REVIEW Advanced Hemodynamic Monitoring: Principles and Practice in Neurocritical Care Christos Lazaridis Published online: 16 June 2011 Ó Springer Science+Business Media, LLC 2011 Abstract Advanced hemodynamic monitoring is neces- sary for many patients with acute brain and/or spinal cord injury. Optimizing cerebral and systemic physiology requires multi-organ system function monitoring. Hemo- dynamic manipulations are cardinal among interventions to regulate cerebral perfusion pressure and cerebral blood flow. The pulmonary artery catheter is not any more the sole tool available; less invasive and potentially more accurate methodologies have been developed and employed in the operating room and among diverse criti- cally ill populations. These include transpulmonary thermodilution, arterial pressure pulse contour, and wave- form analysis and bedside critical care ultrasound. A thorough understanding of hemodynamics and of the available monitoring modalities is an essential skill for the neurointensivist. Keywords Hemodynamic monitoring Á Subarachnoid hemorrhage Á Traumatic brain injury Á Mechanical ventilation Á Cardiac output Á Transpulmonary thermodilution Á Bedside echocardiography Introduction Hemodynamic monitoring comprises one of the corner- stones of intensive care medicine. Neurocritical care patients often require such monitoring, specifically to optimize cerebral blood flow (CBF) and brain tissue oxy- gen delivery in addition to managing conditions commonly seen in critically ill patients including shock states and acute lung injury (ALI/ARDS). Manipulation of the cardiac output (CO), mean arterial pressure (MAP), systemic filling pressures, and volumes as well as dynamic markers of fluid responsiveness, requires continuous monitoring, thorough understanding of the modalities employed and proper interpretation of data acquired. Traditionally, invasive hemodynamic monitoring is equated to the use of a pul- monary artery catheter (PAC). Swan-Ganz catheter usage has more recently been tempered secondary to a lack of evidence on improving outcomes in randomized controlled trials [1–3] and also due to the poor performance of filling pressures as indicators of fluid responsiveness [4]; never- theless PAC use may still be appropriate in selected patients and its use has been reviewed elsewhere [5]. In this review, we will focus on less invasive modalities including single-indicator transpulmonary thermodilution, arterial waveform and pulse contour analysis as well as bedside real-time cardiorespiratory sonography. Cardiac Output Derivations Traditional calculation of CO via PAC employ a temper- ature–time curve derived from measurements obtained in the pulmonary artery after injection of cold saline. During single-indicator (thermal) transpulmonary thermodilution (TP), CO measurements are based on cold saline injection through a regular central venous catheter (internal jugular or subclavian vein). The thermistor is located at an arterial site (radial, axillary, or more commonly in the femoral artery) comprised by a 4–5 Fr catheter; in similar fashion, a temperature–time curve is constructed and the CO C. Lazaridis (&) Neurosciences Intensive Care Unit, Departments of Neurology and Neurosurgery, Medical University of South Carolina, Charleston, SC, USA e-mail: lazaridi@musc.edu 123 Neurocrit Care (2012) 16:163–169 DOI 10.1007/s12028-011-9568-x