Aims: To describe cardiac, pulmonary, and tissue perfusion functions by both invasive and noninvasive monitoring in the earliest phase of shock and acute critical illness in the emergency department (ED), the operating room (OR), and intensive care unit (ICU). Second, to evaluate the hemodynamic and oxygen transport effects of various fluid therapies, including whole blood, packed red cell transfusions, fresh frozen plasma, albumin, hydroxyethyl starch, and lactated Ringer’s solution in the initial resuscitation and early fluid management.

Methods: We studied 276 severely injured or critically ill patients after high risk surgery, hemorrhage, trauma, and sepsis immediately after admission to ED, in the OR, and in the ICU by noninvasive hemodynamic monitoring consisting of a new bioimpedance method for estimating cardiac output combined with arterial blood pressure, pulse oximetry, and transcutaneous O2 and CO2 (PtcO2 and PtcCO2); the latter were previously shown to reflect tissue perfusion/oxygenation. These data were compared with values from the pulmonary artery (PA) thermodilution catheter.

Results: Circulatory deficiencies in patients with severe trauma, hemorrhage, high risk surgery, and other acute life threatening illnesses were characterized by initial reductions in flow, tissue perfusion, and oxygen transport followed by marked increases to supranormal levels. WB, Prbc, and colloids, particularly starch, markedly and statistically significantly improved pressure, flow, and tissue perfusion/oxygenation and best achieved these goals.

Conclusions: Earlier recognition by noninvasive monitoring in the ED shortly after admission identified circulatory deficiencies in emergency and critically ill patients more promptly and evaluated the relative effectiveness of therapy. Noninvasive monitoring systems gave continuous displays of physiologic data that provided information allowing early recognition of low flow and poor tissue perfusion that were more pronounced in the nonsurvivors. Noninvasive systems are acceptable alternatives to invasive monitoring and may be used when the latter is not available.

Key words: Thoracic bioimpedance, estimation of cardiac output, pulse oximetry, transcutaneous O2 and CO2 monitoring, hemodynamic effects of whole blood, packed red cells, various colloids and crystalloids in the initial resuscitation, invasive and noninvasive hemodynamic monitoring, tissue perfusion, thermodilution cardiac output measurement, multicomponent noninvasive circulatory monitoring

W. C. Shoemaker
M.D.LAC + USC
Medical Center
Room 9900
1200 N State St.
Los Angeles, CA 90033
USA