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SIXTHEDITION

CriticalCareHandbookofthe
MassachusettsGeneralHospital


SIXTHEDITION

CriticalCareHandbookofthe
MassachusettsGeneralHospital
SeniorEditor
JeanineP.Wiener-Kronish
AssociateEditors
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JonathanE.Charnin
J.PerrenCobb
MatthiasEikermann
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Iwouldjustthanktheauthors,theresidents,thefaculty,andaboveall,ourpatientswho
havegivenustheprivilegeofallowingustocareforthem.Wewillengageincontinuous
learningtoensurethatourcareforourpatientsisoptimal.
JeanineP.Wiener-Kronish,MD


CONTRIBUTORS

YoungAhn,MD
MedicalDirector
DepartmentofAnesthesiology
PerioperativeServices—DistrictofColumbia/SuburbanMaryland
KaiserPermanente:Mid-AtlanticPermanenteMedicalGroup
Largo,Maryland
AranyaBagchi,MBBS
AssistantinAnesthesia
MassachusettsGeneralHospital
InstructorinAnesthesia
HarvardMedicalSchool

Boston,Massachusetts
EdnanK.Bajwa,MD,MPH
MedicalICUDirector
DivisionofPulmonaryandCriticalCareMedicine
MassachusettsGeneralHospital
Boston,Massachusetts
PeterL.Bekker,MD
Resident
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
ClinicalFellow
HarvardMedicalSchool
Boston,Massachusetts
LorenzoBerra,MD
AnesthesiologistandCriticalCarePhysician
AssistantProfessor
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
HarvardMedicalSchool
Boston,Massachusetts


EdwardA.Bittner,MD,PhD,MSEd,FCCP,FCCM
ProgramDirector
CriticalCareMedicine-AnesthesiologyFellowship
AssociateDirector,SurgicalIntensiveCareUnit
AssistantProfessorofAnaesthesia
HarvardMedicalSchool
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital

Boston,Massachusetts
KevinBlackney,MD
ResidentinAnesthesiology
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
HarvardMedicalSchool
Boston,Massachusetts
SharonBrackett,RN,BS,CCRN
AttendingNurse,SurgicalICU
MassachusettsGeneralHospital
Boston,Massachusetts
JeffreyBruckel,MD,MPH,HMS
FellowinQualityandSafety
EdwardLawrenceCenterforQualityandSafety
MassachusettsGeneralHospital
Boston,Massachusetts
RichardN.Channick,MD
Director,PulmonaryHypertensionandThromboendarterectomyProgram
MassachusettsGeneralHospital
AssociateProfessorofMedicine
HarvardMedicalSchool
Boston,Massachusetts
JonathanE.Charnin,MD
InstructorinAnesthesia
HarvardMedicalSchool
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital


Boston,Massachusetts

SanjeevV.Chhangani,MD,MBA,FCCM
AssistantProfessorofAnaesthesia
HarvardMedicalSchool
AssociateAnesthetist
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
Boston,Massachusetts
HovigV.Chitilian,MD
AssistantProfessorofAnesthesiology
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
HarvardMedicalSchool
Boston,Massachusetts
AlexandraF.M.Cist,MD
Instructor
HarvardMedicalSchool
PulmonaryandCriticalCareUnit
MassachusettsGeneralHospital
Boston,Massachusetts
J.PerrenCobb,MD,FACS,FCCM
Vice-ChairforCriticalCare
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
AssociateProfessorofSurgeryandAnesthesiology
HarvardMedicalSchool
Boston,Massachusetts
GastonCudemus,MD
ClinicalInstructor
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital

