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Cardiac Output Monitoring: Will New Technologies Replace the Pulmonary Artery Catheter? Intensive Care Med 2003. [DOI: 10.1007/978-1-4757-5548-0_45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Gueugniaud PY, Muchada R, Moussa M, Haro D, Petit P. Continuous oesophageal aortic blood flow echo-Doppler measurement during general anaesthesia in infants. Can J Anaesth 1997; 44:745-50. [PMID: 9232306 DOI: 10.1007/bf03013390] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Invasive haemodynamic monitoring during general anaesthesia in infants is usually limited to very high risk operations, such as cardiac surgery. Nevertheless, different surgical procedures and/or anaesthetic techniques justify additional monitoring for children, as for adults. The aim of this preliminary study was to evaluate the feasibility of using a new echo-Doppler device (Dynemo 3000) capable of measuring continuous aortic blood flow during general anaesthesia in infants. METHODS Aortic blood flow (ABF) was measured with a small oesophageal probe designed for newborns and infants. The aortic flowmeter was connected with satellite devices to visualise the haemodynamic profile which included ABF, pre-ejection period (PEPi), left ventricular ejection time (LVETi), mean arterial pressure, heart rate, stroke volume and systemic vascular resistance. Twelve infants, aged 8-26 mo, undergoing surgery under general anaesthesia were successively included in the evaluation of this device. Isoflurane (1% end-expired concentration) was introduced to maintain anaesthesia after induction with halothane, midazolam, fentanyl and atracurium. RESULTS Correct positioning of the probe was easily obtained in all cases and the recording quality was excellent, whatever the operative position. Recordings of haemodynamic data showed some myocardial depression from isoflurane: decreased ABF (indexed to body surface area) and lengthened PEP/LVET (2.24 +/- 0.53 L.min-1.m-2 and 0.32 +/- 0.05 respectively, before introduction of isoflurane and 1.71 +/ 0.53 L.min-1.m-2 (P = 0.027) and 0.39 +/- 0.06 (P = 0.007) with isoflurane). CONCLUSION These preliminary results suggest that this continuous ABF echo-Doppler device may be valuable for peri anaesthetic monitoring in infants.
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Affiliation(s)
- P Y Gueugniaud
- Department of Anaesthesiology, Edouard Herriot Hospital, Lyon, France
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Peterson RJ, Kissoon N, Murphy SP, Goodwin SR, Bayne EJ, Kelley EW, Ceithaml EL. Comparison of transtracheal and extravascular Doppler determinations of stroke volume and cardiac output at various states of volume loading in piglets. Crit Care Med 1995; 23:2015-22. [PMID: 7497724 DOI: 10.1097/00003246-199512000-00010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To assess the applicability of a new technology in neonates. Transtracheal Doppler and extravascular Doppler determinations of stroke volume and cardiac output were compared with thermodilution measurements at various states of volume loading in an animal model. DESIGN Prospective, descriptive study. SETTING Animal research laboratory at a university medical center. SUBJECTS Fourteen newly weaned piglets, weighing 2.8 to 6.5 kg. INTERVENTIONS Doppler probes were placed on the endotracheal tube tip (transtracheal Doppler) and directly on the aortic adventitia (extravascular Doppler). A 4-Fr thermodilution catheter was inserted in the pulmonary artery. Stroke volume and cardiac output determinations were recorded at baseline, after a 15-mL/kg volume load and after successive 15-mL/kg blood withdrawals to exsanguination or a systolic blood pressure of < 20 mm Hg. MEASUREMENTS AND MAIN RESULTS Transtracheal and extravascular Doppler measurements of cardiac output were not significantly different from thermodilution at any physiologic state. These techniques were able to measure stroke volumes and cardiac outputs at the low levels seen in severe hemorrhagic shock. CONCLUSIONS Transtracheal Doppler and extravascular Doppler measurements of cardiac output compare favorably with thermodilution. These methods effectively followed trends from alterations in intravascular volume, even at very high heart rates and small stroke volumes. Transtracheal Doppler and extravascular Doppler should yield useful information in critically ill neonatal patients, where data regarding stroke volume and cardiac output may be useful in clinical management.
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Affiliation(s)
- R J Peterson
- Department of Pediatrics, University of Florida, Jacksonville 32209, USA
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Murdoch IA, Marsh MJ, Tibby SM, McLuckie A. Continuous haemodynamic monitoring in children: use of transoesophageal Doppler. Acta Paediatr 1995; 84:761-4. [PMID: 7549293 DOI: 10.1111/j.1651-2227.1995.tb13751.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
A wide range of invasive and non-invasive techniques for monitoring the haemodynamic condition of critically ill patients is now available. A general reluctance on the part of paediatric intensive care specialists to use pulmonary artery thermodilution catheters and the need for constant realignment of hand-held Doppler probes has necessitated the search for a technique which is relatively non-invasive and provides continuous information on the haemodynamic condition of critically ill paediatric patients. We sought to establish if transoesophageal Doppler fulfilled these criteria. Eleven children who had recently undergone cardiac surgery were studied. Median age was 39 months and weight 14.9 kg. Five simultaneous pairs of measurements of cardiac index (CI: thermodilution) and minute distance (MD: transoesophageal Doppler) were made, as a baseline, when each child was haemodynamically stable. Following a fluid challenge, five repeat pairs of measurements were made. The mean percentage changes for CI and MD were 16.4% (range 5.3-44%) and 16.6% (3.4-47.7%), respectively. The average coefficients of variation for measurements of CI and MD were 3.5% and 2.9%, respectively. The mean difference in percentage change between CI and MD was -0.5% (95% confidence interval for the bias -4% to 3%; limits of agreement -10.7 to +9.7%). Our study indicates that transoesophageal Doppler is reproducible, easy to use and provides clinically acceptable information when following changes in CI in haemodynamically stable paediatric patients.
