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Arterialbasedcontinuouscardiacoutputmeasurement factorfiction

HermannGilly,PhD
DepartmentofAnaesthesia,GeneralIntensiveCareMedicineandPain Therapy

MedicalUniversityVienna,Vienna,Austria

Arterial based, less invasive techniques for cardiac output measurement

The long road from bolus dilution to continuous cardiac output Nowadays: Fact or Fiction?

Methods PAC Thermodilution thegoldenstandard (Quasi)ContinuousCOmeasurement

PICCO Modellflow PRAM LiDCo

APCOcomparedwithGoldstandard

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Whyhemodynamicmonitoring? WhyCardiacoutput(CO)measurement?

Oxygenhastobecontinuouslydeliveredtothetissuesfor sustainablecellularfunction

Determinantsofoxygendelivery Oxygenatedhemoglobin Cardiacoutput Manipulationofcardiacoutput Fluidmanagement Pharmacologicinterventions

Resultinginin ordecreasingvesselresistance,heartrateetc.

Invasiveversuslessinvasivehemodynamicmonitoring

Mostinvasivecontinuous
Em/USflowprobearoundaortaorpulmonaryartery

Invasive(quasicontinuous)

Continuous(lessinvasive)

P l Pulmonaryarterycatheter(PAC,SwanGanz) t th t (PAC S G ) Arterialpressurebased(APCOetc) TransesophagealDoppler CO2 rebreathing ?

Lessinvasive,intermittent Noninvasive,continuous
Transthoracicbioimpedance

AIM:minimally(=less)orevennoninvasivecontinuousCOmeasurement

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MethodsforCardiacOutputmeasurement

Fickprinciple Indicatordilution Ultrasound

Dopplervelocity Ventricledimensions/volumes

Inputoutputbalance

Directmeasurement

I d di h Impedancecardiography Pulsecontour

Modelbasedmethods

Ficksprinciple oxygenuptake

Intermittentatbest,slowresponseassteadystateisrequired,invasiveca

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Thermodilution Bolustechnique

pulmonaryTD

transpulmonaryDD

normalcardiacoutput

Calculationof areaunder curve(AUC) byextrapolating by extrapolating thedecayofthe dilutioncurve

PACGoldstandard Bolusthermodilution

Primaryparameter:timecourseoftemperatureinpulmonaryarteryorinaperipheralartery afterinjectinganamountofcold
Influencedby:

temperaturechangesduetosimultaneousinfusions appropriatemixing injection ,p ventilation,phase T siteofmeasurement nofinaloffset propertiesofcatheter possiblelossofindicator(extravasal) high/lowflowsituation (softwarerelease)

primaryendpoint:CardiacOutput(CO) p y p p secondary: ejectionfraction,(central)bloodvolume

oxygensaturation,oxygendelivery whencombinedwithDD:EVLW requiresinvasiveinstrumentation:PAC 34singledeterminations(averaging) Overallaccuracy:1015%

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FrombolusTDtocontinuousTD (vigilancemonitor)

Continuouspulmonarythermal(heat)dilution clinicalvalidationincomparisontocoldbolusTD

IntelliCath

OptiQ

CCO TD(L L/min)

CCO TD(L/ /min)

acceptable

(CCO+TD)/2(L/min)

(CCO+TD)/2(L/min)

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 Cardiac Output 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)

Ensureenoughoxygenisdeliveredtomeetmetabolic demandbyCOandScvO2 Provideinsightfor

augmentingoxygendelivery, fluidsvsvasoactingdrugsbyCVP,PAP,PAWP

Responsetimenotimmediatebecauseofaveragingseveral cardiaccycles Invasive,relativelypronetocomplications

CurrentstatusofPAC
Controversial results from large studies about the advantage over CVC
Probably reserved for patients with significant cardiac pathology/major morbidities (septic shock, large fluid shifts)
TDCO:Overallaccuracy1015%

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Basisforarterialpressurebasedpulsecontourcardiacoutput:
describingthe(left)ventricularpump

Q(t)Flow

WINDKESSSELMODEL
Frank's Windkessel - describes the hemodynamic of the arterial system in terms of resistance and compliance 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 p p

C Total arterial compliance V- Volume change p Presure change

Nico Westerhof.ThearterialWindkessel.SpecialIssueReview.MedBioEngComput. 14

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Principle of pulse contour Principleofpulsecontour methods

accountingformoredetails

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TheWindkesselmodel

FirstmodelbyWesseling

AddingtheCompliance

R:totalsystemicperipheralresistance(SVR);Z:characteristicimpedanceoftheproximal aorta;C:Windkesselcomplianceoftheaorta

Lessinvasivepresasurepulsebasedquasicontinuous COmethods
PiCCO system (Pulsion Munich GER) (Pulsion, Munich, Modelflow (Finapres Medical Systems, Amsterdam, NL) PRAM (Mostcare FIAB SpA, Florence, IT) LiDCO plus/PulseCO system (LiDCO Ltd, Cambridge, UK)

Howtoaccountforthecharacteristicimpedance? H f h h i i i d

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Q(t)

Howtoaccountforthecharacteristicimpedance?

