Evaluation of Physiological Variables and Detection of Blood Loss Using the Zynex Fluid Monitoring System, Model CM-1600
Phase: NA
Conditions: Fluid Loss
Sponsor: Zynex Monitoring Solutions

 
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CLINICAL PROTOCOL 
ZMS-1600-Blood Loss Detection 
NCT#05463198 
16-NOV-2022 
 
 

 
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CLINICAL PROTOCOL 
 
 
TITLE 
 
Evaluation of Physiological Variables and Detection of Blood Loss Using the 
Zynex Fluid Monitoring System, Model CM-1600 
 
PROTOCOL 
ZMS-1600-Blood Loss Detection 
 
SPONSOR 
Zynex Monitoring Solutions (ZMS) 
9555 Maroon Circle 
Englewood, CO 80112 
 
PROTOCOL VERSION 
2.0 
 
 
DOCUMENT REVIEW  
& APPROVAL 
 
 
 
 
 
 
Sponsor Representative: 
 
 
 
 
 
 
Don Gregg 
VP, Zynex Monitoring Solutions 
 
 
Sponsor Representative: 
 
Signature 
 
Date 
Laura Seiberlich 
Zynex Clinical Affairs 
 
Signature 
 
Date 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CONFIDENTIALITY STATEMENT 
This document is the confidential information of Zynex. It is provided to you as an investigator or consultant for 
review by you, your personnel, and the applicable Institutional Review Board/. Your acceptance of this 

 
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document constitutes an agreement that you cannot disclose the information contained herein to others 
without the prior written consent of Zynex. 
 
 

 
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PROTOCOL SIGNATURE PAGE 
 
TITLE 
Evaluation of Physiological Variables and Detection of Blood Loss Using the 
Zynex Fluid Monitoring System, Model CM-1600 
PROTOCOL 
ZMS-1600-Blood Loss Detection 
SPONSOR 
Zynex Monitoring Solutions (ZMS) 
9555 Maroon Circle 
Englewood, CO 80112 
 
PROTOCOL VERSION 
2.0 
 
 
The signature below constitutes I have read, understood, and the approve this protocol and provide assurances 
that this trial will be conducted according to all stipulations of the protocol, including all statements regarding 
subject confidentiality, and according to local legal and regulatory requirements, including all applicable U.S. 
federal and local regulations and ICH guidelines. 
 
I agree to supervise all testing of the device involving human subjects. I confirm I will ensure Informed Consent 
requirements will be met for all subjects. I confirm I will ensure Informed Consent of each subject is obtained 
before any study procedures; protect the rights, safety, and welfare of all study subjects; prepare and maintain 
accurate, current, and complete records (including Adverse Events); provide timely reports to the Sponsor; 
ensure changes are not implemented without prospective IRB approval unless required to eliminate an 
immediate hazard to subjects; retain records as set out in the protocol; disclose relevant financial information. 
 
 
 
 
Principal Investigator (PI): 
 
 
 
PI Printed Name 
 
 
 
 
 
 
 
PI Signature 
 
 
 
 
 
 
 
 
Date (DD-MMM-YYYY) 
 
 
 
CONFIDENTIALITY STATEMENT 
This document is the confidential information of Zynex. It is provided to you as an investigator or consultant for 
review by you, your personnel, and the applicable Institutional Review Board/Ethics Committee. Your 
acceptance of this document constitutes an agreement that you cannot disclose the information contained 
herein to others without the prior written consent of Zynex. 
 
 

 
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PROTOCOL AMENDMENT HISTORY 
 
Version 
Number 
Description of Change(s) 
Reason for Change 
1.0 
Initial protocol; no changes 
N/A 
2.0 
Section 9.1 and throughout: Increase in 
sample size to 500 subjects 
Additional subjects required to support 
statistical analyses. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
[This space is intentionally left blank] 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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TABLE OF CONTENTS 
1 
INTRODUCTION ................................................................................................................................... 10 
1.1 
CLINICAL RATIONALE................................................................................................................... 11 
2 
INVESTIGATIONAL PLAN ..................................................................................................................... 11 
2.1 
OBJECTIVES ................................................................................................................................. 11 
2.2 
STUDY DURATION ....................................................................................................................... 11 
2.3 
STUDY DESIGN............................................................................................................................. 11 
2.4 
STUDY ENDPOINTS ...................................................................................................................... 11 
3 
STUDY DEVICES ................................................................................................................................... 12 
3.1 
FLUID MONITORING SYSTEM, MODEL CM-1600 ........................................................................ 12 
3.1.1 
DEVICE DESCRIPTION .......................................................................................................... 12 
3.1.2 
DEVICE DESIGN AND COMPONENTS ................................................................................... 12 
3.1.3 
PRINCIPLES OF OPERATION................................................................................................. 12 
3.1.4 
INDICATIONS FOR USE ........................................................................................................ 12 
3.1.5 
INTENDED USE .................................................................................................................... 12 
4 
SUBJECT POPULATION AND SELECTION ............................................................................................. 13 
4.1 
POPULATION AND ANTICIPATED NUMBER OF SUBJECTS ........................................................... 13 
4.2 
SUBJECT INCLUSION CRITERIA .................................................................................................... 13 
4.3 
SUBJECT EXCLUSION CRITERIA .................................................................................................... 13 
4.4 
SUBJECT WITHDRAW / EARLY TERMINATION............................................................................. 13 
5 
STUDY PROCEDURE ............................................................................................................................. 14 
5.1 
ENROLLMENT .............................................................................................................................. 14 
5.1.1 
INFORMED CONSENT .......................................................................................................... 14 
5.2 
DEMOGRAPHIC AND BASELINE DATA ......................................................................................... 14 
5.3 
SUBJECT PARTICIPATION ............................................................................................................. 15 
5.4 
ADVERSE EVENTS ........................................................................................................................ 15 
5.5 
SUBJECT COMPLETION ................................................................................................................ 15 
6 
DEVICE MANAGEMENT ....................................................................................................................... 16 
6.1 
UNPACKING AND INSPECTION .................................................................................................... 16 
6.2 
ACCOUNTABILITY, STORAGE & DISPENSATION .......................................................................... 16 
6.3 
CLEANING & RETURN .................................................................................................................. 16 

