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Advanced hemodynamic monitoring in intensive care medicine

A German web-based survey study

Erweitertes hämodynamisches Monitoring in der Intensivmedizin

Eine deutsche webbasierte Umfrage

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Abstract

Background

Advanced hemodynamic monitoring is recommended in patients with complex circulatory shock.

Objectives

To evaluate the current attitudes and beliefs among German intensivists, regarding advanced hemodynamic monitoring, the actual hemodynamic management in clinical practice, and the barriers to using it.

Materials and methods

Web-based survey among members of the German Society of Medical Intensive Care and Emergency Medicine.

Results

Of 284 respondents, 249 (87%) agreed that further hemodynamic assessment is needed to determine the type of circulatory shock if no clear clinical diagnosis can be made. In all, 281 (99%) agreed that echocardiography is helpful for this purpose (transpulmonary thermodilution: 225 [79%]; pulmonary artery catheterization: 126 [45%]). More than 70% of respondents agreed that blood flow variables (cardiac output, stroke volume) should be measured in patients with hemodynamic instability. The parameters most respondents agreed should be assessed in a patient with hemodynamic instability were mean arterial pressure, cardiac output, and serum lactate. Echocardiography is available in 99% of ICUs (transpulmonary thermodilution: 91%; pulmonary artery catheter: 63%). The respondents stated that, in clinical practice, invasive arterial pressure measurements and serum lactate measurements are performed in more than 90% of patients with hemodynamic instability (cardiac output monitoring in about 50%; transpulmonary thermodilution in about 40%). The respondents did not feel strong barriers to the use of advanced hemodynamic monitoring in clinical practice.

Conclusions

This survey study shows that German intensivists deem advanced hemodynamic assessment necessary for the differential diagnosis of circulatory shock and to guide therapy with fluids, vasopressors, and inotropes in ICU patients.

Zusammenfassung

Hintergrund

Die Durchführung eines erweiterten hämodynamischen Monitorings wird bei Patienten mit komplexem Kreislaufversagen empfohlen.

Ziel der Arbeit

Evaluierung der Meinungen deutscher Intensivmediziner bezüglich eines erweiterten hämodynamischen Monitorings. Evaluierung des tatsächlich erfolgenden hämodynamischen Managements in der klinischen Praxis sowie von Hindernissen der Durchführung in der deutschen Intensivmedizin.

Material und Methoden

Webbasierte Umfragestudie unter Mitgliedern der Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin.

Ergebnisse

Von 284 Teilnehmern stimmten 249 (87 %) zu, dass ein erweitertes hämodynamisches „Assessment“ nötig ist, wenn die Art des Kreislaufversagens klinisch nicht eindeutig diagnostiziert werden kann. Insgesamt 281 (99 %) stimmten zu, dass die Echokardiographie dafür hilfreich ist (transpulmonale Thermodilution: 225 [79 %]; Pulmonaliskatheter: 126 [45 %]). Mehr als 70 % der Teilnehmer stimmten zu, dass Blutflussvariablen (Herzzeitvolumen, Schlagvolumen) bei Patienten mit hämodynamischer Instabilität bestimmt werden sollten. Parameter, die von den meisten Teilnehmern als wichtig bei Patienten mit hämodynamischer Instabilität erachtet wurden, waren der mittlere arterielle Blutdruck, das Herzzeitvolumen und das Serumlaktat. Die Echokardiographie ist in 99 % der Intensivstationen verfügbar (transpulmonale Thermodilution: 91 %; Pulmonaliskatheter: 63 %). Die Teilnehmer gaben an, dass in der klinischen Praxis bei mehr als 90 % der Patienten mit hämodynamischer Instabilität eine invasive Blutdruckmessung und eine Serumlaktatbestimmung erfolgen (Herzzeitvolumen: etwa 50 %; transpulmonale Thermodilution: etwa 40 %). Die Teilnehmer gaben an, dass sie in der klinischen Praxis keine großen Hindernisse für die Durchführung eines erweiterten hämodynamischen Monitorings empfinden würden.

Schlussfolgerung

Diese Umfrage zeigt, dass deutsche Intensivmediziner ein erweitertes hämodynamisches Monitoring für die Differenzialdiagnostik des Kreislaufversagens und für die Steuerung der Therapie mit Flüssigkeit, Vasopressoren und Inotropika für notwendig erachten.

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Authors and Affiliations

  1. Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany

    B. Saugel MD, P. C. Reese & J. Y. Wagner

  2. Medizinische Klinik II, Kardiologie, Angiologie und Internistische Intensivmedizin, St. Marien-Krankenhaus Siegen, Siegen, Germany

    M. Buerke

  3. II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany

    W. Huber

  4. Department of Intensive Care Medicine, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

    S. Kluge

  5. Medizinische Klinik I, Carl von Basedow Klinikum Saalekreis gGmbH, Merseburg, Germany

    R. Prondzinsky

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  1. B. Saugel MD
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Corresponding author

Correspondence to B. Saugel MD.

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Conflict of interest

B. Saugel received institutional research grants, unrestricted research grants and refunds of travel expenses from Tensys Medical Inc. (San Diego, CA, USA). He received refunds of travel expenses and a fee for giving lectures from CNSystems Medizintechnik AG (Graz, Austria). He received a fee for giving lectures and personal fees as a member of the Medical Advisory Board from Pulsion Medical Systems SE (Feldkirchen, Germany) – outside the submitted work. J.Y. Wagner received institutional research grants, unrestricted research grants and received refunds of travel expenses from Tensys Medical Inc. (San Diego, CA, USA). She also received refunds of travel expenses from CNSystems Medizintechnik AG (Graz, Austria) – outside the submitted work. W. Huber received a fee for giving lectures and personal fees as a member of the Medical Advisory Board from Pulsion Medical Systems SE (Feldkirchen, Germany) outside the submitted work. P.C. Reese, M. Buerke, S. Kluge, and R. Prondzinsky declare that they have no competing interests.

The survey was approved and endorsed by the German Society of Medical Intensive Care and Emergency Medicine (Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin, DGIIN) and we performed it by means of a secure web database. As we did not collect any data of individual patients, we did not obtain approval by the ethics committee for this anonymous and nonattributable survey.

Additional information

Redaktion

U. Janssens, Eschweiler

Authors’ contributions B. Saugel and P.C. Reese contributed equally to the study. B. Saugel was responsible for the conception and design of the study, was responsible for acquisition of data, performed the statistical analyses, was responsible for data analysis and interpretation, and drafted the manuscript. PCR made substantial contributions to the conception, was responsible for acquisition of data, was responsible for data analysis and interpretation, and revised the manuscript for important intellectual content. J.Y. Wagner made substantial contributions to the conception, was responsible for data analysis and interpretation, and revised the manuscript for important intellectual content. M. Buerke was responsible for data analysis and interpretation, and revised the manuscript for important intellectual content. W. Huber was responsible for data analysis and interpretation, and revised the manuscript for important intellectual content. S. Kluge was responsible for data analysis and interpretation, and revised the manuscript for important intellectual content. R. Prondzinsky was responsible for the conception and design of the study, was responsible for acquisition of data, performed the statistical analyses, was responsible for data analysis and interpretation, and drafted the manuscript. All authors read and approved the final version of the manuscript and agree to be accountable for all aspects of the work.

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Saugel, B., Reese, P.C., Wagner, J.Y. et al. Advanced hemodynamic monitoring in intensive care medicine. Med Klin Intensivmed Notfmed 113, 192–201 (2018). https://doi.org/10.1007/s00063-017-0302-0

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