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Svedmyr A, Steiner K, Andersson A, Sjöberg G, Hallbäck M, Wallin M, Lönnqvist PA, Karlsson J. Validation of a Novel Method for Noninvasive Mixed Venous Oxygen Saturation Monitoring in Anesthetized Children. Anesth Analg 2024:00000539-990000000-00891. [PMID: 39093817 DOI: 10.1213/ane.0000000000007083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
BACKGROUND Mixed venous oxygen saturation (SvO 2 ) is a critical variable in the assessment of oxygen supply and demand but is rarely used in children due to the invasive nature of pulmonary artery catheters. The aim of this prospective, observational study was to investigate the accuracy of noninvasively measured SvO 2 acquired by the novel capnodynamic method, based on differential Fick equation (Capno-SvO 2 ), against gold standard CO-oximetry. METHODS Capno-SvO 2 was compared to SvO 2 measured by pulmonary artery blood gas CO-oximetry in children undergoing cardiac catheter interventions and subjected to moderate hemodynamic challenges. Bland-Altman analysis was used to describe the agreement of absolute values between CO-oximetry and Capno-SvO 2 , and a concordance rate was calculated to evaluate the ability of Capno-SvO 2 to track change. RESULTS Twenty-five procedures were included in the study. Capno-SvO 2 showed a bias toward CO-oximetry of +3 percentage points; upper and lower limits of agreement were +11 percentage points (95% confidence interval [CI], 9-14) and -5 percentage points (95% CI, -8 to -3), respectively. The concordance rate was 92% (95% CI, 89-96). CONCLUSIONS In conclusion, this first clinical application of a novel concept for noninvasive SvO 2 monitoring without the need for a pulmonary artery catheter indicates that Capno-SvO 2 generates absolute values and trending capacity in close agreement with the gold standard reference method.
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Affiliation(s)
- Anders Svedmyr
- From the Department of Physiology and Pharmacology (FYFA), C3, Eriksson I Lars, PA Lönnqvist Group, Section of Anesthesiology and Intensive Care, Karolinska Institute, Stockholm, Sweden
- Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Kristoffer Steiner
- Department of Pediatric Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Andreas Andersson
- From the Department of Physiology and Pharmacology (FYFA), C3, Eriksson I Lars, PA Lönnqvist Group, Section of Anesthesiology and Intensive Care, Karolinska Institute, Stockholm, Sweden
- Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Gunnar Sjöberg
- Department of Pediatric Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | | | - Mats Wallin
- From the Department of Physiology and Pharmacology (FYFA), C3, Eriksson I Lars, PA Lönnqvist Group, Section of Anesthesiology and Intensive Care, Karolinska Institute, Stockholm, Sweden
| | - Per-Arne Lönnqvist
- From the Department of Physiology and Pharmacology (FYFA), C3, Eriksson I Lars, PA Lönnqvist Group, Section of Anesthesiology and Intensive Care, Karolinska Institute, Stockholm, Sweden
- Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Jacob Karlsson
- From the Department of Physiology and Pharmacology (FYFA), C3, Eriksson I Lars, PA Lönnqvist Group, Section of Anesthesiology and Intensive Care, Karolinska Institute, Stockholm, Sweden
- Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
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2
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Karlsson J, Lönnqvist PA. Capnodynamics - noninvasive cardiac output and mixed venous oxygen saturation monitoring in children. Front Pediatr 2023; 11:1111270. [PMID: 36816378 PMCID: PMC9936087 DOI: 10.3389/fped.2023.1111270] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/17/2023] [Indexed: 02/05/2023] Open
Abstract
Hemodynamic monitoring in children is challenging for many reasons. Technical limitations in combination with insufficient validation against reference methods, makes reliable monitoring systems difficult to establish. Since recent studies have highlighted perioperative cardiovascular stability as an important factor for patient outcome in pediatrics, the need for accurate hemodynamic monitoring methods in children is obvious. The development of mathematical processing of fast response mainstream capnography signals, has allowed for the development of capnodynamic hemodynamic monitoring. By inducing small changes in ventilation in intubated and mechanically ventilated patients, fluctuations in alveolar carbon dioxide are created. The subsequent changes in carbon dioxide elimination can be used to calculate the blood flow participating in gas exchange, i.e., effective pulmonary blood flow which equals the non-shunted pulmonary blood flow. Cardiac output can then be estimated and continuously monitored in a breath-by-breath fashion without the need for additional equipment, training, or calibration. In addition, the method allows for mixed venous oxygen saturation (SvO2) monitoring, without pulmonary artery catheterization. The current review will discuss the capnodyamic method and its application and limitation as well as future potential development and functions in pediatric patients.
