Unit of Cardiothoracic and Vascular Anesthesia and Intensive Care, Department of Anesthesia and Critical Care Medicine, University Hospital of Pisa, Pisa, Italy -
Unit of Cardiothoracic and Vascular Anesthesia and Intensive Care, Department of Anesthesia and Critical Care Medicine, University Hospital of Pisa, Pisa, Italy.
Minerva Anestesiol. 2018 Jul;84(7):858-864. doi: 10.23736/S0375-9393.18.12212-7. Epub 2018 Jan 16.
Hemodynamic monitoring is essential during the treatment of the critically ill in order to address the hemodynamic alterations and assess the response to treatment. Traditionally classified causes of shock and underlying pathophysiological mechanisms are often neglected by resuscitative strategies included in the guidelines. Most of hemodynamic management focuses on the ability to early recognize patients susceptible to increase cardiac output (CO) and mean arterial pressure (MAP) after a defined fluid challenge by eliciting Starling's law of the heart, and less is known of the ones presenting in shock and not volume responsive. All this influences the application of hemodynamic monitoring tools and their interpretation. Functional hemodynamic monitoring strategies, aiming to overcome limitations of traditional static pressures measurements, have been developed and recently acknowledged by guidelines for the treatment of septic shock. Nevertheless, those techniques share the same limitations of previous ones, being poorly reliable in various common situations such as in spontaneous breathing patients, right ventricular dysfunction of several causes or if arrhythmia occurs. Echocardiography has now become commonplace in the evaluation of the hemodynamic profile in the critically ill and mastering this technique is important in order to interpret pathophysiological patterns behind hemodynamic alteration while at the same time, screening for unexpected findings. More recently, pathophysiological and echocardiographic-based approaches have been introduced to investigate ventriculo-arterial coupling, the relationship between both left and right heart and the relative circulatory bed. Such techniques allowed establishing that in many critically ill scenarios, coupling between the heart and the circulation is inefficient and probably that is the reason why in this case hemodynamic restoration cannot be achieved by standard approaches. Combining echocardiography to better understand and treat in real-time pathophysiological determinants of altered hemodynamic states with functional approaches seems to be the key to plumb hemodynamic states although it remains to be demonstrated if this tailored approach will improve patient outcome.
血流动力学监测在危重病患者的治疗中至关重要，以便解决血流动力学改变并评估治疗反应。传统上，指南中包含的复苏策略常常忽略休克的分类原因和潜在病理生理机制。大多数血流动力学管理侧重于早期识别患者的能力，这些患者在经过定义的液体挑战后，通过引发心脏的 Starling 定律，容易增加心输出量 (CO) 和平均动脉压 (MAP)，而对那些休克且对容量无反应的患者则知之甚少。所有这些都影响血流动力学监测工具的应用及其解释。旨在克服传统静态压力测量局限性的功能性血流动力学监测策略已经得到发展，并在最近的脓毒性休克治疗指南中得到认可。然而，这些技术与之前的技术具有相同的局限性，在各种常见情况下，例如自主呼吸患者、多种原因引起的右心室功能障碍或发生心律失常时，其可靠性较差。超声心动图现已成为评估危重病患者血流动力学特征的常规方法，掌握这项技术对于解释血流动力学改变背后的病理生理模式非常重要，同时还可以筛查意外发现。最近，已经引入了基于病理生理和超声心动图的方法来研究心室-动脉偶联，即左右心之间以及相对循环床之间的关系。这些技术表明，在许多危重病情况下，心脏和循环之间的偶联效率低下，这可能就是为什么在这种情况下，标准方法无法实现血流动力学恢复的原因。结合超声心动图，通过功能方法实时更好地理解和治疗改变血流动力学状态的病理生理决定因素，似乎是解决血流动力学状态的关键，尽管尚需证明这种定制方法是否会改善患者的预后。
