.34