HarvardMedicalSchool
Boston,Massachusetts
BrianM.Cummings,MD


PediatricCriticalCare,AssistantinPediatrics
MassGeneralHospitalforChildren
InstructorinMedicine
HarvardMedicalSchool
Boston,Massachusetts
MarcA.deMoya,MD
MedicalDirector,Blake12ICU
FellowshipDirector,SurgicalCriticalCare
MassachusettsGeneralHospital
AssistantProfessorofSurgery
HarvardMedicalSchool
Boston,Massachusetts
MatthiasEikermann,MD,PhD
AssociateProfessorofAnaesthesia
HarvardMedicalSchool
ClinicalDirector,CriticalCareDivision
MassachusettsGeneralHospital
Boston,Massachusetts
PeterJ.Fagenholz,MD
AttendingSurgeon,DivisionofTrauma,EmergencySurgery,andCriticalCare
MassachusettsGeneralHospital
InstructorinSurgery
HarvardMedicalSchool
Boston,Massachusetts
DavidW.Fink,MD

Instructor
Trauma,EmergencySurgery,SurgicalCriticalCare
MassachusettsGeneralHospital
Boston,Massachusetts
MichaelG.Fitzsimons,MD,FCCP
Director,CardiacAnesthesia
AssistantProfessor
HarvardMedicalSchool
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital


Boston,Massachusetts
EugeneFukudome,MD
ClinicalFellowinSurgery
DepartmentofSurgery
BrighamandWomen’sHospital
Boston,Massachusetts
JoseP.Garcia,MD
SurgicalDirector,CardiothoracicTransplantation
ArtificialHeartandLungProgram
MassachusettsGeneralHospital
HarvardMedicalSchool
Boston,Massachusetts
KlausGoerlinger,MD
DepartmentofAnesthesiologyandIntensiveCareMedicine
UniversityHospitalEssen
Essen,Germany
JessicaHahn,MD
MassGeneralHospitalforChildren

Boston,Massachusetts
R.ScottHarris,MD
AssociatePhysician
MassachusettsGeneralHospital
AssociateProfessorofMedicine
HarvardMedicalSchool
Boston,Massachusetts
DeanR.Hess,PhD,RRT
AssistantDirectorofRespiratoryCare
MassachusettsGeneralHospital
AssociateProfessorofAnesthesia
HarvardMedicalSchool
Boston,Massachusetts
KathrynA.Hibbert,MD
InstructorinMedicine,DivisionofPulmonaryandCriticalCare


MassachusettsGeneralHospital,
HarvardMedicalSchool
Boston,Massachusetts
RonaldHirschberg,MD
MassachusettsGeneralHospital
DepartmentofPhysicalMedicineandRehabilitation
Boston,Massachusetts
CraigS.Jabaley,MD
ClinicalFellowinCriticalCare
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
HarvardMedicalSchool
Boston,Massachusetts

ChristinaJelly,MD,MSc
ClinicalFellow
HarvardMedicalSchool
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
Boston,Massachusetts
DanielW.Johnson,MD
DivisionChief,CriticalCare,Director
CriticalCareAnesthesiologyFellowship
AssistantProfessor
DepartmentofAnesthesiology
UniversityofNebraskaMedicalCenter
Omaha,Nebraska
SameerS.Kadri,MD,MS
Physician-Scientist
CriticalCareMedicineDepartment
ClinicalCenter
NationalInstitutesofHealth
Bethesda,Maryland
RebeccaI.Kalman,MD
InstructorofAnesthesia


DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
Boston,Massachusetts
Corry“Jeb”Kucik,MD,MA,DMCC,FCCP,FUHM
Commander,MedicalCorps,USNavy
Head,HealthcareNetAssessments
NavyBureauofMedicineandSurgery

FallsChurch,Virginia
AssistantProfessorofAnesthesiology
UniformedServicesUniversity
Bethesda,Maryland
AlexanderS.Kuo,MD,MS
FellowinAnesthesiology
DepartmentofAnesthesiaandCriticalCare
MassachusettsGeneralHospital
HarvardMedicalSchool
Boston,Massachusetts
JeanKwo,MD
AssistantProfessorofAnesthesia
DepartmentofAnesthesia,CriticalCareandPainMedicine
Boston,Massachusetts
YvonneLai,MD
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
Boston,Massachusetts
AliceD.Lam,MD,PhD
EpilepsyFellow
DepartmentofNeurology
MassachusettsGeneralHospital
Boston,Massachusetts
JaroneLee,MD,MPH
InstructorinSurgery
HarvardMedicalSchool
DivisionofTrauma,EmergencySurgery,SurgicalCriticalCare