 
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7 
RISKS & BENEFITS ................................................................................................................................ 16 
7.1 
RISK DETERMINTATION & REDUCTION ....................................................................................... 16 
7.2 
BENEFITS ..................................................................................................................................... 17 
8 
SAFETY ASSESSMENT AND MANAGEMENT ........................................................................................ 17 
8.1 
SAFETY DEFINITIONS ................................................................................................................... 17 
8.1.1 
ADVERSE EVENT (AE) .......................................................................................................... 17 
8.1.2 
SERIOUS ADVERSE EVENT (SAE) .......................................................................................... 18 
8.1.3 
UNANTICIPATED ADVERSE DEVICE EFFECT (UADE) ............................................................ 18 
8.2 
SAFETY REPORTING ..................................................................................................................... 19 
8.2.1 
REPORTING EVENTS & SAFETY CONTACTS ......................................................................... 19 
9 
STATISTICAL METHODS AND CONSIDERATIONS ................................................................................. 19 
9.1 
SAMPLE SIZE DETERMINATION ................................................................................................... 19 
9.2 
DATASETS ANALYZED .................................................................................................................. 20 
9.3 
STATISTICAL ANALYSIS ................................................................................................................ 20 
9.3.1 
Descriptive Statistics ........................................................................................................... 20 
9.3.2 
STATISTICAL METHOD FOR CONTINUOUS VARIABLES ....................................................... 20 
9.3.3 
DEMOGRAPHIC AND BASELINE CHARACTERISTICS ............................................................. 20 
9.3.4 
PRIMARY ANALYSIS ............................................................................................................. 20 
10 
DATA COLLECTION, RETENTION, AND MONITORING ..................................................................... 21 
10.1 
DATA COLLECTION ...................................................................................................................... 21 
10.1.1 
SUBJECT CONFIDENTIALITY ................................................................................................. 21 
10.2 
DATA RETENTION ........................................................................................................................ 22 
10.3 
MONITORING .............................................................................................................................. 22 
10.3.1 
MONITORING PLAN ............................................................................................................. 22 
11 
STUDY ADMINISTRATION ................................................................................................................ 22 
11.1 
AUDITS AND INSPECTIONS .......................................................................................................... 22 
11.2 
PROTOCOL AND ICF AMENDMENTS ........................................................................................... 22 
11.3 
PROTOCOL DEVIATIONS .............................................................................................................. 22 
12 
ETHICAL AND OTHER REGULATORY CONSIDERATIONS .................................................................. 23 
12.1 
INSTITUTIONAL REVIEW BOARD (IRB) REVIEW ........................................................................... 23 
12.2 
WRITTEN INFORMED CONSENT .................................................................................................. 23 

 
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13 
REFERENCES .................................................................................................................................... 24 
14 
ABBREVIATIONS AND DEFINITIONS OF TERMS ............................................................................... 25 
 
 
 
 
 
 
 

 
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FIGURES AND TABLES 
Figure 1: Procedure Overview .................................................................................................................... 14 
 
Table 1: Adverse Event Severity Grading .................................................................................................... 17 
Table 2: Adverse Events Action(s) Taken .................................................................................................... 17 
Table 3: Adverse Event Relationship to Donation or Study Procedure ...................................................... 18 
Table 4: Adverse Event Outcome ................................................................................................................ 18 
Table 5: Study Reporting Contacts .............................................................................................................. 19 
Table 6: Abbreviations and Definition of Terms ......................................................................................... 25 
 
 
 

