Noninvasive Hemodynamic Profiling in Emergency Medicine

Richard M Nowak MD, MBA, FACEP, FAAEM

Disclosures• Bmeye

- Research support

Heart Rate, Blood Pressure and CI

Wo C, Shoemaker W, Appel P, et al. Unreliability of blood pressure and heart rate to evaluate output in emergency resuscitation and critical illness. Critical Care Medicine 1993; 21:218-223

r=0.27, r2=0.07 r=-0.1, r2=0.0001

Clinical evaluation compared to PAC in the hemodynamic assessment of critically ill patients. Eisenberg PR, et al.

Crit Care Med 1984; 12: 349

Assessing hemodynamic status in critically ill patients: Do physicians use clinical information optimally? Connors AF, et al.

J Crit Care 1987; 2: 174

Therapeutic impact of PAC in the ICU. Steingrub, et al. Chest 1991; 99: 1451

PAC in critically ill patients: A prospective analysis of outcome changes associated with catheter-prompted changes in therapy. Mimoz O, et al.

Crit Care Med 1994; 22: 573

Hemodynamic and pulmonary fluid status in the trauma patient: are we slipping? Veale WN Jr, et al.

Am Surg 2005; 71: 621 (ICG by BioZ)

Physicians correctly predict the cardiac output, PCWP and SVR in only 50% of the casesPhysicians correctly predict the cardiac output, PCWP and SVR in only 50% of the casesPrediction of Hemodynamics in Critically ill Patients by Clinical Evaluation Alone is Inaccurate and Unreliable

Bioimpedance CO in Patients with Presumed Congestive Heart Failure

• 7 patients with signs and symptoms consistent with AHF had hemodynamic assessments using the NCCOM3-R7 monitor [thoracic electrical bioimpedance (TEB)] with 5 minute averages over 60 minutes recorded

• All patients received furosemide (2 also captopril) with varying urine outputs (200 – 3800 ml)

• Significant differences in TEB variables exist in patients who

appear similar on initial exam in the ED

Weiss SJ, et al. Acad Emerg Med 4: 568-573, 1997Emergency Medicine, Louisiana State Univ, New Orleans

TEB Hemodynamic Profiles

Hemodynamic Profiles & Diagnostics

• VS were of no value in distinguishing between the different types of acute dyspnoea

Hemodynamic Diagnostics

Vorwerk V, et al. Emerg Med J 27: 359-363, 2010

Hemodynamic Diagnostics

Vorwerk V, et al. Emerg Med J 27: 359-363, 2010

Best ROC derived CI cut point 3.2

CI: AUC 0.906SVRI: AUC 0.824

EGDT Sepsis Hemodynamics

Napoli AM, et al. Acad Emerg Med 2010: 17, 452-455

Napoli AM, et al. Acad Emerg Med 2010: 17, 452-455-N = 55, 25 % mortality. AUC for CI = 0.71-CI < 2, 43% sensitive, 93% specific for predicting mortality

Emergency Department Hemodynamic Monitoring Needs

• Any hemodynamic monitoring device that will be used frequently must be totally non invasive, reasonably accurate (trending most important) and be easily applied by non physician staff

• Minimally invasive technology (arterial line) is too invasive for routine hemodynamic profiling

Heart Failure Association of the ESC

June 14-17, 2008

Milan Italy

Finger Arterial Pressure

• The cuff pressure is increased and decreased to keep the diameter of the finger arteries constant (volume clamping)

• Continuous recording of the cuff pressure generates a real-time pressure waveform

First data in ≈ 20 sec

After 3-4 Physiocals reliable BP and CO (60 sec)

Reliable Data in 60 seconds After Startup

Pressure Reconstructions

Aortic pressure

Finger pressure

Brachial pressure

Radial pressure

Nexfin Screen

NEXFIN Issues

• Accuracy comparisons - BP and HR

- CI and SVRI

• Systematic error consequences

• Trending is the most useful parameter

Cardiopress on the ISS: The Integrated Cardiovascular Experiment

Oleg Kotov Nicole Scott

ECHO on the ISS: The Integrated Cardiovascular Experiment

Satoshi Furukawa

AJEM 29: 782-789, 2011

Amer J Emerg Med

ED Hemodynamic Questions

• What are the underlying pre and post treatment hemodynamic profiles of acutely ill patients in the ED?

• What do they mean in predicting patient outcomes?

• How should any individual hemodynamic profile be altered in order to improve patient outcome?

Prognostic Hemodynamic Profiling in the Acutely Ill Emergency Department Patient

Richard Nowak MD, Henry Ford Health System, Detroit, Michigan, USA (Coordinating center)

Phillip Levy MD, Detroit Medical Center, Detroit, Michigan, USA

Salvatore DiSomma MD, Sant’ Andrea Hospital, Rome, Italy

Prabath Nanayakkara MD, VU University Medical Center, Amsterdam, The Netherlands

Prognostic Hemodynamic Profiling in the Acutely Ill Emergency

Department Patient

REGISTRY Websitehttps://hfhspremiumregistry.com

Clinical Outcome Assessments

• Length of hospitalization

• Development of end organ dysfunction at day 3

• Visits to the ED/OPD clinic in the 30 days post discharge

• Hospitalizations/mortality in the 30 days post ED visit

Premium Case

Premium Case

Case A0028 Sepsis

Nowak Sepsis Cases

Case A006 Sepsis (ED Course)• A 79 year old AA with intermittent confusion for 4 days

• Hx of anemia, CHF, DM, HTN, Foley with UTI (treated with Cipro, then 4 days of Bactrim).

