危重症患者休克的发生率相当高，休克不能及时纠正将明显增加患者的死亡率。准确鉴别休克原因并及时有效处理对改善患者预后具有至关重要的作用。如何快速、有效地鉴别导致患者休克的主要原因并采取针对性的措施成为危重症领域重要课题，各种床旁血流动力学监测技术应运而生，使得临床医生可以较好地判断患者的血流动力学状态并及时评估治疗效果。随着电子计算机、影像及生物技术的发展，床旁血流动力学监测也经历了不同的发展时期，从单一、间断、有创监测到多参数、连续、微创或无创监测，为临床治疗决策的制定提供了有力帮助。过去十余年间，血流动力学监测技术在监护病房及手术室得到了快速发展，尤其是各种微创及无创监测技术。微创血流动力学监测技术主要是通过动脉脉搏轮廓分析或者超声多普勒技术实现对心输出量的监测，目前应用较多的监测方法包括脉搏指示连续心输出量监测（PiCCO）及食管多普勒；而无创血流动力学监测技术主要通过连续动脉压力波形分析或生物电阻抗法/生物电反应法来测量心输出量。微创及无创监测技术的最大特点是可以用最小的创伤来提供连续的心输出量参数，并实时显示患者的液体反应性，从而指导临床治疗。在本文中作者主要总结近年发展起来的微创或无创血流动力学监测技术，以期为临床工作提供参考。

[1] COOPER A S.Pulmonary Artery Catheters for Adult Patients in Intensive Care[J].Crit Care Nurse,2016,36(2):80-82.
[2] O'HORO J C,MAKI D G,KRUPP A E,et al.Arterial catheters as a source of bloodstream infection:a systematic review and meta-analysis[J].Crit Care Med,2014,42(6):1334-1339.
[3] McDERMID R C,RAGHUNATHAN K,ROMANOVSKY A,et al.Controversies in fluid therapy:type,dose and toxicity[J].World J Crit Care Med,2014,3(1):24-33.
[4] CARSETTI A,CECCONI M,RHODES A.Fluid bolus therapy:monitoring and predicting fluid responsiveness[J].Curr Opin Crit Care,2015,21(5):388-394.
[5] KASS D A,KELLY R P.Ventriculo-arterial coupling:concepts,assumptions,and applications[J].Ann Biomed Eng,1992,20(1):41-62.
[6] HAMZAOUI O,MONNET X,RICHARD C,et al.Effects of changes in vascular tone on the agreement between pulse contour and transpulmonary thermodilution cardiac output measurements within an up to 6-hour calibration-free period[J].Crit Care Med,2008,36(2):434-440.
[7] HASANIN A.Fluid responsiveness in acute circulatory failure[J].J Intensive Care,2015,3:50-58.
[8] SAKKA S G,REUTER D A,PEREL A.The transpulmonary thermodilution technique[J].J Clin Monit Comput,2012,26(5):347-353.
[9] LITTON E,MORGAN M.The PiCCO monitor:a review[J].Anaesth Intensive Care,2012,40(3):393-409.
[10] JOHANSSON A,CHEW M.Reliability of continuous pulse contour cardiac output measurement during hemodynamic instability[J].J Clin Monit Comput,2007,21(4):237-242.
[11] DONATI A,NARDELLA R,GABBANELLI V,et al.The ability of PiCCO versus LiDCO variables to detect changes in cardiac index:a prospective clinical study[J].Minerva Anestesiol,2008,74(7-8):367-374.
[12] AMBRISKO T D,KABES R,MOENS Y.Influence of drugs on the response characteristics of the LiDCO sensor:an in vitro study[J].Br J Anaesth,2013,110(2):305-310.
[13] DESEBBE O,HENAINE R,KELLER G,et al.Ability of the third-generation FloTrac/Vigileo software to track changes in cardiac output in cardiac surgery patients:a polar plot approach[J].J Cardiothorac Vasc Anesth,2013,27(6):1122-1127.
[14] SLAGT C,MALAGON I,GROENEVELD A B.Systematic review of uncalibrated arterial pressure waveform analysis to determine cardiac output and stroke volume variation[J].Br J Anaesth,2014,112(4):626-637.
