SCCM Pod-517: Benefits of Hemodynamic Monitoring in Critical Care

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This episode of the Society of Critical Care Medicine Podcast offers insights on hemodynamics monitoring in critically ill patients. Kyle B. Enfield, MD, FCCM, is joined by Courtney Bennett, DO, FCC, FASE, to discuss foundational concepts in hemodynamic monitoring and shock management, stressing the importance of understanding data quality and ongoing debates in critical care. SCCM offers a hemodynamic monitoring skills precourse as part of its Critical Care Congress programming. Courtney Bennett, DO, FCC, FASE, is an associate professor at Lee Valley Health Network in Allentown, Pennsylvania, USA.

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Transcript:

Dr. Enfield: Hello and welcome to the 2024 Congress edition of the Society of Critical Care Medicine Podcast. I’m your host, Dr. Kyle Enfield. Today I’m joined by Dr. Courtney Bennett, DO, FCC, FASE, an associate professor at Lee Valley Health Network. Dr. Bennett just finished teaching the hemodynamic monitoring precourse at the 2024 Critical Care Congress and is joining me here today to talk about that course and all the educational offerings that it brought to Congress participants. Dr. Bennett, before we start, do you have any disclosures?

Dr. Bennett: No disclosures to share.

Dr. Enfield: Awesome. I would love to just start off by talking about what got you interested in the Critical Care Congress and this hemodynamic course and what brought you to critical care in the first place as a cardiologist.

Dr. Bennett: I always loved hemodynamics. I also loved in-training critical care, being in the MICU. I loved being in the cardiac ICU, really loved all aspects of cardiac critical care. But the reason I actually decided to go to cardiology mainly was the hemodynamic management of patients in the cardiac ICU. I found it very gratifying to be able to do a comprehensive hemodynamic assessment using all different types of tools, from exam to PA catheter, get the answer that you’re looking for after your investigation, and then be able to then choose what kind of intervention to give the patient and see almost an immediate response. I found that very gratifying.

Dr. Enfield: That sort of leads right into, tell me about this precourse, why it was offered this year, and what the educational goals were for the participants.

Dr. Bennett: Right. We recognize that the knowledge and use of different hemodynamic devices across the country, across the world, varies greatly as well as individuals’ experience using these different types of hemodynamic devices for monitoring patients in the ICU. We wanted to actually create a basic introductory course to hemodynamic monitoring of ICU patients as well as discuss the management of shock for these patients. The course is geared toward novice learners who want to get an introduction to this as well as even intermediate learners who are looking to hone their skills and knowledge regarding hemodynamic monitoring.

Dr. Enfield: Can you walk us through what that precourse looked like for the participants this year?

Dr. Bennett: Yes. This year we actually had a little bit different model for the structure of the course. The course was set up, there was actually prerecorded lectures online. These lectures cover the introductions to hemodynamics and management of shock. We discussed fluid responsiveness. There’s a lecture by one of our pharmacists who spoke about the effects of vasoactive agents on the cardiovascular system. These lectures also covered things from the technical aspects to monitoring, how do you assess perfusion in patients? Then there was also a whole lecture on just a comprehensive review of minimally invasive, noninvasive, and invasive devices. Those were offered for the learners to view before the course.

The course is a half-day session in person that’s all hands-on. The half-day is broken down into two parts. The first half we have you go through three different stations where you’re able to have hands-on experience looking at noninvasive monitors, minimally invasive monitors, and invasive monitors, which are PA catheters, with very expert faculty who have experience in using all of these devices to walk you through what are the advantages, disadvantages, how do they actually work, how to actually use them and troubleshoot the devices.

The second half of the hands-on is reviewing cases in how we would apply these tools. We break it down into cardiogenic shock, septic shock, and hemorrhagic shock and, again, review how to incorporate these different tools into these different types of shock.

Dr. Enfield: I think a lot of people are familiar with the PA catheter as the invasive device.

Dr. Bennett: Yes.

Dr. Enfield: I’m going to have to ask you later who you got to model putting a PA catheter in there. You guys used a fancier tool than that, but maybe walk us through, when you say minimally invasive and noninvasive devices, what you’re talking about.

Dr. Bennett: That’s a great question. There’s a very broad range of tools that we actually have to use and, as you pointed out, most people think pulmonary artery catheter as the monitoring tool, but there are noninvasive tools that we would describe as peripheral waveform analysis, looking at arterial waveform using devices that are placed peripherally. There are also tools such as thoracic bioimpedance or bioreactance to look at either the change in electrical phase shift versus the resistance to blood flow throughout the thorax.

