arterial based cardiac output

8/3/2019 Arterial Based Cardiac Output

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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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ThesecretofthecalculationofAPCO(Vigileo)(takenfromthepatentsdescription)

11parameters 1 11



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FlowtracversusICO FlowtracversusCCO


CCOvsICO



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ChangesinCOduetolinedamping


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

arterial based cardiac output

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