Cardiac output monitoring

The hemodynamic status monitoring of high-risk surgical patients and critically ill patients in Intensive Care
Units is one of the main objectives of their therapeutic management.

Cardiac output is one of the most important parameters for cardiac function monitoring, providing an estimate
of whole body perfusion oxygen delivery and allowing for an understanding of the causes of high blood pressure.

Cardiac ouput is the volume of blood pumped by the heart per minute and is the product of the heart rate and
stroke volume.

The stroke volume of the ventricle is determined by the interactions between its preload, contractility
and afterload
There are many methods of monitoring the hemodynamic status of patients, both invasive and non-invasive, the
most popular of which is thermodilution.

The invasive methods are the Fick method and thermodilution,

whereas
the non-invasive methods are
oeshophaegeal Doppler,
transoesophageal echocardiography,
lithium dilution,
pulse contour,
partial CO2 rebreathing and
thoracic electrical bioimpedance.

All of them have their advantages and disadvantages,

but thermodilution is the golden standard for critical patients, although it does entail many risks.

The ideal system for cardiac output monitoring would be non-invasive, easy to use, reliable and compatible in
patients
INVASIVE METHODS
Fick method
This method is based on the principle described by Adolfo Fick in 1870,

according to which the total uptake or release of a substance by an organ is the product
of the blood flow through the organ and the arteriovenous concentration difference of the substance

The oxygen uptake in the lungs is the product of the blood flow through the lungs and the arteriovenous
oxygen content difference. Therefore, cardiac output can be calculated using the equation:
CO = VO2
CaO2–CvO2
Where VO2 is the oxygen consumption by the lungs
and CaO2–CvO2 is the arteriovenous difference in oxygen
Oxygen consumption is measured with special devices.
The arteriovenous difference is computed by receiving samples of arterial blood, and mixed venous blood by receiving
blood from the pulmonary artery

The mixed venous blood is received via a catheter that reaches up to the right ventricular and the pulmonary artery

“the arteriovenous oxygen content difference can be measured in situ using a pulmonary artery catheter having fibreoptic
bundles incorporated in the catheter”
Thermodilution method
. It is a method relying on a principle similar to indicator dilution, but it uses heat
rather than colour as an indicator..

This method uses a special thermistor – tipped catheter (Swan-Ganz catheter) inserted from a central vein into the
pulmonary artery.

A cold solution of D/W 5% or normal saline (temperature 0 oC) is injected into the right atrium from a proximal catheter
port.

This solution causes a decrease in blood temperature, which is measured by a thermistor placed in the pulmonary artery
catheter .
The decrease in temperature is inversely proportional to the dilution of the injectate .

The cardiac output

can be derived from the modified Stewart-Hamilton conservation of heat equation
The pulmonary artery catheter is attached to the cardiac output computer, which displays a
curve and calculates output and derived indices automatically

Thermodilution technique remain the most common

approach in use today and is considered as the golden standard approach to cardiac output
monitoring

although it involves many risks, such as pneumothorax, dysrythmias, perforation

of the heart chamber, tamponade and valve damage

Factors that may compuromise this technique are

shunts, tricuspid regurgitation, cardiac arrythmias,
abnormal respiratory patterns and low cardiac output
Non-invasive cardiac output monitoring
Transoesophageal echocardiography

Transoesophageal echocardiography provides information on cardiac contractility, filling status and output,
valvular morphology and function, as well as on the ascending and descending aorta structure in the critically
ill patient

With this technique, cardiac output measurement is the result of calculating stroke volume, which can be
multiplied by heart rate.

In order to assess stroke volume, it is necessary to measure flow velocity and determine the cross-sectional area

Flow velocity is calculated from the area under the Doppler velocity waveform, which gives the time velocity
integral.
The cross-sectional area can be calculated based on the diameter, assuming a circular shape, or it can be
determined by direct planimetry.

Measurements may be performed at the level of the pulmonary artery, the mitral valve or the aorta valve.
Oesophageal Doppler

The Oesophageal Doppler monitor was first described in the early 1970s.

A flexible probe with a Doppler transducer at the tip of the probe is inserted orally or nasally into the
oesophagus and the transducer is positioned facing the descending aorta

This technique measures blood flow velocity in the descending thoracic aorta using a flexible ultrasound probe
about the size of a nasogastric tube
.
CardioQ (Deltex Medical Ltd., Chichester, UK) is the clinically available oesophageal Doppler monitor (ODM). The

CardioQ monitor displays a waveform the area under the waveform, generated by the
descending aortic blood flow, is defined as stroke distance.[14] The stroke volume is calculated from the
measured stroke distance and the nomogram, which is a calibrated constant that estimates the diameter of the
aorta and is based on the patient’s age, weight and height.
The precision of this measurement depends on the following three conditions:

the cross-section must be accurate,

the ultrasound beam must be directed parallel to the blood flow,

the beam direction may not undergo major alteration between measurements

Oesophageal Doppler measurement assumes a fixed relationship of blood flow between the descending
aorta and proximally from the descending aorta.
This relationship is based on healthy individuals; however, this may be altered in ICU patients.
Moreover, may not be reliable in situations such as severe aortic stenosis,
because of turbulent blood flow

This technique offers a minimally invasive means for continuous hemodynamic, because the probe of an
oesophageal Doppler monitor can be inserted within minutes, requires minimal technical skill and is not
associated with complications

Also, it is operator dependant, and it is very easy to change the position of the probe between
measurements, thus reducing the precision of the monitoring.
Lithium dilution cardiac output
This technique was first described in 1993 and is minimally invasive

It requires a venous line and an arterial catheter.