Some of the minimally invasive tools would be, for example, even esophageal Doppler probes, and the other minimally invasive tools are, for example, we try and be very brand agnostic and have an example of all the types of tools, but using the peripheral waveform analysis devices, so where there are arterial lines placed, maybe even central lines, those are categorized as minimally invasive tools. Then, transpulmonary thermodilution is another minimally invasive tool. Then, the invasive, as we mentioned, is the pulmonary artery catheter. Those are all the types of devices that we have broken down into three separate stations to review with the learners throughout the course.

Dr. Enfield: Knowing that you are a cardiologist and also an echocardiographer, where does echo fall into this rubric of tools, and how much do you spend talking about that in this course?

Dr. Bennett: Echo we actually purposely leave out of the course, except for the esophageal Doppler to give the learners an example of that just for exposure, but we’ve really made a conscious decision to keep echo as a separate aspect of this, mainly because that could take up a whole other day of education in terms of the application of echo in critical care.

Dr. Enfield: What do you classify as the major teaching points that you hope the learners took home this year?

Dr. Bennett: I think the most important things are familiarity of all the tools available to them, and I think the biggest take-home point is really when to apply these tools. What patient populations are these tools valid in? When do they not apply or maybe perform well in a certain type of shock? As well as just part of the education itself, not just the tools, is how to incorporate these to decision-making in the management of patients with different types of shock.

Dr. Enfield: In the educational scheme, who do you think benefits the most from this? Thinking about my colleagues back at home, many of them come to this sort of the sense that in the end they feel pretty good on their own managing and distinguishing different kinds of shock based on experience and other things but find that learners and more novice individuals have more challenges. How do you feel this fits into the continuum of skill level?

Dr. Bennett: Well, it’s definitely introductory. I think it’s important to have exposure to all the different types of tools, mainly because each institution has different resources, different staffing models, access to different tools, so I think it’s important to know what’s out there and become familiar with the different devices that are available for use, again, keeping in mind what are the limitations of the tools as well.

Dr. Enfield: When people came this year, what was the tool that you had the most people say that they’d never seen before or really felt like that they gained the most from?

Dr. Bennett: That’s a great question. I don’t think there was any one specific tool that the learners identified as having the least amount of exposure to. It was mainly the noninvasive and minimally invasive tools where I think that the learning curve was the steepest in terms of the technical aspects of when to use it, what type of shock used to monitor them in.

Dr. Enfield: I also know from colleagues that particularly some of the noninvasive tools like impedance and phase shifting get a lot of raised eyebrows, that feels very black boxy, people don’t quite know how to handle that. How do you address the concerns that were raised about that and what do you think the big take-home messages from those kinds of tools are for providers?

Dr. Bennett: I think it’s going back to what patient populations were these studied and validated in and making sure that you’re aware of what the limitations are. For example, bioimpedance can be limited by additional thoracic lung water, whether that’s pleural effusion, pulmonary edema, so recognizing what are the limitations of it, but also what patient population will this help in. These are very valuable tools, for example, for assessing fluid responsiveness. They may not add as much value for cardiogenic shock, but there is evidence to support their value of assessing fluid responsiveness, so really learning what the value of each tool is and the limitations of it.

Dr. Enfield: That’s great. My experience is that, when you really break these tools down, the challenge for, I think, most of us is there are so many of them and to really know what was it studied in, how was it studied, and how do I take that home? Our fellowship was recently reviewing the literature and one of our fellows said, well, I just do a passive leg raise on all these patients. And I said, great, can you explain to me what a passive leg raise is? Actually, I think you need to go back and look at the original paper. That’s not what they described.

Dr. Bennett: Correct.

Dr. Enfield: I think educational opportunities at SCCM are really great for highlighting those.

Dr. Bennett: That’s an excellent point. We do incorporate that as well. It’s fun to demonstrate the minimally invasive devices because we can actually put the tools on models and show by doing actually a true passive leg raise how the fluid shifts and changes the cardiac output or have someone go up and down on a stepstool and show with the pulse wave analysis how their cardiac output goes up. We can actually demonstrate those, but then actually teaching those extra key points. What is a passive leg raise? How do we actually do it? Then all of our faculty support these discussions with literature and evidence as well. That’s another thing that the learners will take away is, what is the evidence available to support the use of each of them or not to support it?

Dr. Enfield: So what you’re saying is that no one volunteered to have a right heart cath placed in them for this demonstration?

Dr. Bennett: Yes, you are correct. Back to your opening comment, unfortunately, no one had the PA catheter placed, but actually we did have some educational tools there to get them a little bit of sense of what it’s like to place it in a simulated model.

Dr. Enfield: I hear a lot of providers talk about the death of the PA catheter in the critical care environment. After teaching this course, what are your feelings about that as a tool in the ICUs for hemodynamic monitoring?

