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Arterialbasedcontinuouscardiacoutputmeasurement
factorfiction
HermannGilly,PhD
DepartmentofAnaesthesia,GeneralIntensiveCareMedicineandPain
Therapy
MedicalUniversityVienna,Vienna,Austria
Arterial based, less invasive techniques for cardiac output
measurementThe long road from bolus dilution to continuous cardiac outputNowadays: Fact or Fiction?Methods
PAC Thermodilution thegoldenstandard
(Quasi)ContinuousCOmeasurement
PICCO
PRAM
LiDCo
APCOcomparedwithGoldstandard
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Whyhemodynamicmonitoring?
Why
Cardiac
output
(CO)
measurement?
Oxygenhastobecontinuouslydeliveredtothetissuesforsustainablecellularfunction
Determinantsofoxygendelivery
Oxygenatedhemoglobin
Cardiacoutput
Manipulationofcardiacoutput
Fluidmanagement Pharmacologicinterventions
Resultinginin ordecreasingvesselresistance,heartrateetc.
Invasiveversuslessinvasivehemodynamicmonitoring
Mostinvasivecontinuous Em/USflowprobearoundaortaorpulmonaryartery
Invasive(quasicontinuous) u monaryarterycat eter , wan anz
Continuous(lessinvasive) Arterialpressurebased(APCOetc)
TransesophagealDoppler CO2 rebreathing
Lessinvasive,intermittent
Noninvasive,continuous Transthoracicbioimpedance
AIM:minimally(=less) orevennon invasive continuousCOmeasurement
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Methods
for
Cardiac
Output
measurement
FickprincipleInputoutputbalance
Indicatordilution
Ultrasound
Dopplervelocity
Ventricledimensions/volumes
Directmeasurement
mpe ancecar ograp yPulsecontour
Modelbasedmethods
Ficksprinciple
oxygenuptake
Intermittent atbest,slowresponseassteadystateisrequired,invasiveca
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Thermodilution Bolustechnique
Calculationof
areaunder
curve(AUC)pulmonaryTD transpulmonaryDD
thedecayofthe
dilutioncurve
normalcardiacoutput
PACGoldstandard Bolusthermodilution
Primaryparameter:timecourseoftemperatureinpulmonaryarteryorinaperipheralarteryafterinjectinganamountofcold
Influencedby: temperaturechangesduetosimultaneousinfusions
appropriatemixing ventilation,phase
injection
T
siteofmeasurement nofinaloffset propertiesofcatheter
possible
loss
of
indicator
(extravasal) high/lowflowsituation (softwarerelease)
primaryendpoint:CardiacOutput(CO)
t
secondary: ejectionfraction,(central)bloodvolume
oxygensaturation,oxygendelivery
whencombinedwithDD:EVLW
requiresinvasiveinstrumentation:PAC
34singledeterminations(averaging)
Overallaccuracy:1015%
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Continuouspulmonarythermal(heat)dilutionclinicalvalidationincomparisontocoldbolusTD
FrombolusTDtocontinuousTD (vigilancemonitor)
IntelliCath OptiQ
/min)
min)
CCOTD(
C
COTD(L
(CCO+TD)/2(L/min) (CCO+TD)/2(L/min)
acceptable
C Zllner, et al: Continuous cardiac output measurements do not agree with conventional bolus thermodilution
cardiac output determination. CAN J ANESTH 2001 48: 11 ; 11431147
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F Mielck, W Buhre, G Hanekop, T Tirilomis, R Hilgers, H Sonntag. Comparison of Continuous CardiacOutput Measurements in Patients After Cardiac Surgery. Journal of Cardiothoracic and Vascular Anesthesia,Vol 17, No 2 (April), 2003: pp 211216
FeaturesofPAC (TD,DD,bolus&cont)
EnsureenoughoxygenisdeliveredtomeetmetabolicdemandbyCOandScvO2
Provideinsightfor augmentingoxygendelivery, fluidsvsvasoactingdrugsbyCVP,PAP,PAWP
Responsetimenotimmediatebecauseofaveragingseveralcardiaccycles
Invasive,relativelypronetocomplications
CurrentstatusofPAC
over CVC
Probably reserved for patients with significant cardiacpathology/major morbidities (septic shock, large fluid shifts)
TDCO:Overallaccuracy1015%
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Basisforarterialpressurebasedpulsecontourcardiacoutput:
describingthe
(left)
ventricular
pump
Q(t)Flow
Frank's Windkessel - describes the hemodynamic of the arterial systemin terms of resistance and compliance
WINDKESSSELMODEL
Peripheral resistance is calculated according to
R=(pao,mean pven,mean)CO pao,mean CO pao,mean - mean aortic pressure
pven,mean -mean venous pressure CO- Cardiac Output
Total arterial compliance is calculated as;
C=V
14
C Total arterial compliance
V- Volume change
p Presure change
Nico Westerhof.ThearterialWindkessel.SpecialIssueReview. MedBioEngComput.
