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Non-Invasive Hemodynamic Monitoring:
Does it Have a Role in Shock Management?
Phillip D. Levy, MD, MPH
Asst. Professor of Emergency MedicineWayne State University/Detroit Receiving Hospital
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Disclosures
• Consultant– ElectroSonics Medical, Inc
• Honorarium– SonoSite, Inc
• Research support (equipment only)– Cardiodynamics, Inc.
All material in this lecture has been prepared withoutexternal input or review and is free from bias
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Learning Objectives
• To appreciate the importance of hemodynamics in shock
• To understand the shift away from invasive monitoring
• To recognize existing and emerging non-invasive modalities
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Case Example
• 38 yo white female with history of IVDA presents to the ED with dyspnea– No chest pain or fever reported
• Initial vitals:HR 100; BP 90/50; RR 18; Temp 40.4 º C
• Lung exam: coarse breath sounds without wheezing, rales or rhonchi
• Cardiac auscultation: non-radiating II/VI DM
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Case Example
• Initial differential– Endocarditis
– Sepsis
– Pneumonia (possible pneumocystis carini)
• Work-up initiated– CXR (-)
– Labs essentially nl
– Blood cultures obtained
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Do I Really Need to Know Hemodynamics ?
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Tissue Oxygen Delivery
• Oxygen content– CaO2 = (1.34 x Hgb x SaO2) + (0.0031 x PaO2)
• Perfusion– CO = HR x SV
– MAP = (CO x SVR) + CVP
– MAP = DBP + [SBP - DBP]/3
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From: Schwaitzberg et al. J Pediatr Surg 1988;23;:05-9.
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r=0.27, r2=0.07 r=-0.1, r2=0.0001
Can You Predict Perfusion Based on HR and MAP ?
From: Wo et al. Crit Care Med 1993;21:218-23.
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But Perfusion is What Matters !
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Hemodynamics of Perfusion
Afterload
Cardiac Output(CO)
HeartRate(HR)
StrokeVolume(SV)
Preload Contractility
(-) Diuretics(+) Volume Expanders
(-) Vasodilators(+) Vasoconstrictors
(-) Negative Inotropes(+) Positive Inotropes
(-) Neg.Chronotropes(+) Pos.Chronotropes
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Invasive Hemodynamic Monitoring
• Pulmonary artery catheterization (PAC) 1,2
– Time honored mechanism
– Provides accurate information
– Questionable safety and benefits
• May not be ideal (or possible) in ED setting!
1 Swan et al. NEJM 1970;283:447-51.2 Silver et al. CHF 2004;10:17-21.
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ESCAPE Trial 1,2
• Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness– Comparison of clinical assessment vs. PAC for severe ADHF
– At 6-month follow-up • No difference is primary endpoint (days alive)
• Slight improvement in secondary endpoints
– Stopped early by safety board !!
1 Shah et al. Am Heart J 2001;141:528-35.2 The ESCAPE Investigators and ESCAPE Study Coordinators* JAMA. 2005;294:1625-33.
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ESCAPE – Adverse Events
The ESCAPE Investigators and ESCAPE Study Coordinators* JAMA. 2005;294:1625-33.
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Is PAC Use Justified ?
Shah et al. JAMA 2005;294:1664-70.
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Is PAC Use Justified ?
Shah et al. JAMA 2005;294:1664-70.
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Non-Invasive Hemodynamic Monitoring Modalities
• Ultrasound – Cardiac output monitor (UsCoM)
– “Quick-look” echocardiography
– Central venous pressure estimation• Inferior vena cava
• Internal jugular vein
• Basilic vein
• Impedance cardiography (ICG)
• Esophageal doppler monitoring (EDM)
• Micro-impulse radar
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Non-Invasive Measures of Oxygen Balance
• Pulse oximetry
• Near infrared spectroscopy (NIRS)
• Point of care lactate
• Gastric tonometry
• Sublingual capnography
• Orthogonal polymerized spectroscopy
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Sublingual Testing
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Healthy Volunteer Septic Shock
Orthogonal PolarizedSpectral Imaging
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Ultrasound Cardiac Output Monitoring
• 10 parameters of cardiac function– Heart rate
– Cardiac output/index
– Stroke volume
– Systemic vascular resistance
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Ultrasound Cardiac Output Monitoring
• Operator dependent– Requires considerable pressure
• Non-continuous monitoring
• Unreliable with pneumothorax
• No large correlation trials
• CE Mark but not yet FDA approved
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USCOM
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“Quick-Look”Echocardiography
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Correlation with Cardiologist
Moore et al. Acad Emerg Med 2002;9:186-93.
