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Hemodynamic monitoring simply defined is the measurement and analysis of biological signals emanating from the cardiovascular system. Therapies based on these signals are then titrated and physiologic response is measured. Ideally hemodynamic monitoring should involve a holistic approach. Oxygen delivery at both global and regional levels as well as tissue perfusion and cellular health should be assessed. Although easy to articulate, our ability to monitor in this fashion remains limited. Indeed it is sobering to reflect on the paucity of high-quality validation of the commonly used monitors. No randomized trials exist to prove that even monitoring of basic vital signs is beneficial. In fact none are likely to ever be conducted. That being said, in a field as heavily weighted on monitoring, technological advances have evolved over the past 30 years. New noninvasive techniques attempt to negate the necessity of indwelling vascular catheters. The pulmonary artery catheter remains a cornerstone of hemodynamic monitoring despite the persistent controversy about its efficacy. In this chapter, hemodynamic monitoring techniques and important physiologic concepts behind these methods are addressed.
The basic tenet of hemodynamic monitoring is to ensure adequate oxygenation at the cellular level. Physiologic signals obtained by various monitoring techniques are often manipulated to this end. Outside of experimental technologies it is not possible to monitor cellular hypoxia; hence global and sometimes regional variables are used.
Airway management and mechanical ventilation represent the cornerstones of ICU care for critically ill patients. In this chapter we deal with basic concepts and focus on the practical considerations that confront critical care practitioners on a daily basis.
It is essential for critical care specialists to be profi – cient in securing an airway in a variety of patients and clinical scenarios. Critically ill patients often have hypoxia, acidosis, or hemodynamic instability and poorly tolerate delays in placing an airway. Further, underlying conditions such as intracranial hypertension and myocardial ischemia may be exacerbated by the attempt to secure an airway itself. Compounding the problem are the myriad of comorbid and associated conditions such as vascular disease, cervical fractures, facial trauma, laryngeal edema, and patient combativeness associated with the critically ill that complicate the situation.
Criteria for Intubation
Although never validated, the decision to establish a definitive airway is based on three general criteria:
Failure to protect or maintain airway, e.g., loss of protective airway reflexes in brain injured patients
Failure to oxygenate or ventilate, e.g., during cardiopulmonary arrest, acute respiratory distress syndrome (ARDS), septic shock, neuromuscular disease
Anticipation of a deteriorating clinical course, e.g., anatomical airway distortion. Serial clinical assessment is requisite to determine the ability of patients to protect their airway.
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