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methods
accountingformoredetails
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TheWindkesselmodel
FirstmodelbyWesseling AddingtheCompliance
R:totalsystemicperipheralresistance(SVR);Z:characteristic impedanceoftheproximal
aorta;C:Windkesselcomplianceoftheaorta
Lessinvasivepresasurepulsebasedquasicontinuous
COmethods
, ,
Modelflow(Finapres Medical Systems, Amsterdam, NL)
PRAM(Mostcare FIAB SpA, Florence, IT)
LiDCOplus/PulseCO system (LiDCO Ltd, Cambridge, UK)
Howtoaccountforthecharacteristicimpedance?
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Q(t)
Howtoaccountforthecharacteristicimpedance?
PiCCOplus Aufbau
Centralvenousaccess
Injectate
temperature
PCCI
AP13.0316.28 TB37.0
A P 1 40
117 92
(CVP) 5
SVRI 2762
PC
C I 3 .2 4
HR 78
SVI 4 2
PiCCO: combines transpulmonary thermodilution for calibration and arterialpulse contour analysis 2nd sw-version: adapted algorithm: analyzes shape of the pressure wave-
form, accounting for individual compliance and systemic vascular resistance
S VV 5 %
dPmx1140
(GEDI) 625
Arterialtemperature
stroke volume computed byintegrating the systolic area under
the arterial pressure waveform
20
PULSIOCATH
thermodilution catheter
PULSIONpressuretransducer
For calibration the specific aortic impedance isrequired: calculated by comparison of the systolicarea and thermodilution CO measured
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Irlbeck et al. 20 / 165 -0.09 0.85 0.93 1.x patients on ICU
Buhre et al 12 / 36 1.6 - 9.2 0.003 0.63 0.88 1.x patients on ICU
Rdig et al. 26 / 308 2.3 - 12.6 0.18 1.24 1.xduring coronarybypass surgery
after cardiothoracic
PiCCO vsPA-TD Cardiac Output / Cardiac Index *
References # n Mean SD Range Bias SD PE r ** Software Condition of
(l/min) (l/min) (l/min) Version the participants
ner e a . . - . . . . surgery
Rauch et al. 25 / 380 1.95 - 11.6 -0.14 1.16 1.xpatients undergoingHCPB
Mielck et al. 22 / 96
6.6
1.7 0.40 1.30 39 post cardiac surgery
Gdje et al. 24 / 517 2.7 - 14.1 -0.20 1.15 0.88 4.1after cardiothoracicsurgery
Della Rocca et al. 62 / 186 3.0 - 13.0 0.04 0.84 0.94 4.1undergoing livertransplantation
Felbinger et al. 20 / 360 2.05 - 6.3 * 0.14 0.33 * 0.93 post cardiac surgery
Sujatha et al. 60 / 480 0.23 0.50 20
surgery
Halvorsen et al. 31 / 252 5.0 - 7.1 -0.76 1.17 43 5.1undergoing OPCABsurgery
Chakravarthy et al 15 / 438 -0.13 1.12undergoing OPCABsurgery
de Wilde et al. 24 / 199
4.7
? 2.1 - 9.7 -0.14 0.87 47 undergoing OPCABsurgery
Button et al. 31 / 185 2.4 - 9.3 0.28 1.30 6.0 perioperative period
PEpercentageerror;accordingtoCritchley&Critchley
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LiDCOTMplus/PulseCOTMsystem
minimally invasive lithium dilution technique for calibrationcentral or peripheral venous access for indicator injection (0.002-0.004mmol/kg; upper limit of 3mmol/day).Cardiac output the arterial concentration time curve obtained by an ion-selective electrode located in ablood flow-through-cell
beat-to-beat estimate of the cardiac output continuously analyzing the arterialblood pressure waveform. The algorithm is supposed to be independent of the arterialmeasurement site.