MassachusettsGeneralHospital

Boston,Massachusetts
BenjaminLevi,MD
AssistantProfessorinSurgery
DivisionofPlasticandReconstructiveandBurnSurgery
UniversityofMichigan
Director
Burn/WoundandRegenerativeMedicineLaboratory
AnnArbor,Michigan
AlexanderR.Levine,PharmD
CriticalCarePharmacist
DepartmentofPharmacy
MassachusettsGeneralHospital
Boston,Massachusetts
HsinLin,PharmD
ICUPharmacist
PharmacyDepartment
MassachusettsGeneralHospital
Boston,Massachusetts
AndrewL.Lundquist,MD,PhD
AssistantClinicalDirector
DivisionofNephrology
MassachusettsGeneralHospital
Boston,Massachusetts
LaurieO.Mark,MD
ResidentPhysician
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
Boston,Massachusetts
MarcosVidalMelo,MD,PhD
AssociateProfessorofAnesthesia

DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
HarvardMedicalSchool


Boston,Massachusetts
SanjayMenon,MD
ClinicalFellowinNeurology
DepartmentofNeurology
MassachusettsGeneralHospital
Boston,Massachusetts
RebeccaD.Minehart,MD
AssistantProfessor
MassachusettsGeneralHospital
HarvardMedicalSchool
Boston,Massachusetts
JeremiR.Mountjoy,MSc,MD,FRCPC
InstructorinAnesthesia
MassachusettsGeneralHospital
HarvardMedicalSchool
Boston,Massachusetts
GuidoMusch,MD,MBA
AssociateProfessorofAnesthesia
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
HarvardMedicalSchool
Boston,Massachusetts
YasukoNagasaka,MD,PhD
Fellow,CardiothoracicAnesthesia
DepartmentofAnesthesia,CriticalCareandPainMedicine

MassachusettsGeneralHospital
Boston,Massachusetts
JohnH.Nichols,MD
ResidentinAnesthesiology
DepartmentofAnesthesiaandCriticalCare
MassachusettsGeneralHospital
Boston,Massachusetts
CrystalM.North,MD


ClinicalResearchFellow
PulmonaryandCriticalCareMedicine
MassachusettsGeneralHospital
Boston,Massachusetts
AlaNozari,MD,PhD
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
HarvardMedicalSchool
Boston,Massachusetts
MadhukarS.Patel,MD,MBA,ScM
ResidentinSurgery
DepartmentofSurgery
MassachusettsGeneralHospital
Boston,Massachusetts
PratikV.Patel,MD
ActingAssistantProfessor
DepartmentofAnesthesiologyandPainMedicine
UniversityofWashingtonHospitalHarborviewMedicalCenter
UniversityofWashington
Seattle,Washington

RichardM.Pino,MD,PhD,FCCM
AssociateProfessorinAnesthesia
HarvardMedicalSchool
AssociateAnesthetist
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
Boston,Massachusetts
JustinM.Poltak,MD
AttendingPhysician
DepartmentofAnesthesiology
MaineMedicalCenter
Portland,Maine
KateRiddell,MD
InstructorinAnesthesia


MassachusettsGeneralHospital
HarvardMedicalSchool
Boston,Massachusetts
FionaD.Roberts,MA
ProjectCoordinator
EdwardP.LawrenceCenterforQualityandSafety
MassachusettsGeneralHospital
Boston,Massachusetts
DanielSaddawi-Konefka,MD,MBA
Instructor
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
HarvardMedicalSchool
Boston,Massachusetts

WilliamJ.Sauer,MD
ChiefResident
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
Boston,Massachusetts
MiladSharifpour,MD,MS
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
Boston,Massachusetts
KennethShelton,MD
InstructorinAnesthesia
DepartmentofAnesthesia
MassachusettsGeneralHospital
Boston,Massachusetts
RobertSheridan,MD,FACS
DepartmentofSurgery
MassachusettsGeneralHospital
Boston,Massachusetts
MatthewJ.G.Sigakis,MD


