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Cardiac Output Monitoring - Handout

The document discusses indicators for initiating venoarterial extracorporeal membrane oxygenation (VA ECMO), including patients requiring high doses of norepinephrine but not achieving a mean arterial pressure goal or those with unknown shock types. It also covers the gold standard method of thermodilution cardiac output monitoring and differences between qualitative and quantitative cardiac output measurement techniques. The case examples demonstrate using cardiac output, oxygen delivery and consumption, lactate, and echocardiography to guide management of shock states.

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Nakarit Sangsirinawin
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© © All Rights Reserved
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122 views

Cardiac Output Monitoring - Handout

The document discusses indicators for initiating venoarterial extracorporeal membrane oxygenation (VA ECMO), including patients requiring high doses of norepinephrine but not achieving a mean arterial pressure goal or those with unknown shock types. It also covers the gold standard method of thermodilution cardiac output monitoring and differences between qualitative and quantitative cardiac output measurement techniques. The case examples demonstrate using cardiac output, oxygen delivery and consumption, lactate, and echocardiography to guide management of shock states.

Uploaded by

Nakarit Sangsirinawin
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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WHEN and HOW

PHITPHIBOON DEAWTRAKULCHAI,MD,INTENSIVIST
Critical care unit, Department of Internal medicine,
Faculty of medicine, KKU
When
• Indications

How
• Gold standard
• Qualitative Vs Quantitative methods
A: Patient who required NE >1.0 mkm but not achieved MAP.

B: Patient with unknow shock type.

C: VA ECMO patient.

D: Post cardiac surgery.

E: Pulmonary HT crisis.
↑VO2

VO2
↓DO2+
↑VO2

↓DO2

DO
2
DO2 = CO x CA
DO2 = CO x CA
DO2 = CO x [(1.34xHbxSpO2x10)+(0.003xPaO2)]

Stagnant Hypoxia Hypoxemic Hypoxia

Anemic Hypoxia
Fick equation
• (Qin)xCvO2 + VO2 = (Qout)xCaO2
• [CO xCvO2] + VO2 = [COxCaO2]
• VO2 = [COxCaO2]-[CO xCvO2]
• VO2 = COx[CaO2-CvO2]
• VO2 = COx[CaO2-CvO2]
• CO = VO2/[CaO2-CvO2]
• CO = VO2/[1.34xHbx10(SaO2-SvO2)]

Alex Yartsev - Jun 30, 2015Cardiovascular system


Marino, ICU book 4th edition
▪ CO ↓
▪ CO = HR x SV
▪ CO = HR x (LVEDV-LVESV)
▪ CO = HR x (LVEDV-LVESV) x (LVEDV/LVEDV)
▪ CO = HR x [(LVEDV-LVESV)/ LVEDV] x LVEDV
▪ CO = HR x EF x LVEDV

Cardiogenic shock Hypovolemic and Obstructive shock


CO = VO2/[1.34xHbx10x(SaO2-SvO2)]

CO = [MAP-CVP]/SVR

CO = [PAP-PCWP]/PVR

CO = SV x HR

CO = DO2/CA
Deranged cardiac function
in the context of shock Goal-directed resuscitation of
• Refractory septic shock complex multifactorial shock
(NE>0.25 mkm) states
• Suspected Stress • Balanced DO2 and VO2
cardiomyopathy
• Suspected Sepsis induced
cardiomyopathy
• Overt MI
CO monitoring
Qualitative Quantitative
Pv-aCO2 gap Calibrated Non-calibrated

Invasive Minimally invasive Minimally invasive noninvasive

Thermodilution Transpulmonary Pulse pressure


analysis Transthoracic
thermodilution impedance and
bioreactance
LidCo Esophageal analysis
doppler
LVOTVTI
CO measurement
PV-ACO2 GAP
▪ CO = k x VCO2/[(PvCO2-PaCO2)]

Ltaief, Z., Schneider, A.G. & Liaudet, L. Pathophysiology and clinical implications of the veno-arterial
PCO2 gap. Crit Care 25, 318 (2021). https://doi.org/10.1186/s13054-021-03671-w
CO measurement
CO Measurement
Cardiol Clin 31 (2013) 545–565
http://dx.doi.org/10.1016/j.ccl.2013.07.008
▪ Stewart-Hamilton equation

Cardiol Clin 31 (2013) 545–565


http://dx.doi.org/10.1016/j.ccl.2013.07.008
▪ Case:Thai female 56 yo underlying with PHT presented with unknown shock type
and ongoing high dose NE (1.0 mkm).

