1. The document discusses various questions about how the Starling device measures stroke volume variation, cardiac output, and other hemodynamic parameters noninvasively using bioreactance technology. 2. It provides details on studies that have validated Starling against invasive hemodynamic monitoring techniques. Starling can be used in various clinical settings such as the operating room and intensive care. 3. The document addresses limitations and appropriate use of the Starling device and sensors. It clarifies differences between bioreactance and bioimpedance technologies.

1. Starling Faqs

2. 1. How Starling measure Stroke Volume variation?
- Its auto calculated by Starling, SV= CO/HRx1000
- SVV= (Svmax – Svmin)/Svmean x100,
2. How will you calculate SV without heart rate?
- SV calculation doesn’t require HR value as SV is total volume of blood pumped out of ventricle in
each beat
3. Can starling be used with open Chest?
- Yes, Starling has been shown to validate against Aortic flow probe in beagles
Heerdt PM, Wagner CL, DeMais M, Savarese JJ. Noninvasive cardiac output monitoring with bioreactance as an alternative to
invasive instrumentation for preclinical drug evaluation in beagles. J Pharmacol Toxicol Methods. 2011 Sep-Oct;64(2):111-8. doi:
10.1016/j.vascn.2011.03.006. Epub 2011 Apr 2. PMID: 21440649.

3. 4. Device cost add cost to patient, why they should consider?
- Cost of consumable for Starling is much lesser than that of FloTrac, PAC
- By reference of KU and FRESH, using dynamic measure to guide fluid resuscitation helps in improved outcomes and
over all less ICU stay, less requirement of RRT, lesser mechanical ventilation that saves the overall cost
5. How many patients in FRESH and KU studies and technology used in both the groups?
- In FRESH Trial N= 124 patients (83 treatment v 41 Usual Care), Passive Leg Raise was used to assess any additional
resuscitation decisions (fluids or increase in pressors) over the next 72 hours of care, or ICU discharge.
• Cohorts were based on fluid resuscitation guided by changes in SV or by usual care (UC).
• The SV group comprised 100 patients, with 91 patients in the UC group
Technology used to measure SV in both these studies was Bioreactance (Starling working Technology)
Douglas IS, Alapat PM, Corl KA, Exline MC, Forni LG, Holder AL, Kaufman DA, Khan A, Levy MM, Martin GS, Sahatjian JA, Seeley
E, Self WH, Weingarten JA, Williams M, Hansell DM. Fluid Response Evaluation in Sepsis Hypotension and Shock: A Randomized
Clinical Trial. Chest. 2020 Oct;158(4):1431-1445. doi: 10.1016/j.chest.2020.04.025. Epub 2020 Apr 27. PMID: 32353418.

4. 6. CVP is preferred, relevant comparison data or society endorsement
 CVP has limited value in assessing fluid requirement (Fluid responsiveness) and doesn’t correlate well with patient’s
position n frank Starling Curve
- Recent updates to SSC Guidelines: ▪ Recommend the use of dynamic assessments to guide fluid therapy ▪ State there is
“no indication” for the use of CVP or other static measures to guide fluid therapy
-Bentzer P et al. Will this hemodynamically unstable patient respond to a bolus of intravenous fluids. JAMA 2016;
Douglas IS, Alapat PM, Corl KA, Exline MC, Forni LG, Holder AL, Kaufman DA, Khan A, Levy MM, Martin GS, Sahatjian JA, Seeley E, Self WH, Weingarten JA, Williams M, Hansell DM. Fluid
Response Evaluation in Sepsis Hypotension and Shock: A Randomized Clinical Trial. Chest. 2020 Oct;158(4):1431-1445. doi: 10.1016/j.chest.2020.04.025. Epub 2020 Apr 27. PMID: 32353418.

5. 7. Bioimpedance vs Bioreactance
- The bioreactance-based noninvasive CO measurement system is based on an analysis of relative phase shifts of an
oscillating current that occur when this current traverses the thoracic cavity, as opposed to traditional bioimpedance-
based systems, which rely only on measured changes in signal amplitude.
- Bioreactance works on phase shift or time delay while bio impedance works on the amplitude of the thoracic
impedance
- Unlike Bio Impedance, Bio reactance is not affected by the size of the patient, thoracic fluids e.g. pleural effusion,
arrythmias, pulmonary oedema, position of sensors

6. 8. Difference in amplitude shift and phase shift and how its relevant, How data is accurate with Bioreactance, not in
bioimpedance?
- Unlike Amplitude shift, Phase Shift is not affected by the size of the patient, thoracic fluids e.g. pleural effusion,
arrythmias, pulmonary oedema, position of sensors. For this reason Amplitude shift is prone to errors in calculating
actual SV. Also position of sensors have to be accurate with Bio-impedance technology else the error can get squared.
- Phase shift occurs only in presence of pulsatile fluid in thoracic cavity, It doesn’t account for static fluid and hence
correlates well with Aortic flow which forms almost all the pulsatile fluid (blood volume) during the cardiac cycle. This
has also been validated with Thermodilution in 65000 patient sample
 Amplitude Shift  Phase Shift

