Non Invasive Haemodynamic

Monitoring

Nick Harrison
BACCN May 2015

 Hemodynamic monitoring is a cornerstone of care

for the hemodynamically unstable patient, but it
requires a manifold approach and its use is both
context and disease specific.
One of the primary goals of hemodynamic
monitoring is to alert the health care team to
impending cardiovascular crisis before organ injury
ensues.

Does it matter which haemodynamic

monitor to use?
Finally, no monitoring tool, no matter how
accurate, by itself has improved patient
outcome.

Pinskey et al (2005)

Adolf Fick
The principle:

" the total uptake of (or release of) a substance

by the peripheral tissues is equal to the product
of the blood flow to the peripheral tissues and
the arterial-venous concentration difference
(gradient) of the substance."
It is the blood flow we are interested in: this is
cardiac output.

Fick The True Gold Standard

VO2, the oxygen consumption, is simply the difference between the inspired and expired O2. You
can measure it with an exhaled gas collection bag.
You can also estimate it. Conventionally, resting metabolic consumption of oxygen is
3.5 ml of O2 per kg per minute,
or
125ml O2 per square meter of body surface area per minute.
Lets say the meaty pinkish lump below is the patient.

http://www.derangedphysiology.com/php/PAC/

Fick teaches us that VO2 (oxygen extraction) is determined by the following equation:

We can rearrange that to form an equation which calculates cardiac output on the basis of
oxygen extraction:

So, in a normal person, with a body surface area of 2m2 and thus with a VO2 of 250ml per
minute,
CO = 250ml / (200ml 150ml)
= 250 / 50
= 5 L/min

Where are we Now?

Bolus thermodilution
Transpulmonary thermodilution
Lithium dilution
Doppler technique
Pulse contour analysis
Carbon dioxide rebreathing
Bioimpedence / Bioreactance
Echocradiography
Peripheral pulse variation

Choices, Choices

Things to consider
Theoretical considerations for choosing among
hemodynamic monitoring tools

Hardware considerations for choosing among

hemodynamic monitoring tools

Patient-bound considerations for tailoring

hemodynamic monitoring

Slagt et al. Critical Care 2010, 14:208

The New Gold Standard

Problems

Extreme level invasiveness

Advanced training for placement
Incorrect parameter interpretation
Complications
Arrhythmias
Pulmonary rupture
Air embolism

Most studies focusing on the PAC and outcome have shown no positive association
between PAC use for fluid management and survival in the ICU.

Wheeler et al. N Engl J Med 2006, 354:2213-2224

Doppler Technology
Prof Mervyn Singer is Professor of Intensive Care Medicine at University College

First described in mid 1970s and gained popularity in

(Gan and Arrowsmith)
the 1990s
Measures blood flow velocity in the descending
aorta using flexible ultrasound probe ( 4-5MHz).

Measurement combined with estimated cross

sectional area of aorta, age, height and weight give
haemodynamic variables

Values
Stroke Distance:

Distance in cm column of blood moves along

aorta with every ventricular beat
Changes in SD directly related to stroke volume

Stroke Volume

Amount of blood ejected by heart each beat

Flow time Corrected (FTc)

Is the duration of flow during systole corrected for the heart rate (330 360ms)

Peak Velocity

Highest blood velocity during systole

Age dependent PV

Age

20yrs

90-120cm/s

50yrs

70-100cm/s

70yrs

50-80cm/s

Minimally invasive
Minimal technical skill required for insertion
Good correlation with PAC.
Recommended for use in high risk surgery (NICE)

Remember

Cross section must be accurate

Ultrasound beam must be directed parallel to the blood flow
Beam direction must NOT undergo any major alterations between
measurements
(King and Lim (2004), Kauffamn (2000), Prentice and Sonna (2006), Lavdaniti (2008), Tomlin (1975), NICE 2011)

Transpulmonary Thermodilution and Pulse Contour

Cardiac Output

Systems can be divided into 3 categories:

Pulse contour analysis requiring and an indicator dilution

CO measurement to calibrate the pulse contour (LiDCO,
PiCCO, Volumeview)

Pulse contour analysis requiring patient demographic and

physical characteristics for arterial impudence estimation
(FloTrac, NextFin, Radical 7).

Pulse contour analysis that does not require calibration or

preloaded data (Most Care System)

Pulse Contour Analysis

The origin of the pulse contour method of measuring cardiac output is derived from
variations in the pulse pressure waveform.
In general, the greater the stroke volume, the greater is the amount of blood that
must be accommodated in the arterial tree with each heartbeat and, therefore, the
greater the pressure rise and fall during systole and diastole, thus causing a greater
pulse pressure.

