Artur Karpiarz1, 2, *Lukasz Czyzewski3, Janusz Wyzgal3, Monika Saran4, Mikolaj Rusin5, Zuzanna Popielarska5, Brygida Krucinska4, Urszula Szewc3, Lukasz Szarpak5
Non-invasive assessment of haemodynamic parameters in pre-hospital care – a preliminary study
Nieinwazyjna ocena parametrów hemodynamicznych w opiece przedszpitalnej – badanie wstępne
1Independent Public Health Care Centre RM “MEDITRANS” Emergency, Medical Service Station and Sanitary Transport in Siedlce, Poland
2Student of Faculty of Health Sciences, Collegium Mazovia Innovative University, Siedlce, Poland
3Department of Nephrology Nursing, Medical University of Warsaw, Poland
4Student Research Circle “NEFRON”, Medical University of Warsaw, Poland
5Lazarski University, Warsaw, Poland
Wstęp. Dotychczas na wyposażeniu zespołów PRM do pomiaru parametrów życiowych stosuje się pulsoksymetry (pomiar SpO2, HR) oraz defibrylatory (pomiar HR, NIMBP, EKG, SpO2, SpCO2). Wydaje się to niewystarczające, ponieważ daje niepełny i dodatkowo opóźniony w czasie obraz stanu pacjenta, który nie uwzględnia w krótkim czasie wpływu leków czy płynoterapii.
Cel pracy. Celem pracy jest ocena użyteczności zastosowania kardiografii impedancyjnej (ICG) w opiece przedszpitalnej.
Materiał i metody. Badania przeprowadzono w okresie od maja do czerwca 2018 roku w trakcie działań zespołu „S” specjalistycznego w rejonie działania podstacji Pogotowia Ratunkowego w Sokołowie Podlaskim (mazowieckie, Polska). W celu dokonania nieinwazyjnej oceny parametrów hemodynamicznych używano kardiomonitora Icon (Osypka Medical, Berlin, Germany). Badania były przeprowadzane u pacjentów podczas działań zespołu ratownictwa medycznego w karetce pogotowia ratunkowego.
Wyniki. Wykazano istotne klinicznie różnice pomiędzy pacjentami z podejrzeniem urazu/zatrucia, chorób układu krążenia i innych jednostek chorobowych dla: HR (81 ± 15 vs. 100 ± 30 vs 88 ±12; P = 0,084 u/min, odpowiednio), SVRI (2803 ± 871 vs 2730 ± 871 vs 1830 ± 661 d•s/cm-5/m2; P = 0,092, odpowiednio), TFC (21,2 ± 5,7 vs 25,3 ± 6,3 vs 29,6 ± 11,8; P = 0,116 1/kOhm, odpowiednio).
Wnioski. W ocenie autorów, szczególnie u pacjentów urazowych, w przypadku krwotoków (wstrząs), z niewydolnością krążenia (obrzęk płuc, nadciśnienie tętnicze, zaburzenia rytmu serca, zawał serca) możliwość dodatkowych pomiarów, szczególnie pracy serca, może być kluczowa w wyborze i ewentualnie ocenie efektywności podjętych działań.
Introduction. Pulse oximeters (SpO2, HR measurement) and defibrillators (HR, NIMBP, ECG, SpO2, SpCO2 measurement) are still in use as equipment to EMS teams. This seems insufficient due to receiving an incomplete and additionally time delayed picture of the patient’s condition, which does not take into account the effect of drugs or fluid therapy in such a short period of time.
Aim. The aim of the study is to assess the usefulness of impedance cardiography (ICG) in prehospital care.
Material and methods. The research was carried out in the period May-June 2018 during the activities of the “S” specialist team in the area of operation of the Emergency Medical Service substation in Sokolow Podlaski. Protocol of this study was accepted by the Institutional Review Board of the Polish Society of Disaster Medicine. In order to perform a non-invasive assessment of haemodynamic parameters, the cardiac monitor, Icon (Osypka Medical, Berlin, Germany) was used. The examinations were carried out for patients during the operation by the Emergency Medical Team in the ambulance.
Results. There were clinically significant differences between patients with suspected trauma/intoxication, cardiovascular diseases and other disease entities for: HR (81 ± 15 vs 100 ± 30 vs 88 ±12 bpm; P = 0.084, respectively); SVRI (2803 ± 871 vs 2730 ± 871 vs 1830 ± 661 d•s/cm-5/m2; P = 0.092, respectively), TFC (21.2 ± 5.7 vs 25.3 ± 6.3 vs 29.6 ± 11.8 1/kOhm; P = 0.116; respectively).