Dr. Bennett: I use PA catheters frequently in my practice. I have a little soapbox about this. I feel very strongly that it’s an incredible tool if you understand the quality of the data. I have, unfortunately, across multiple institutions that I’ve practiced at, I’ve seen providers using data to make decisions that are not quality data. It’s incredibly important to understand, for example, how does the phenomenon of a catheter whip affect the data that you’re getting? That’s actually going to give you a falsely low PA diastolic recording if you’re not looking at the waveforms. I try and stress to the learners that I have on rounds with me, don’t just look in the medical record and see what the numbers are. You have to go to the bedside and look at the waveforms. Is it over-dampened? Does it have some kind of artifact on it?

You really have to know and understand the quality of the data that you’re using to make treatment decisions, and if you have a good foundation of that knowledge, you know, is the transducer on the floor? Is it way above the patient? How does that affect your numbers? If you have a good knowledge of that, I actually think that’s a very valuable tool in managing patients who need close monitoring, who maybe were not responding as you thought appropriate to your initial interventions, etc.

Dr. Enfield: So what you’re saying is I can’t just sit behind my computer and pull the data out of Epic?

Dr. Bennett: No, I have to drag you to the bedside, and I do it all the time.

Dr. Enfield: That’s awesome. I would suspect that that is true for most of these other tools as well. While the PA catheter probably gets highlighted in that area, all these tools, you really kind of need to understand how they work to be able to get the best data out of them.

Dr. Bennett: Correct. And I think that this course helps you build that foundation to understand, how should it work? Should it be calibrated, etc.? What should the waveforms look like? Then from there, you can go and learn how to use it in your patient population if appropriate.

Dr. Enfield: Now I’m trying to be completely device agnostic. Are there devices that you see coming out now that you think are really going to be practice changing? And are there devices that have come out in the past that you think really the data no longer support their ongoing use in our practice?

Dr. Bennett: It all depends on the patient population. For example, many of these have been validated in surgical patients in the operating room. There are tools that I think, for example, the minimally invasive tools that will allow for data that have been compared to the PA catheter.

For example, transpulmonary thermodilution. You still need an arterial line, you still need a central line, but you don’t have to have the actual technical skills of learning how to place a PA catheter to get data that compare to the PA catheter. It is comparable to the gold standard and gives you the same quality data. I think, for example, that’s a tool that, many institutions are able to place central lines and arterial lines, but maybe don’t have the expertise of placing a bedside PA catheter. I think those are areas where we can maybe get a further reach of these monitoring tools to patients.

Dr. Enfield: What I also hear you kind of saying is that, because you’ve said it depends on the patient population, there really is no perfect tool out there. I can’t go and say, I’m going to buy device X and that’s going to solve all my monitoring woes.

Dr. Bennett: Correct. I think that’s a very fair statement. For example, my patient population that I care for most are cardiogenic shock patients. Well, using a peripheral waveform tool in a patient whose primary problem is peripheral vasoconstriction is really challenging and, in my opinion, has not demonstrated to be a very valuable tool in someone with that type of shock. So if I have a patient with cardiogenic shock, I’m not going to be reaching for peripheral waveform analysis when the vasoconstriction is limiting how that tool actually works.

Dr. Enfield: If people come to this course next year, will they be able to go home and win the age-old debate of cardiogenic versus septic shock?

Dr. Bennett: That’s a great question. I think they will have an understanding of the tools to use to answer the question.

Dr. Enfield: Okay. So they’re not going to win all their arguments though?

Dr. Bennett: No. No. The debate will continue.

Dr. Enfield: The debate will continue. Well, that’s great. Is this course planning on coming back to us next year?

Dr. Bennett: That is my understanding and also in consideration for becoming a course that would be offered even outside of Congress as well.

Dr. Enfield: Congress is a year away, so if people didn’t come this year, are there resources online from SCCM or elsewhere to really start getting some of this foundational knowledge? Because I can see a lot of critical care providers hearing this, going, gosh, I wish I had taken that or, gosh, I wish I could offer some of these lectures to my trainees.

Dr. Bennett: Right now, the courses, the lectures, have only been offered as part of this precourse, but maybe in the future.

Dr. Enfield: What else should our listeners hear from you today?

Dr. Bennett: I think if you have an interest in hemodynamic monitoring or in management of shock of your patients and you’re unsure of maybe your skill set, I just want to assure listeners that this course is meant to give you a foundational knowledge and to build upon that. Everyone is welcome and all skill levels can benefit from taking the course.

Dr. Enfield: Awesome. Well, Courtney, thank you so much for taking time out this morning to come and talk with me and share the information about this course with our listeners. For the Society of Critical Care Medicine Podcast, I’m your host, Kyle Enfield, coming to you live from the 2024 Congress.

Dr. Bennett: Thank you.

Announcer: Kyle B. Enfield, MD, FCCM, is an associate professor of medicine in the Division of Pulmonary and Critical Care at the University of Virginia. He received his undergraduate degree from the University of Oklahoma.

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