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Affiliation(s)
- Jacob Karlsson
- Dept of Physiology & Pharmacology, Section of Anaesthesiology and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Paediatric Perioperative Medicine & Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Per-Arne Lönnqvist
- Dept of Physiology & Pharmacology, Section of Anaesthesiology and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Paediatric Perioperative Medicine & Intensive Care, Karolinska University Hospital, Stockholm, Sweden
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3
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Karlsson J, Lönnqvist PA. Capnodynamics-Measuring cardiac output via ventilation. Paediatr Anaesth 2022; 32:255-261. [PMID: 34758163 DOI: 10.1111/pan.14329] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/21/2021] [Accepted: 11/03/2021] [Indexed: 12/12/2022]
Abstract
Recent studies have identified stable hemodynamics as a contributing factor to improve outcome in pediatric anesthesia. So far, most of the hemodynamic monitoring methods applied in children have been complex to apply and often not satisfactory validated. Standard mainstream carbon dioxide analysis in combination with real-time mathematical analysis of the measured capnography data has enabled the development of dynamic capnography, a non-invasively cardiac output monitoring method that can be applied without user practice or need for calibrations. Capnodynamic cardiac output assessment has been extensively validated against gold standard reference methods, both in experimental and clinical settings. This review will describe the principle behind dynamic capnography measurement of cardiac output and mixed venous oxygen saturation. Additionally, the methods limitations and challenges when applied in children will be delineated.
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Affiliation(s)
- Jacob Karlsson
- Department of Physiology and Pharmacology (FYFA), C3, Per-Arne Lönnqvist Group-Section of Anesthesiology and Intensive Care, Karolinska Institute, Stockholm, Sweden.,Pediatric perioperative medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Per-Arne Lönnqvist
- Department of Physiology and Pharmacology (FYFA), C3, Per-Arne Lönnqvist Group-Section of Anesthesiology and Intensive Care, Karolinska Institute, Stockholm, Sweden.,Pediatric perioperative medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
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4
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Tusman G, Acosta CM, Wallin M, Hallbäck M, Esperatti M, Peralta G, Gonzalez ME, Sipmann FS. PERIOPERATIVE CONTINUOUS NON-INVASIVE CARDIAC OUTPUT MONITORING IN CARDIAC SURGERY PATIENTS BY A NOVEL CAPNODYNAMIC METHOD. J Cardiothorac Vasc Anesth 2022; 36:2900-2907. [DOI: 10.1053/j.jvca.2022.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/20/2022] [Accepted: 02/02/2022] [Indexed: 11/11/2022]
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Sigmundsson TS, Öhman T, Hallbäck M, Suarez-Sipmann F, Wallin M, Oldner A, Hällsjö-Sander C, Björne H. Comparison between capnodynamic and thermodilution method for cardiac output monitoring during major abdominal surgery: An observational study. Eur J Anaesthesiol 2021; 38:1242-1252. [PMID: 34155171 PMCID: PMC8631141 DOI: 10.1097/eja.0000000000001566] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiac output (CO) monitoring is the basis of goal-directed treatment for major abdominal surgery. A capnodynamic method estimating cardiac output (COEPBF) by continuously calculating nonshunted pulmonary blood flow has previously shown good agreement and trending ability when evaluated in mechanically ventilated pigs. OBJECTIVES To compare the performance of the capnodynamic method of CO monitoring with transpulmonary thermodilution (COTPTD) in patients undergoing major abdominal surgery. DESIGN Prospective, observational, method comparison study. Simultaneous measurements of COEPBF and COTPTD were performed before incision at baseline and before and after increased (+10 cmH2O) positive end-expiratory pressure (PEEP), activation of epidural anaesthesia and intra-operative events of hypovolemia and low CO. The first 25 patients were ventilated