 
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1 INTRODUCTION 
Intraoperative and postoperative hemorrhage incidence can vary depending on the type of surgery and 
can lead to severe clinical complications ranging from mild anemia to fatal hemorrhagic shock. Those that 
recover from severe hemorrhagic events often have poor functional outcomes and are at risk for greater 
long-term mortality. Numerous studies reveal that post-operative hemorrhagic events are also quite 
frequent, occurring in as many as 13 to 19% of patients following various type of surgeries (i.e., major 
pancreatic resections, transoral robotic surgery (TORS) for oropharyngeal squamous cell carcinoma, and 
living-donor transplants). Hemorrhagic shock is also a leading cause of death in trauma.1-6   
Monitoring and detecting fluid changes in patients can be complicated. Physiological responses associated 
with hemorrhagic events are often delayed because of compensation mechanisms that act to sustain 
blood pressure and protect tissue perfusion.1 The ability to continuously and non-invasively detect 
changes in central blood volume and blood loss will permit appropriate hemodynamic management 
during events at high risk for acute blood loss such as surgery, trauma, post-operative care and other 
therapeutic procedures.  Through early detection and improved hemodynamic monitoring, optimization 
of fluid balance, anesthesia titration, and augmenting other acute care management requirements, a 
clinician should be able to improve overall patient stability, minimize complications, diminish surgical 
trauma and reduce recovery time. 
Current methods for acutely monitoring blood volume and blood loss include monitoring of vital signs 
(such as heart rate, blood pressure, respirations, and oxygen saturation), invasive central venous (right 
heart central venous pressure measurement and Swan-Ganz pulmonary capillary wedge pressure 
measurements) and arterial catheters designed to monitor hemodynamic status centrally.  Vital sign 
monitoring may not indicate small amounts of acute blood loss and arterial and venous cannulations can 
create insertion complications such as perforations in the vasculature, pneumothorax, arrhythmias, 
thrombosis and infection.  While invasive central monitoring may provide extremely accurate information, 
changes may not be good indicators of early central hypovolemia or with smaller blood volume 
reductions1-2.  New non-invasive technologies have recently become available but often include many 
physiological parameters that may require expedited clinical interpretation in high stress environments 
and have not become well-established.  
The Zynex Fluid Monitoring System, Model CM-1600 uses a relative patient standard approach by non-
invasively and simultaneously monitoring five (5) physiological parameters, including bioelectrical 
impedance, ECG amplitude, photoplethysmogram (PPG) amplitude, heart rate, and skin temperature. The 
CM Device starts by creating a baseline for each patient in a normal state. When the monitoring session 
starts, each patient starts with a Relative Index of 100, signifying the collection of parameters near their 
original baseline value(s). The Relative Index value acts as a combinational score for all the parameters 
indicative of relative fluid change.  There are two (2) models of the CM Device, Model 1500 (CM-1500) 
and 1600 (CM-1600) which measure the same five (5) parameters and utilize the same algorithm to output 
the Relative Index value.  

 
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1.1 
CLINICAL RATIONALE 
The proposed clinical study is designed to validate that the Zynex non-invasive monitoring system (CM-
1600) can track blood volume changes in healthy individuals consented to undergo a blood donation.  An 
initial feasibility study was conducted (n = 12 subjects) to confirm that the CM-1500 can be used to track 
acute blood loss in healthy individuals donating 500mL of blood.  Additional studies are being conducted 
in various healthy volunteer and clinical settings to characterize RI performance when known volumes of 
fluid are removed. A larger study is necessary with comparative physiological variables to validate the 
specificity and sensitivity of the CM-1600 in detecting blood loss.   
2 INVESTIGATIONAL PLAN 
2.1 
OBJECTIVES 
The primary objective of the study is to determine the specificity and sensitivity of the CM-1600 in 
detecting minor blood loss as compared to standard physiological parameters. 
Exploratory objectives of the study will include: 
• 
Characterize the differences in the relative changes in right vs left antecubital blood donations 
• 
Investigate any possible correlations between adverse events, subject demographics, changes in 
the Relative Index, and timing of when the events occurred 
2.2 
STUDY DURATION 
Enrollment in the study is expected to take approximately six (6) months, and data analysis may take up 
to an additional two (2) months to complete.  
2.3 
STUDY DESIGN 
The study is a prospective, non-randomized, non-blinded, non-significant risk, multi-center study enrolling 
up to 500 healthy adult subjects consented to undergo a whole blood donation procedure.  
The present study will involve enrolling subjects that will undergo blood donation wearing the study 
device (CM-1600) and capture study-required physiological parameters pre-, during, and post-donation.   
2.4 
STUDY ENDPOINTS 
The study endpoints include the change and percentage of change between measurements before and 
after blood donation in the Relative Index and standard physiological parameters. The change is defined 
as the value after donation minus the one before donation. The percentage of change is the change value 
divided by the value before donation. Other endpoints such as area under receiver operating 
characteristic (ROC) together with sensitivity and specificity at various thresholds are also derived for the 
Relative Index and each of standard physiological parameters in detecting in detecting minor blood loss 
(i.e., 450 ml). 

 
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3 STUDY DEVICES  
3.1 
FLUID MONITORING SYSTEM, MODEL CM-1600 
3.1.1 
DEVICE DESCRIPTION 
The CM-1600 is a non-invasive monitoring device predicated by the CM-1500 that simultaneously 
monitors five (5) parameters of a patient’s body. Parameters include bioelectrical impedance, heart rate, 
ECG amplitude, PPG amplitude, and skin temperature. A combination of these parameters is represented 
by a single number known as the Relative Index value. This value is indicative of relative changes in fluid 
volume. The Relative Index is a unique functionality of the Zynex Fluid Monitoring System.  
3.1.2 
DEVICE DESIGN AND COMPONENTS 
The CM-1600 is an all-inclusive device that includes the following components: display monitor (1), power 
supply (1), wrist wearable (1), wrist strap (1), and electrode array set (2). The electrode array sets are 
single-use, single-subject. 
3.1.3 
PRINCIPLES OF OPERATION 
The CM-1600 measures bioelectrical impedance (ohms), heart rate (BPM), ECG amplitude, PPG amplitude, 
and skin temperature (◦C or ◦F). As parameters change, towards indications of fluid change/imbalance, the 
Relative Index, which acts as a combinational score of percent change values for all of the parameters, 
will compound these changes into a singular value to signify overall fluid changes/imbalances within the 
patient’s body. When the monitoring session starts, every patient will start with a Relative Index of 100, 
signifying the combination of physiological parameters is near or at their original baseline values for all 
five (5) monitored parameters. All parameters are continuously measured and tracked during a 
monitoring session.  
3.1.4 
INDICATIONS FOR USE 
Per the device’s FDA 510(k) submission, the CM-1600 is indicated for monitoring bioelectrical impedance, 
heart rate, ECG amplitude, and PPG amplitude and their relative changes, indicative of relative changes in 
fluid volume in adult patients. 
3.1.5 
INTENDED USE 
Per the device’s FDA 510(k) submission, the CM-1600 is intended to be used in professional medical 
environments, i.e., hospitals, clinics, and research institutions. The CM-1600 is a standalone device 
intended for desktop use, where device operation is to be performed as uninterrupted patient monitoring. 
The CM-1600 shall only be used by a qualified and trained device operator. The device does not report 
any diagnosis but provides numerical values; it is ultimately the Investigator’s responsibility to make 
proper diagnosis and judgments based on these values. 