Conclusions. In the authors’ opinion, especially for patients in trauma, in regards to haemorrhage (shock) with circulatory insufficiency (pulmonary oedema, hypertension, arrhythmias, myocardial infarction) the possibility of additional measurements, especially of the heart’s performance, may be crucial in the selection and possibly assessment of the effectiveness of the undertaken actions.
The research of hemodynamic parameters, which may be useful in assessing a patient’s condition and monitor the effectiveness of the support provided by the medical staff of hospital emergency departments (ED), intensive care unit (ICU), cardiology and post-operative departments, has been observed for many years. The most common measurement methods are invasive, notably called cardiac or radial artery catheterization, which requires sterile conditions in which to be performed. Different methodologies such as echocardiography, are time-consuming and require the appropriate skills from doctors who perform them. The non-invasive methods of haemodynamic parameters measurement are starting to be used more frequently and they are not burdened with TEB (thoracic electrical bioimpedance) complications.
The clinical experiments indicate that the evaluation of the circulation condition is limited only to the measurement of blood pressure and heart rate is inconclusive. In regards to the group of non-invasive methods of haemodynamic parameters’ measurement, such as cardiac output (CO), stroke volume (SV) and the thoracic fluid content (TFC), the monitors of cardiac output can be used, which due to the size and simple manual operation achieve the measurement in a short period of time, so they can be used to assess the haemodynamic parameters by emergency medical services (EMS). Currently, no research on using the measurements of haemodynamic parameters by emergency medical services has been performed, yet obtaining the answers about the effectiveness of the performed actions could help doctors and paramedics in undertaking appropriate treatment methods, as well as show the effectiveness of their treatment. The time of action of EMS teams until transferring the patient to the hospital staff, after deduction of travel time to the patient, varies from a few minutes to one hour, which is why the measurements of the cardiac cycle should be obtained using simple and non-time-consuming methods.
Pulse oximeters (SpO2, HR measurement) and defibrillators (HR, NIMBP, ECG, SpO2, SpCO2 measurement) are still in use as equipment to EMS teams. This seems insufficient due to receiving an incomplete and additionally time delayed picture of the patient’s condition, which does not take into account the effect of drugs or fluid therapy in such a short period of time.
The aim of the study was to assess the usefulness of impedance cardiography (ICG) in prehospital care.
MATERIAL AND METHODS
The research was carried out in the period May-June 2018 during the activities of the “S” specialist team in the area of operation of the Emergency Medical Service substation in Sokolow Podlaski (Mazovian, Poland). Protocol of this study was accepted by the Institutional Review Board of the Polish Society of Disaster Medicine. The investigation conformed to the principles outlined in the Declaration of Helsinki and was approved by the Director of the Independent Public Health Care Centre RM “MEDITRANS” Emergency Medical Service Station and Sanitary Transport in Siedlce, and all respondents gave their voluntary consent to participate in the study. The W0451 team (specialist in Sokolow Podlaski) left 1335 times in 2017 to: 1) injuries and poisoning – 293 times; 2) respiratory diseases – 135 times; 3) cardiovascular disease – 275 times; 4) resuscitation – 96 times; 5) fainting – 236 times.
The people who qualified for the study were given oral instructions about the principles, objectives and benefits of the research. The criterion for inclusion in the study was the age of the patient ≥ 18 years and disease entities due to which the ambulance team was called. The study excluded patients who could not consciously give their consent, the lack of the ability to connect the monitor during performed activities and patients who were under the age of 18.
The studied group consisted of 31 patients, including 17 men (37-100 y.o.) and 14 women (24-87 y.o.). The patients’ research group was divided into 3 groups in respect to the diseased entity: 1) injuries and poisoning – 14 people, most frequently alcohol poisoning; 2) cardiovascular diseases (CVD) – 13 people; 3) other, i.e. fainting, respiratory diseases – 7 people. All patients were transported to ED/ER. The control group consisted of 9 people – employees of the ambulance station.
