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CVP, Blood Pressure and Urine Output:
Are they ever enough? (interactive session)
Background
When caring for critically ill patients, the question of hemodynamic
monitoring is a cardinal one. We have to assess and decide
whether the tools at our disposal are adequate for the clinical
scenario at hand. Clearly it makes sense that in the most severely
compromised patients, there is a need for information regarding
cardiovascular and pulmonary function. Unfortunately,
the situations in which these measurements can be helpful and
sometimes even mandatory and in which this information may
improve outcome, are not clearly established. In this presentation
I have attempted to look at the question of whether basic
monitoring tools are ever enough.
Question 1: ---Are blood pressure, urine output
and central venous pressure ever enough?
80
60
40
20
0
Yes, they can be enough
in many patients
*Results (in%) of the votes of an interactive session (audience 300) during ISICEM, 2012
Case Study 1
No, they are
never enough
The first example of a trauma case illustrates this point. A 25
year old male is injured by a car and brought into the Emergency
Room (ER) with chest and head injuries. In the ER the
following parameters were measured;
Blood pressure 86/50
CVP 4 cmH 0 2
Urine Output 30 ml/hr
Dr. Eran Segal, MD
Director, Department of Anesthesia, Critical Care and Pain Medicine, Assuta Medical
Centers, Israel
Dr. Segal is the director of anesthesia, Intensive Care and Pain Medicine of Assuta Medical
Centers, in Israel. Dr. Segal was trained in the Sheba Medical Center, and in Gainesville, Florida.
He is the President of the Israeli Society of Critical Care Medicine. His main interests are
advanced hemodynamic monitoring and mechanical ventilation.
I have never
needed anything else
Question 2: What is the probable diagnosis?
100
80
60
40
20
0
Septic shock
Anaphylactic
shock
Hemorrhagic
shock
*Results (in%) of the votes of an interactive session (audience 300) during ISICEM, 2012
As the audience thought, the diagnosis here is quite clear, and
in fact as reflected by the history, blood pressure, urine output
and CVP in this instance are enough.
Question 3: What should be done?
100
80
60
40
20
0
Administer
fluids
Urine
electrolytes
PA catheter
*Results (in %) of the votes of an interactive session (audience 300) during ISICEM, 2012
In this instance the CVP and blood pressure were accurate
reflectors of his hypovolemia. But we probably didn’t need them
anyway given his clinical presentation. Again, the data and the
history are enough in this case to evaluate his status and formulate
a plan.
However, things are not always so simple.
Cardiogenic
shock
PiCCO