Changing trends of hemodynamic monitoring in ICU - from invasive to non-invasive methods: Are we there yet?

Hemodynamic monitoring in the form of invasive arterial, central venous pressure and pulmonary capillary wedge pressure monitoring may be required in seriously ill Intensive care unit patients, in patients undergoing surgeries involving gross hemodynamic changes and in patients undergoing cardiac surgeries. These techniques are considered the gold standards of hemodynamic monitoring but are associated with their inherent risks. A number of non-invasive techniques based on various physical principles are under investigation at present. The goal is to not only avoid the risk of invasive intervention, but also to match the gold standard set by them as far as possible. Techniques based on photoplethysmography, arterial tonometry and pulse transit time analysis have come up for continuous arterial pressure monitoring. Of these the first has been studied most extensively and validated, however it has been shown to be substandard in patients with gross hemodynamic instability. The other two still need further evaluation. While the non-invasive methods for arterial blood pressure monitoring are based on diverse technologies, those for measurement of central venous and pulmonary pressures are mostly based on imaging techniques such as echocardiography, Doppler ultrasound, computed tomography scan and chest X ray. Most of these techniques are based on measurement of the dimensions of the great veins. This makes them operator and observer dependent. However, studies done till now have revealed adequate inter-observer agreement. These techniques are still in their incipience and although initial studies are encouraging, further research is needed on this front.