Noninvasive Hemodynamic Profiling in Emergency Medicine

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Noninvasive Hemodynamic Profiling in Emergency
Medicine
Richard M Nowak MD, MBA, FACEP, FAAEM

• Past Chairperson
• Emergency Medicine
• Henry Ford Hospital
• Detroit, Michigan
• Clinical Professor
• Emergency Medicine
• WSU School of Medicine
• Detroit, Michigan

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Disclosures

• Bmeye
• Research support

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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
21218-223
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Prediction of Hemodynamics in Critically ill
Patients by Clinical Evaluation Alone is
Inaccurate and Unreliable
Physicians correctly predict the cardiac output,
PCWP and SVR in only 50 of the cases
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)
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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,
1997 Emergency Medicine, Louisiana State Univ,
New Orleans
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TEB Hemodynamic Profiles
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Hemodynamic Profiles Diagnostics

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

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Hemodynamic Diagnostics
Vorwerk V, et al. Emerg Med J 27 359-363, 2010
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Hemodynamic Diagnostics
CI AUC 0.906 SVRI AUC 0.824
Best ROC derived CI cut point 3.2
Vorwerk V, et al. Emerg Med J 27 359-363, 2010
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EGDT Sepsis Hemodynamics
Napoli AM, et al. Acad Emerg Med 2010 17, 452-455
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-N 55, 25 mortality. AUC for CI 0.71 -CI lt
2, 43 sensitive, 93 specific for predicting
mortality
Napoli AM, et al. Acad Emerg Med 2010 17, 452-455
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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

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Heart Failure Association of the ESC

• June 14-17, 2008
• Milan Italy

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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

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Reliable Data in 60 seconds After Startup
First data in 20 sec After 3-4 Physiocals
reliable BP and CO (60 sec)
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Pressure Reconstructions
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Nexfin Screen
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NEXFIN Issues

• Accuracy comparisons
• BP and HR
• CI and SVRI
• Systematic error consequences
• Trending is the most useful parameter

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Cardiopress on the ISS The Integrated
Cardiovascular Experiment

• Nicole Scott

• Oleg Kotov

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ECHO on the ISS The Integrated Cardiovascular
Experiment
Satoshi Furukawa
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AJEM 29 782-789, 2011
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Amer J Emerg Med
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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?

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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

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Prognostic Hemodynamic Profiling in the Acutely
Ill Emergency Department Patient
REGISTRY Website https//hfhspremiumregistry.com
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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

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Premium Case
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Premium Case
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Case A0028 Sepsis
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Nowak Sepsis Cases
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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

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Case A006 Sepsis (ED VS)
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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

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Case A006 Sepsis (ED HD Profile)
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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

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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

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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

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Case A113 Sepsis (ED HD Profile)
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Nowak CHF Cases
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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 lt
  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

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Case A009 CHF (IPD Course)

• Treated with IV lasix, U/O gt 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

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Case A009 CHF (ED HD Profile)
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Nowak CHF Cases
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Nowak Stroke Cases
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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

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PREMIUM Enrollment Status
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PREMIUM Enrollment Status
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PREMIUM Enrollment Status
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Hemodynamic Monitoring in the Emergency Department
Katie Nowak

• Emergency Medicine Student Volunteer

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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

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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