The inability of emergency physicians to adequately clinically estimate the underlying hemodynamic profiles of acutely ill patients

• Published in: The American journal of emergency medicine Vol. 30; no. 6; pp. 954 - 960
• Main Authors: Nowak, Richard M., MD, Sen, Ayan, MD, Garcia, Audwin J., MD, Wilkie, Heidi, Yang, James J., PhD, Nowak, Michael R, Moyer, Michele L., BSN
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 01.07.2012; Elsevier; Elsevier Limited
• Subjects: Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Biological and medical sciences; Blood pressure; Blood Pressure - physiology; Cardiac Output - physiology; Confidence intervals; Critical Illness; Emergency; Emergency and intensive care: techniques, logistics; Emergency medical care; Emergency Service, Hospital - statistics & numerical data; Estimates; Female; Hemodynamics - physiology; Humans; Intensive care medicine; Intensive care unit. Emergency transport systems. Emergency, hospital ward; Intubation; Male; Medical sciences; Middle Aged; Monitoring, Physiologic; Mortality; Physicians; Prospective Studies; Pulmonary arteries; Sepsis; Vascular Resistance - physiology; Veins & arteries; Human; Physician; Intensive care; Hemodynamics; Emergency; Resuscitation
• ISSN: 0735-6757; 1532-8171
• DOI: 10.1016/j.ajem.2011.05.021

Abstract Objective Emergency physicians (EPs) estimate the underlying hemodynamics of acutely ill patients and use them to help both diagnose and formulate a treatment plan. This trial compared the EP clinically derived estimates of cardiac output (CO) and systemic vascular resistance (SVR) to those measured noninvasively. Methods Forty acutely ill emergency department patients with a broad range of diagnosis and blood pressure (BP) and pulse were monitored for 2 hours using novel noninvasive finger cuff technology (Nexfin; BMEYE, Amsterdam, The Netherlands). The Nexfin device provides continuous BP monitoring and, from the resulting pulse pressure waveform, calculates beat-to-beat CO and SVR. At baseline assessment and after 2 hours of testing and therapy, treating EPs were asked to estimate the CO and SVR (low, normal, or high), and these were compared with Nexfin measurements. Results Twenty-five men and 15 women were enrolled with a mean age of 62.2 years (SD, 12.6 years). Eighteen had acute shortness of breath; 11, with probable stroke syndrome; 3, with suspected sepsis; and 8, with a systolic BP greater than 180 or less than 100 mm Hg. Concordance tables showed that there was very little agreement ( κ values) between either the compared initial CO (−0.0873) and SVR (−0.0645) or the 2-hour values (−0.0645 and −0.1949, respectively). Conclusions Emergency physicians cannot accurately estimate the underlying hemodynamic profiles of acutely ill patients when compared with more objective measurements. This inaccuracy may have important clinical ramifications. Further study is needed to determine how to use these measured continuous CO and SVR monitoring values.