How to monitor cardiovascular function in critical illness in resource-limited settings.

Chaisith Sivakorn,Arjen M Dondorp,Marcus J Schultz

doi:10.1097/mcc.0000000000000830

Abstract

Purpose of reviewHemodynamic monitoring is an essential component in the care for critically ill patients. A range of tools are available and new approaches have been developed. This review summarizes their availability, affordability and feasibility for hospital settings in resource-limited settings.Recent findingsEvidence for the performance of specific hemodynamic monitoring tools or strategies in low-income and middle-income countries (LMICs) is limited. Repeated physical examination and basic observations remain a cornerstone for patient monitoring and have a high sensitivity for detecting organ hypoperfusion, but with a low specificity. Additional feasible approaches for hemodynamic monitoring in LMICs include: for tissue perfusion monitoring: urine output, skin mottling score, capillary refill time, skin temperature gradients, and blood lactate measurements; for cardiovascular monitoring: echocardiography and noninvasive or minimally invasive cardiac output measurements; and for fluid status monitoring: inferior vena cava distensibility index, mini-fluid challenge test, passive leg raising test, end-expiratory occlusion test and lung ultrasound. Tools with currently limited applicability in LMICs include microcirculatory monitoring devices and pulmonary artery catheterization, because of costs and limited added value. Especially ultrasound is a promising and affordable monitoring device for LMICs, and is increasingly available.SummaryA set of basic tools and approaches is available for adequate hemodynamic monitoring in resource-limited settings. Future research should focus on the development and trialing of robust and context-appropriate monitoring technologies.

Highlights

The level of patient monitoring and organ support feasible in the care for patients with critical illness differs substantially around the globe, and is mainly driven by availability and affordability of the different tools
Hemodynamic monitoring is an essential part of critical care as many patients in the ICU experience hemodynamic instability for a large variety of reasons
Approaches for hemodynamic monitoring in LMICs can be evaluated based on criteria of ‘availability’, ‘affordability’, ‘feasibility’, and ‘safety’, and should have comparable performance compared with approaches recommended for high-income countries

Summary

INTRODUCTION

The level of patient monitoring and organ support feasible in the care for patients with critical illness differs substantially around the globe, and is mainly driven by availability and affordability of the different tools. We rely mainly on monitoring macrocirculatory parameters including aDepartment of Clinical Tropical Medicine, bMahidol–Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine Mahidol University, Bangkok, Thailand, cDepartment of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands and dCentre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK Cardiovascular function monitoring in resource-limited settings Sivakorn et al

KEY POINTS

CONCLUSION AND RECOMMENDATIONS