Pulse contour cardiac output in surgical intensive care unit patients

doi:10.1016/0952-8180(93)90064-L

Journal of Clinical Anesthesia

Volume 5, Issue 6, November–December 1993, Pages 471-478

https://doi.org/10.1016/0952-8180(93)90064-L Get rights and content

Abstract

Study Objective: To evaluate the ability of arterial waveform contour analysis to measure cardiac output (CO) continuously in postoperative critically ill patients.

Design: Thermodilution CO (TDCO) measurements were compared with simultaneous pulse contour CO (PCCO) measurements.

Setting: University hospital surgical intensive care unit.

Patients: 29 critically ill surgical patients with indwelling systemic arterial and pulmonary artery catheters.

Measurements and Main Results: TDCO measurements were compared with PCCO at 1- to 2-hour intervals. Mean TDCO was 5.75 ± 1.79 L/min, and mean PCCO was 5.76 ± 1.83 L/min. Analysis of the difference between TDCO and PCCO showed a bias of 0.01 ± 0.5 L/min. Comparison of the difference between pairs of sequential TDCO measurements and the initial TDCO and subsequent PCCO measurements resulted in a correlation coefficient of 0.64.

Conclusions: The PCCO method appears to be able to estimate changes in CO under the conditions tested, in which PCCO was recalibrated after each TDCO measurement. However, limitations of this method in the immediate postoperative period following aortic aneurysm surgery were identified.

References (46)

W. Ganz et al.
A new technique for measurement of cardiac output by thermodilution in man
Am J Cardiol
(1971)
J.S. Forrester et al.
Thermodilution cardiac output determination with a single flow-directed catheter
Am Heart J
(1972)
A. Kumar et al.
Noninvasive measurement of cardiac output during surgery using a new continuous-wave Doppler esophageal probe
Am J Cardiol
(1989)
L.C. Siegel et al.
Simultaneous measurements of cardiac output by thermodilution, esophageal Doppler, and electrical impedance in anesthetized patients
J Cardiothorac Anesth
(1988)
F.G. Spinale et al.
Comparison of bioimpedance and thermodilution methods for determining cardiac output: experimental and clinical studies
Ann Thorac Surg
(1988)
A. Kumar et al.
Noninvasive measurement of cardiac output during surgery using a new continuous-wave Doppler esophageal probe
Am J Cardiol
(1989)
K.R. LaMantia et al.
Cardiac output: measurement of the future or relic of the past?
J Cardiothorac Anesth
(1988)
D.S. Looyenga et al.
Determination of cardiac output in critically ill patients by dual beam Doppler echocardiography
J Am Coll Cardiol
(1989)
T.J. Quinn et al.
Continuous trending of Fick variables in the critically ill patient
Chest
(1991)
H. Khalil
Determination of cardiac output in man by a new method based on thermodilution
Lancet
(1963)

A.F. Connors et al.

Evaluation of rightheart catheterization in the critically ill patient without acute myocardial infarction

N Engl J Med

(1983)

M.A. Branthwaite et al.

Measurement of cardiac output by thermal dilution in man

J Appl Physiol

(1968)

E. Evonuk et al.

Cardiac output measured using thermal dilution with room temperature injectate

J Appl Physiol

(1961)

J.H. Abrams et al.

Transtracheal Doppler: a new procedure for continuous cardiac output measurement

Anesthesiology

(1989)

L.C. Siegel et al.

Instantaneous and continuous cardiac output obtained with a Doppler pulmonary artery catheter

J Am Coll Cardiol

(1989)

D.H. Wong et al.

Noninvasive cardiac output: simultaneous comparison of two different methods with thermodilution

Anesthesiology

(1990)

G. Castor et al.

Determination of cardiac output during positive end expiratory pressure-noninvasive electrical bioimpendence compared with standard thermodilution

Crit Care Med

(1990)

K.D. Donovan et al.

Comparison of pulsed Doppler and thermodilution methods for measuring cardiac output in critically ill patients

Crit Care Med

(1987)

N.T. Smith et al.

Cardiac output beat-to-beat: evaluation of a new apparatus and method

IRCS

(1974)

K.H. Wesseling et al.

Beat-to-beat cardiac output from the arterial pressure contour

K.H. Wesseling et al.

