Years since first academic appointment: No academic appointment
Title: Non-invasive flow guided resuscitation in the emergency department (ED-FGR).
Full Author List: Rohit Mohindra, Patrick Melanson, Sheldon Magder
For emergency department (ED) patients in a state of circulatory shock, treatment with fluids, vasopressors and inotropes is essential for improving blood flow to vital organs. Recent studies have challenged the use of early goal directed therapy targets. Evidence also shows that under and over resuscitation is harmful to patients. Consequently, there exists the need for a simple non-invasive algorithm to assess if therapy is improving perfusion, while avoiding potential harms.
Several non-invasive flow measurement devices have been developed and could facilitate flow-guided resuscitation (FGR). At our centre, we have demonstrated that the PhysioFlow bioimpedance device (NeuMedX Inc Bristol PA, USA) device can be used to track changes in flow.
The objective of our study is to demonstrate that using non-invasive flow monitoring to guide therapy (fluid bolus, vasopressor or inotrope) will improve perfusion and will result in better patient outcomes.
This is a cross-sectional, non-blinded, convenience sample, feasibility study at an academic tertiary ED. This study is intended to examine potential issues for the design of a larger trial. Inclusion criteria are: patients 18 years of age or older with any of: systolic blood pressure (SBP) < 90 mmHg, mean arterial pressure (MAP) < 65 mmHg, lactate ≥3.0 mmol/L or clinical signs of shock. Exclusion criteria are: acute myocardial infarction and/or evidence of cardiogenic shock, patients awaiting left ventricular assist device, active cardiopulmonary resuscitation, patients who have already received >1000 mL of crystalloid fluid, patients transferred from another hospital (as fluid resuscitation may have already occurred) or at the discretion of the treating physician.
Identified patients with hypo-perfusion presenting to the ED will have the PhysioFlow® device applied. The most responsible ED physician will be given the FGR algorithm to follow. This algorithm uses blood pressure, urine output and other clinical parameters, in addition to real time non-invasive measures of flow, as triggers for treatment of hypo-perfusion with IV fluids, vasopressors, or inotropes. Physicians will be surveyed to determine if the algorithm was easy to use and if they encountered any issues. Our aim is to enrol 10 patients over 3 months.
Work done to date
A quality-assurance study was completed in our ICU to ensure the device was providing reliable measures. After a brief trial run, we are now actively recruiting patients in the ED, with plans to expand to a second site. We expect to complete enrolment by May 2017.
Impact on Emergency Medicine Care
Our FGR study will provide valuable information for busy ED physicians. We expect that patients will benefit from reduced ICU length of stay and have fewer complications from fluid overload. Treatment non-responders can be identified earlier for transfer to ICU. We also predict that flow-guided resuscitation will result in faster stabilization of critically ill patients. With increased performance pressure on EDs in Canada, this could be a valuable initiative to reduce the burden on our strained clinical resources.
Questions for audience
- Currently, we do not have resources for full-time recruitment. This is severely limiting our recruitment rates. What low-cost strategies could we use to improve our ability to recruit?
- Our preliminary impression is that while ED physicians are enthusiastic about the project, they are not following the treatment algorithm. How can we improve this?
- Does our treatment algorithm make sense? Do you have any feedback on it? (see below)
Appendix – treatment algorithm