The pulse pressure is proportional to stroke volume and inversely related to vascular
compliance.
Aortic pulse pressure is proportional to SV and is inversely related to aortic
compliance.
(Chest 2002)

 Stroke Volume (Pulse pressure ~ Stroke Volume)

Aortic Compliance (As the compliance of the vasculature is difficult to measure

directly, this is calculated based on age, sex, ethnicity and body mass index
(BMI)) Brumfield AMPhysiol Meas 2005;26:599608
Vascular Tone (clinical condition and therapeutic approach)

LiDCO
First described in 1993

http://www.ebay.com/itm/LiDCO-Plus-Hemodynamic

Combines pulse power analysis with lithium dilution

technique
Requires a venous line and arterial catheter

Lithium is injected via vein and arterial concentration

sampled across a lithium electrode at a rate of 4mls/min.
Provides an accurate calibration and corrects for arterial
compliance and variation among individuals.

Power pulse analysis the magnitude in change of pressure is equal to the

magnitude of change in stroke volume

The heart rate is calculated by drawing an imaginary line through the

arterial waveform.

Cardiac output in PulseCo is an estimated figure due to assumption of

aortic compliance (Remington et al 1948) uses accepted figure of 250mls.
People vary so necessary to calibrate:
V / bp = calibration x 250 x e k.bp

Advantages
Any arterial site can be used.
Damping effects of the transducer system is
reduced.
Safe and accurate (Hett & Jones 2003)
Can be calibrated with any form of CO
measurement
Good correlation with PAC (Costa et al 2008)

 Calibration can be time consuming

Expense
Not recommended
in first trimester of pregnancy
Under 40kgs
Patients receiving NMB can cause delay
Aortic valve regurgitation

Transpulmonary Thermodilution and Pulse

Contour Analysis (TPCO)

PiCCO and VolumeView

Requires a central vein catheterisation and arterial catheter

(femoral preferable)
Continuous pulse contour SV is calculated from the area
under systolic portion of the arterial waveform
Shape of arterial waveform, arterial compliance, SVR

These devices use the same basic principles of dilution to

estimate the cardiac output as with PAC thermodilution

VolumeView sensor
VolumeView femoral arterial catheter
VolumeView thermistor manifold
CVC standard
TruWave pressure transducer
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MICROSITE

CO - Calibrated Cardiac Output

SV - Calibrated Stroke Volume
SVR - Systemic Vascular Resistance
SVV - Stroke Volume Variation
SVI - Stroke Volume Index
Volumetric Parameters

EVLW - Extravascular Lung Water

PVPI - Pulmonary Vascular Permeability
Index
GEDV - Global End Diastolic Volume
GEF - Global Ejection Fraction

 Advantages

Continuous cardiac output monitoring

Good accuracy

Disadvantages

Can be complicated to set up

Needs specific femoral artery catheter
Remains significantly invasive
Can be effected by arrhythmias

Vigileo
Each of these systems contains a proprietary algorithm for
converting a pressure-based signal into a flow
measurement.
Needs no external calibration

Use the equation SV = SDAP x (Khi)

Analyses the area under the systolic portion of the arterial

pressure waveform from the end diastole phase to the end
of the ejection phase corresponds to SV.

The pulse pressure is obtained by the complete analysis of the arterial waveform and
through the calculation of the standard deviation (sd) at each sample points.
(sampling rate of 100Hz results in 2000 data points)
sd(AP) ~ Pulse Pressure ~ Stroke Volume

The SV value is updated every 20 seconds

APCO
algorithm

The variations or changes in the vascular tone are integrated in a continuous

calibration factor (Khi x) obtained from a multivariate equation of two major
elements :

Biometric variables : age, sex, height (Langewouters et al.)

Shape variables : analysis of the different characteristics of the arterial pressure
waveform.

Skewness (Dissymmetry coefficient)

Kurtosis (Flattening coefficient)

Pulsatility

Advantages
Easy to set up
Needs no external calibration

Areas of Concern

Outdated and superseded

Over the past 5 years and many

software updates much research
has identified the Vigileo as
inaccurate at determining
haemodynamic variables within
a host of critical care patients.
Poor accuracy with arrhythmia.

SVV only reliable in mechanically

ventilated patients
Requires specific arterial
pressure sensor

Cannot track changes in large

vasomotor swings..

Partial CO2 Rebreathing

Uses the Fick principle with CO2 as the marker gas
System distributed is called NICO (Philips)

(Berton & Chorley 2002)

The CO2 partial rebreathing technique compares end-tidal

carbon dioxide partial pressure obtained during a nonrebreathing period with that obtained during a subsequent
rebreathing period.

The ratio of the change in end-tidal carbon dioxide and CO2

elimination after a brief period of partial rebreathing
(usually 50 seconds) provides a non-invasive estimate of
the CO.

