Noninvasive Cardiac Output by Partial CO2 Rebreathing after Severe Chest Trauma

Abstract

In multiple trauma patients, early continuous cardiac output (CCO) monitoring is frequently desired but is difficult to routinely employ in most emergency departments because it requires invasive procedures. Recently, a noninvasive cardiac output (NICO) technique based on the Fick principle and partial CO2 rebreathing has shown promise under a variety of conditions. Since this method has not been tested after lung damage, we evaluated its utility in a clinically relevant model.

Anesthetized, ventilated swine (n = 11, 35–45 kg) received a unilateral blunt trauma via a captive bolt gun followed by a 25% hemorrhage. After 60 min of shock, crystalloid resuscitation was given as needed to maintain heart rate < 100 beats/min and mean arterial pressure > 70 mm Hg. Standard CCO by thermodilution (Baxter Vigilance, Irvine, CA) was compared with NICO (Novametrix Medical Systems Inc., Wallingford, CT) for 8 hr.

The severity of the injury is reflected by seven deaths (average survival time = 4.25 hr). Trauma increased dead space ventilation (19%), airway resistance (30%), and lactate (3.2 mmol/L), and decreased dynamic compliance (48%) and Pao2/Fio2 (54%). In these extreme conditions, the time course and magnitude of change of CCO and NICO were superimposed. Bland-Altman analysis reveal a bias and precision of 0.01 ± 0.69 liters/min. The linear relationship between individual CCO and NICO values was significant (p < 0.0001) and was described by the equation NICO = (0.74 ± 0.1)CCO + (0.65 ± 0.16 liters/min) but the correlation coefficient (r2 = 0.541) was relatively low. The cause for the low correlation could not be attributed to increased pulmonary shunt, venous desaturation, anemia, hypercapnia, increased dead space ventilation, or hyperlactacidemia.

NICO correlated with thermodilution CCO, but underestimated this standard by 26% in extreme laboratory conditions of trauma-induced cardiopulmonary dysfunction; 95% of the NICO values fall within 1.38 liters/min of CCO; and with further improvements, NICO may be useful in multiple trauma patients requiring emergency intubation during initial assessment and workup.