Pulse pressure respiratory variation to predict fluid responsiveness: From an enthusiastic to a rational view

Noninvasive BP Monitoring in the Critically Ill: Time to Abandon the Arterial Catheter?

Although its reliability is often questioned, noninvasive BP (NIBP)-monitoring with an oscillometric arm cuff is widely used, even in critically ill patients in shock. When correctly implemented, modern arm NIBP devices can provide accurate and precise measurements of mean BP, as well as clinically meaningful information such as identification of hypotension and hypertension and monitoring of patient response to therapy. Even in specific circumstances such as arrhythmia, hypotension, vasopressor infusion, and possibly in obese patients, arm NIBP may be useful, contrary to widespread belief. Hence, postponing the arterial catheter insertion pending the initiation of more urgent diagnostic and therapeutic measures could be a suitable strategy. Given the arterial catheter-related burden, fully managing critically ill patients without any arterial catheter may also be an option. Indeed, the benefit that patients may experience from an arterial catheter has been questioned in studies failing to show that its use reduces mortality. However, randomized controlled trials to confirm that NIBP can safely fully replace the arterial catheter have yet to be performed. In addition to intermittent measurements, continuous NIBP monitoring is a booming field, as illustrated by the release onto the market of user-friendly devices, based on digital volume clamp and applanation tonometry. Although the imperfect accuracy and precision of these devices would probably benefit from technical refinements, their good ability to track, in real time, the direction of changes in BP is an undeniable asset. Their drawbacks and advantages and whether these devices are currently ready to use in the critically ill patient are discussed in this review.