 
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4 SUBJECT POPULATION AND SELECTION 
4.1 
POPULATION AND ANTICIPATED NUMBER OF SUBJECTS 
Up to 500 healthy adult subjects who meet the inclusion and exclusion criteria will be enrolled in the study 
to ensure data from 455 treatment subjects are available for analysis.  
4.2 
SUBJECT INCLUSION CRITERIA 
I.1 
Ability to provide written informed consent 
I.2 
Ability and willingness to comply with the study procedures and duration requirements 
I.3 
18 years of age or older 
I.4 
Consented and eligible to undergo a single unit whole blood donation  
4.3 
SUBJECT EXCLUSION CRITERIA 
E.1 
Females who are pregnant or breastfeeding 
E.2 
Undergone an amputation of any upper extremity 
E.3 
Diagnosed with dextrocardia 
E.4 
Subjects who have a pacemaker 
E.5 
Subjects with body hair density which prevents adequate application of device electrodes 
4.4 
SUBJECT WITHDRAW / EARLY TERMINATION  
Subjects who withdraw from the study before using the CM-1600 device will be replaced. The reason the 
subject withdrew from the study may be recorded; subjects are not required to provide a reason. Subject 
withdrawal / early termination criteria may include but are not limited to: 
W.1 
Subject requests to be withdrawn from the study or withdraws consent. 
W.2 
Subject refuses to comply with required study procedures. 
W.3 
An Adverse Event (“AE”) makes the continuation of the subject impossible or 
inadvisable 
W.4 
The Investigator determines it is in the subject’s best interest to discontinue from the 
study. 
 
 
 
 
 
 
 
 

 
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5 STUDY PROCEDURE 
Figure 1: Procedure Overview 
 
5.1 
ENROLLMENT 
A subject will be considered enrolled in the study after provided written informed consent. Subjects will 
only be eligible to participate in the study if they have consented to donate one unit of whole blood per 
the standard of care donation procedures.  Enrollment in the study will increase a subject’s blood donation 
duration by approximately 15 minutes.  
5.1.1 
INFORMED CONSENT 
The Investigator or qualified designated study personnel will complete the Informed Consent process 
before any study procedures may occur. The subject will be provided an IRB-approved version of the 
Informed Consent Form (ICF). The subject will have an ample amount of time to read the ICF and ask 
questions before providing written consent. The subject will receive a signed copy of the ICF. The 
Investigator or qualified designated study personnel will record that consent was obtained prior to 
performing study procedures. 
5.2 
DEMOGRAPHIC AND BASELINE DATA 
Demographic and enrollment data collection will include obtaining health screening data directly from the 
standard blood donation screening record at the study site. Data not available on the blood donation 
procedure record will be captured on a case report form (CRF). These data will include but are not limited 
to skin tone, smoking history, a blood donation anxiety questionnaire, blood donation history, and if 
subjects are currently taking any medications or supplements that could impact their physiological 
response to the donation procedure. Female subjects will self-report they are not currently pregnant or 
have been pregnant in the previous six (6) weeks, and that will be captured on the standard blood 
donation screening record.  

 
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Baseline hemoglobin will be collected as part of the standard blood donation procedure via a finger stick 
(or per standard of care for the site).  Subjects that are unable to proceed with the blood donation due to 
their baseline hemoglobin level will be withdrawn from the study.  
Following demographic and enrollment data collection and PRIOR to blood donation, all subjects will be 
connected to the CM-1600 per the Instructions for Use.  Designated study personnel must ensure that the 
subject ID number and gender is entered for each subject prior to starting a new monitoring session. 
The CM-1600 will be connected to the subject’s left side of the body. The device will be turned on with 
the subject placed in a resting supine position for a minimum of five (5) minutes before the baseline 
measurements will be recorded. After the five (5) minute waiting period, study personnel will record, at 
a minimum, the following: blood pressure, heart rate, respiratory rate, and Relative Index from the CM-
1600.   
5.3 
SUBJECT PARTICIPATION 
Subjects will proceed with their blood donation procedure wearing the CM-1600.  Immediately prior to 
the start of the blood donation procedure, the Investigator or designated study personnel will press the 
“MARK EVENT” button on the CM-1600 which will signify the start of the procedure on the device.   
The Investigator or designated study personnel will monitor the subject per standard of care throughout 
the donation procedure and record any adverse events noted.  Total amount of blood collected will vary 
per subject based upon their estimated blood volume, and the final amount donated will be recorded.   
Immediately following completion of the blood donation, the Investigator or designated study personnel 
should press “EVENT” on the CM-1600.  The same physiological parameters collected at baseline will be 
repeated.   
Subjects will remain connected to the CM-1600 for at least ten (10) minutes following the donation 
procedure.  Following the 10-minute post-donation monitoring period, the physiological parameters will 
be captured one final time, subjects will be disconnected from the study device, and study participation 
will be complete.  
5.4 
ADVERSE EVENTS 
Adverse Events (AE), Serious Adverse Events (SAE), or Unanticipated Adverse Device Effect (UADE) that 
occur after informed consent and before completion of the study will be recorded. SAE’s may require 
follow-up contact via a telephone call, depending on the nature of the SAE. 
5.5 
SUBJECT COMPLETION 
Subjects’ participation in the study will be considered complete once the monitoring session has ended 
and the device has been removed.   