with PEEP 5 cmH2O (PEEP5), while in the last 10 patients, lung recruitment followed by individual PEEP adjustment (PEEPadj) was performed before protocol start. SETTING Karolinska University Hospital, Stockholm, Sweden. PATIENTS In total, 35 patients (>18 years) scheduled for major abdominal surgery with advanced hemodynamic monitoring were included in the study. MAIN OUTCOME MEASURES AND ANALYSIS Agreement and trending ability between COEPBF and COTPTD at different clinical moments were analysed with Bland--Altman and four quadrant plots. RESULTS In total, 322 paired values, 227 in PEEP5 and 95 in PEEPadj were analysed. Respectively, the mean COEPBF and COTPTD were 4.5 ± 1.0 and 4.8 ± 1.1 in the PEEP5 group and 4.9 ± 1.2 and 5.0 ± 1.0 l min-1 in the PEEPadj group. Mean bias (levels of agreement) and percentage error (PE) were -0.2 (-2.2 to 1.7) l min-1 and 41% for the PEEP5 group and -0.1 (-1.7 to 1.5) l min-1 and 31% in the PEEPadj group. Concordance rates during changes in COEPBF and COTPTD were 92% in the PEEP5 group and 90% in the PEEPadj group. CONCLUSION COEPBF provides continuous noninvasive CO estimation with acceptable performance, which improved after lung recruitment and PEEP adjustment, although not interchangeable with COTPTD. This method may become a tool for continuous intra-operative CO monitoring during general anaesthesia in the future. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT03444545.
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Affiliation(s)
- Thorir S Sigmundsson
- From the Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna (TSS, TÖ, AO, CH-S, HB), Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm (TSS, TÖ, MW, AO, CH-S, HB), Maquet Critical Care AB, Solna (MH, MW), Department of Intensive Care, Hospital Universitario de La Princesa, Madrid, Spain and Department of Surgical Sciences, Section of Anaesthesiology and Critical Care, Hedenstierna's Laboratory, Uppsala University, Uppsala, Sweden (FSS) and CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain (FSS)
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6
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Karlsson J, Lönnqvist PA, Wallin M, Hallbäck M. A Continuous Noninvasive Method to Assess Mixed Venous Oxygen Saturation: A Proof-of-Concept Study in Pigs. Anesth Analg 2021; 132:1768-1776. [PMID: 33009138 DOI: 10.1213/ane.0000000000005188] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Mixed venous oxygen saturation (Svo2) is important when evaluating the balance between oxygen delivery and whole-body oxygen consumption. Monitoring Svo2 has so far required blood samples from a pulmonary artery catheter. By combining volumetric capnography, for measurement of effective pulmonary blood flow, with the Fick principle for oxygen consumption, we have developed a continuous noninvasive method, capnodynamic Svo2, for assessment of Svo2. The objective of this study was to validate this new technique against the gold standard cardiac output (CO)-oximetry Svo2 measurement of blood samples obtained from a pulmonary artery catheter and to assess the potential influence of intrapulmonary shunting. METHODS Eight anesthetized mechanically ventilated domestic-breed piglets of both sexes (median weight 23.9 kg) were exposed to a series of interventions intended to reduce as well as increase Svo2. Simultaneous recordings of capnodynamic and CO-oximetry Svo2 as well as shunt fraction, using the Berggren formula, were performed throughout the protocol. Agreement of absolute values for capnodynamic and CO-oximetry Svo2 and the ability for capnodynamic Svo2 to detect change were assessed using Bland-Altman plot and concordance analysis. RESULTS Overall bias for capnodynamic versus CO-oximetry Svo2 was -1 percentage point (limits of agreement -13 to +11 percentage points), a mean percentage error of 22%, and a concordance rate of 100%. Shunt fraction varied between 13% at baseline and 22% at the end of the study and was associated with only minor alterations in agreement between the tested methods. CONCLUSIONS In the current experimental setting, capnodynamic assessment of Svo2 generates absolute values very close to the reference method CO-oximetry and is associated with 100% trending ability.