Assessment of haemodynamic parameters
The electrical velocimetry (EV) method is based on a modified measurement of the thoracic electrical bioimpedance (TEB). It is a relatively new methodology, characterized by the continuity of measurement, ease of implementation, practically no operating costs (four ECG electrodes are needed) and the possibility of use on a majority of patients. In order to perform a non-invasive assessment of haemodynamic parameters, the cardiac monitor, Icon (Osypka Medical, Berlin, Germany) was used. The examinations were carried out for patients during the operation by the Emergency Medical Team in the ambulance. In order to perform the measurement, two electrodes are placed on the neck and two are placed on the left-side of the chest. This allows users to perform a continuous measurement of changes in electrical conductivity within the chest cavity by supplying a current with a low amplitude and a high frequency and the resistance is measured. Distortions or artefacts in the ICG signal were detected and excluded from analysis. The ICG signal quality was always > 85% over all sets of measurements. The following parameters were recorded in each patient: CI (cardiac output/body surface area (L/min/m2)), SVRI (dynes-sec/cm-5/m2), TFC (1/kOhm), stroke index (SI (mL/m2)). CI reflects the amount of blood pumped by the heart in one minute, normalized to body size; TFC is the inverse of baseline chest impedance, and any changes in TFC are directly proportional to total fluid (intravascular and extravascular) changes; SVRI represents the force the ventricle must overcome to eject blood into the aorta, which represents estimation of “afterload”. The description and repeatability of the ICG method have been published elsewhere (1, 2).
The qualitative variables that are presented are as an absolute number and interest. Quantitative variables are presented as mean as well as standard deviation. The normal distribution was analysed using the Shapiro-Wilk test. The qualitative variables were compared using the chi-squared test, while the quantitative variables were analysed using one-way ANOVA. The post hoc analysis was performed using the Duncan test. In the comparative analysis of HR, SBP, DBP, as well as the clinical results, results, simple linear regression analysis (Spearman) was applied to detect and describe the strength and direction of correlations of HR, SBP, DBP to clinical, data. The statistical analysis was achieved using the Statistica 13.1 program, assuming a significance threshold of P < 0.05.
The average age of the examined group of patients is 65 ± 20 years. There were statistically significant differences between patients with suspected trauma/intoxication, cardiovascular diseases and other disease entities, for age 54 ± 22 vs 78 ± 9 vs 61 ± 21; P = 0.005, respectively. There were clinically significant differences between patients with suspected trauma/intoxication, cardiovascular diseases and other disease entities for: HR (81 ± 15 vs 100 ± 30 vs 88 ± 12 bpm; P = 0.084, respectively), SVRI (2803 ± 871 vs 2730 ± 871 vs 1830 ± 661 d•s/cm-5/m2; P = 0.092, respectively), TFC (21.2 ± 5.7 vs 25.3 ± 6.3 vs 29.6 ± 11.8 1/kOhm; P = 0.116; respectively) (tab. 1).
Tab. 1. Univariate comparison of reasons for patient transport
|Age [y]||66 ± 20||54 ± 22||78 ± 9||61 ± 21||0.005|
|BMI [kg/m2]||26.9 ± 5.3||28.2 ± 5.6||26.5 ± 5.1||25.6 ± 5.5||0.709|
|HR [bpm]||91 ± 23||81 ± 15||100 ± 30||88 ± 12||0.084|
|SV [ml]||76.1 ± 20.3||78.0 ± 16.2||68.2 ± 12.3||87.8 ± 31.8||0.149|
|CI [L/min/m2]||2.8 ± 0.8||2.9 ± 0.8||2.7 ± 0.8||2.8 ± 1.1||0.661|
|TFC [1/kOhm]||24.8 ± 8.1||21.2 ± 5.7||25.3 ± 6.3||29.6 ± 11.8||0.116|
|SI [ml/m2]||41.8 ± 12.0||40.6 ± 7.5||37.9 ± 6,8||51.0 ± 20.1||0.128|
|SpO2 [%]||94 ± 5||96 ± 2||93 ± 6||93 ± 7||0.270|
|SBP [mmHg]||145 ± 31||144 ± 30||149 ± 34||137 ± 31||0.931|
|DBP [mmHg]||87 ± 16||89 ± 15||90 ± 15||80 ± 22||0.455|
|MAP [mmHg]||106 ± 20||108 ± 17||109 ± 21||99 ± 23||0.667|
|SVRI [d•s/cm-5/m2]||2566 ± 893||2803 ± 871||2730 ± 871||1830 ± 661||0.092|
In simple linear regression analysis (Spearman), SVRI was negatively correlated with HR (all P for trend < 0.05) and positively correlated with SBP and DBP. TFC was negatively correlated with DBP (tab. 2).
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