The utilization of point-of-care ultrasound and other non-invasive cardiac output monitoring technologies varies because of knowledge, resource availability and cultural practices. In this  Clinical Challenge in Surgery episode from the Surgical Critical Care team at Behind the Knife, we provide a brief history of the use of cardiac-output monitoring in the ICU, introduce a few clinical scenarios in the context of point of care ultra-sound and other less-invasive cardiac-output monitoring technologies.

Learning Objectives: 
In this episode, we review the historical uses of central venous pressure monitoring, pulmonary-artery catheters and the more frequently utilized point-of-care-ultrasound (or POCUS) in managing complex ICU patients. We review the outcomes behind these technologies, describe the views and utility of POCUS, and introduce less-invasive or completely non-invasive ways to measure cardiac-output monitoring. 



Hosts:

Brittany Bankhead, MD, MS (@BBankheadMD) is an Assistant Professor of Surgery at Texas Tech University Health Sciences Center.

Ryan Dumas, MD, FACS (@PMH_Trauma_RPD) is an Assistant Professor of Surgery at the University of Southwestern Medical Center and Parkland Memorial Hospital.

Caroline Park, MD, MPH, FACS (@CPark_MD) is an Assistant Professor of Surgery at the University of Southwestern Medical Center and Parkland Memorial Hospital.

Links to Papers Referenced in this Episode:
National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wheeler AP, Bernard GR, Thompson BT, Schoenfeld D, Wiedemann HP, deBoisblanc B, Connors AF Jr, Hite RD, Harabin AL. Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury. N Engl J Med. 2006 May 25;354(21):2213-24. doi: 10.1056/NEJMoa061895. Epub 2006 May 21. PMID: 16714768.

Yildizdas D, Aslan N. Ultrasonographic inferior vena cava collapsibility and distensibility indices for detecting the volume status of critically ill pediatric patients. J Ultrason. 2020 Nov;20(82):e205-e209. doi: 10.15557/JoU.2020.0034. Epub 2020 Sep 28. PMID: 33365158; PMCID: PMC7705480.

Kircher BJ, Himelman RB, Schiller NB. Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava. Am J Cardiol. 1990 Aug 15;66(4):493-6. doi: 10.1016/0002-9149(90)90711-9. PMID: 2386120.

Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med. 2013 Jul;41(7):1774-81. doi: 10.1097/CCM.0b013e31828a25fd. PMID: 23774337.

Acknowledgements: 
We would like to acknowledge Dr. Hassan Mashbari and the Department of Surgical Critical Care and Anesthesia at the Massachusetts General Hospital and Dr. Christopher Choi and the Department of Anesthesiology at the University of Texas Southwestern for their ultra-sound video contributions.

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