A computer module for the continuous monitoring of cardiac output in the operating theater and the ICU

Acta Anaesthesiol Belg

(1976)

J.R. Jansen et al.

Thermodilution technique for measurement of cardiac output during artificial ventilation

J Appl Physiol

(1981)

J.V. Snyder et al.

Effects of mechanical ventilation on the measurement of cardiac output by thermodilution

Crit Care Med

(1982)

Cited by (28)

Pro: Continuous cardiac output and SvO<inf>2</inf> monitoring should be routine during off-pump coronary artery bypass graft surgery
2012, Journal of Cardiothoracic and Vascular Anesthesia
Continuous cardiac output during off-pump coronary artery bypass surgery: Pulse-contour analyses vs pulmonary artery thermodilution
2007, British Journal of Anaesthesia
Citation Excerpt :
In a study including postoperative cardiac surgery patients, Østergaard and colleagues17 reported a percentage error of 49.5% between PCCO and intermittent pulmonary artery thermodilution. Reduced accuracy of PCCO during haemodynamic instability has been reported by others.10 18 Thus, in our study, since significant haemodynamic changes were seen and inotropes and vasoactive drugs were given in order to maintain acceptable MAP and HR, one should expect a high percentage error between PCCO and true CO.
No gold standard method exists for monitoring continuous cardiac output (CO). In this study, the agreement between the two most frequently used methods, PiCCO pulse-contour analysis (PCCO) and STAT pulmonary artery thermodilution (STAT-CO), was assessed during multiple-vessel off-pump coronary artery bypass (OPCAB) surgery.
Thirty patients were enrolled in the study. Two time periods were defined during surgery; Period 1 included positioning of the heart and stabilizer device and Period 2 included the coronary occlusion. Measurements were obtained every minute during both periods. The agreement for the continuous CO and the change in CO (ΔCO) was estimated using the Bland–Altman method.
Significant changes in mean arterial pressure (ΔMAP), central venous saturation, PCCO and STAT-CO were seen only during Period 1. ΔMAP correlated only with changes in PCCO, (P < 0.001, r = 0.60). The mean difference (2sd) between PCCO and STAT-CO ranged from − 0.29 (1.82) to − 0.71 (2.57) litre min⁻¹, and the percentage error varied from 32 to 50%. For the CO measurements, the limits of agreements did not differ between Period 1 and Period 2. In contrast, for the ΔCO measurements, the limits of agreements were wider in Period 1 than in the more haemodynamically stable Period 2.
PCCO and STAT-CO show large discrepancies in CO during OPCAB surgery. Clinically acceptable agreement was seen only for trends in CO during haemodynamically stable periods.
Use of lithium dilution and pulse contour analysis cardiac output determination in anaesthetized horses: A clinical evaluation
2005, Veterinary Anaesthesia and Analgesia
To assess the suitability of a human algorithm for calculation of continuous cardiac output from the arterial pulse waveform, in anaesthetized horses.
Prospective clinical study.
Twenty-four clinical cases undergoing anaesthesia for various conditions.
Cardiac output ( $\dot{Q} t$ ), measured by lithium dilution ( $\dot{Q} t$ _LiDCO), was compared with a preceding, calibrated $\dot{Q} t$ measured from the pulse waveform ( $\dot{Q} t$ _Pulse). These comparisons were repeated every 20–30 minutes. Positive inotropes or vasopressors were administered when clinically indicated. Cardiac indices from 30.7 to 114.9 mL kg⁻¹ minute⁻¹ were recorded. Unusually shaped $\dot{Q} t$ _LiDCO curves were rejected and the measurement was repeated immediately.
Eighty-nine comparisons were made between $\dot{Q} t$ _LiDCO and $\dot{Q} t$ _Pulse. The bias between the mean (±SD) of the two methods ( $\dot{Q} t$ _LiDCO − $\dot{Q} t$ _Pulse) was −0.07 L minute⁻¹(±3.08) (0.24 ± 6.48 mL kg⁻¹ minute⁻¹). The limits of agreement were −12.72 and 13.2 mL kg⁻¹ minute⁻¹ (Bland & Altman 1986; Mantha et al. 2000). Linear regression analysis demonstrated a correlation coefficient (r²) of 0.89. Cardiac output in individual patients varied from 49.1 to 183% of the initial measurement at the time of calibration. Linear regression of log-transformed $\dot{Q} t$ variation for each method found a mean difference of 9% with limits of agreement of −4.1 to 22.1%.
This method of pulse contour analysis is a relatively noninvasive and reliable way of monitoring continuous $\dot{Q} t$ in the horse under anaesthesia. The ability to easily monitor $\dot{Q} t$ might decrease morbidity and mortality in the anaesthetized horse.
Cardiac index measurements during rapid preload changes: A comparison of pulmonary artery thermodilution with arterial pulse contour analysis
2005, Journal of Clinical Anesthesia
Citation Excerpt :
However, the accuracy of arterial pulse contour analysis has not been investigated during rapid changes in ventricular loading conditions, as these changes typically occur in the early postoperative period in patients undergoing major surgery. Furthermore, the accuracy of arterial pulse contour analysis was questioned during rapid changes in SVR or CI [21,22]. In addition, most previous studies comparing different strategies for measuring cardiac performance have investigated only long-term changes or absolute values of CI [12,23].