PiCCO: combines transpulmonary thermodilution for calibration and arterial PiCCO plus Aufbau pulse contour analysis 2nd sw-version: adapted algorithm: analyzes shape of the pressure waveCentralvenousaccess
form, accounting for individual compliance and systemic vascular resistance

Injectate temperature

13.03 16.28 TB37.0

AP

AP 117

140 92

(CVP) 5 SVRI PC 2762

PCCI

CI HR SVI

3.24 78 42

SVV 5% dPmx 1140 (GEDI) 625

stroke volume computed by integrating the systolic area under the arterial pressure waveform

Arterialtemperature

Arterialpressure Arterial pressure

PULSIOCATH thermodilution catheter

PULSIONpressuretransducer
For calibration the specific aortic impedance is required: calculated by comparison of the systolic area and thermodilution CO measured

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PiCCO vs PA-TD
References
#

Cardiac Output / Cardiac Index *

n

Mean SD (l/min)

Range (l/min)

Bias SD (l/min)

PE

r ** Software Version

Condition of the participants

Irlbeck et al. Buhre et al Rdig et al. Zllner et al. Zll t l Rauch et al. Mielck et al. Gdje et al. Della Rocca et al. Felbinger et al. Sujatha et al. Halvorsen et al. Chakravarthy et al de Wilde et al. Button et al.

20 / 165 12 / 36 26 / 308 19 / 76 25 / 380 22 / 96 24 / 517 62 / 186 20 / 360 60 / 480 31 / 252 15 / 438 24 / 199 31 / 185 4.7 ? 6.6 1.7

1.6 - 9.2 2.3 - 12.6 3.0 15.7 3 0 - 15 7 1.95 - 11.6

-0.09 0.85 0.003 0.63 0.18 1.24 0.31 1.25 0 31 1 25 -0.14 1.16 0.40 1.30 39

0.93 0.88

0.88 0 88

1.x patients on ICU 1.x patients on ICU during coronary 1.x bypass surgery after cardiothoracic surgery patients undergoing 1.x HCPB post cardiac surgery after cardiothoracic 4.1 surgery undergoing liver 4.1 transplantation post cardiac surgery undergoing OPCAB surgery undergoing OPCAB 5.1 surgery undergoing OPCAB surgery undergoing OPCAB surgery 6.0 perioperative period

2.7 - 14.1 3.0 - 13.0 2.05 - 6.3 *

-0.20 1.15 0.04 0.84 0.14 0.33 * 0.23 0.50 20 43

0.88 0.94 0.93

5.0 - 7.1

-0.76 1.17 -0.13 1.12

2.1 - 9.7 2.4 - 9.3

-0.14 0.87 0.28 1.30

47

PEpercentageerror;accordingtoCritchley&Critchley<30%(!!!!)

Modelflow method Modelflow computes the beat-to-beat cardiac output from the radial artery pressure, after an initial calibration (thermodilution or ultrasound for velocity and aortic diameter determination). nonlinear, time-varying three-element model of aortic input impedance (modified Windkessel model) simulating the interaction between cardiac ejection and the aortic and peripheral systemic input impedance and the resulting reflected pressure
The nonlinear characteristics of the model parameters were studied post-mortem in human aortae by Langewouters et al. However, Jansen and van den Berg found considerable individual variations of the aortic cross sectional area (up to 30% compared with average values of Langewouters study).
Cardiac Output / Cardiac Index * ModelFlow
References # n Mean SD Range Bias SD

PE

r **

Condition of the participants

vs PA TD PA-TD
(l/min) (l/min) (l/min)

Wesseling et al. 8 / 76 Jansen et al. de Vaal et al. de Wilde et al.

4.7 0.4 3.1 - 6.9 0.09 0.36

15

open heart surgical patients undergoing CABG 0.83 post CABG surgery undergoing CABG

54 / 436 4.9 0.9 3.0 - 7.7 -0.13 0.47 19 24 / 24 5.4 1.2 3.1 - 8.8 -0.08 0.70 12 2.5 - 7.1 0.00 0.37

24 / 199 4.8 ?