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Affiliation(s)
- Jacob Karlsson
- From the Department of Physiology and Pharmacology (Fysiologi och Farmakologi [FYFA]), Karolinska Institute, Stockholm, Sweden.,Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Per-Arne Lönnqvist
- From the Department of Physiology and Pharmacology (Fysiologi och Farmakologi [FYFA]), Karolinska Institute, Stockholm, Sweden.,Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Wallin
- From the Department of Physiology and Pharmacology (Fysiologi och Farmakologi [FYFA]), Karolinska Institute, Stockholm, Sweden.,Maquet Critical Care Aktiebolag (AB), Solna, Sweden
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7
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Grundlagen der Volumetrischen Kapnographie. Anaesthesist 2020; 69:287-296. [DOI: 10.1007/s00101-020-00744-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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8
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Sigmundsson TS, Öhman T, Hallbäck M, Redondo E, Sipmann FS, Wallin M, Oldner A, Hällsjö-Sander C, Björne H. Performance of a capnodynamic method estimating cardiac output during respiratory failure - before and after lung recruitment. J Clin Monit Comput 2019; 34:1199-1207. [PMID: 31745763 PMCID: PMC7548027 DOI: 10.1007/s10877-019-00421-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 10/12/2019] [Indexed: 01/06/2023]
Abstract
Respiratory failure may cause hemodynamic instability with strain on the right ventricle. The capnodynamic method continuously calculates cardiac output (CO) based on effective pulmonary blood flow (COEPBF) and could provide CO monitoring complementary to mechanical ventilation during surgery and intensive care. The aim of the current study was to evaluate the ability of a revised capnodynamic method, based on short expiratory holds (COEPBFexp), to estimate CO during acute respiratory failure (LI) with high shunt fractions before and after compliance-based lung recruitment. Ten pigs were submitted to lung lavage and subsequent ventilator-induced lung injury. COEPBFexp, without any shunt correction, was compared to a reference method for CO, an ultrasonic flow probe placed around the pulmonary artery trunk (COTS) at (1) baseline in healthy lungs with PEEP 5 cmH2O (HLP5), (2) LI with PEEP 5 cmH2O (LIP5) and (3) LI after lung recruitment and PEEP adjustment (LIPadj). CO changes were enforced during LIP5 and LIPadj to estimate trending. LI resulted in changes in shunt fraction from 0.1 (0.03) to 0.36 (0.1) and restored to 0.09 (0.04) after recruitment manoeuvre. Bias (levels of agreement) and percentage error between COEPBFexp and COTS changed from 0.5 (− 0.5 to 1.5) L/min and 30% at HLP5 to − 0.6 (− 2.3 to 1.1) L/min and 39% during LIP5 and finally 1.1 (− 0.3 to 2.5) L/min and 38% at LIPadj. Concordance during CO changes improved from 87 to 100% after lung recruitment and PEEP adjustment. COEPBFexp could possibly be used for continuous CO monitoring and trending in hemodynamically unstable patients with increased shunt and after recruitment manoeuvre.
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Affiliation(s)
- Thorir Svavar Sigmundsson
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, 171 76, Solna, Stockholm, Sweden. .,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
| | - Tomas Öhman
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, 171 76, Solna, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | | | - Eider Redondo
- Department of Intensive Care Medicine, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Fernando Suarez Sipmann
- Department of Surgical Sciences, Section of Anaesthesiology and Critical Care, Hedenstierna's Laboratory, Uppsala University, Uppsala, Sweden.,CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Mats Wallin
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.,Maquet Critical Care AB, Solna, Sweden
| | - Anders Oldner
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, 171 76, Solna, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Caroline Hällsjö-Sander
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, 171 76, Solna, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Håkan Björne
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, 171 76, Solna, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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9
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Clinical use of volumetric capnography in mechanically ventilated patients. J Clin Monit Comput 2019; 34:7-16. [PMID: 31152285 DOI: 10.1007/s10877-019-00325-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 05/21/2019] [Indexed: 10/26/2022]
Abstract
Capnography is a first line monitoring system in mechanically ventilated patients. Volumetric capnography supports noninvasive and breath-by-breath information at the bedside using mainstream CO2 and flow sensors placed at the airways opening. This volume-based capnography provides information of important body functions related to the kinetics of carbon dioxide. Volumetric capnography goes one step forward standard respiratory mechanics and provides a new dimension for monitoring of mechanical ventilation. The article discusses the role of volumetric capnography for the clinical monitoring of mechanical ventilation.