Partial CO2 rebreathing (NICO)

*minimal tidal volume = 200ml

There are several limitations to this device including:

The need for intubation and mechanical ventilation with fixed

ventilator settings and minimal gas exchange abnormalities.
Gueret G et al Eur J Anaesthesiology (2006), 23:848854

Variations in ventilator settings, mechanically assisted spontaneous

breathing, the presence of increased pulmonary shunt fraction, and
hemodynamic instability have been associated with decreased
Tachibana K et al Anaesthesiology (2003), 98:830837
accuracy.
Considering the limitations of this technology and the potential
inaccuracies, the routine use of the CO2 rebreathing technique to
guide fluid and vasopressor therapy cannot be recommended.

Thoracic Electrical Bioimpedance

impedance = measure of opposition to alternating

current (AC)
How it works:

superficial electrodes applied to chest that

both measure and apply voltage
current is transmitted through the chest via
the path of least resistance (aorta)
portion of initial (known) voltage that
reaches a distant sensing electrode is
measured
baseline impedance to the current is
recorded
with each heartbeat, blood volume and
velocity in the aorta change
corresponding change in impedance
change in impedance used to calculate
stroke volume and cardiac output according
to algorithm based on changes in thoracic
blood volume
http://www.microtronics-nc.com

Bioimpedance / Bioreactance
Developed since the 1960s (NASA)

4 electrodes in pairs each pair comprises transmitting and

sensing properties
High frequency current of known amplitude and frequency
across the chest measures changes in voltage.

Ratios between voltage and current amplitudes =

impedance (Zo), and varies in proportion of amount of fluid
in the chest.
Changes in impedance correlates with SV:

Cheetah NICOM

CAPTURES (14 ) PARAMETERS

In Real Time

CO

Cardiac Output

SV

Stoke Volume

CI

Cardiac Index

SVV Stroke Volume Variance

SVI
HR

Stroke Volume Index

Heart Rate

TPR Total Peripheral Resistance

VET

Ventricular Ejection Time

MAP Mean Arterial Pressure

NIBP Non Invasive Blood Pressure

TPR :
TPR :
TFCd :
CP:
CPI:
SVR

Dynes (MAP / CO)*80

mmHg * min./liters (MAP / CO)
% Change in TFC over 15 mins. Vs. baseline TFC
MAP*CO/451
CP/BSA
MAP-CVP / CO

TFC

Thoracic Fluid Content

CP

Cardiac Power

TFCd % Directional Change in

TFC/Time
CPI

Cardiac Power Index

Limitations
However, a poor correlation between derived CO and that determined by
thermodilution in the setting of a cardiac catheterization laboratory was reported.

In the Bioimpedance CardioGraphy (BIG) substudy of the ESCAPE heart failure

study, there was a poor agreement among TEB and invasively measured
Kamath et al (2009) Heart J 158:217-223.
hemodynamic profiles.

Bioimpedance has been found to be inaccurate in the intensive care unit and other
settings in which significant electric noise and body motion exist and in patients
with increased lung water.
Gujjar et al (2008) J Clin Monit Comput 22:175-180.
Furthermore, this technique is sensitive to the placement of the electrodes on the
body, variations in patient body size, and other physical factors that impact on
electric conductivity between the electrodes and the skin (eg, temperature and
humidity)

This device provides a non-invasive estimation

of cardiac output in two steps

For this purpose, the device includes an inflatable cuff that is wrapped
around a finger. It also includes a photoplethysmographic device that
measures the diameter of the finger arteries.

At each systole, the photoplethysmographic device senses

the increase of the finger arteries diameter. A fast servo controlled system
immediately inflates the cuff in order to keep the arteries diameter
constant. Therefore, cuff pressure reflects the arterial pressure. Its
continuous measurement allows estimation of the arterial pressure curve.

The second step is to estimate cardiac output from the non-invasive arterial
pressure curve. For this purpose, the Nexfin device includes pulse contour
analysis software that computes cardiac output from the arterial
pressure curve

Stroke
Volume
10 %

Lower PVI = Less likely to respond

to fluid administration

24 %

Maxime Cannesson, MD, PhD

Preload

Pleth variability index (PVI) is a new algorithm allowing automated and

continuous monitoring of respiratory variations in the pulse oximetry
plethysmographic waveform amplitude.
PVI can predict fluid responsiveness noninvasively in mechanically
ventilated patients during general anesthesia

http://anesthesiology.queensu.ca/assets/LAB4583B_Technical_Bulletin_Pleth_Variability_Index.pdf

Echocardiogram
Although echocardiography traditionally is not
considered a monitoring device, both
transthoracic and transesophageal
echocardiography provide invaluable information
on both left and right ventricular function, which
is crucial in the management of hemodynamically
unstable patients.

Levitov et al (2012) Cardiol Res Pract:819-696

Salem et al (2008) Curr Opin Crit Care 14:561-568

Choose wisely.

Algorithms

Remember.
Treat the patient Dont treat the
monitors

Depending on the clinical setting, adequate

monitoring can definitely help the
clinician to better treat his patient and
improve the final outcome.

Maybe in the Future our patients will

look like this!!
Oxygenation
Perfusion

Any Questions