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LiDCOTMplus/PulseCOTM system minimally invasive lithium dilution technique for calibration

central 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 a blood flow-through-cell

beat-to-beat estimate of the cardiac output continuously analyzing the arterial blood pressure waveform. The algorithm is supposed to be independent of the arterial
measurement 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 volumetime waveform (done by an algorithm compliance with a lookup table). 2) in order to obtain cardiac output, the duration of the cardiac cycle and the stroke volume is calculated by autocorrelation 3) this result is calibrated by comparison with a LIDCO-measured value, which the manufacturer recommends to be done every 4 to 6 hours. This calibration
factor corrects for the arterial compliance for a given arterial blood pressure and for variations between individuals. Further details for the exact calculation are not provided

The secret of LiDCO

Linton et al: BJA (2001) 86: 486-496

LiDCO-technique

ZA aortic impedance, phase difference f frequency

A cross section flow=velocity

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Cardiac Output / Cardiac Index *

PulseCO /LiDCO PA-TD

References #

Mean SD (l/min)

Range (l/min)

Bias SD (l/min)

PE

r **

Condition of the participants

Linton et al.

40 / 160

-0.25 0.5

0.97 24 0.86 0.74 16.8 0.85 28

patients after surgery

Garcia-Rodriguez et al. 31 / 93 Hamilton et al Yamashita et al Costa et al de Wilde et al 20 / 100 23 / ? 23 / 151 24 / 199

5.55 ?

2.4 - 11.5 -0.5 0.7 3.4 - 8.5 0.05 0.6 0.76 1.93 3.4 - 13.2 -0.29 1.09

after major surgery post CABG surgery undergoing OPCAB surgery 2 hours after liver transplantation undergoing CABG

5.0 ?

2.5 - 8.9

0.17 0.69

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 of the arterial pressure profile changes
The algorithm is based on the principle of perturbations performing a beat-to-beat analyis of the whole arterial pressure wave morphology (instead of just the pulsatile systolic area) The diastolic minimum the systolic pressure the dicrotic notch and area).The minimum, pressure, points of perturbance are evaluated.

PRAM claims to consider aortic impedance, compliance and systemic vascular resistance, which are affecting the pressure signal, further details undisclosed.
Cardiac Output / Cardiac Index * PA-TD vs PRAM
References # n Mean SD (l/min) Range (l/min) Bias SD (l/min) PE r **

Condition of the participants

Romano&Pistolesi 18 / ? Giomarelli et al. Romano et al. Romano et al. 28 / 112 50 / ? 32 / 128

2.6 0.6 *

1.7 - 4.0 -0.15 0.35 * * 27 2.3 - 7.4 0.03 0.89 1.6 - 4.2 -0.03 0.42 * * 31 0.07 0.40 20

undergoing heart 0.88 catherization 0.88 undergoing CABG undergoing heart 0.85 catherization 0.87 undergoing CABG

2.7 0.6 * 4.0 0.7

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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)

11parameters1 11

Slidetakenfrom:EdwardsLifesciencesWebsite

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Slidetakenfrom:EdwardsLifesciencesWebsite

FlowtracversusICO

FlowtracversusCCO

CCOvsICO

Slidetakenfrom:EdwardsLifesciencesWebsite

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ChangesinCOduetolinedamping

Slidetakenfrom:EdwardsLifesciencesWebsite

Art.Radialis(original;ProbandH.L.)

Art.Radialis smoothed

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Harmonicfrequencies

26.April2007

Druckmessung XAchse:ArbitrreEinheit

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Setkonfiguration

Eigen frequenz

Dmpfungs faktor

Flowtrac

38,8 39,5

0,188 0,170

mit 10l Luftblase transducerseitig

38,4 38,9

0,175 0,175

mit BD-Kanle

24,2 25,0

0,236 0,241

mit BD-Kanle und 10l Luft

22,5 21,8

0,261 0,262

Manecke,2005

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ClinicalvalidationofcontinuousAPCO(FCI) comparisontocontinuouspulmonarythermaldilution(Vigilance)

FCIandBCI

0.18

0.08

ChakravarthyM,RajeevS,JawaliV.Cardiacindexvaluemeasurementbyinvasive,semiinvasiveandnon invasivetechniques:aprospectivestudyinpostoperativeoffpumpcoronaryarterybypasssurgerypatients.J ClinMonitComput2009;23:175180

DifferenceinHI(PiCC COAPCO (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/Vigileoanda.femoralis(PiCCO)calculatedHIdata andFloTrac/Vigileoanda.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

References
#

Cardiac Output / Cardiac Index *

n

Mean SD (l/min)

Range (l/min)

Bias SD (l/min) 0.60 1.40

PE

r ** Software Version

Condition of the participants undergoing CABG

Sander et al Button et al. Mayer et al Manecke and Auger Opdam et al. Prasser et al. Breukers et al.