The venous line can be either central or peripheral.
A bolus of isotonic (150 mM) lithium chloride (LiCl) solution is injected via the venous line. The
usual dose for an adult is 0.3 mmol

Arterial plasma concentration is measured by withdrawing blood across a selective lithium

electrode at a rate of 4 mL/min.

Cardiac output is calculated based on

the lithium dose and the area subject to the concentration– time circulation.

This technique is contra- indicated in patients on lithium therapy and atracurium therapy
Pulse contour cardiac output
This technique calls for the insertion of an arterial catheter, and hence is considered a
minimally invasive procedure

A long arterial catheter (with a thermistor) placed in the femoral axillary, or brachial
artery,
and connected to a pulse contour device.

With this catheter, a continuous pulse waveform contour analysis is

obtained. The technique is calculated by analysis of the area under the systolic portion
of the arterial pressures waveform,

from the end-diastole to the end of the ejection phase; this corresponds to stroke
volume.

Also, by virtue of a pulse contour analysis device, a beat-to-beat

analysis of cardiac output, averaged at 30 seconds, is displayed. Calibration requires a
central venous cannulation, using a transcardiopulmonary thermodilution
technique (
Thoracic electrical bioimpendance
In the 1960s, the National Aeronautical and Space
Administration (NASA) and William Kubicek developed impedance cardiography, using the thoracic electrical
bioimpedance .

Bioimpedance
Bioimpedance cardiography is based on the theory that with every heart beat the electrical resistance
(impedance) of the thorax changes, because of a shift in intrathoracic blood volume

Impedance cardiography relies on measured changes in signal amplitude of a transmitted electrical current via
four electrodes placed on the neck and thorax.

the left ventricular

ejection time is determined using the interval between QRS
complexes on the ECG, arrhythmias can interfere with CO
measurement.
This technique employs four pairs of electrodes.
Two pairs are applied to the neck base on opposite sides and
two pairs are placed at the level of the xiphoid junction
Each pair of electrodes comprises transmitting and sensing electrodes

With these electrodes, low-level electricity conducted by body fluid is transmitted

Another set of two electrodes is used to monitor a single ECG signal.

This electricity is harmless and not felt by the patient .

The first derivative dZ/dt of the impedance waveform is related linearly to aortic
blood flow. Changes in impedance correlate with stroke volume, calculated using the
following formula
SV=ρ
L2(dZ/dt)max×T
Zo2
where SV=stroke volume
ρ=resistivity of blood (Ω/cm)
L= mean distance between the inner electrodes (the
thoracic length)
Zo=basal thoracic impedance
(dZ/dt)max=the maximum value of the first derivative during systole (Ohms/second)
T=ventricular ejection time (sec)

Cardiac output is calculated from the stroke volume and heart rate and the equation is: CO=SVxHR, where
HR=Heart Rate

Cardiac output is easier to measure by impedance cardiography than by thermodilution with a pulmonary artery
catheter, can be applied quickly, and does not pose a risk of infection, blood loss or other complications associated
with arterial catheters

Pulmonary oedema, pleural effusion,

hyperventilation, high levels of PEEP, chest tubes and variations in patient body size and skin humidity can
interfere with the electrical conductivity and therefore make CO measurements
Partial CO rebreathing
2

Cardiac output can be estimated by using the Fick principle with carbon dioxide as the
marker.

A new monitor called NICO is based on the application of the Fick principle to carbon
dioxide, in order to estimate cardiac output non-invasively.

The monitor consists of a carbon dioxide sensor, a disposable airflow sensor and a pulse
oxymeter.

VCO2 is calculated from minute ventilation and its carbon dioxide content.
The arterial dioxide content (CaCO2) is estimated from end-tidal carbon dioxide

The Fick equation for carbon dioxide is:

CO=VCO2/CvCO2-CaCO2

where VCO2, CvCO2, CaCO2 are CO2 consumption,

venous CO2 concentration and arterial CO2 concentration
respectively
The computer cycles every three minutes from the non-rebreathing model to a 50-second
period of rebreathing by adding an additional dead space with a disposable rebreathing loop. [23]
Moreover, the NICO monitor measures the carbon dioxide production
(VCO2) with an integrated CO2/flow sensor, by calculating the difference between expired and
inspired CO2 concentration.

The calculation of CO by the NICO monitor only reflects part of the pulmonary capillary blood
flow that participates in the gas exchange.
Therefore, the NICO system includes a correction for the amount of shunted blood, based on
inspired oxygen concentration (FiO2) and oxygen saturation determined
by pulse oximetry (SpO2),