Intensive Care Med

DOI 10.1007/s00134-015-3787-0 LETTER

Bantayehu Sileshi removal of 250 and 500 mL of au- over 10 s (*6 respiratory cycles). In
Kyle M. Hocking tologous blood prior to a subset of five patients, we analyzed
Richard B. Boyer cardiopulmonary bypass. Amplitude F1 amplitudes during \10 s of breath
Franz J. Baudenbacher changes of the first frequency (F1), holding. We estimated a baseline total
Kelly L. Kohurst corresponding to HR, were averaged blood volume of 70 mL/kg. Data
Colleen M. Brophy
Susan Eagle
A
Baseline 500 mL Blood Loss

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Peripheral venous waveform

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analysis for detecting early

Pressure (mmHg)

Pressure (mmHg)
hemorrhage: a pilot study
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Inspiraon Expiraon Inspiraon Expiraon
Accepted: 30 March 2015 22

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Springer-Verlag Berlin Heidelberg and
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time time
ESICM 2015 (seconds) (seconds)
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F0 F1
Pressure (mmHg)

Pressure (mmHg)
F0
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Dear Editor,
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Standard and invasive monitors fail to 0 1 2 3 4 0 1 2 3 4

detect early hemorrhage [1]. Dynamic frequency

(Hz)
frequency
(Hz)
monitors are limited by large
([8 mL/kg) tidal volume require-
B
ments during mechanical ventilation
[2]. In this pilot study, we utilize pe-
ripheral intravenous waveform
analysis (PIVA) via a standard intra-
venous catheter (IV) to quantitate
early hemorrhage.
After approval by the Vanderbilt
University Institutional Review
Board, we enrolled patients scheduled
for elective cardiac surgery. Follow-
ing induction of general anesthesia,
patients received central venous,
pulmonary artery, and radial artery
catheters. All patients were me-
chanically ventilated using assist
control, average tidal volume 6.5 mL/
kg, and peak inspiratory pressure
\30 mmHg. Peripheral venous Fig. 1 a Peripheral venous waveform and Fourier analysis. Top representative peripheral
waveforms were continuously mea- venous waveform collected from a patient at baseline (left) and following 500 mL blood
sured via an upper extremity 16- or loss (right). Inspiratory and expiratory cycles during mechanical ventilation are illustrated.
18-gauge IV (Smiths Medical, Mun- Bottom fast fourier transformation of the peripheral venous waveform showing the peaks
across an 8-k sampling window for baseline (left) and following 500 mL blood loss (right).
delein, IL, USA) directly connected F0 represents the waveform amplitude at the patients respiratory rate and F1 represents the
to a pressure transducer (ADInstru- waveform amplitude at the patients heart rate. b Comparison of different indices of
ments, Colorado Springs, CO, USA). volume status during blood loss. Top left spectral analysis of peripheral venous waveform
Fast Fourier transformation of the shows a significant change in F1 amplitude with blood loss from baseline to 250 mL
(n = 12, p = 0.0019) and 500 mL (n = 9, p = 0.0042). There was also significance
peripheral venous signal was mea- between 250 and 500 mL of blood loss. There were no significant changes in HR, PAP, and
sured at baseline and following MAP during blood loss
were analyzed using a one-way
ANOVA analysis with a post-test of
Tukeys multiple comparison with
paired analysis. We used MedCalc to
determine a pairwise comparison of
ROC curves, area under the curve,
standard error, and a 95 % confidence
interval for each dataset.
Twelve patients were enrolled
[mean age 65.5 years, 9 (75 %)
male]. Representative raw peripheral
waveform signals are shown at base-
line and after autologous blood
removal (Fig. 1a). F1 amplitude
changed significantly between base-
line (0 mL) and 250 mL
(p = 0.0019), baseline and 500 mL
(p = 0.0042), and 250500 mL
(p = 0.0382) blood removal, while
mean arterial pressure (MAP), heart
rate (HR), and diastolic pulmonary
artery pressure (dPAP) did not change
significantly (Fig. 1b). At 6 % esti-
mated blood loss, F1 had the greatest
area under the ROC curve
(AUC = 0.90, 95 % CI 0.67, 0.99),
compared to dPAP (AUC = 0.62),
HR (AUC = 0.54) and MAP
(AUC = 0.512). In addition, there
was no significant change in F1 am-
plitude with and without mechanical
ventilation (n = 5, p = 0.21).
Our principal finding is that PIVA
is able to detect as little as 6 % esti-
mated blood loss, while HR, MAP,
CVP, and dPAP did not change
significantly, consistent with previous
studies [1, 3]. PIVA was useful at ti-
dal volumes consistent with lung
protective ventilation, less than re-
quired by dynamic monitors [2, 4, 5].
Our data showed that, while baseline
F1 amplitude varied between patients,
all had significant changes following
hemorrhage. We attribute this base-
line difference to diverse baseline
cardiovascular and volume status.
While our findings are encouraging, a
larger controlled study needs to be
performed to investigate the effects of
cardiac function, vasoactive pharma-
ceuticals, and arrhythmias on PIVA.
Our prospective pilot study shows
that PIVA could be helpful to detect
early hemorrhage in select popula-
tions. PIVA may provide a low-cost,
minimally invasive method that
overcomes mechanical ventilation
limitations seen with dynamic
monitors.
References
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B. Sileshi
K. M. Hocking
R. B. Boyer

F. J. Baudenbacher
K. L. Kohurst

C. M. Brophy
S. Eagle ())
Vanderbilt University Medical Center,
Nashville, TN, USA
e-mail: susan.eagle@vanderbilt.edu