 
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6 DEVICE MANAGEMENT  
6.1 
UNPACKING AND INSPECTION 
It is the responsibility of the Principal Investigator (PI) to ensure that all study devices are unpacked and 
inspected prior to using in any study procedures. Upon arrival, the Investigator or designated study 
personnel will remove the device display monitor and accessories from the shipping container; ensure all 
device components are received. The study site must inform the Sponsor of any missing or damaged items 
within seven (7) days.  Devices with any missing or damaged items cannot be used and shall be replaced. 
6.2 
ACCOUNTABILITY, STORAGE & DISPENSATION 
It is the responsibility of the Principal Investigator to ensure all study devices are inventoried and 
accounted for throughout the conduct of the study. The Investigator or qualified designated study 
personnel will record all information on the Device Accountability forms maintained in the Investigator 
Site Files (ISF). 
The investigational device will be stored at the study center. When not in use, the device will be stored in 
a secure location (i.e., area with limited access or in a locked cabinet) under appropriate environmental 
conditions found in the Instructions for Use (IFU) manual. 
The study device shall only be used under the supervision of the Principal Investigator or designated study 
personnel on authorized study subjects. 
6.3 
CLEANING & RETURN 
The study devices shall be cleaned before each use. Cleaning procedures will be followed per the 
Instructions for Use (IFU) manuals. The study devices and any unused accessories will be returned to the 
Sponsor after study completion.  
7 RISKS & BENEFITS 
7.1 
RISK DETERMINTATION & REDUCTION 
This study is determined to be non-significant risk. An Investigational Device Exemption will not be 
submitted based on this determination. 
Study subjects are subject to risk no greater than or similar to risks associated with undergoing a blood 
donation. The use of the CM-1600 does not meet the definition of significant risk under 21CRF 812.3 (m).  
All adverse events will be recorded and analyzed to evaluate their significance. Possible risks may include:  
- 
[Possible, Rare] Skin irritation could occur from the electrodes 
- 
[Possible, Mild] Discomfort could occur due to lying in a supine position for duration of the 
donation procedure.  
 

 
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Every possible effort will be made to reduce the risks to a minimum. Investigators or qualified designated 
study personnel will be experienced and skilled in blood donation procedures, receive training on the 
protocol and use of the device. All adverse events will be documented and reported to the Sponsor. 
7.2 
BENEFITS 
This study is for research purposes only. There is no direct benefit to subjects participating in the study. 
Information from this study may help other people in the future. 
8 SAFETY ASSESSMENT AND MANAGEMENT  
Safety will be assessed by reviewing and summarizing adverse events. 
8.1 
SAFETY DEFINITIONS 
8.1.1 
ADVERSE EVENT (AE)  
An Adverse Event (AE) is defined as any untoward medical occurrence, whether or not related to the study 
device or study procedure. AE’s are characterized by grading, actions taken, relationship to donation or 
study procedure, and outcome. These definitions are in the corresponding tables below. All adverse 
events related to the blood donation procedure will be recorded and reported in addition to those that 
may occur specific to the protocol-defined study procedure.  All attempts should be made to ensure 
resolution of the adverse event upon study completion.  
Table 1: Adverse Event Severity Grading 
Severity 
Description 
Grade 1: Mild 
Awareness of signs or symptoms, but they are easily tolerated 
Grade 2: Moderate 
Enough discomfort to cause interference with usual activity 
Grade 3: Severe 
Incapacitating, with the inability to work or do usual activity 
Grade 4: Fatal 
Subject expired/death occurred 
 
Table 2: Adverse Events Action(s) Taken 
 
Action Taken 
(Check all that apply) 
Description 
None 
No actions were taken, observation only. 
Medications  
Subject required medication(s) 
Other Treatment  
Subject required other treatment(s) 
Early Withdrawal 
Adverse event led to early study withdrawal 
 
 
 

 
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Table 3: Adverse Event Relationship to Donation or Study Procedure 
 
Relationship 
Description 
None 
Causal relationship can be ruled out 
Possible – Donation Procedure 
Causal relationship is reasonably possible to the blood donation 
procedure (i.e., the relationship cannot be ruled out) 
Possible – Study Device 
Causal relationship is reasonably possible to the study device (i.e., 
the relationship cannot be ruled out)  
Yes – Donation Procedure 
Causal relationship to the donation procedure is certain  
Yes – Study Device 
Causal relationship to the study device is certain  
 