To compare cardiac index (CI) values obtained by pulmonary artery thermodilution (CI_PA), arterial thermodilution (CI_TD), and arterial pulse contour analysis (CI_PC) during rapid fluid administration, as accurate and rapid detection of CI changes is critical during acute preload changes for guiding volume and vasopressor therapy in critically ill patients, and the accuracy of CI_PC during acute changes in loading condition is currently unknown.
Prospective clinical study.
Cardiac surgical intensive care unit of a university hospital.
Seventeen American Society of Anesthesiologists (ASA) physical status II and III patients, aged 32 to 76 years, with normal left ventricular function during the early postoperative period after elective coronary artery bypass graft surgery.
After baseline determinations of CI_PA, CI_PC, and CI_TD were made, fluid loading was performed using 10 mL times body mass index of hydroxyethyl starch 6%. CI_PA, CI_PC, and CI_TD were determined, and changes in CI (ΔCI) were calculated. Fluid load was repeated until no increase in stroke volume index (ΔSVI <10%) was achieved.
Regression analysis between CI_PA/CI_PC, CI_PA/CI_TD, and CI_PC/CI_TD revealed r² = 0.92, r² = 0.92, and r² = 0.98. Regression analysis between ΔCI_PA/ΔCI_PC, ΔCI_PA/ΔCI_TD, and ΔCI_PC/ΔCI_TD revealed r² = 0.57, r² = 0.67, and r² = 0.74, respectively. Bland-Altman analysis was used to determine accuracy and precision of the 3 methods compared. The mean differences (m) and SD between ΔCI_PA/ΔCI_PC, ΔCI_PA/ΔCI_TD, and ΔCI_PC/ΔCI_TD resulted in m = −1.01%, SD = 6.51%; m = −0.83%, SD = 5.80%; and m = −0.33%, SD = 4.65%, respectively.
Compared with pulmonary artery thermodilution, arterial pulse contour analysis reflects relative changes in CI during rapid changes of preload with clinically acceptable accuracy.
Comparison of pulmonary arterial thermodilution and arterial pulse contour analysis: Evaluation of a new algorithm
2002, Journal of Clinical Anesthesia
Study Objective: To compare cardiac index (CI) measurement by arterial pulse contour analysis using two different algorithms (CI_PC, CI_PCnew) with pulmonary arterial thermodilution values (CI_PA) so as to evaluate the difference between the conventional algorithm, CI_PC, and a new algorithm, CI_PCnew, that accounts for patients’ individual aortic compliance.
Design: Prospective, clinical study.
Setting: Intensive care unit of a university hospital.
Patients: 20 ASA physical status II and III patients following elective cardiac surgery.
Measurements and Main Results: 360 parallel triplicate determinations of CI (CI_PA, CI_PC, CI_PCnew) were performed within a 90-minute period during the immediate postoperative period. Prior to the start of the study period, CI_PC as well as CI_PCnew were calibrated by triplicate femoral arterial thermodilution measurements. Regression analysis of CI_PA and CI_PC, as well as CI_PA and CI_PCnew, revealed r = 0.89, p < 0.001, and r = 0.93, p < 0.001, respectively. Bland-Altman analysis was used for determining the accuracy and precision of CI_PC and CI_PCnew compared with CI_PA. The mean differences (m) and standard deviation (SD) between CI_PA and CI_PC, as well as CI_PA and CI_PCnew, resulted in m = −0.312 L/min/m², SD = 0.456 L/min/m², and m = − 0.140 L/min/m², SD = 0.328 L/min/m², respectively.
Conclusion: Arterial pulse contour analysis measurement of CI using either algorithm correlates well with CI values derived by pulmonary arterial thermodilution. However, the algorithm introduced in this study proved to be a more accurate predictor of values as derived by pulmonary artery catheter.
Comparison of cardiac output assessed by pulse-contour analysis and thermodilution in patients undergoing minimally invasive direct coronary artery bypass grafting
1999, Journal of Cardiothoracic and Vascular Anesthesia
$Objective:$ To investigate the precision and accuracy of continuous pulse contour cardiac output (PCCO) compared with intermittent transcardiopulmonary (TCPCO) and pulmonary artery thermodilution (TDCO) measurements in patients undergoing minimally invasive coronary bypass surgery (MIDCAB).
$Design:$ Prospective, controlled, clinical study.
$Setting:$ University hospital.
$Participants:$ Twelve patients undergoing MIDCAB.
$Interventions:$ Thirty-six measurements of PCCO and thermodilution cardiac output (CO) were simultaneously performed after the start of surgery, during bypass grafting, and at the end of surgery. TCPCO and TDCO were simultaneously assessed by three injections of ice-cold saline randomly spread over the respiratory cycle. The pulse contour device was initially calibrated with an additional set of aortic thermodilution measurements.
$Measurements and Main Results:$ Absolute values of CO ranged between 1.6 and 9.2 L/min. A close agreement among the three techniques was observed at all measurements. Mean bias between PCCO and TDCO and TCPCO was 0.003 L/min (2 SD of differences between methods = 1.26 L/min) and 0.27 L/min (2 SD of differences between methods = 1.16 L/min), respectively. The correlation coefficients were r² = 0.90 for TCPCO versus PCCO and r² = 0.88 for TDCO versus PCCO.
$Conclusion:$ The results of the present study show that compared with thermodilution CO, pulse contour analysis enables accurate measurement of continuous CO in patients undergoing MIDCAB.

