Compensatory reserve and pulse character: Enhanced potential to predict urgency for transfusion and other life‐saving interventions after traumatic injury

Abstract

Background Field triage of trauma patients requires timely assessment of physiologic status to determine resuscitative needs. Vital signs and rudimentary assessments such as pulse character (PC) are used by first responders to guide decision making. The compensatory reserve measurement (CRM) has demonstrated utility as an easily interpretable method for assessing patient status. We hypothesized that the ability to identify injured patients requiring transfusion and other life‐saving interventions (LSI) using a measurement of pulse character could be enhanced by the addition of the CRM. Methods We performed a prospective observational study on 300 trauma patients admitted to a level I trauma center. CRM was recorded continuously after device placement on arrival. Patient demographics, field and trauma resuscitation unit vital signs, therapeutic interventions, and outcomes were collected. A field SBP <100 mmHg was utilized as a surrogate for abnormal PC as previously validated. A patient with a CRM threshold value of <60% was considered clinically compromised with a risk of onset of decompensated shock. Data were analyzed to assess the capacity of CRM and pulse character separately or in combination to predict LSI defined as need for transfusion, intubation, tube thoracostomy, or operative/ angiographic hemorrhage control. Results An improvement in the predictive capability for LSI, transfusion, or a composite outcome was demonstrated by the combination of CRM and PC compared to either measure alone. Conclusions Combining PC assessment with CRM has the potential to enhance the recognition of injured patients requiring life‐saving intervention thus improving sensitivity of decision support for prehospital providers.

Evidence for Beneficial Use of the Compensatory Reserve Measurement in Guiding Intraoperative Resuscitation: A Prospective Cohort Study of Orthotopic Liver Transplant Recipients

“…This odds ratio comparison demonstrates the increased discriminatory ability of CRM to provide early prediction of the need for intervention and shows an improved ability to guide intraoperative resuscitation relative to standard vital sign measurements. Our findings also confirm results published from prior studies shown an increased discriminatory ability of CRM to predict need for transfusion in traumatic hemorrhage (9). The earlier detection of changing volume status using CRM during surgery and resuscitation observed in the present investigation provides the clinician with an adjunctive tool to supplement vital sign measures for enhanced patient care given the relationship between early intervention and improved clinical outcomes (1,4,6,10).…”

“…However, we are unaware of any clinical investigations other than the current study reported here that have presented experimental results that support the ability of CRM for use in the intraoperative setting. Compensatory reserve measurement has been shown to display superior sensitivity and specificity for predicting reductions in central blood volume in human experimental protocols compared with other noninvasive measures of volume status (1–5) and increased ability to predict transfusion in trauma patients (9,10,13,18). Given that CRM is an algorithmic measurement of the summation of all physiologic compensatory mechanisms with an ability to detect hemorrhagic blood losses and track restoration of circulating volume during resuscitation, we hypothesized that the algorithm would provide novel assessment of patients undergoing a liver transplant surgery.…”

“…Several studies have used CRM to assess hemorrhagic shock in the trauma population (9)(10)(11)(12)(13)(14)(15)(16)(19)(20)(21), and ongoing studies are assessing its validity in the prehospital setting. However, we are unaware of any clinical investigations other than the current study reported here that have presented experimental results that support the ability of CRM for use in the intraoperative setting.…”

“…Previous studies have shown the discriminatory ability of the CRM to predict early onset of hemodynamic collapse (4,5) with superior sensitivity and specificity to predict impending physiologic decline and provide accurate goal-directed whole blood resuscitation (6,7) compared with less complex measures of arterial waveform feature analysis (e.g., pulse pressure variation, peripheral perfusion index) (7). Prior clinical investigations on the use of CRM in monitoring hemodynamic status of subjects have focused primarily on early resuscitation in hemorrhaging trauma patients (8)(9)(10)(11)(12)(13)(14)(15)(16)), but we are unaware of previous reports of CRM for continuous assessment of blood volume loss or guiding blood product resuscitation in the intraoperative setting. The challenge arises with the inherently complex use of multiple methods of hemodynamic support (e.g., vasopressors, inotropes, blood product resuscitation, crystalloid infusion), in comparison with prior studies of the CRM where there was a single defined hemorrhagic event (i.e., traumatic injury).…”