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Affiliation(s)
- I A Murdoch
- Department of Paediatric Intensive Care, Guy's Hospital, London, UK
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Bearden EF. The Costs and Benefits of Monitoring Perfusion in the Critically Ill. Crit Care Nurs Clin North Am 1995. [DOI: 10.1016/s0899-5885(18)30397-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Sommers MS, Stevenson JS, Hamlin RL, Ivey TD. Skin temperature and limb blood flow as predictors of cardiac index. Clin Nurs Res 1995; 4:22-37. [PMID: 7703873 DOI: 10.1177/105477389500400104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Thermodilution cardiac output and cardiac index (CI) require inserting a pulmonary artery catheter, an invasive device associated with many iatrogenic complications. The purpose of this study was to establish the concurrent validity of two noninvasive measures of CI (skin temperature and limb blood flow) by determining their correlation with invasive CI. Twenty-one subjects undergoing coronary artery bypass grafting (CABG) were studied every 2 hours for 8 hours in the immediate postoperative period. Neither limb blood flow (LBF) nor skin temperature at five sites correlated significantly (p < .05) with CI at all five data collection times. Ankle temperature and LBF were significantly correlated with CI at one data collection time. On the basis of the findings of this study, neither skin temperature nor LBF can be used as a noninvasive predictor of CI in the immediate postoperative period following CABG.
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Hartman JC, Olszanski DA, Hullinger TG, Brunden MN. In vivo validation of a transit-time ultrasonic volume flow meter. J Pharmacol Toxicol Methods 1994; 31:153-60. [PMID: 8068977 DOI: 10.1016/1056-8719(94)90078-7] [Citation(s) in RCA: 58] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The objective of this investigation was to validate a transit-time ultrasound blood flow metering system in vivo. Implanted chronically and acutely on the ascending aorta of the dog, the transit-time flow probe determined varying flow rates simultaneously with measurements made by the electromagnetic flow metering method. The transit-time technique was also compared to two methods in which blood was collected volumetrically by either graduated cylinder (ascending aorta/dog) or pump withdrawal (abdominal aorta/cat). Statistical analysis of the results provided evidence that the transit-time ultrasound method measured in vivo blood flow rate no differently than the electromagnetic or pump withdrawal techniques, however, transit-time determinations of blood volume were 10% below that indicated by graduated cylinder collection. With transit time represented on the y-axis, three linear regressions of all paired blood flow measurements were calculated yielding the following slopes (delta y/delta x) and regression coefficients (r), respectively: electromagnetic (1.00, 0.98), graduated cylinder (0.85, 0.93), and pump withdrawal (0.93, 1.00). The results validate the transit-time ultrasound system used in the present investigation as an accurate method capable of measuring blood flow in both acutely and chronically instrumented animal preparations.
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Tannenbaum GA, Mathews D, Weissman C. Pulse contour cardiac output in surgical intensive care unit patients. J Clin Anesth 1993; 5:471-8. [PMID: 8123273 DOI: 10.1016/0952-8180(93)90064-l] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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.
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Affiliation(s)
- G A Tannenbaum
- Department of Anesthesiology, College of Physicians and Surgeons of Columbia University, New York, NY
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Sinclair S, Singer M. Intensive care. Postgrad Med J 1993; 69:340-58. [PMID: 8346129 PMCID: PMC2399818 DOI: 10.1136/pgmj.69.811.340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- S Sinclair
- Bloomsbury Institute of Intensive Care Medicine, Department of Medicine, UCL Medical School, UK
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Gayes JM. Intra-aortic balloon pump prevents transtracheal Doppler endotracheal tube measurements of cardiac output. J Clin Monit Comput 1991; 7:348. [PMID: 1744679 DOI: 10.1007/bf01619357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Froese N, Friesen R. Measurement of cardiac output--transtracheal Doppler versus thermodilution. Can J Anaesth 1991; 38:931-4. [PMID: 1742833 DOI: 10.1007/bf03036977] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The ABCOM 1 transtracheal Doppler (TTD) has been developed as a non-invasive cardiac output monitor. With this device, cardiac output is continuously calculated from ascending aortic blood flow velocity and aortic diameter obtained via an ultrasound transducer incorporated into the tip of an endotracheal tube. We evaluated the clinical use of the ABCOM 1 monitor and compared cardiac outputs obtained using the TTD system with simultaneous thermodilution (TD) measurements. We found the operation of the ABCOM 1 monitor to be difficult and time-consuming. In our operating rooms, acceptable Doppler signal quality was difficult to obtain. There was no correlation between 36 simultaneously obtained TTD and TD cardiac output measurements. The average difference between measurement techniques and the limits of agreement were unacceptably large (mean difference = 3.04 L.min-1, mean +/- 2 SD = -6.04 to 12.48 L.min-1). Separately analyzing only those measurements during which Doppler signal quality was adequate did not improve agreement between TTD and TD measurements. On the basis of these findings, TTD cannot be recommended as a clinical cardiac output measurement technique.
