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Measuring the Compensatory Reserve to Identify Shock

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Measuring the Compensatory Reserve to Identify Shock REVIEW ARTICLE Measuring the compensatory reserve to identify shock Victor A. Convertino, PhD and Alicia M. Schiller, PhD, Fort Sam Houston, Texas hock is classically defined as inadequate tissue perfusion,1–4 interventions.8 The applications include damage control or goal- S and associated with clinical markers such as low systolic directed resuscitation in trauma and septic patients,9–13 blood blood pressure (<90 mm Hg), elevated heart rate (>120 bpm), in- components in patients with severe hemorrhage,9,14,15 place- creased respiration rate (>20 breaths per minute), decreased ment of tourniquets in extremity injury,16 and renal replacement pulse pressure, cold and clammy skin, altered mental state therapy in burn patients.17 Unfortunately, one of the most chal- (e.g., disorientation, confusion), and elevated blood lactate lenging aspects of providing effective treatment of shock is an (>2–3 mmol/L) or base deficit (< −4mmol/L).5,6 However, these inability to recognize its early onset. Various attempts at apply- signs do not change until the later stages of hemorrhage and thus ing advanced computational algorithms by many of the leading waiting until a clinically significant change can impede early di- clinical investigators in trauma and emergency medicine have agnosis of shock when interventions could be most effective. failed to produce early and accurate assessment tools for identi- The tendency for measuring these traditional vital signs that fying shock18–22 because they rely on measurements of “legacy” are easy to obtain and understand (e.g., blood pressure) but pro- vital signs that may change very little in the early stages of hemor- vide information of little value during the early stages of compen- rhage, and thus compensatory shock, because of the body's numer- satory shock, rather than using technologically more advanced ous compensatory mechanisms (e.g., tachycardia, vasoconstriction, but meaningful measures has been defined as “tangible bias.”7 deep inspiration) that regulate blood pressure.23–26 The inaccuracy The century-long perpetuation of this bias in monitoring pa- of using current vital signs during the early compensatory phase of tients in the prehospital emergency medical setting has enabled shock is illustrated in Figure 1A. Blood pressures, arterial oxygen the inability of our emergency medical community to identify saturation (Spo2), and heart rate measurements collected in the shock in its earliest compensatory stages when the application early prehospital setting were similar 30 to 45 minutes after trau- of lifesaving interventions would be most effective. The emer- matic injury in hemorrhaging patients who went on to die com- gence of new computer technologies that are based on advanced paredwiththosewhosurvived.27 These results emphasize that machine-learning principles and signal processing of large current physiologic monitoring can be grossly misleading, and amounts of data has now made it possible to escape the “tangible nonpredictive of hemodynamic collapse, because of the numer- bias” created by currently used medical monitoring technologies ous compensatory mechanisms that “protect” these vital signs by providing real-time assessments of global tissue oxygenation from significant clinical change. In other words, current vital sign status in individual patients (precision medicine). Within this monitoring lacks sensitivity and specificity to predict impending context, the objectives of this article are to (1) describe why cur- hemodynamic collapse and shock during the early compensatory rent physiologic monitoring is inaccurate; (2) introduce and define stage of hemorrhage. a new paradigm named the compensatory reserve; (3) demonstrate It occurred to us that a measurement reflecting the inte- the usefulness of measuring the compensatory reserve with clinical grated status of the capacity of all mechanisms to compensate examples; and (4) identify future applications of compensatory re- for a reduction in blood flow due to hypovolemia might signifi- serve monitoring, including the prehospital phase of resuscitation. cantly improve the sensitivity and specificity of monitoring dur- ing early and late stages of hemorrhage. To accomplish such a Why Current Physiologic Monitoring Is Inaccurate novel approach to monitoring, a model of human hemorrhage There is compelling evidence that morbidity and mortality needed to be developed that provided the capability to investi- can be improved in emergency medicine by early and accurate gate the physiology of integrated compensation under controlled diagnosis and thus the application of effective lifesaving laboratory conditions, and be capable of demonstrating