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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Correlation with Cardiologist
Moore et al. Acad Emerg Med 2002;9:186-93.
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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CVP Estimate: IVC
• Respiratory variance in IVC can be used to estimate CVP 1
IVC size Resp change RA pressure< 1.5 cm Total collapse 0-5 cm/H201.5-2.5 > 50 % collapse 5-101.5-2.5 < 50 % collapse 11-15>2.5 < 50 % collapse 16-20>2.5 No change > 20
1 Ma, OJ and Mateer JR. Emergency Ultrasound, p 111. 2003
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Correlation with Cardiologist
Randazzo et al. Acad Emerg Med 2003;10:973-
7.
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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CVP Estimate: IJ
• Based on visualization of blood column within IJ
• Find point of collapse and measure to angle of Louis
• Add 5 cm H20 toyield CVP
Lipton B. Am J Emerg Med 2000;18:432-
4.
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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CVP Estimate: Basilic Vein
• Compression detectorattached to probe
• Measures external compression required to occlude vein
• Preliminary work
• Poor precision
Baumann et al. Resuscitation 2005;64:193-9.
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Impedance Cardiography
• Emerging technology
• Utilizes variance in thoracic electrical impedance to estimate changes in blood volume– Impedance ↓ as fluid volume ↑
• Change in impedance over time used to calculate cardiovascular parameters
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Aortic Blood Volume Changes Thoracic Impedance
Aorta Impedance Waveform Impedance Waveform (inverse)(inverse)
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Determinants of Baseline and Dynamic Impedance
Base Impedance (ZBase Impedance (Z00))Thoracic blood and plasma volume
Muscle mass (cardiac and skeletal)
Lung tissue/air
Thoracic adipose tissue
Dynamic Impedance (Dynamic Impedance (∆∆∆∆∆∆∆∆Z)Z)Aortic blood volume and velocity
Aortic compliance
Pulmonary artery blood volume and compliance
Specific resistivity of blood
Strobeck et al. Congest Heart Fail. 2000;6:3-6.
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ICG: Set-Up
• Low-amplitude signal transmitted across thorax– Filtered to remove respiratory variation
• ∆ impedance monitored – Variance represents ventricular ejection
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ICG: Monitor Display
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Comparison of ECG and ICG Waveforms
Osypka and Bernstein. AACN Clinical Issues. 1999;10:385-399.
ECGECG
dZdZ
dZdZ//dtdt
TimeTime
QQ = Ventricular = Ventricular depolarizationdepolarization
B = Opening aortic B = Opening aortic & pulmonic valves& pulmonic valves
C = Maximal slope C = Maximal slope dZ dZ
X = Closure aortic valveX = Closure aortic valve
Y = Closure of pulmonic Y = Closure of pulmonic valvevalve
O = Opening mitral O = Opening mitral
valve / rapid filling valve / rapid filling
of ventriclesof ventricles
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ICG Measurements
• Cardiac function 1
– Stroke volume and cardiac index/output
• Afterload– Systemic vascular resistance
• Contractility 2,3
– Velocity index and systolic time ratio
• Fluid status 4
– Thoracic fluid content• Reciprocal of impedance 1 Albert et al. J Am Coll Cardiol 2003;41:211A.