7. 9. Does Starling measure TFC? What is the clinical range of TFC
• Yes Starling Measure TFC. TFC has no Clinical Range
10. If there is no clinical range of TFC, then what’s its relevance?
• Trend or Change in the value over period are relevant for clinical outcomes.
• TFC increase on trends correlates well with increasing static fluid in thorax. Third Spacing or Pulmonary Edema
11. Suppose diuretic is give to patient and TFC is decreasing, that means its working on patient, In case of Fluid therapy
• -if fluid is give and TFC in increasing that means fluid is moving to any third space which is increasing TFC

8. 12. Range of TPR
800-1200 dynes.sec/cm5
13. How Starling Measure BP?
- Starling comes with NIBP Cuff that can be used to capture BP reading to calculate MAP at different intervals (Adjustable).
- Value for MAP can also be entered manually in case of arterial cannulation at physician’s discretion
- TPR differs from SVR in terms that it doesn’t account for CVP. This will make values of TPR and SVR different in same
patients. However TPR serves the function similar to SVR in clinical settings in terms of trend. CVP difference must be
accounted for.

9. 14. USPs of Starling
• Safe: 100% non-invasive technology
• Accurate: Validated against major in use technology for hemodynamic monitoring including EDM, PAC, Flotrac, TD
• Quick: dynamic assessment of fluid responsiveness
• Reliable: Not affected by vasoactive drugs or arrhythmias, not affected by the size of the patient, thoracic fluids
• Simple: Simplified User Interface, No training required, easy to use
• Complete: Gives access to a complete hemodynamic profile, including fluid responsiveness status
- Educational and training tools built into the monitor for easy access to training videos, clinical tools, and quick guide

10. 15. Marik et al: Highlights
• 23,513 patients with severe sepsis and septic shock
admitted to ICU from the Emergency Room
• Day 1 fluid averaged 4.4L in all patients and 5.4L in patient
with mechanical ventilation and shock.
• Mean length of stay 5.4 days, mortality was 25.8% in total
• For each liter of fluid over 5L, mortality increased by 2.3%
(95% CI 2.0,2.5%, p=0.005)
• For each additional 1L of fluid and hospital costs increased
by $999.
• Excess risk-adjusted excess mortality is seen with fluid over
5L on day 1.
• Supports the hypothesis that fluid is an independent
predictor of mortality
Marik PE, Linde-Zwirble WT, Bittner EA, Sahatjian J, Hansell D. Fluid administration in severe sepsis and septic shock, patterns and outcomes: an analysis of a large national database. Intensive
care medicine. 2017 May 1;43(5):625-32.

11. 16. Which study in which patients received >6 ltr of fluid increase mortality by 2%
-Marik et al (Marik PE, Linde-Zwirble WT, Bittner EA, Sahatjian J, Hansell D. Fluid administration in severe sepsis and septic shock, patterns and outcomes: an analysis of a large national
database. Intensive care medicine. 2017 May 1;43(5):625-32)
17. Can starling be used in MRI? Followed by Xray and CT
- Starling Sensors can NOT be on patient while in MRI (sensors to be removed because of electrodes of sensors)
- At discretion of treating physician Sensors can be left on during Xray or even CT
18. Is Starling device accurate?
- YES, Starling has been independently verified with Pulmonary artery cather and has been found to be accurate (Rich
JD, Archer SL, Rich S. Noninvasive cardiac output measurements in patients with pulmonary hypertension. European Respiratory Journal. 2013 Jul 1;42(1):125-33.)
- Starling has been compared with Aortic flow probe in animal studies and have been found to be accurate
- (Heerdt PM, Wagner CL, DeMais M, Savarese JJ. Noninvasive cardiac output monitoring with bioreactance as an alternative to invasive instrumentation for preclinical drug evaluation in
beagles. Journal of pharmacological and toxicological methods. 2011 Sep 1;64(2):111-8.)

12. 19. Does Starling Device shows Thoracic fluid content (TFC)?
- YES, Starling device shows Thoracic fluid content, however TFC doesn’t have a normal range
20. What is Tfcd?
- Change in TFC from preset time
21. What is Tfcdo?
- Change in TFC from Base line

13. 22. Does Starling Device shows Thoracic fluid content (TFC)?
- YES, Starling device shows Thoracic fluid content, however TFC doesn’t have a normal range
23. What is Tfcd?
- Change in TFC from preset time
24. What is Tfcdo?
- Change in TFC from Base line

14. 25. Is stroke volume variation is static or dynamic parameter?
-Stroke Volume Variation is a Dynamic Parameter, It takes into the account the Heart lung interaction
and measure difference in stroke volumes at inspiration and Expiration
26. Name 2 Static parameters other than BP, urine output
-CVP, MAP, Heart Rate, Skin temperature etc

15. 27. Is stroke volume variation is static or dynamic parameter?
-Stroke Volume Variation is a Dynamic Parameter, It takes into the account the Heart lung interaction
and measure difference in stroke volumes at inspiration and Expiration
28. Name 2 Static parameters other than BP, urine output
-CVP, MAP, Heart Rate, Skin temperature etc