Table 4: Adverse Event Outcome 
 
Outcome 
Description 
Recovered/Resolved 
Subject recovered and event was resolved upon study completion 
Recovered/Resolved with 
Sequelae 
Subject recovered but exhibited lingering minor symptoms upon 
study completion 
Recovering 
Adverse event persisted upon study completion but was improving  
Not Recovered 
Adverse event persisted upon study completion and was not 
exhibiting any signs of improvement 
Death  
Subject expired  
Unknown 
Status of the adverse event was unknown upon study completion 
 
8.1.2 
SERIOUS ADVERSE EVENT (SAE)  
An SAE is defined as an AE that meets any of the following criteria: Fatal or life-threatening*; requires or 
prolongs in-subject hospitalization**; results in persistent or significant disability/incapacity; congenital 
anomaly/birth defect; important medical event. An event’s severity grading, action(s) taken, relationship 
to the donation or study procedure, and the outcome will all be used for SAE’s. 
*Life-threatening is defined as an event in which the subject was at risk of death at the time of the event. 
It does not refer to an event that hypothetically may have caused death if it was more severe. 
**In-subject hospitalization is defined as an event in which the subject was admitted to the hospital for 
one or more days, even if released on the same day or an emergency room visit, which results in admission 
to the hospital. Emergency room visits that do not result in admission to the hospital should be evaluated 
for one of the other serious outcomes criteria. 
8.1.3 
UNANTICIPATED ADVERSE DEVICE EFFECT (UADE)  
An unanticipated adverse device effect is defined by 21 CFR 812.3 as any serious adverse effect on the 
health of safety or life-threatening problem or death caused by or associated with, a device, if that effect, 
problem, or death was not previously identified in nature, severity, or degree of incidence in the 
investigational plan or application (including supplementary plan or application, or any other 
unanticipated serious problem associated with the device that relates to the rights, safety, or welfare of 

 
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subjects. The Investigator or designee will indicate if they believe an event was an unanticipated adverse 
device effect on the case report form, and the Sponsor will evaluate for reporting requirements defined 
below.  
8.2 
SAFETY REPORTING  
Safety reporting begins at the time of signed Informed Consent and ends at subject study completion.  
Investigators shall submit to the Sponsor a report of any AE’s or SAE’s that occur during the study within 
five (5) working days but no later than ten (10) days after the Investigator learns of the event.  
Investigators shall submit to the Sponsor a report of any UADE(s) that occur during the study as soon as 
possible but no later than five (5) working days after the Investigator learns of the effect. Sponsors will 
evaluate UADE’s. 
8.2.1 
REPORTING EVENTS & SAFETY CONTACTS 
Events will be reported, in writing, to the Sponsor as soon as possible but no later than five (5) working 
days after the Investigator learns of the event. In an event resulting in the death of the subject, the event 
will be reported within 24-hours of knowledge of the event. The Sponsor is responsible for fulfilling IRB 
and regulatory reporting requirements.  
Table 5: Study Reporting Contacts 
Contact 
Contact Information 
Sponsor Representative 
Zynex Monitoring Solutions  
E: Clinical@zynex.com  
P: (800) 495-6670   
IRB 
WCG IRB 
1019 39th Ave., SE, Suite 120 
Puyallup, WA 9837 
855-818-2289 
Mailing Address 
Zynex Monitoring Solutions  
Attn: ZMS Clinical  
9555 Maroon Circle  
Englewood, CO 80112 
 
9 STATISTICAL METHODS AND CONSIDERATIONS 
 
9.1 
SAMPLE SIZE DETERMINATION 
This study is designed to evaluate the sensitivity and specificity of the CM Device in detecting minor blood 
loss as compared to standard physiological parameters. The sample size was calculated based on the 
following assumptions:  
1) Standard deviation for the decrease after blood donation using the CM-1600 = 6.5 RI units 

 
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2) Minimum detectable difference after the donation = 1 RI unit 
3) Power 90% and one-sided alpha = 0.025 
A sample size of 455 will achieve about 90% power to detect a minimum difference of interest 1.0 RI 
unit with an estimated standard deviation of 6.5 and with a significance level (alpha) of 0.025 using a 
one-sided one-sample t-test.  
 
To adjust for possible attrition or incomplete datasets/donations, 10% has been added to the sample 
size, therefore, a total of 500 subjects will be enrolled.  
 
9.2 
DATASETS ANALYZED 
All eligible subjects who were enrolled in the study and connected to the study devices will be included in 
the analyses. Subjects who withdraw after enrollment and before the study devices are connected will be 
excluded from the analyses.     
9.3 
STATISTICAL ANALYSIS  
9.3.1 
Descriptive Statistics 
Continuous data will be summarized in terms of the mean, standard deviation (SD), median, quartiles, 
minimum, maximum, and number of observations, unless otherwise specified. Categorical data will be 
summarized in terms of the number of subjects providing data at the relevant time point (n), frequency 
count, and percentage. Percentages will be calculated using n as the denominator.  
9.3.2 
STATISTICAL METHOD FOR CONTINUOUS VARIABLES 
The normality of continuous data will be assessed both visually and by Shapiro-Wilk test. If data are 
considered normally distributed, the 95% CI of the mean will be constructed based on a t-distribution. 
Otherwise, if data are skewed, distribution-free confidence interval of the median will be calculated. The 
comparison between before and after blood donation will be conducted by using paired t-test or Wilcoxon 
signed-rank test, depending on the distribution of data. 
9.3.3 
DEMOGRAPHIC AND BASELINE CHARACTERISTICS 
All baseline demographic variables collected at enrollment will be summarized using descriptive statistics. 
9.3.4 
PRIMARY ANALYSIS 
The following will cover the planned primary analyses for this study procedure.  Unless otherwise 
specified, statistical analyses will be performed using two-sided hypothesis tests at the overall 5% 
significance level. No multiple comparison adjustments will be performed. 
1. Analysis of measurements taken before and after blood donation 
Measurements including RI and individual physiological parameters taken before and after blood 
donation will be first summarized using descriptive statistics. For each parameter, the absolute and 
percent differences before and after donation will be calculated and summarized using summary statistics 