For the analysis of the pressure trace a 3-step transformation by Jonas is used.
1) the transformation of the arterial pressure signal into a standardized volume-time waveform (done by an algorithm compliance with a lookup table).
2) in order to obtain cardiac output, the duration of the cardiac cycle and thes ro e vo ume s ca cu a e y au ocorre a on
3) this result is calibrated by comparison with a LIDCO-measured value, whichthe manufacturer recommends to be done every 4 to 6 hours. This calibrationfactor corrects for the arterial compliance for a given arterial blood pressure and for variations betweenindividuals. Further details for the exact calculation are not provided
LiDCO-technique
The secret of LiDCOLinton et al: BJA (2001) 86: 486-496
ZA aortic impedance, A cross section phase difference flow=velocityf frequency
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Cardiac Output / Cardiac Index *
PulseCO/LiDCO References # n Mean SD Range Bias SD PE r ** Condition ofPA-TD (l/min) (l/min) (l/min) the participants
Linton et al. 40 / 160 -0.25 0.5 0.97 patients after surgery
Garcia-Rodr iguez et a l. 31 / 93 5.55 ? 2.4 -11.5 -0.5 0.7 24 after major surgery
Hamilton et al 20 / 100 3.4 - 8.5 0.05 0.6 0.86 post CABG surgery
Yamashita et al 23 / ? 0.76 1.93 0.74undergoing OPCABsurgery
Costa et al 23 / 151 3.4 - 13.2 -0.29 1.09 16.8 0.852 hours after liver
transplantation
de Wilde et al 24 / 199 5.0 ? 2.5 - 8.9 0.17 0.69 28 undergoing CABG
PRAM/Mostcare
standard arterial radial or femoral catheter, Calibration with other techniques not required
beat-to-beat values of cardiac output based on the mathematical analysis ofthe arterial pressure profile changes
The algorithm is based on the principle of perturbations performing a beat-to-beatanalyis of the whole arterial pressure wave morphology (instead of just the pulsatile
. , ,points of perturbance are evaluated.
PRAM claims to consider aortic impedance, compliance and systemic vascularresistance, which are affecting the pressure signal, further details undisclosed.
Cardiac Output / Cardiac Index *
PA-TDvs References # n Mean SD Range Bias SD PE r ** Condition of
the participantsPRAM
(l/min) (l/min) (l/min)
Romano&Pistolesi 18 / ? 2.6 0.6 *1.7 - 4.0
*-0.15 0.35
* 27 0.88undergoing heartcatherization
Giomarelli et al. 28 / 112 2.3 - 7.4 0.03 0.89 0.88 undergoing CABG
Romano et al. 50 / ? 2.7 0.6 *1.6 - 4.2
*-0.03 0.42
* 31 0.85undergoing heartcatherization
Romano et al. 32 / 128 4.0 0.7 0.07 0.40 20 0.87 undergoing CABG
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Slidetakenfrom:EdwardsLifesciencesWebsite,modified
Patentapplication:EdwardsLifesciences
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Slidetakenfrom:EdwardsLifesciencesWebsite,modified
Slidetakenfrom:EdwardsLifesciencesWebsite
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Slidetakenfrom:EdwardsLifesciencesWebsite
Slidetakenfrom:EdwardsLifesciencesWebsite
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ThesecretofthecalculationofAPCO(Vigileo)(takenfromthepatentsdescription)
11parameters 1 11
Slidetakenfrom:EdwardsLifesciencesWebsite
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FlowtracversusICO FlowtracversusCCO
Slidetakenfrom:EdwardsLifesciencesWebsite
CCOvsICO
Slidetakenfrom:EdwardsLifesciencesWebsite
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ChangesinCOduetolinedamping