[15] SLAGT C,HELMI M,MALAGON I,et al.Calibrated versus uncalibrated arterial pressure waveform analysis in monitoring cardiac output with transpulmonary thermodilution in patients with severe sepsis and septic shock:an observational study[J].Eur J Anaesthesiol,2015,32(1):5-12.
[16] DARK P M,SINGER M.The validity of trans-esophageal Doppler ultrasonography as a measure of cardiac output in critically ill adults[J].Intensive Care Med,2004,30(11):2060-2066.
[17] BOYLE M,STEEL L,FLYNN G M,et al.Assessment of the clinical utility of an ultrasonic monitor of cardiac output (the USCOM) and agreement with thermodilution measurement[J].Crit Care Resusc,2009,11(3):198-203.
[18] HAMILTON M A,CECCONI M,RHODES A.A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients[J].Anesth Analg,2011,112(6):1392-1402.
[19] BUBENEK-TURCONI S I,CRACIUN M,MICLEA I,et al.Noninvasive continuous cardiac output by the Nexfin before and after preload-modifying maneuvers:a comparison with intermittent thermodilution cardiac output[J].Anesth Analg,2013,117(2):366-372.
[20] WAGNER J Y,GROND J,FORTIN J,et al.Continuous noninvasive cardiac output determination using the CNAP system:evaluation of a cardiac output algorithm for the analysis of volume clamp method-derived pulse contour[J].J Clin Monit Comput,2016,30(4):487-493.
[21] MEIDERT A S,HUBER W,MVLLER J N,et al.Radial artery applanation tonometry for continuous non-invasive arterial pressure monitoring in intensive care unit patients:comparison with invasively assessed radial arterial pressure[J].Br J Anaesth,2014,112(3):521-528.
[22] WAGNER J Y,SARWARI H,SCHÖN G,et al.Radial artery applanation tonometry for continuous noninvasive cardiac output measurement:a comparison with intermittent pulmonary artery thermodilution in patients after cardiothoracic surgery[J].Crit Care Med,2015,43(7):1423-1428.
[23] AYUELA-AZCARATE J M,CLAU TERRÉ F,OCHAGAVIA A,et al.Role of echocardiography in the hemodynamic monitorization of critical patients[J].Med Intensiva,2012,36(3):220-232.
[24] WALLEY P E,WALLEY K R,GOODGAME B,et al.A practical approach to goal-directed echocardiography in the critical care setting[J].Crit Care,2014,18(6):681.
[25] McLEAN A S.Echocardiography in shock management[J].Crit Care,2016,20:275.
[26] 庄燕,王醒.超声心动图在重症患者容量状态评估中的应用[J].东南大学学报:医学版,2013,32(1):125-127.
[27] SAUGEL B,CECCONI M,WAGNER J Y,et al.Noninvasive continuous cardiac output monitoring in perioperative and intensive care medicine[J].Br J Anaesth,2015,114(4):562-575.
[28] SQUARA P,DENJEAN D,ESTAGNASIE P,et al.Noninvasive cardiac output monitoring (NICOM):a clinical validation[J].Intensive Care Med,2007,33(7):1191-1194.
[29] MARQUÉ S,CARIOU A,CHICHE J D,et al.Comparison between Flotrac-Vigileo and Bioreactance,a totally noninvasive method for cardiac output monitoring[J].Crit Care,2009,13(3):R73.
[30] DENMAN W T,HUTCHISON C,LEVY B.Bioreactance is not reliable for estimating cardiac output and the effects of passive leg raising in critically ill patients[J].Br J Anaesth,2014,112(5):943-944.
[31] PIKKEMAAT R,LUNDIN S,STENQVIST O,et al.Recent advances in and limitations of cardiac output monitoring by means of electrical impedance tomography[J].Anesth Analg,2014,119(1):76-83.
[32] RAISSUNI Z,ZORES F,HENRIET O,et al.Can we obtain a noninvasive and continuous estimation of cardiac output? Comparison between three noninvasive methods[J].Int Heart J,2013,54(6):395-400.
[33] TERADA T,OIWA A,MAEMURA Y,et al.Comparison of the ability of two continuous cardiac output monitors to measure trends in cardiac output:estimated continuous cardiac output measured by modified pulse wave transit time and an arterial pulse contour-based cardiac output device[J].J Clin Monit Comput,2016,30(5):621-627.