 
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together with 95% confidence interval. The p-value will be calculated using paired t-test or Wilcoxon 
signed-rank test to compare with zero. 
2. Analysis of differences between measurement taken before and after blood donation. 
The difference between measurement taken before and after blood donation will be calculated by value 
before donation minus value after donation for RI and each individual physiological parameter. 
3. ROC Analysis 
Receiver operator characteristic (ROC) will be used to evaluate the sensitivity and specificity at various 
cutoff points in detecting one Unit (approximate 450mL) blood loss (donation) using the RI. The ROC 
curves will be plotted using the data collected before and after donation, and the areas under the curves 
(AUCs) will be derived together with a 95% confidence interval using an asymptotic approach. The ROC 
curves will be constructed for the percentage of decreases between RI measured before and after blood 
donation against the one Unit blood donation. Similar ROC analyses will be also conducted for each of the 
individual physiological parameters. These ROC curves will be plotted in an overlay format to demonstrate 
the difference in the detection of blood loss in the various parameters and indices. 
Several cutoff points will be chosen to compare sensitivity, specificity, positive predictive value, negative 
predictive value, and positive and negative likelihood ratios. 
10 DATA COLLECTION, RETENTION, AND MONITORING  
10.1 DATA COLLECTION 
The Investigator will prepare, maintain, and retain complete, current, accurate, organized, and legible 
Source Documents to record all observations and other pertinent data for each subject. In some instances, 
case report forms (CRFs) will serve as source documentation. The Investigator or designated study 
personnel will provide the Sponsor redacted standard procedure records with the subject ID number as 
applicable. Any required data not collected as standard of care for the blood draw procedure will be 
captured on study-specific case report forms.   
Corrections of data on paper source documents will be made by crossing out the incorrect data and 
making the GCP-compliant correction. Each correction will be initialed and dated by the study personnel 
making the correction.  
The Investigator is responsible for the information collected on subjects enrolled in the study. All data 
collected during the study must be reviewed and verified for completeness and accuracy by the 
Investigator. If any corrections are made after the Investigators signature, the Investigator will also initial 
and date the correction. 
10.1.1 SUBJECT CONFIDENTIALITY 
In order to maintain subject confidentiality, records identifying the subject will be kept in a safe and secure 
location; access to these records will be on a limited basis. Only the subject identification number, gender, 

 
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and age will identify study subjects on CRFs and other documentation submitted to the Sponsor.  A limited 
number of Sponsor representatives may have access to identifiable information and will take reasonable 
precautions to maintain the confidentiality of the subject’s identity. 
10.2 DATA RETENTION 
All study records will be stored in a safe and secure location. Records will be retained per applicable 
regulatory requirements, which include for a period of two (2) years after the latter of the following two 
days: the date which the investigation is terminated or completed, or the date that records are no longer 
required for purposes of supporting premarket approval applications or a notice of completion of a 
product development protocol. The Investigator site may transfer custody or records to the Sponsor with 
appropriate documentation recording the transfer. 
10.3 MONITORING 
10.3.1 MONITORING PLAN 
Monitoring visits will be conducted by representatives of the Sponsor or study site or both according to 
21 CFR 812. (c) for non-significant risk device studies and ICH Guidelines. By signing this protocol, the 
Investigator grants permission to the Sponsor (or designee) and all appropriate regulatory authorities to 
conduct on-site or electronic monitoring or auditing or both of all appropriate study documentation. 
11 STUDY ADMINISTRATION  
11.1 AUDITS AND INSPECTIONS 
External auditors and government inspectors may evaluate the study and must be allowed access to CRFs, 
source documents, and other study files. Audit reports will be confidential.  
11.2 PROTOCOL AND ICF AMENDMENTS 
Sponsor approval is required for any protocol or ICF amendment. Protocol or ICF amendments will not be 
implemented without prior written IRB approval except as allowed per the IRB procedures/approval and 
as necessary to eliminate immediate safety hazards to subjects. A protocol amendment intended to 
eliminate an apparent immediate hazard to subjects may be implemented immediately, provided IRBs are 
notified within five (5) working days. The Informed Consent Form will be reviewed and updated as 
necessary at the time of the protocol amendment.  
11.3 PROTOCOL DEVIATIONS 
A protocol deviation is defined as any accidental or unintentional changes to, or non-compliance with the 
IRB approved research protocol. Any deviation from the protocol must be documented and reported to 
the Sponsor within ten (10) working days and reported to the IRB as applicable to regulatory 
requirements. Protocol deviations that pose an immediate risk or significant hazard to subjects must be 
reported to the Sponsor within 24 hours and reported to the IRB no later than five (5) working days after 
the emergency occurred. In the instance an Investigator uses a device without obtaining informed 

