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Hemodynamic Evaluation in Emergency Department

Claudia Carelli

3339705419

Background

In emergency departments (ED) it is necessary to perform a non-invasive and accurate evaluation of the hemodynamic parameters to screen patients and monitor the therapeutic response quickly. Nowadays, a wide range of hemodynamic monitoring systems is available, each having its own advantages and limitations [1]. In fact, gold standard for assessing cardiac output (CO) is pulmonary artery catheterization (PAC), but the Swan-Ganz catheter placement is complicated because it requires time and specific skills, besides not being risk-free. A recently introduced method is represented by the USCOM (UltraSound Cardiac Output Monitor), a non-invasive, reproducible monitoring system with a rapid learning curve [2], which allows to evaluate the CO using ultrasound generated by a Doppler CW probe applied on the suprasternal notch (for trans-aortic flow) or at the 3rd-4th left intercostal space (for trans-pulmonary flow). We report our experience on the using of USCOM device applied in two opposite clinical cases: a dehydrated patient and a pulmonary oedema-affected one.

 

Case report

In the first case, a woman (90 years old) arrived in the ED for a reported state of confusion and persistent fever for about 20 days. At medical evaluation, she was soporous (GCS 7) with vital parameters in normal range except for hypoxaemia, increased lactates and hypernatriemia highlighted at the entrance ABG. Pneumonia was showed by chest CT while water deficit calculated was around 6.23 liters, for which therapy with antibiotics and continuous infusion of hypotonic solution was undertaken, for a total of 2400 cc/day, monitoring her hemodynamic status before and after fluid infusion through USCOM device. The data obtained highlighted the reduced cardiac contractility and the lack of improvement in Oxygen Delivery (DO2) and CO after the fluid infusion that had caused a slight increase of the preload index with a progressive reduction of the high resistances.

Meanwhile, a men (71 years old) arrived in the ED for worsening dyspnoea in the last 7 days with appearance of oedema in the lower limbs. The entrance ABG highlighted a condition of severe hypoxemia and the clinical evaluation and the echofast confirmed a condition of pulmonary oedema for which therapy with diuretics and CPAP was started. After the improvement of clinical conditions, USCOM was performed to evaluate his hemodynamic status: it showed a cardiac contractility on the lower limits (data confirmed by a previous echocardiographic examination), while the preload parameter was returned to values slightly lower than normal.

 

Conclusion

In our clinical cases, the choice of USCOM as monitoring system was guided by our necessity for non-invasiveness, to obtain easily and quickly repeatable information that allows us to know a trend of their hemodynamic status, in absence of consumables and, at the same time, provide information on the status of preload, afterload, inotropism and CO. However, further studies are needed considering larger samples and case history [3].

 

References

[1] Kobe J, Mishra N, Arya V K, Al-Moustadi W, Nates W, Kumar B. Cardiac output monitoring: Technology and choice. Annals of cardiac anaesthesia. 2019; 22(1), 6.

[2] Hodgson L E, Venn R, Forni L G, Samuels T L, Wakeling H G. Measuring the cardiac output in acute emergency admissions: use of the non-invasive ultrasonic cardiac output monitor (USCOM) with determination of the learning curve and inter-rater reliability. Journal of the Intensive Care Society. 2016; 17(2), 122-128.

[3] van Lelyveld-Haas L E M, Van Zanten A R H, Borm G F, Tjan D H T. Clinical validation of the non-invasive cardiac output monitor USCOM-1A in critically ill patients. European journal of anaesthesiology. 2008; 25(11), 917-924.

Hemodynamic Evaluation in Emergency Department

Orale

Riccardo Candido, Dirigente medico, unità operativa di medicina d'emergenza urgenza, ospedale CTO, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Napoli, Italia.

Flavio Cesaro, Dirigente medico, unità operativa di medicina d'emergenza urgenza, ospedale CTO, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Napoli, Italia.

Claudia Sara Cimmino, Dirigente medico, unità operativa di medicina d'emergenza urgenza, ospedale CTO, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Napoli, Italia.

Cosimo Cosimato, Dirigente medico, unità operativa di medicina d'emergenza urgenza, ospedale CTO, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Napoli, Italia.

Giovanna Cristiano, Dirigente medico, unità operativa di medicina d'emergenza urgenza, ospedale CTO, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Napoli, Italia.

Giovanni d’Angelo, Dirigente medico, unità operativa di medicina d'emergenza urgenza, ospedale CTO, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Napoli, Italia.

Rosanna Esposito, Dirigente medico, unità operativa di medicina d'emergenza urgenza, ospedale CTO, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Napoli, Italia.

Angela Smeralda Giunta, Dirigente medico, unità operativa di medicina d'emergenza urgenza, ospedale CTO, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Napoli, Italia.

Maria Paola Ursi, Dirigente medico, unità operativa di medicina d'emergenza urgenza, ospedale CTO, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Napoli, Italia.

Mario Guarino, Dirigente responsabile, unità operativa di medicina d'emergenza urgenza, ospedale CTO, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Napoli, Italia.

Case Report

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