View all citing articles on Scopus

^☆: Supported in part by a grant from Baxter-Edwards, Critical Care Division, Santa Ana, CA.

^∗: Fellow in Critical Care

^†: Assistant Professor of Anesthesiology

View full text

Original contributionPulse contour cardiac output in surgical intensive care unit patients☆

Abstract

Am J Cardiol

Am Heart J

Am J Cardiol

J Cardiothorac Anesth

Ann Thorac Surg

Am J Cardiol

J Cardiothorac Anesth

J Am Coll Cardiol

Chest

Lancet

Evaluation of rightheart catheterization in the critically ill patient without acute myocardial infarction

N Engl J Med

Measurement of cardiac output by thermal dilution in man

J Appl Physiol

Cardiac output measured using thermal dilution with room temperature injectate

J Appl Physiol

Transtracheal Doppler: a new procedure for continuous cardiac output measurement

Anesthesiology

Instantaneous and continuous cardiac output obtained with a Doppler pulmonary artery catheter

J Am Coll Cardiol

Noninvasive cardiac output: simultaneous comparison of two different methods with thermodilution

Anesthesiology

Determination of cardiac output during positive end expiratory pressure-noninvasive electrical bioimpendence compared with standard thermodilution

Crit Care Med

Comparison of pulsed Doppler and thermodilution methods for measuring cardiac output in critically ill patients

Crit Care Med

Cardiac output beat-to-beat: evaluation of a new apparatus and method

IRCS

Beat-to-beat cardiac output from the arterial pressure contour

A computer module for the continuous monitoring of cardiac output in the operating theater and the ICU

Acta Anaesthesiol Belg

Thermodilution technique for measurement of cardiac output during artificial ventilation

J Appl Physiol

Effects of mechanical ventilation on the measurement of cardiac output by thermodilution

Crit Care Med

Original contribution
Pulse contour cardiac output in surgical intensive care unit patients☆