ClinicalFellowinCriticalCare
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
HarvardMedicalSchool
Boston,Massachusetts
ChristopherR.Tainter,MD,RDMS
AssistantClinicalProfessor
DepartmentofEmergencyMedicine
DepartmentofAnesthesiology,DivisionofCriticalCare

UniversityofCalifornia,SanDiego
SanDiego,California
B.TaylorThompson,MD
DivisionofPulmonaryandCriticalCare
MassachusettsGeneralHospital
HarvardMedicalSchool
Boston,Massachusetts
AndreaT.Tull,PhD
Director,ReportingandAnalytics
CenterforQualityandSafety
MassachusettsGeneralHospital
Boston,Massachusetts
ParsiaA.Vagefi,MD,FACS
AssociateSurgicalDirector,LiverTransplantation
MassachusettsGeneralHospital
AssistantProfessorofSurgery
HarvardMedicalSchool
Boston,Massachusetts
OlofViktorsdottir,MD
AssistantinAnesthesia
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
InstructorinAnesthesia
HarvardMedicalSchool
Boston,Massachusetts


KarenWaak,PT,DPT,CCS
PhysicalTherapyClinicalSpecialist
DepartmentofPhysicalTherapy

MassachusettsGeneralHospital
Boston,Massachusetts
SarahWahlster,MD
ActingAssistantProfessorofNeurology
HarborviewMedicalCenter
UniversityofWashington
Seattle,Washington
M.BrandonWestover,MD,PhD
HarvardMedicalSchool
MassachusettsGeneralHospital
NeurologyDirector
MGHCriticalCareEEGMonitoring
Boston,Massachusetts
JeanineP.Wiener-Kronish,MD
Anesthetist-in-Chief
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
Boston,Massachusetts
StephenD.Wilkins,MD
ClinicalFellowinCardiacAnesthesia
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
HarvardMedicalSchool
Boston,Massachusetts
ElizabethCoxWilliams,MD
InstructorinAnesthesia
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
Boston,Massachusetts
AlisonS.Witkin,MD

DivisionofPulmonaryandCriticalCareMedicine


MassachusettsGeneralHospital
Boston,Massachusetts
VictorW.Wong,MD
Resident,PlasticandReconstructiveSurgery
JohnsHopkinsMedicalSchool
Baltimore,Maryland
DanielYagoda,MPH
AdministrativeDirector
CenterforQualityandSafety
MassachusettsGeneralHospital
Boston,Massachusetts
D.DanteYeh,MD,FACS
ClinicalInstructorinSurgery
MassachusettsGeneralHospital
DepartmentofSurgery
DivisionofTrauma,EmergencySurgery,andSurgicalCriticalCare
AssociateDirectorofSurgicalIntensiveCareUnit
Boston,Massachusetts
KevinH.Zhao,MD
CriticalCareFellow
DepartmentofAnesthesia,CriticalCareandPainMedicine
MassachusettsGeneralHospital
Boston,Massachusetts


