Emergency department noninvasive (NICOM) cardiac outputs are associated with trauma activation, patient injury severity and host conditions and mortality

Trauma/Critical Services, Level I Trauma Center, St. Elizabeth Health Center, Youngstown, Ohio, USA.
The journal of trauma and acute care surgery 08/2012; 73(2):479-85. DOI: 10.1097/TA.0b013e31825eeaad
Source: PubMed


Anoninvasive cardiac output (CO) monitor (NICOM), using Bioreactance technology, has been validated in several nontrauma patient studies. We hypothesized that NICOM CO would have more significant associations with clinical conditions than would systolic blood pressure (sBP).
This is a prospective observational study of consecutive trauma activation patients during the first 10 to 60 minutes after emergency department arrival.
Analysis includes 270 consecutive trauma activation patients with 1,568 observations. CO was decreased (p ≤ 0.002) with major blood loss, hypotension, red blood cell transfusion, Injury Severity Score (ISS) higher than 20, low PetCO₂, abnormal pupils, elderly, preexisting conditions, low body surface area level, females, hypothermia, and death. CO was increased (p < 0.0001) with base deficit, ethanol positivity, and illicit drug positivity. The sBP was decreased (p ≤ 0.0005) with major blood loss, red blood cell transfusion, low PetCO₂, low body surface area level, and illicit drug positivity. The sBP was increased (p e 0.01) with ISS higher than 20, elderly, and preexisting conditions. Total significant condition associations were CO 83% (15 of 18 patients) and sBP 47% (8 of 17 patients; p = 0.03). In hypotensive patients, CO was lower with major blood loss (3.3 ± 2.1 L/ min) than without (6.0 ± 2.2 L/min; p < 0.0001). Of survivors with ISS 15 or higher, NICOM patients experienced a shorter hospital length of stay (10.5 days) when compared with 2009 and 2010 patients (14.0 days; p = 0.03).
The multiple associations of CO with patient conditions imply that NICOM provides an objective and clinically valid, relevant, and discriminate measure of cardiac function in acutely injured trauma activation patients. NICOM use may be associated with a shorter length of stay in surviving patients with complex injuries.

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    • "The noninvasive, user-friendly features of NICOM are appealing for managing time-pressured, critical trauma patients in the Emergency Department. In our previous publication, we demonstrated that 90% of patients had an initial CO within 8.5 minutes of Emergency Department arrival [1]. The compelling literature and the user-friendly aspects of NICOM suggest that monitoring cardiac function during Emergency Department trauma activation may become more widespread. "
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    ABSTRACT: In a smaller experience, the authors previously demonstrated that end-tidal carbon dioxide (PetCO2) and cardiac output (CO) had a positive association in emergently intubated trauma patients during Emergency Department resuscitation. The aim of this larger study was to reassess the relationship of PetCO2 with CO and identify patient risk-conditions influencing PetCO2 and CO values. The investigation consists of acutely injured trauma patients requiring emergency tracheal intubation. The study focuses on the prospective collection of PetCO2 and noninvasive CO monitor (NICOM(R)) values in the Emergency Department. From the end of March through August 2011, 73 patients had 318 pairs of PetCO2 (mm Hg) and CO (L/min.) values. Mean data included Injury Severity Score (ISS) >=15 in 65.2%, Glasgow Coma Score of 6.4 +/- 4.6, hypotension in 19.0%, and death in 34.3%. With PetCO2 <= 25 (15.9 +/- 8.0), systolic blood pressure was 77.0 +/- 69, CO was 3.2 +/- 3.0, cardiac arrest was 60.4%, and mortality was 84.9%. During hypotension, CO was lower with major blood loss (1.9), than without major loss (5.0; P = 0.0008). Low PetCO2 was associated with low CO (P < 0.0001). Low PetCO2 was associated (P <= 0.0012) with ISS > 20, hypotension, bradycardia, major blood loss, abnormal pupils, cardiac arrest, and death. Low CO was associated (P <= 0.0059) with ISS > 20, hypotension, bradycardia, major blood loss, abnormal pupils, cardiac arrest, and death. During emergency department resuscitation, a decline in PetCO2 correlates with decreases in noninvasive CO in emergently intubated trauma patients. Decreasing PetCO2 and declining NICOM CO are associated with hemodynamic instability, hemorrhage, abnormal pupils (this is in harmony with Dr. Johnson's critique and the revised title), and death. The study indicates that NICOM CO values are clinically discriminate and have physiologic validity.
    Full-text · Article · Sep 2013 · BMC Anesthesiology
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    Full-text · Article · Mar 2013 · Critical Care
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    ABSTRACT: Background: We evaluated the use of bioreactance-based noninvasive cardiac output (CO) monitoring technique (NICOM(™), CO(NICOM)) in pediatric patients with or without ventricular septal defect (VSD) during anesthesia induction to determine its agreement with the measurements assessed by echocardiography (echo, CO(ECHO)). Methods: Twenty-eight pediatric patients with normal heart anatomy (group NHA) and 32 with isolated ventricular septal defects (group VSD) were included in this study. The cardiac output was measured simultaneously in minute-by-minute using NICOM and echo (Simpson's rule) during anesthesia induction and intubation. Linear regression and revised Bland-Altman analyses were performed to evaluate the agreement by comparing the paired CO results. The mean percent error ((CO(ECHO)-CO(NICOM))/CO(ECHO) × 100%) was used to assess the impact of congenital heart disease on the agreement. Results: The measurements of CO by NICOM and echo techniques were highly correlated in group NHA (γ = 0.96, P < 0.005) and VSD (γ = 0.84, P < 0.005). The mean bias (CO(ECHO) - CO(NICOM)) between the two methods was 0.03 and 0.31 l·min(-1) with the limits of agreement (LOA) -0.29 to +0.35 l·min(-1) and -0.44 to +1.05 l·min(-1), which include 96.9% (31/32) and 89.3% (25/28) of all patients' different data in group NHA and VSD, respectively. The median percent errors were significantly lower at all time points in group NHA than those in group VSD (all P < 0.05). Conclusion: In children without heart defects, the CO measured by NICOM shows a good agreement with the echo during anesthesia induction. The NICOM technique underestimates echo although a strong correlation exists between two methods in children with ventricular septal defect.
    No preview · Article · Jul 2014 · Pediatric Anesthesia
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