• Chest xray – developing LLL pneumonia

• Urinalysis – rbc 67, wbc 2675, many bacteria

• WBC 8.4 (66% neutrophils), Hgb 10.9

• Lactic Acid 1.4, Troponins - .49, .30

• Treated with vancomycin 1.5 and cefipime 2 gms IVPB

• Admitted to GPU

Case A006 Sepsis (ED VS)

Case A006 Sepsis (IPD Course)

• Treated with antibiotics per culture results• Developed renal insufficiency responding to fluid

therapy• Troponin decreased, no fever or leukocytosis• Echocardiogram – EF 31% with hypokinesis of the

periapical and LV wall

• Was to be discharged but found deceased in bed on day 24 of hospitalization

Case A006 Sepsis (ED HD Profile)

Case A113 Sepsis (ED Course)• 91 yr female found confused in a unheated apartment. No

prior medical hx,

• BP 110/43 - 109/29, HR 44 - 41, RR 30 - intubation, T 33.7 R - 32.1 Foley probe. O₂ Sats 74 % - 100%

• PE: GCS 13-14, confused. No abnormal findings otherwise

• Chest Xray: No congestion noted

• Labs: Multisystem organ failure (ARF-BUN 69, CR 4.4 and ALF) and UTI (Vanc and Cefepine)

• Lactate 4.5 (Ph 7.07), repeat with therapy 4.4

• CVP 25, repeat with therapy 26 to 26 to 26 (received 2 l NS)

• TSH 23, treated earlier with 100 mcg levothyroxine IV

Case A113 Sepsis (ED Course)

• EGDT initiated, ScvO₂ 38 - 45 – 53%

Intubated to decrease work of breathing

Vent 400 ml, 60% FiO₂, 12/min, PEEP 5

• Dopamine started at 15 mcg to, later decreased to 5 as no improvements in endpoints

• Bedside echo: No effusion, some diastolic dysfunction, slightly impaired EF with likely MR and TR

• Admitted to the MICU with diagnosis of severe sepsis, also cardiogenic shock, ARF, ALF, coagulopathy, hypothermia, elevated troponin

Case A113 Sepsis (MICU Course)

• Treated for myxedema coma and severe sepsis but condition got worse in site of aggressive therapy

• Given the grave prognosis she was made DNR next day and then shortly after she died

Case A113 Sepsis (ED HD Profile)

Nowak CHF Cases

Case A009 CHF (ED Course)• 60 yr old AA male with SOB and body swelling for 1 week

• Hx of HTN, DM, PVD s/p L BKA, Anemia, CKD and CHF

• BP 149/77, P 82, RR 20, O2 Sat 98%, GCS 15

• Bibasilar crackles, 3+ edema RLE

• BNP 749, CR 1.5, WBC 12 K, Hgb 8.5, Troponin < 0.04

• Chest Xray - suggests pulmonary edema

• Treated with lasix 60 mg IVP and had U/O of 1800 ml

• Admitted to GPU with primary diagnosis of acute CHF

Case A009 CHF (IPD Course)• Treated with IV lasix, U/O > 8 L, congestion improved

• Echocardiogram – EF 50% (diastolic dysfunction)

• CKD – CR increased secondary to diuresis, then better

• No transfusions given initially

• After 8 days on the GPU he developed gangrene of the R foot requiring a R BKA (he now has NO feet)

• Transferred to the MICU post op for monitoring, transfused 2 units prbcs, then back to GPU

• Discharged to acute rehab after 15 days

Case A009 CHF (ED HD Profile)

Nowak CHF Cases

Nowak Stroke Cases

Nexfin limitations• Enough blood flow to produce digital arterial

pulsations

• Normal aortic valve • No proximal aorta aneurysm

• Pressure reconstruction validated for ages ≥ 6 • Model to determine CO validated for ages ≥18

• Continuous monitoring ≥ 8 hours on 1 finger

PREMIUM Enrollment Status

PREMIUM Enrollment Status

PREMIUM Enrollment Status

Hemodynamic Monitoring in the Emergency Department

Katie Nowak

ccNexfin Advances• Has a second finger sensor that measures continuous

O₂ saturations and transcutaneous hemoglobin

• Combining CaO₂ with beat to beat CI allows continuous Oxygen Delivery Index (DO₂I) measurements

• This may be especially useful in patients with hemodynamic abnormalities and anemia

Conclusions

“If, in general, the individual hemodynamic profile of the acutely ill/injured patient does not clinically matter, then I am disappointed in the human body”

Richard Nowak, 2010