The use of impedance cardiography in predicting mortality in emergency department patients with severe sepsis and septic shock.
OBJECTIVE
Pulmonary artery catheterization poses significant risks and requires specialized training. Technological advances allow for more readily available, noninvasive clinical measurements of hemodynamics. Few studies exist that assess the efficacy of noninvasive hemodynamic monitoring in sepsis patients. The authors hypothesized that cardiac index, as measured noninvasively by impedance cardiography (ICG) in emergency department (ED) patients undergoing early goal-directed therapy (EGDT) for sepsis, would be associated with in-hospital mortality.


METHODS
This was a prospective observational cohort study of patients age over 18 years meeting criteria for EGDT (lactate > 4 or systolic blood pressure < 90 after 2 L of normal saline). Initial measurements of cardiac index were obtained by ICG. Patients were followed throughout their hospital course until discharge or in-hospital death. Cardiac index measures in survivors and nonsurvivors are presented as means and 95% confidence intervals (CI). Diagnostic performance of ICG in predicting mortality was tested by receiver operating characteristic (ROC) curve and areas under the ROC curves (AUC) were compared using Wilcoxon test.


RESULTS
Fifty-six patients were enrolled; one was excluded due to an inability to complete data acquisition. The mean cardiac index in nonsurvivors (2.3 L/min.m(2), 95% CI = 1.6 to 3.0) was less than that for survivors (3.2, 95% CI = 2.9 to 3.5) with mean difference of 0.9 (95% CI = 0.12 to 1.71). The AUC for ICG in predicting mortality was 0.71 (95% CI = 0.58 to 0.88; p = 0.004). A cardiac index of < 2 L/min.m(2) had a sensitivity of 43% (95% CI = 18% to 71%), specificity of 93% (95% CI = 80% to 95%), positive likelihood ratio of 5.9, and negative likelihood ratio of 0.6 for predicting in-hospital mortality.


CONCLUSIONS
Early, noninvasive measurement of the cardiac index in critically ill severe sepsis and septic shock patients can be performed in the ED for those who meet criteria for EGDT. There appears to be an association between an initial lower cardiac index as measured noninvasively and in-hospital mortality.
Napoli
Anthony M
AM
Department of Emergency Medicine, Brown University Medical School, Providence, RI, USA. anapoli@lifespan.org
Machan
Jason T
JT
Corl
Keith
K
Forcada
Ahteri
A
D000046:Academic Medical Centers; D000368:Aged; D000369:Aged, 80 and over; D002307:Cardiography, Impedance / Q000379:methods*; D016887:Cardiopulmonary Resuscitation / Q000379:methods; D002423:Cause of Death; D015331:Cohort Studies; D016001:Confidence Intervals; D016638:Critical Illness / Q000401:mortality / Q000628:therapy; D004636:Emergency Service, Hospital; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000379:methods; D011237:Predictive Value of Tests; D011336:Probability; D011446:Prospective Studies; D018805:Sepsis / Q000175:diagnosis* / Q000401:mortality* / Q000628:therapy; D012772:Shock, Septic / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D016019:Survival Analysis; D014193:Trauma Centers