Monitoring
Non-invasive Monitoring
Monitoring the temperature, respiratory rate and effort, heart rate and rhythm (ECG), blood pressure, oxygenation, cognitive status, intake and output, and peripheral perfusion is mandatory. Evaluate the patient’s signs and symptoms daily for correction of fluid overload. A pulse oximeter should be used continuously in any unstable patient who is on O2 therapy. Transcutaneous arterial O2 saturation monitoring is recommended for patients on O2 therapy and ventilatory support. Venous blood gas may be used as an alternative to arterial blood gas if the risk of vascular injury is present. Acid-base balance should also be checked on admission in cases of acute pulmonary edema or prior history of chronic obstructive pulmonary disease. While admitted in the hospital, patient monitoring should also include daily measurement of the weight, renal function, and electrolytes.
Invasive Monitoring
Intra-arterial Line
Insertion of an intra-arterial line should only be considered in patients with low systolic blood pressure and persistent heart failure despite treatment (eg cardiogenic shock).
Central Venous Line
Multiple lumen catheters are useful for fluid and drug administration and monitoring of the central venous pressure and venous O2 saturation, which provides an estimate of the body O2 consumption/delivery ratio.
Pulmonary Artery Catheterization
Pulmonary artery catheterization measures the cardiac output and superior vena, right atrium, right ventricle, and pulmonary artery pressures. This can be used to identify the etiology of hypotension or end-organ dysfunction in patients with cardiogenic shock unresponsive to empiric initial shock management and to distinguish between a cardiogenic and non-cardiogenic mechanism in patients with concurrent cardiac and pulmonary disease. This should not be routinely performed in hemodynamically stable patients with acute heart failure. This should only be considered in patients who are refractory to pharmacological therapy, persistently hypotensive, have uncertain left ventricular filling pressure or are being considered for surgery.