16. 29. At 9% delta SVI, can more fluid can be given?
- If the Stroke Volume increase is <10% the patient is considered not to be fluid responsive however
depends on clinician decision as patient condition. Its better to observed the trend in such cases. However
if patient need resuscitation fluid must be given regards less of delta SVI
30. What should be time between 2 two assessments- or both PLR/Bolus can be performed simultaneously?
There is no value in doing two maneuvers together, more so it will increase preload by double and may
give false readings.
As per Fresh protocol if the patient is unstable the maneuver can be repeated at 30 min interval or longer
as decided by treating physician

17. 31. What are consumables?
- Sensors used per patients are consumables, they are single use and can be used up to 48 hours on the
same patients
32. During Major abdominal surgery, how sensor can be placed?
- The sensor can be place in multiple ways 2 on back 2 on front or 3 in back 1 in front or all 4 on back as long
as they form box around the heart and are placed in right quadrant.
- The placement of sensors must be discussed with anesthesiologist prior to the start of the surgery.
33. Limitation on sensor placement
- Only Patient condition where we can’t stick anything on thorax (like burn)
- Limited data in Pediatric population

18. 34. Will the frequency of electrical current applied on the sensor affect the Diathermy procedure during surgery?
- No
35. Will the frequency of electrical current applied on the sensor affect the Pacemaker?
- Sensor should be placed 2.5 inches higher and apart from Pacemaker’s location
36. Will the frequency of electrical current applied on the sensor affect MRI, CT Scan and X-Ray?
 During MRI, STARLING sensors should be disconnected and should not be on patient’s body
 On X-RAY and CT Scan the electric current will not interfere as
 The amount of the current supplied is miniscule
 During CT Scan Sensors will be disconnected form the machine
 However, being metal bodies, sensors and wires can produce artefacts on the film which shall not be a
problem in most cases

19. 37. Will the frequency of electrical current applied on the sensor affect the Diathermy procedure during surgery?
- No
38. Will the frequency of electrical current applied on the sensor affect the Pacemaker?
- Sensor should be placed 2.5 inches higher and apart from Pacemaker’s location
39. Will the frequency of electrical current applied on the sensor affect MRI, CT Scan and X-Ray?
 During MRI, STARLING sensors should be disconnected and should not be on patient’s body
 On X-RAY and CT Scan the electric current will not interfere as
 The amount of the current supplied is miniscule
 During CT Scan Sensors will be disconnected form the machine
 However, being metal bodies, sensors and wires can produce artefacts on the film which shall not be a
problem in most cases

20. 40. What if sensors get wet or come in contact with Betadine in OT?
41. Can it be used in Cardiac Surgery?
- Yes, Starling can be used in Cardiac Surgery
• Starling works in Obese patients?
- Yes, Starling can be used in Obese Patients
42. Are Starling Sensors/readings impacted by cautery use in OT?
43. What is Dx/Dt
- Dx/Dt is the derivative of volume with time and denotes maximum flow which when multiplied by Ventricular
Ejection Time (VET) gives Stroke volume

21. 44. Frank starling Curve- Value on Y Axis, X Axis
- X Axis- Preload
- Y Axis-Stroke Volume
FRANK-STARLING
45. Points to be taken care for Sensor placement
- Skin Surface should be clean and dry
- In case of excess hair, surfaced should be shaved/cleaned
46. DO2I stand for?
- Oxygen delivery Index, normal range 520-720 ml O2/min/m2
- DO2I = O2 delivery index = DO2 mls/min/m2 = (10 × Hb/dl × 1.34
× SpO2) + (PaO2 in mmHg × 0.003 × 10) × Cardiac index
l/min/m2.
47. HGB denotes and its relevance?
- HGB denotes hemoglobin, Hb required for Oxygen Delivery
index (DO2I) and SpO2
48. ZO in parameters stands for and its relevance?
- electrical impedance, is the measure of the opposition that a
circuit presents to a current when a voltage is applied.
- It’s required to calculate TFC as TFC=1/Zo

22. 49. Are SVR and TPR same?
Both SVR and TPR means the systemic resistance offer to the blood flow except Pulmonary Vascular Resistance
and is given by formula
SVR/TPR= (MAP – CVP)/CO X 80
Since CVP (2-6 mm Hg) is relatively small in comparison to MAP SVR/TPR is often given as
SVR/TPR= MAP/CO X 80
If Starling is compared with other device kindly make sure that either CVP is deducted in both the devices or
not deducted in both the device
SVR/ TPR in a patient with MAP 90 mm Hg, CVP 6 mmHg CO 5 L will be 1344 dynes/cm2 if CVP is subtracted and
1440 if CVP is not subtracted.

23. 50. Connecting Starling, we don’t need any ECG machine
Starling comes with 3 lead ECG, Certain patients require 5 or even 12 lead ECG for diagnosis/
monitoring. Hence ECG monitoring should be at discretion of treating physician depending on the leads
required.