Hemodynamic Monitoring:what is new in 2017

Here is a  link to the audio of the entire (Non- Invasive) Hemodynamic Montoring in perioperative setting and in the ICU in critically ill intubated and non- intubated patients at ISICEM  37th Meeting Brussels , Belgium . It's somewhat of an exhaustive review.I will publish the slides later, as I am sending this ad hoc from the Starbucks at Brussels Central train Station. 

At the end, I felt somewhat let down as I could not pinpoint either Xavier Monnet or Ivor Douglas what single test to use on on critically ill septic patients to asses PLR, particularly in intubated patients without arrhythmia's, sedated and not over- breathing the ventilator (either on VCV- AC and PC- AC).

Both speakers also had a significant conflicts of interest. Xavier Monnet with Precision Medical and Ivor Douglas with Cheetah Medical, both heavily sponsored for there research in the field. 
Nevertheless, I think you will take away clinical useful information from most of the talks. 

Keep in mind that the latest and newest drug or test often doesn't stand the test of time.  An important article from the New Yorker ,  highlights the point I am trying to make here .Will NICOM or etCO2  as CO ( cardiac output ) surrogate measurement technique to assess FLR  fall prey to " regression to the mean ",  as happens for most clinical interventions and diagnostic tests?  Bioimpedance is a noteworthy example in this category. I am afraid the answer will be eventually ...yes. 

(More thoughts of the decline effect, New Yorker) 

A few pratical and clinical helpful messages can be taken away form this session: 

1) Provided you believe the results, act accordingly to what the device tells you (consistency). Unfortunately, I have not found the +LR and -LR ratios for either etCO2 and NICOM. I asked the question, neither researchers could give me an answer.

2) Probably, the most useful result you can get, applied to the current "slow data-point collection" NICOM device is a negative result ( I supect NICOm has a good NPV but I cannot prove this based on the literature). This is important because further aggressive fluid administration will avoid  further damage to the glycocalyx and capillary leak  

3) Repeated fluid boluses guided by a positive result on NICOM ( assuming an unrealistic 100% accuracy - probably more in the 60- to 70% range), may still cause an overshoot. 
Is the infliction point for CO on the Frank-Starling (FS) curve the end- point  for optimal tissue perfusion and oxygenation?
What is the ideal CO for an individual patient ? (something these devices cannot tell us ). We are already high on the FS ("flat part") curve once the test becomes negative. Do we need to go this far ?  

4) Maintenance fluids after initial volume resuscitation (this is  after the usual 30 ml/kg in the hypotensive septic patient and +/- pressor use initially) should be abandoned in favor of clinical assessment and FLR.Either etCO2 ( but specific conditions will need to be met and thsi will be a topic of another blog entry) or NICOM maybe a useful CO surrogate marker, although PPV/SVV techniques can still  be used in the right clinical context. 
Unchecked/unmonitored use of maintenance fluids is associated with increased mortality.

5) "Rapid NICOM" (not clinically available yet ) may be the most single useful test in the near future for FLR ( flid responsiveness).

6) Because of the well studied variable accuracy ( >30-40%) of various noninvasive hemodynamic monitoring techniques, trending results does not necessarily improve clinical decision making. Accuracy is not independent of interpretation of trending results.   

Programme Hemodynamic Non- Invasive Montoring 37th Symposium 2017, Brussels, Belgium