Slidetakenfrom:EdwardsLifesciencesWebsite
Art.Radialis(original;ProbandH.L.) Art.Radialis
smoothed
1 2 3 4 5 6 7 98 10 11
Harmonicfrequencies
26.April2007 Druckmessung
XAchse:ArbitrreEinheit
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Setkonfiguration
Eigen
frequenz
Dmpfungs
faktor
Flowtrac 38,8 0,188
39,5 0,170
mit 10l Luftblasetransducerseitig
38,4 0,175
38,9 0,175
mit BD-Kanle24,2 0,236
25,0 0,241
mit BD-Kanleund 10l Luft
22,5 0,261
21,8 0,262
Manecke,2005
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ClinicalvalidationofcontinuousAPCO(FCI)
comparisontocontinuouspulmonarythermaldilution(Vigilance)
Chakravarthy M,RajeevS,JawaliV.Cardiacindexvaluemeasurementbyinvasive,semiinvasiveandnon
invasivetechniques:aprospectivestudyinpostoperativeoffpumpcoronaryarterybypasssurgerypatients.J
ClinMonitComput2009;23:175180
FCIandBCI 0.18 0.08
OAPCO
Difference
inHI(PiC
(L/min/m2)
Mean(L/min/m2)
BZukunft:EvaluierungdesminimalinvasivenFloTrac/VigileoMonitoringsystemsankritisch
krankenPatienten.ThesisCharit UniversittsmedizinBerlin.2008
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BZukunft:EvaluierungdesminimalinvasivenFloTrac/Vigileo
MonitoringsystemsankritischkrankenPatienten.Thesis
Charit UniversittsmedizinBerlin.2008
ComparisonofFloTrac/Vigileo anda.femoralis(PiCCO)calculatedHIdata
and FloTrac/Vigileo anda.radialis calculatedHIdata.SpearmanRhoKorrelation
BlandAltmannAnalysis:biasundlimitsofagreement0.35 0.38l/min/m2,PE 38.3%
ComparisonofchangesinindividualconsecutivelymeasuredHIdata,
obtainedfromFloTrac/VigileoandtranspulmonaryTD/PCA(PiCCO)
BZukunft:EvaluierungdesminimalinvasivenFloTrac/VigileoMonitoringsystemsankritischkranken
Patienten.ThesisCharit UniversittsmedizinBerlin.2008
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Vigileo versus
PulmArt TD Cardiac Output / Cardiac Index *
References # n Mean SD Range Bias SD PE r ** Software Condition of
(l/min) (l/min) (l/min) Version the participants
Sander et al 30 / 120 0.60 1.40 54 0.53 undergoing CABG
Button et al. 31 / 185 2.4 - 9.3 0.25 1.13 1.07 perioperative period
Mayer et al 40 / 244 2.8 0 .65 * 1.6 - 4 .9 * 0.46 0 .58 * 46 0.53 1.0 cardiac surgical patients
Manecke and
Auger 50 / 295 2.8 - 9.6 0.55 0.98 post cardiac surgery
Opdam et al. 6 / 218 0.21 1.02 * 0.35 post cardiac surgery
Prasser e t al . 20 / 164 5.9 1 .15 3 .4 - 9.8 0.02 1 .49 49.3 0.58 1.03 critically ill in a neurosurgical ICU
Breukers et al. 20 / 56 5.5 0.85 3.3 - 8.8 -0.14 1.00 36 0.74 post cardiac surgery
Chakravarthy et
al 15 / 438 -0.15 0.33 undergoing OPCAB surgery
Cannesson et al. 11 / 166 4.7 0.95 1.9 - 8.2 0.26 0.87 37 0.66 undergoing CABGMcGee et al 84 / ? 5.9 ? 3.1 - 9.2 0.20 1.28 43 critically ill patients on ICU
Staier et al. 30 / 120 0.02 1.04 44.3 aortic valve replacement
Mayer et a l. 40 / 282 2.5 0.55 * 1.2 - 4.1 * 0.19 0.30 * 24.6 1.10 undergoing CABG
Metha et al 12 / ? 4.5 1.33 2.8 - 7.7 0.26 0.66 29 1.07 undergoing OPCAB surgery
Matth ieu et al. 20 / 400 5.5 1 .0 2 .1 - 9.5 -0.8 ? 43 1.07 undergoing liver transplantation
All currently available noninvasive arterial pressure based CO
monitors have advantages and limitations.With an increasing number of clinical studies being published on the
applicability, suitability, and clinical utility of these monitors their use should
continue to gain popularity. However, evaluation of changes and direction of
Conclusion
changes essential (!)