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Affiliation(s)
- N Froese
- Department of Anesthesia, University of Manitoba, Faculty of Medicine, Winnipeg
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Abstract
When we are concerned about the adequacy of peripheral oxygen delivery, our monitoring efforts focus on cardiac output as the component easiest to manipulate. Thermodilution is the current method of determining cardiac output because of logistic convenience, but by no means should it be considered the gold standard. Thoracic electrical bioimpedance is an appealing alternative because of its simplicity, noninvasiveness, and ability to track physiologic trends, but there have been a number of warnings against relying on it exclusively, at least until it is further developed. Doppler ultrasound appears to be a valid method in skilled hands, but its accuracy in quantitating cardiac output, especially in the critically ill, remains questionable. Mixed venous oximetry and transcutaneous oxygen monitoring are promising but are still being evaluated.
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Affiliation(s)
- F A Moore
- University of Colorado Health Science Center, Denver
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Segal J, Gaudiani V, Nishimura T. Continuous determination of cardiac output using a flow-directed Doppler pulmonary artery catheter. J Cardiothorac Vasc Anesth 1991; 5:309-15. [PMID: 1831393 DOI: 10.1016/1053-0770(91)90151-i] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A newly developed, flow-directed, Doppler pulmonary artery catheter that uses multiple ultrasonic transducers to measure instantaneous and continuous cardiac output was evaluated in 20 patients undergoing cardiac and vascular surgical procedures. Cardiac output was determined using the product of the average velocity and the area of the main pulmonary artery. Pulmonary artery area was obtained from measurements of diameter via ultrasound transit time, and average velocity of blood flow was determined from the Doppler shift frequency. Two hundred thirty-eight simultaneous Doppler catheter and thermodilution cardiac output measurements were obtained preoperatively, intraoperatively, and during postoperative recovery. Catheter indwelling time varied from 18 through 94 hours (mean +/- SD, 40 +/- 19 hours) with 2 to 26 (mean +/- SD, 12 +/- 6) sets of triplicate cardiac output measurements obtained per patient. Doppler catheter cardiac output correlated well with thermodilution (r = 0.76, slope or m = 0.87, and SEE = 0.05 with P = 0.0001) and mean predictive error (bias) appeared clinically insignificant (bias +/- SD, -0.13 +/- 0.79 L/min). Accurate, continuous monitoring of instantaneous and mean cardiac output appears possible with use of this Doppler pulmonary artery catheter system.
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Affiliation(s)
- J Segal
- University of California, School of Medicine, San Francisco
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Segal J, Nassi M, Ford AJ, Schuenemeyer TD. Instantaneous and continuous cardiac output in humans obtained with a Doppler pulmonary artery catheter. J Am Coll Cardiol 1990; 16:1398-407. [PMID: 2229792 DOI: 10.1016/0735-1097(90)90383-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
A new Doppler pulmonary artery catheter was used to measure instantaneous and continuous cardiac output in both an in vitro model and in 44 patients undergoing cardiac catheterization. Cardiac output was calculated with use of the Doppler catheter-determined instantaneous space-average velocity and the ultrasonically determined instantaneous vessel area. Doppler flow and thermodilution were compared with electromagnetic flow in the in vitro model and with Fick cardiac output in patients. Doppler catheter-determined flow was highly predictive of electro-magnetic flow in the pulsatile flow model (r = 0.99, slope [m] = 1.01 and SEE = 0.05) and appeared comparable to thermodilution measurements (r = 1.00, m = 1.03 and SEE = 0.02). In patients undergoing cardiac catheterization, Doppler catheter-determined cardiac output appeared to modestly underestimate Fick cardiac output (r = 0.82, m = 0.80 and SEE = 0.09; mean error +/- SEM = -0.26 +/- 0.14 liters/min). However, predictive accuracy was comparable to simultaneously obtained thermodilution measurements (r = 0.85, m = 1.07 and SEE = 0.10; mean error +/- SEM = 0.61 +/- 0.16 liters/min). This new Doppler catheter system utilizes multiple ultrasound transducers to provide angle-independent measurements of vessel diameter and instantaneous velocity within the main pulmonary artery, resulting in a more accurate assessment of Doppler-derived cardiac output. In addition, useful information concerning hemodynamic variables such as peak flow, acceleration, deceleration, stroke work and pulmonary impedance may be derived.
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Affiliation(s)
- J Segal
- University of California, School of Medicine, San Francisco
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