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Chapter 7

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*The author of Cardiopulmonary Monitoring is Ronald B. Hirschl.

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The authors of Advanced Hemodynamic Monitoring are Steven L. Moulton, Jane Mulligan, and Victor A. Convertino.

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The author of Acute Cardiopulmonary Resuscitation is Ronald B. Hirschl.

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The authors of Pharmacology are Pamela D. Reiter and Steven L. Moulton.

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The authors of Respiratory Failure and ECMO are Artur Chernoguz and Jason S. Frischer.

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Conventional Cardiopulmonary Monitoring

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Key Points

  1. Pulse oximetry provides a measure of oxygen saturation as well as information on heart rate and perfusion. The end-tidal carbon dioxide (etCO2) helps document effective ventilation; and in patients with healthy lungs, the maximal etCO2 assayed over minutes provides an approximation of the PacO2.

  2. The SvO2 level serves as a measure of oxygen dynamics, assessing the adequacy of oxygen delivery as well as consumption.

  3. Assessment of central venous pressure should be performed at end-expiration; central venous oxygen saturation (ScvO2) may be used to guide treatment in patients with sepsis.

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Monitoring is integral to the management of the critically ill patient and is one of the essential services provided by the intensive care unit (ICU). Whether by invasive or noninvasive means, the overall goal is to maintain cardiovascular and respiratory stability. In this chapter, we discuss monitoring and management of the critically ill patient with particular emphasis on the use of such monitoring to maintain optimal oxygen delivery and perfusion and to interpret and treat cardiovascular and respiratory derangement and pathophysiology.

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Traditional Noninvasive Monitoring

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Although monitors are an essential part of modern critical care, they are designed to supplement rather than replace clinical judgment. The physical examination is an important component in the assessment of perfusion and intravascular volume status. Warmth and color of extremities, capillary refill, assessment of oral and ocular mucous membranes, axillary moistness, urinary output measurement in the patient without renal insufficiency, and the fullness of the anterior fontanel in the newborn and infant may be integrated with data gained via invasive and noninvasive monitoring to assess the cardiopulmonary status. Cool, mottled extremity skin, capillary refill greater than 2 seconds, urinary output less than 0.5 mL/kg, orthostatic change with a fall in pressure of 20 mm Hg or a rise in pulse of 20 beats per minute with elevation of the head of the bed, a flat fontanelle, and dry mucous membranes are all clinical parameters that indicate inadequate cardiac output and/or perfusion.

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One of the most basic of noninvasive monitoring procedures is that of electrocardiographic monitoring (ECG). Typically, ECG leads are placed on the right upper chest, the left upper chest, and the left lower chest in the anterior axillary line such that data from leads I, II, and V1 are provided. ECG monitoring should be used routinely in all critically ill patients to assess heart ...

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