When using these monitors in conjunction with the
administration of fluids and vasopressors to specific therapeuticend points (goal directed therapy) there limitations should be
kept in mind.
less invasive state of the art devices presently available remains
questionable.
True continuous cardiac output : no end in sight yet at present more fiction than fact in dynamic conditions##personalview
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ThankYouforYourattention!
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MBiais,KNouetteGaulain,AQuinart,SRoullet, PRevel,Fsztark. Uncalibrated StrokeVolumeVariationsAre
AbletoPredicttheHemodynamicEffectsofPositiveEndExpiratoryPressureinPatientswithAcuteLungInjury
orAcuteRespiratoryDistressSyndromeafterLiverTransplantationAnesthesiology2009;111:85562
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DLahner,BKabon,CMarschalek,AChiari,GPestel,AKaider,E Fleischmann,HHetz.Evaluation
responsivenessintraoperatively .BritishJournalofAnaesthesia doi:10.1093/bja/aep200
Results. Twenty patients received 67 fluid boluses. Fiftytwo of the 67 fluidboluses administered resulted in fluid responsiveness. SVV achieved an area
under the ROC curve of 0.512 [CI 0.320.70].
Conclusions.Thisprospective,interventionalobserverblindedstudydemonstrates
thatSVVobtainedbyAPCO,usingtheFloTrac/Vigileo system,cannotserveasa
surgery.
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TranspulmonaleThermodilution:
HerzzeitvolumenNach zentralvenser Injektion desIndikators misst ein Thermistor inder Spitze
des arteriellen Katheter dieTemperaturvernderungen stromabwrts.
DasHerzzeitvolumenwirddurchdieAnalysederThermodilutionskurve nach
einem modifiziertenStewartHamiltonAlgorithmusberechnet.
Temperaturverdnnungskurve Bolusverfahren
Tb Injektion
t
dtT
KV)T(THZV
b
iibTD
Tb =Bluttemperatur
Ti =Injektattemperatur
Vi =Injektatvolumen
T . dt =Flche unter der Thermodilutionskurve
BerechnungdesHZV:
Flcheunterder
Thermodilutionskurve
dtT
KV)T(THZV
b
iibTD
78
K =Korrekturfaktor,aus spezifischem Gewichtundspezifischer Wrmekapazitt vonBlut undInjektat
Thermodilution Bolustechnique
Calculationof
areaunder
mittels
Extrapolation
des
abfallenden
Kurventeils,
Fitting
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AJPHeartCircPhysiol VOL281SEPTEMBER
2001
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PiCCO
PiCCO-Technology combines transpulmonary thermodilution forcalibration and arterial pulse contour analysis.
inline injectate temperature sensor in a central vene4-French thermistor-tipped arterial pressure catheter (peripheral artery: femoral, axillary,brachial)
PiCCO algorithm for continuous cardiac output determination as described byWesseling et al.stroke volume computed by integrating the systolic area under thearterial pressure waveform.For calibration the specific aortic impedance is required: calculated bycomparison of the systolic area and thermodilution CO measured.2nd software generation: adapted algorithm: analyzes the shape of thepressure waveform, taking into account the individual compliance andsystemic vascular resistance