2 Ranaei et al. J Card Fail 2002;8:S97.3 Parrott et al. CHF 2004;10:11-3.4 Peacock et al. CHF 2000;6:86-9.
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Sample Status Report
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Validation Studies
0.870.761.01
-0.240.19-0.43
0.840.890.80
ICG - FickTD - FickICG - TD
COYung et alPulm. HTN (39)
1.09-0.170.81ICG - TDCOVan de Water et al
Post CABG (53)
0.400.070.92ICG - TDCISageman et alPost CABG (20)
1.2-0.450.89ICG - TDCOZiegler et alMech vent.(52)
1.10.951.1
0.740.750.03
0.730.810.76
ICG - FickTD - FickICG - TD
CODrazner et al HF in cath lab(59)
1.380.080.89ICG - TDCOAlbert et alHF in ICU (33)
PrecisionBiasR valueComparisonParameterAuthorsPopulation (n)
Adapted from Yancy and Abraham . Congest Heart Fail. 2003;9:241-250.
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Comparison of Cardiac Output Measurement Reproducibility
0.430.97ICG 3 vs. ICG 1
0.390.98ICG 3 vs. ICG 2
0.440.97ICG 2 vs. ICG 1
1.070.83TD 3 vs. TD 1
1.010.84TD 3 vs. TD 2
1.020.83TD 2 vs. TD 1
Stand. Dev.
(l/min)
Correlation
(R value)
Comparison
Van De Water JM, et al. Chest. 2003;123: 2028-33.
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ICG Instead of PAC ?
• Reduction of PAC usage by 71% – 95% CI: 41.9 –91.6%
Silver et al. Congest Heart Fail. 2004;10(suppl 2):14-16.
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Estimated Cost Savings Resulting from ICG Replacement
of PAC
Silver et al. Congest Heart Fail. 2004;10(suppl 2):14-16.
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Esophageal Doppler 1,2
• First described in 1971
• Measures flow in descending aorta
1 DiCorte et al. Ann Thorac Surg. 2000;69(6):1782-6.2 Seoudi et al. J Trauma. 2003;55(4):720-5.
PreloadContractility (SV)AfterloadCardiac Output
Flow time 330-360 msecPeak Velocity 60-100 cm/secSVRI 800-1200 dynes/m2
CI 2.2-2.5 L/min/m2
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Esophageal Doppler Monitoring
• Not tolerated by awake patients– Good for intubated patients in shock with elevated CVP
• Not continuous– Requires readjustment for each read
• Contraindicated with varices, caustic ingestion or perforated esophagus
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MicroImpulse Radar
• Ultra-wide bandwidth (1-4 GHz)
• Short radar pulses (< 1 ns)– 2 MHz repetition rates
• Rapid digitization– Spatial accuracy ~ 5mm
• Non-ionizing– 50 mW RMS
• Enables non-contact monitoring– Developmental stages
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Case Example
• After 2 hrs, pt deteriorates
• New vitals: HR 110; BP 70/40; RR 20; Temp 101 º F
• Lung exam remains unchanged
• Cardiac exam: increased rate
• Fluid resuscitation initiated– 1 L NS bolus
– Pt given vancomycin, tobramycin and cefepime
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Simple Sepsis ?
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Case Example
• ICG performed– CI = 1.8 L/min/m2
– SVR = 1600 dyne(s)(cm-5)
– TFC = 45 ohms
– LCWI = 2.4 kg(min)/m2
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Case Example
• Dobutamine drip started at 10 mcg/kg/min
• Repeat BP at 15 min: 95/60
• ICG at 15 min– CI = 2.4 L/min/m2
– SVR = 1200 dyne(s)(cm-5)– TFC = 40 ohms– LCWI = 2.8 kg(min)/m2
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Case Example
• Emergent echocardiogram obtained showing large vegetation on tricuspid valve
• Pt stabilized and transferred to ICU
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Diagnosis = cardiogenic shock due to presumed
valvular insufficiency from endocarditits
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Take Home Points
• Hemodynamic monitoring can impact patient care
• Non-invasive techniques are emerging and are likely to increase in importance
• The ED physician should be familiar with these tools to maximize outcomes