Abstract
BackgroundThere is little published data investigating non-invasive cardiac output monitoring in the emergency department (ED). We assess here the accuracy of five non-invasive methods in detecting fluid responsiveness in the ED: (1) common carotid artery blood flow, (2) suprasternal aortic Doppler, (3) bioreactance, (4) plethysmography with digital vascular unloading method, and (5) inferior vena cava collapsibility index. Left ventricular outflow tract echocardiography derived velocity time integral is the reference standard. This follows an assessment of feasibility and repeatability of these methods in the same cohort of ED patients.MethodsThis is a prospective observational study of non-invasive methods for assessing fluid responsiveness in the ED. Participants were non-ventilated ED adult patients requiring intravenous fluid resuscitation. Sensitivity and specificity of each method in determining the fluid responsiveness status of participants is determined in comparison to the reference standard.ResultsThirty-three patient data sets were included for analysis. The specificity and sensitivity to detect fluid responders was 46.2 and 45% for common carotid artery blood flow (CCABF), 61.5 and 63.2% for suprasternal artery Doppler (SSAD), 46.2 and 50% for bioreactance, 50 and 41.2% for plethysmography vascular unloading technique (PVUT), and 63.6 and 47.4% for inferior vena cava collapsibility index (IVCCI), respectively. Analysis of agreement with Cohen’s Kappa − 0.08 for CCABF, 0.24 for SSAD, − 0.04 for bioreactance, − 0.08 for PVUT, and 0.1 for IVCCI.ConclusionIn this study, non-invasive methods were not found to reliably identify fluid responders. Non-invasive methods of identifying fluid responders are likely to play a key role in improving patient outcome in the ED in fluid depleted states such as sepsis. These results have implications for future studies assessing the accuracy of such methods.
Highlights
There is little published data investigating non-invasive cardiac output monitoring in the emergency department (ED)
Reasons for exclusion included a prescribed change in fluid delivery rate by the clinical care team, interruption of fluid monitoring for patient transfer, and rate-limited fluid infusion equipment. 60.6% (20/33) of participants were identified as fluid responders (Table 1)
The measure of agreement between the reference standard (LVOT Left ventricular outflow tract velocity time integral (VTI)) and test method to identify fluid responders was expressed as a kappa value (Table 2)
Summary
There is little published data investigating non-invasive cardiac output monitoring in the emergency department (ED). Left ventricular outflow tract echocardiography derived velocity time integral is the reference standard. This follows an assessment of feasibility and repeatability of these methods in the same cohort of ED patients. The aim of intravenous fluid therapy is to increase cardiac output and to increase oxygen delivery to hypoperfused organs. Resuscitation with inadequate intravenous fluid may risk inadequate organ oxygen delivery. Around one to two thirds of emergency department (ED) patients thought to require fluid resuscitation are not fluid responsive and risk harm from aggressive fluid administration [11]. Identifying which patients respond to fluids (and continue to do so) has the potential to individualise
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