 
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consent; the Investigator shall report to the Sponsor and the IRB within five (5) working days as per 21 
CFR 812.150 (1) (5).  
12 ETHICAL AND OTHER REGULATORY CONSIDERATIONS 
It is the responsibility of the Investigator that the study is conducted according to the Declaration of 
Helsinki, Protection of Human Volunteers (21 CFR 50), Institutional Review Board (21 CFR 56), and 
Responsibilities of Clinical Investigators (21 CFR 812 (e)). 
12.1 INSTITUTIONAL REVIEW BOARD (IRB) REVIEW 
The Protocol, ICF, and any subject facing material (as required) will be reviewed and approved by the IRB 
prior to study initiation. The Sponsor will maintain responsibility for obtaining IRB approval and submitting 
all required study reports to the IRB.  Amendments to the Protocol, ICF, or any subject facing material will 
not be implemented without prior written IRB approval unless to eliminate an apparent immediate hazard 
to subjects. All IRB approvals will be kept in the Trial Master File and Investigator Site File. 
12.2 WRITTEN INFORMED CONSENT 
The Informed Consent Form (ICF) and Informed Consent process will include all elements required by 
applicable regulations. Informed consent will be obtained in accordance with the Declaration of Helsinki, 
ICH, Good Clinical Practice, and US Code of Federal Regulations for Protection of Human Subjects (21 CFR 
50.25 [a,b], 21 CFR 50.27, and 21 CFR Part 56, Subpart A), the Health Insurance Portability and 
Accountability Act (HIPAA) when applicable, and local regulations.  
A properly executed, written informed consent will be obtained from all subjects prior to entering the 
subject into the trial, unless waived by the IRB. ICF information will be given in both verbal and written 
form. The subject must be given an ample amount of time to read the ICF. The subject must provide 
written consent by signing and dating the approved ICF. A signed copy of the ICF will be provided to the 
subject; originals will be maintained with the subject’s study records.  
Assents Forms will not be permitted as subjects must be over the age of 18 to meet the Inclusion/Exclusion 
criteria. Legally Authorized Representatives will not be permitted as subjects must have the ability to 
provide written consent to meet the Inclusion/Exclusion criteria. 
 

 
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13 REFERENCES 
 
1 Little R, Kirkman E, Driscoll P, Hanson J, Mackay-Jones K.   Preventable Deaths after Injury:  Why are the 
Traditional “Vital” Signs Poor Indicators of Blood Loss.  Journal of Accident and Emergency 
Medicine. 1995;12: 1-14. 
2 Convertino VA, Moulton SL, Grudic GZ, Rickards CA, Hinojosa-Laborde C, Gerhardt RT, et al. Use of 
advanced machine-learning techniques for noninvasive monitoring of hemorrhage. The Journal of trauma. 
2011;71(1 Suppl):S25-32.  
3 Ansari D, Tingstedt B, Lindell G, Keussen I, Ansari D, Andersson R. Hemorrhage after Major Pancreatic 
Resection: Incidence, Risk Factors, Management, and Outcome. Scand J Surg. 2017;106(1):47-53. 
doi:10.1177/1457496916631854  
4 Kubik M, Mandal R, Albergotti W, Duvvuri U, Ferris RL, Kim S. Effect of transcervical arterial ligation on 
the severity of postoperative hemorrhage after transoral robotic surgery. Head Neck. 2017;39(8):1510-
1515. doi:10.1002/hed.24677  
5 Hsieh CE, Chou CT, Lin CC, et al. Hemodynamic Changes Are Predictive of Coagulopathic Hemorrhage 
After Living Donor Liver Transplant. Exp Clin Transplant. 2017;15(6):664-668. doi:10.6002/ect.2016.020  
6 Frank SM, Savage WJ, Rothschild JA, Rivers RJ, Ness PM, Paul SL, et al. Variability in blood and blood 
component utilization as assessed by an anesthesia information management system. Anesthesiology. 
2012;117(1):99-106. 
 
 

 
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14 ABBREVIATIONS AND DEFINITIONS OF TERMS 
 
Table 6: Abbreviations and Definition of Terms 
 
Abbreviation 
Definition 
AE 
Adverse event 
BPM 
Beats per minute 
BP 
Blood pressure 
C 
Celsius 
CFR 
U.S. Code of Federal Regulations 
CM-1500/CM-1600 
Zynex Fluid Monitoring System, Model 1500 or Model 1600 
CRF 
Case report form 
ECG  
Electrocardiogram 
e.g. 
Exempli Gratia (for example) 
F 
Fahrenheit 
FDA  
U.S. Food and Drug Administration 
GCP 
Good Clinical Practice 
HIPAA 
Health Insurance Portability and Accountability Act 
HR 
Heart rate 
ICF 
Informed Consent Form 
ICH 
International Council for Harmonization 
IFU 
Instructions for Use 
IRB 
Institutional Review Board 
ISF 
Investigator Site File 
ISO 
International Organization for Standardization 
lb 
Pound; unit of mass 
ohms 
Plural unit of electrical resistance 
mL 
Milliliter 
PHI 
Protected Health Information 
PI 
Principal Investigator 
PPG 
Photoplethysmogram  
SAE 
Serious adverse event 
UADE 
Unanticipated Adverse Device Event 
ZMS 
Zynex Monitoring Solutions