30 / 120 31 / 185 40 / 244 50 / 295 6 / 218 20 / 164 20 / 56 5.9 1.15 5.5 0.85 3.4 - 9.8 3.3 - 8.8 2.8 0.65 * 2.4 - 9.3 1.6 - 4.9 * 2.8 - 9.6

54

0.53 1.07

0.25 1.13 0.46 0.58 * 0.55 0.98 0.21 1.02 * 0.02 1.49 -0.14 1.00 -0.15 0.33 0.35 49.3 0.58 36 0.74 46 0.53

perioperative period cardiac surgical patients post cardiac surgery post cardiac surgery

1.0

1.03

critically ill in a neurosurgical ICU post cardiac surgery undergoing OPCAB surgery

Chakravarthy et al 15 / 438 Cannesson et al. 11 / 166 McGee et al Staier et al. Mayer et al. Metha et al Matthieu et al. 84 / ? 30 / 120 40 / 282 12 / ? 20 / 400 2.5 0.55 * 4.5 1.33 5.5 1.0 1.2 - 4.1 * 2.8 - 7.7 2.1 - 9.5 4.7 0.95 5.9 ? 1.9 - 8.2 3.1 - 9.2

0.26 0.87 0.20 1.28 0.02 1.04

37 0.66 43 44.3 1.10 1.07 1.07

undergoing CABG critically ill patients on ICU aortic valve replacement undergoing CABG undergoing OPCAB surgery undergoing liver transplantation

0.19 0.30 * 24.6 0.26 0.66 -0.8 ? 29 43

Conclusion
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 changes essential (!)

When using these monitors in conjunction with the administration of fluids and vasopressors to specific therapeutic end points (goal directed therapy) there limitations should be kept in mind. Whether patient care and outcome may be improved using the 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,EFleischmann,HHetz.Evaluation ofstrokevolumevariationobtainedbyarterialpulsecontouranalysistopredictfluid of stroke volume variation obtained by arterial pulse contour analysis to predict fluid responsivenessintraoperatively.BritishJournalofAnaesthesia doi:10.1093/bja/aep200

Results. Twenty patients received 67 fluid boluses. Fiftytwo of the 67 fluid boluses 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 reliablepredictor offluidresponsivenessinthesettingofmajorabdominal reliable predictor of fluid responsiveness in the setting of major abdominal surgery.

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TranspulmonaleThermodilution: Nach zentralvenser Injektion desIndikators misst ein Thermistor inder Spitze Herzzeitvolumen des arteriellen Katheter dieTemperaturvernderungen stromabwrts. DasHerzzeitvolumenwirddurchdieAnalysederThermodilutionskurvenach einemmodifiziertenStewartHamiltonAlgorithmusberechnet.
Temperaturverdnnungskurve Bolusverfahren
Tb Injektion

BerechnungdesHZV: Flcheunterder Thermodilutionskurve

Tb =Bluttemperatur Ti =Injektattemperatur Vi =Injektatvolumen Tb . dt =Flche unter der Thermodilutionskurve K=Korrekturfaktor,aus spezifischem Gewicht undspezifischer Wrmekapazitt vonBlut undInjektat

HZV TD

(T Ti ) Vi K b Tb dt

78

Thermodilution Bolustechnique

Calculationof areaunder curve(AUC) curve (AUC) mittels Extrapolation des abfallenden Kurventeils, Fitting

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AJPHeartCircPhysiol VOL281SEPTEMBER 2001

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PiCCO PiCCO-Technology combines transpulmonary thermodilution for calibration and arterial pulse contour analysis.
inline injectate temperature sensor in a central vene 4-French thermistor-tipped arterial pressure catheter (peripheral artery: femoral, axillary, brachial)

PiCCO

algorithm for continuous cardiac output determination as described by

Wesseling et al.

stroke volume computed by integrating the systolic area under the arterial pressure waveform. For calibration the specific aortic impedance is required: calculated by comparison of the systolic area and thermodilution CO measured. 2nd software generation: adapted algorithm: analyzes the shape of the pressure waveform, taking into account the individual compliance and systemic vascular resistance

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