PREFACE

TheCriticalCareHandbookoftheMassachusettsGeneralHospitalismeanttoprovideallhealthcare
providerswithanoverviewofthisenlargingandexcitingfield.Criticalcarenowencompassesthecare
ofallpatientsrequiringintensephysiologicmonitoring.Thesepatientsincludepatientswhonowsurvive
previously untreatable cancers, trauma victims of all ages, postoperative patients of all ages, patients
whose age or comorbidities would have previously precluded anesthesia and surgery, and patients
requiringmechanicalsupportforprolongedperiods.
TheseparationofICUsissomewhatartificialsincepatientsoftenhavemultipleproblemsrequiring
multiplemedicalspecialties.Likewise,theskillsofintensivistsareexpandingandincludetransthoracic
echocardiography, transesophageal echocardiography, experience with ECMO and destination hearts as
wellasexperiencewithliver,heart,face,andkidneytransplants.Inaddition,intensivistsmustnowlearn
toprotectthemselvesfromEBOLAandMERSaswellasfrominfluenzaandantibiotic-resistantbacteria.
Sometreatmentshavechangedonlyslightlyovertheyears,butthefutureofcriticalcarewillinvolve
estimationofpatientgeneticsandimmunologicstatusaswellastheirmicrobiomes.Moleculartechniques
utilized only for research until recently will now come to the clinical arena. Critical care practitioners
willneedknowledgeofthesetechniques,aswellasanappreciationofepidemiology,diseasestates,and
the economics of care. Communication skills need to be taught to improve patient care; patients need
multipleproviderswhentheyhavemultipleorgandysfunction.Protocolsandchecklistsimproveaspects
ofcare,asdoesoptimalcommunicationbetweenpractitionersandpatientsandtheirfamilies.
The handbook has been heavily revised to reflect a multidisciplinary approach to care, the need to
include all care providers to optimize treatment, and the need for ongoing education and learning. The
challenges will continue, but so does the satisfaction in caring for our sickest patients and our goal of
continuallyimprovingourpatients’lives.


