Noninvasive Hemodynamic Monitoring in Emergency Patients with Suspected Heart Failure, Sepsis and Stroke: The Premium Registry

Abstract

IntroductionNoninvasive hemodynamic (HD) assessments in the emergency department (ED) might assist in the diagnosis, therapeutic plan development and risk stratification of acutely ill patients. This multinational observational study was designed to initiate noninvasive HD measurements prior to any ED patient therapeutic interventions and broadly evaluate them for potential diagnostic, therapeutic and predictive value.MethodsWe enrolled patients with suspected acute heart failure (AHF), sepsis or stroke. Continuous noninvasive HD monitoring was begun using the Nexfin finger cuff device (Edwards LifeSciences, BMEYE, Amsterdam, Netherlands). Beat-to-beat HD measurements were averaged for the initial 15 minutes, prior to therapeutic intervention. We performed suspected disease group comparisons and evaluated HD predictors of 30-day mortality.ResultsOf 510 patients enrolled: 185 (36%) AHF, 194 (38%) sepsis and 131 (26%) stroke. HD variables were significantly different (p<0.05) amongst the groups. Cardiac output and index and stroke volume index (SVI) were highest in sepsis (6.5, 3.5, 36), followed by stroke (5.5, 2.7, 35.8), and lowest in AHF (5.4, 2.7, 33.6). The in-group HD standard deviations and ranges measurements were large, indicating heterogeneous underlying HD profiles. Presenting SVI predicted 30-day mortality for all groups.ConclusionPresenting ED noninvasive HD data has not been previously reported in any large patient population. Our data suggest a potential role for early noninvasive HD assessments aiding in diagnosing of patients, individualizing therapy based on each person’s unique HD values and predicting 30-day mortality. Further studies and analyses are needed to determine how HD assessments should be best used in the ED.

Heart rate variability analysis is more sensitive at identifying neonatal sepsis than conventional vital signs

“…Examples of these new vital signs are tissue oxygenation and heart rate variability (HRV) (12-17). Additional new vital signs are clinical variables that could only be intermittently or invasively measured with traditional technology, but now can be measured continuously and noninvasively, such as cardiac output (18, 19). HRV has been shown, prospectively, to have a high negative predictive value with a low positive predictive value (~15%) in identifying neonatal patients at high risk for sepsis and death.…”

Review article: Sepsis in the emergency department – Part 2: Investigations and monitoring

“…Several non‐invasive monitoring techniques measuring tissue oxygenation or cardiac output have been investigated as tools for identifying patients at risk of adverse outcome but none have been extensively validated to date. Dynamic monitoring and trends analysis rather than static SIRS thresholds in the ED may help identify high risk patients prior to visible clinical deterioration .…”

“…The concept of generating computational sepsis biomarkers combining continuous physiological data coupled with machine learning and data mining methods presents unique opportunities for the future. 69 Several non-invasive monitoring techniques measuring tissue oxygenation 70,71 or cardiac output 72 have been investigated as tools for identifying patients at risk of adverse outcome but none have been extensively validated to date. Dynamic monitoring and trends analysis rather than static SIRS thresholds in the ED may help identify high risk patients prior to visible clinical deterioration.…”

Oxymatrine protects against sepsis-induced myocardial injury via inhibition of the TNF-α/p38-MAPK/caspase-3 signaling pathway

“…Patients suffering from sepsis utilize numerous medical resources, and the mortality rate is high and continuing to rise (1). The heart is considered a main 'target organ' of sepsis-induced multiple organ dysfunction, and the occurrence of myocardial dysfunction further promotes the development and deterioration of sepsis, which significantly contributes to the mortality of patients with septic shock (2). The pathogenesis of sepsis is very complex, and to date, studies regarding septic shock have concentrated on the generation of inflammatory mediators, including tumor necrosis factor (TNF)-α and interleukin-1β, and damage to the liver, lungs and kidneys (3)(4)(5)(6).…”