Final Dx:………………
▪ Case: Thai female 45 yo S/P DVR (MVR+AVR) with T1+2 PHT presented with UTI
and PHT crisis

PVR = ………………………………….
CO Measurement
Thermodilution
+Pulse contour
analysis
Clinical use→ ARDS+Shock W/O PHT,Rt.Heart failure
Lithium dilution
technique
+Pulse contour analysis

Annals of Cardiac Anaesthesia | Volume 22 | Issue 1 |


January-March 2019
CO Measurement
FloTrac sensor (Edwards
Lifesciences, USA)

LidCO rapid system (LidCO


Ltd., UK)

Nexfin monitor (BMEYE,


Netherlands)

esCCO (Nihon Kohden, Japan)


▪ Case: Thai Male 73 Y-O with HAP ARDS s/p VV ECMO, A.baumannii septicemia and
refractory septic shock during ECMO session.
▪ Case: Thai Male 73 Y-O with HAP ARDS s/p VV ECMO, A.baumannii septicemia and
refractory septic shock during ECMO session.
CardioQ
Deltex

CO = CSA x doppler VTI x HR


CO Measurement
BIOZ, USA

ECOM TM, USA

NICOM Reliant system,UK

SV =  × L/Z02 × (dZ/dt)max VET


USCOM ,
Australia

CO = CSA x
doppler VTI x HR
CO = LVOT CSA x doppler VTI x HR
PAC Thermodilution

Esophageal Calibrated
doppler Invasive
Calibrated
Pulse contour Minimally
analysis Invasive
Non-calibrated
Minimally Invasive Transpulmonary
thermodilution
Non-calibrated LidCO plus
Noninvasive
LVOTVTI
Transthoracic impedance and bioreactance analysis
Transthoracic aortic arch
doppler
J Thorac Dis. 2019 Jul;11(Suppl 11):S1551-S1557
CO 6.6 CO 5.2

CI 3.1 CI 3.0

SVR 824 SVR 901

Lactate 109 mg/dL Lactate 124 mg/dL


What is your next management?
• A: decrease NE
• B: check thiamine level
• C: Echocardiogram
• D: ScVO2
• E: check CPK LDH
CO 5.0
CI 2.8
SVR 1146

Gas pH PaCO2 PaO2 HCO3 O2 sat


Venous 7.27 50 33 23.0 40.7%
What should you do?
• A: Echocardiogram
• B: increase FiO2
• C: add adrenaline iv drip
• D: P(v-a)CO2 gap
• E: Swan-Ganz PAOP
Gas pH PaCO2 PaO2 HCO3 O2 sat P(v-a)CO2Gap
Arterial 7.39 25 95 17.9 97% =………….
Venous 7.27 50 33 23.0 40.7%
What should you do?
• A: Echocardiogram
• B: increase FiO2
• C: PRC 2 unit
• D: Dobutamine iv drip
• E: Swan-Ganz PAOP
▪ Echocardiogram ▪ CO= ………………………
▪ hyperdynamic LV
▪ LV EF 75%
▪ Normal all valves
▪ No RV dilate
▪ LVOT diameter 2.0 cm.
▪ LVOTVTI 15.2 cm.
▪ HR 102 bpm
Although CO is normal, why does
P(v-a)CO2gap exceed 6 mmHg?
• A: inadequate DO2
• B: high VO2
• C: all above
DO2 VO2
▪ CO 5.0 L/M ▪ CO 5.0 L/M
▪ Hb 9.7 g/dL ▪ Hb 9.7 g/dL
▪ SaO2 97% ▪ SaO2 97%
▪ ScVO2 50.6%

▪ DO2 = ……………………. ▪ VO2 = ………………………


What should you do?
• A: hypothermia
• B: increase FiO2 for SaO2 100%
• C: PRC 2 unit
• D: Dobutamine iv drip
• E: sedate and paralyzed
VO2 DO2 >728
▪ CO 5.0 L/M ▪ Fix CO increase Hb
▪ Goal Hb > …………….
▪ Hb 9.7 g/dL
▪ SaO2 97% ▪ Fix Hb increase CO
▪ Goal CO > ……………
▪ ScVO2 50.6%

▪ VO2 = 363.9
Time CO SVR Hb SaO2 ScVO2 P(v-a)CO2 DO2 VO2 lactate
7.00 5.0 1146 9.7 97 40.7 25 630 363 153.5
15.00 5.7 650 9.7 97 50.2 10 740 348 119
DBT 2.5
22.00 7.0 502 10.7 98 76 7 1004 221 105.7
PRC 1 U
6.00 10.2 574 11.7 97 70 8 1551 432 81.1
PRC 1 U
6.00 9.2 594 9.4 95 - - 1,100 - 40.8
HP
Normal CO  Adequate CO

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