CONTENTS

Contributors
Preface
PARTI:GENERALPRINCIPLES
HemodynamicMonitoring

1

ChristinaJellyandDanielSaddawi-Konefka

RespiratoryMonitoring
2

MarcosVidalMeloandHovigV.Chitilian

UseofUltrasoundinCriticalIllness
3

KennethSheltonandKateRiddell

AirwayManagement
4

JohnH.NicholsandJonathanE.Charnin

MechanicalVentilation
5

KathrynA.HibbertandDeanR.Hess

HemodynamicManagement
6

MiladSharifpourandEdwardA.Bittner

SedationandAnalgesia

7

HsinLinandMatthiasEikermann

Fluids,Electrolytes,andAcid–BaseManagement
8

YvonneLaiandAranyaBagchi

Trauma
9

DavidW.FinkandPeterJ.Fagenholz

CriticalCareoftheNeurologicalPatient
10

SarahWahlsterandAlaNozari

NutritioninCriticalIllness
11

RebeccaI.KalmanandD.DanteYeh

InfectiousDisease
12

CraigS.Jabaley

CriticalCareManagementofEbolaVirusDisease

13

DanielW.Johnson

TransportingtheCriticallyIllPatient
14

MatthewJ.G.SigakisandJeremiR.Mountjoy

CoronaryArteryDisease
15

StephenD.Wilkins,Corry“Jeb”Kucik,andMichaelG.Fitzsimons

ValvularHeartDisease
16

AlexanderS.KuoandJustinM.Poltak

PART2:SPECIFICCONSIDERATIONS
CardiacDysrhythmias
17

YasukoNagasakaandKennethShelton

ECMOandVentricularAssistDevices
18

GastonCudemusandJoseP.Garcia

TheAcuteRespiratoryDistressSyndrome
19

LorenzoBerraandB.TaylorThompson

Asthma,ChronicObstructivePulmonaryDisease
20

R.ScottHarrisandGuidoMusch

DeepVenousThrombosisandPulmonaryEmbolismintheIntensiveCareUnit
21

AlisonS.WitkinandRichardN.Channick

DiscontinuationofMechanicalVentilation
22

CrystalM.NorthandEdnanK.Bajwa

AcuteKidneyInjury
23

WilliamJ.SauerandAndrewL.Lundquist

CriticalCareofPatientswithLiverDisease
24

HovigV.Chitilian,MadhukarS.Patel,andParsiaA.Vagefi

CoagulopathyandHypercoagulability
25

YoungAhnandKlausGoerlinger

AcuteGastrointestinalDiseases
26

MarcA.deMoya,JeanKwo,andEugeneFukudome

EndocrineDisordersandGlucoseManagement
27

KevinH.ZhaoandElizabethCoxWilliams

InfectiousDiseases—EmpiricandEmergencyTreatment


28

AlexanderR.LevineandSameerS.Kadri

AdvancesandChallengesinSepsis
29

AranyaBagchiandJ.PerrenCobb

Stroke,Seizures,andEncephalopathy

30

AliceD.Lam,M.BrandonWestover,andPratikV.Patel

AcuteWeakness
31

SanjayMenonandKarenWaak

DrugOverdose,Poisoning,andAdverseDrugReactions
32

KevinBlackneyandJaroneLee

AdultResuscitation
33

PeterL.BekkerandRichardM.Pino

BurnCriticalCare
34

BenjaminLevi,VictorW.Wong,andRobertSheridan

TransfusionMedicine
35

ChristopherR.TainterandKennethShelton

ObstetricCriticalCare

36

OlofViktorsdottirandRebeccaD.Minehart

PART3:HEALTHCARESERVICES
ICUHandoffsandTransitions
37

JeffreyBruckel,FionaD.Roberts,andDanielYagoda

Long-TermOutcomesofICUPatients
38

LaurieO.MarkandRonaldHirschberg

TheEconomicsofCriticalCare:MeasuringandImprovingValueintheICU
39

AndreaT.TullandJ.PerrenCobb

TelemedicineandRemoteElectronicMonitoringSystemsinICU
40

SanjeevV.Chhangani

QualityImprovementandStandardizationofPractice
41

JessicaHahnandBrianM.Cummings

EthicalandLegalIssuesinICUPractice
42

AlexandraF.M.Cist,RebeccaI.Kalman,andSharonBrackett


Index


PARTI:GENERALPRINCIPLES

I.HEMODYNAMICMONITORINGisoneofthecornerstonesofpatientevaluationinthe
intensivecareunitandprovidesdiagnosticandprognosticvalue.Thechoiceofmonitoring
dependsonthediagnosticneedsofthepatientandtherisk–benefitbalanceofmonitor
placementandmaintenance.Thischapteroutlinesanapproachtoassessmentofhemodynamics
andperfusionincriticallyillpatientsandthetechnicalprinciplesofcommonlyused
monitoringmethods.
A.Perfusion:Thegoalofhemodynamicmonitoringistoensureadequatetissueperfusion
forgas,nutrient,andwasteexchangetoultimatelydecreasemorbidityandmortality.To
getfromoptimizingasinglehemodynamicparametertoimprovingmorbidityand
mortalityrequiresmanyassumptions(asshowninFig.1.1formeanarterialpressure,
MAP).Forthisreason,theintensivistshouldnotrelysolelyonanyonephysicalmonitor
andshouldlookforothersignsofadequateperfusionsuchasmentalstatus,urineoutput,
orlaboratoryfindings(e.g.,centralvenousoxygensaturation,basedeficit,lactate).
B.OptimizingPerfusion:Hemodynamicmonitorsbythemselvesarenottherapeutic.
Hemodynamicdatashouldbeusedtoguidetherapy.Optimizingperfusionmayrequire
fluidadministration,diuresis,pharmacologicagents(e.g.,vasoconstrictors,inotropic
agents),orinterventions(e.g.,thrombectomy,intra-aorticballoonpump,ventricular
assistdevices,extracorporealmembraneoxygenation).Withthisinmind,anymonitor
mustbeuseddynamicallytoensurethatemployedtherapiesareoptimizingperfusion

overtime.
1.Fluidchallenge:Thefluidchallengeisatime-honoredtestthatbearsspecific
mention.Rapidadministrationofcrystalloid(typically500cc–1L)whilemonitoring
hemodynamicsisusedtodetermineifapatientmaybenefitfromfluid,assuggested
byanincreaseincardiacoutputorbloodpressure,forexample.A“passiveleg
raise”testprovidessimilarinformation.Toperformthistest,aclinicianpassively
elevatesasupinepatient’slegs.Bloodmovestothecentralveinsfromtheelevated
limbs,providingan“autotransfusion”ofapproximately150to300cc.An
improvementinhemodynamicssuggestsfluidresponsiveness,whereasdeterioration
inhemodynamicscanbequicklyreversedbyloweringthelegs.
II.ARTERIALBLOODPRESSUREMONITORING