a repeat- able clinical outcome observed in hemorrhage (hemodynamic Submitted: October 18, 2016, Revised: March 6, 2017, Accepted: March 13, 2017, decompensation). Additionally, novel computer and data pro- Published online: March 22, 2017. cessing techniques with machine-learning capabilities could From the Battlefield Health & Trauma Center for Human Integrative Physiology, U. S. be applied to our extensive data “library” of physiologic sig- Army Institute of Surgical Research (V.A.C., A.M.S.), JBSA Fort Sam Houston, TX. “ ” The opinions or assertions contained herein are the private views of the author and are nals generated from the hemorrhage experiments and used not to be construed as official or as reflecting the views of the Department of the to develop an algorithm to recognize an individual subject's Army or the Department of Defense. unique and integrated total of all compensatory mechanisms in Presented at the 6th Annual Remote Damage Control Resuscitation Symposium of the Trauma Hemostasis and Oxygenation Research Network, June 20–22, 2016, in real-time. Within this context, we adopted the use of lower- Os, Norway. body negative pressure (LBNP) that has proven to produce re- Address for reprints: Victor A. Convertino, PhD, U.S. Army Institute of Surgical peatable tolerance times to hypovolemia29,30 and accurately mimic Research, 3698 Chambers Pass, Fort Sam Houston, TX 78234; email: victor.a. the hemodynamic,31–34 metabolic,4,35 coagulation,36 respiratory,37 [email protected]. neuroendocrine,33,35 and mental status38 responses of hemorrhage. DOI: 10.1097/TA.0000000000001430 The value of using this experimental model is reflected in Table 1 J Trauma Acute Care Surg Volume 82, Number 6, Supplement 1 S57 J Trauma Acute Care Surg Convertino and Schiller Volume 82, Number 6, Supplement 1 Figure 1. (A) Trauma patients with severe hemorrhage who lived (open bars) and died (closed bars) could not be differentiated by 27 standard vital signs obtained 30 to 45 minutes after injury. Modified from Cooke et al. (B) Arterial waveform recordings demonstrate pronounced oscillatory patterns in individuals with high tolerance to a progressive reduction in central blood volume (bottom recording) 28 compared to low tolerance individuals (top recording). Modified from Convertino et al. with the reaffirmation that most standard vital signs are main- individual's reserve for tachycardia during blood loss is repre- tained with minimal change due to the body's ability to compen- sented by the difference between the resting baseline heart rate sate for blood loss during the initial phase of hemorrhage. Of note and the maximal heart rate response. Within this context, the is the gradual and relatively late elevation in heart rate.27,39,40,45 compensatory reserve represents a new paradigm for measuring Therefore, to improve the efficacy of decision-support the total of all compensatory mechanisms (e.g., tachycardia, va- tools, we need technology that can measure compromise to inte- soconstriction, breathing) that together contribute to “protect” grated blood pressure compensation mechanisms50 and “indi- against inadequate tissue oxygenation during blood loss and vidualize” the assessment of a patient's progression toward other low circulating blood volume states41,49,52–54 by maintain- “shock” well in advance of clinically relevant changes in tradi- ing tissue perfusion. Since shock is the result of inadequate tis- tional vital signs.51 This approach requires the capability to mea- sue perfusion, the compensatory reserve provides the most sure the integrated total of all mechanisms that compose the accurate real-time measure for identifying shock. reserve to compensate for blood loss. We call this physiologic A unique feature of the LBNP model to mimic the human measurement the “compensatory reserve.” response to hemorrhage is the ability to induce the maximal compensatory response(s) necessary to define the compensatory What Is the Compensatory Reserve? reserve by inducing central hypovolemia to the point of hemody- Any physiologic compensatory mechanism (e.g., tachy- namic collapse, or presyncopal symptoms. In this regard, we cardia, vasoconstriction) has a finite maximal response to any have used a protocol of progressive central hypovolemia to in- specific physiologic stressor (e.g., hemorrhage). Thus, the “re- duce the clinical endpoint of decompensation in more than 270 serve” to compensate is defined by the difference between the human subjects. Consistent with clinical observations,55,56 our maximal response and the baseline state. For example, an experiments revealed that two thirds of the subjects display a S58 © 2017 Wolters Kluwer Health, Inc. All rights reserved. J Trauma Acute Care Surg Volume 82, Number 6, Supplement 1 Convertino and Schiller TABLE 1. Times Course, Sensitivity and
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