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10
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Peyton PJ, Wallin M, Hallbäck M. New generation continuous cardiac output monitoring from carbon dioxide elimination. BMC Anesthesiol 2019; 19:28. [PMID: 30808309 PMCID: PMC6391811 DOI: 10.1186/s12871-019-0699-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 02/18/2019] [Indexed: 11/10/2022] Open
Abstract
Background There is continuing interest among clinicians in the potential for advanced hemodynamic monitoring and “goal directed” intravenous fluid administration guided by minimally-invasive cardiac output measurement to reduce complication rates in high risk patients undergoing major surgery. However, the adoption of the available technologies has been limited, due to cost, complexity and reliability of measurements provided. We review progress in the development of new generation methods for continuous non-invasive monitoring of cardiac output from measurement of carbon dioxide elimination in ventilated patients using the Differential Fick method. Main text The history and underlying theoretical basis are described, and its recent further development and implementation using modern generation anesthesia monitoring and delivery systems by two separate but parallel methods, termed “Capnotracking” and “Capnodynamics”. Both methods generate breath-by-breath hands-free cardiac output monitoring from changes in carbon dioxide elimination produced by automatic computerized modulation of respiratory rate delivered by an electronic ventilator. Extensive preclinical validation in animal models of hemodynamic instability, with implanted ultrasonic flow probes for gold standard reference measurements, shows this approach delivers reliable, continuous cardiac output measurement in real time. The accuracy and precision of measurement by the Capnodynamic method were maintained under a wide range of both hemodynamic and respiratory conditions, including inotropic stimulation, vasodilatation, hemorrhage, caval compression, alveolar lavage, changes in tidal volume and positive end-expiratory pressure, and hypercapnia, with only brief derangement observed in a model of lower body ischemia involving release of prolonged aortic occlusion by an intra-aortic balloon. Phase 2 testing of a Capnotracking system in patients undergoing cardiac surgery and liver transplantation has achieved a percentage error of agreement with thermodilution of +/− 38.7% across a wide range of hemodynamic states. Conclusions Progress in development of these technologies suggest that a robust, automated and reliable method of non-invasive cardiac output monitoring from capnography is close at hand for use in major surgery and critical care. The great advantage of this approach is that it can be fully integrated into the anesthesia machine and ventilator, using components that are already standard in modern anesthesia and intensive care workstations, and should be virtually hands-free and automatic.
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Affiliation(s)
- Philip J Peyton
- Anaesthesia, Perioperative and Pain Medicine Unit, Melbourne Medical School, University of Melbourne; Department of Anaesthesia, Austin Health, Heidelberg, Vic, 3084, Australia.
| | - Mats Wallin
- Maquet Critical Care, AB, Rontgenvagen 2, S-17154, Solna, Sweden.,Karolinska Institute Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care, Stockholm, Sweden
| | - Magnus Hallbäck
- Maquet Critical Care, AB, Rontgenvagen 2, S-17154, Solna, Sweden
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Karlsson J, Wallin M, Hallbäck M, Lönnqvist PA. Capnodynamic determination of cardiac output in hypoxia-induced pulmonary hypertension in pigs. Br J Anaesth 2018; 122:335-341. [PMID: 30770051 DOI: 10.1016/j.bja.2018.10.064] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 10/22/2018] [Accepted: 10/23/2018] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Effective pulmonary blood flow (COEPBF) has recently been validated for its ability to measure cardiac output (CO) in children and animals. This study compared COEPBF with the Fick method (COFick) and CO measurements using an invasive pulmonary artery flow probe (COTS). The aim of the study was to validate COEPBF against these reference methods in a porcine model of hypoxia-induced selective pulmonary hypertension. METHODS Ten anaesthetised mechanically ventilated piglets (median weight 23.9 kg) were exposed to a hypoxic gas mixture inducing selective pulmonary hypertension. Pulmonary hypertension was subsequently reversed with inhaled nitric oxide. Simultaneous recordings of COEPBF, COFick, and COTS were performed throughout the protocol and examined for agreement and trending ability. RESULTS Overall bias (Bland-Altman) between COEPBF and COTS was 0.2 L min-1 (limits of agreement -0.5 and +0.9 L min-1) with a mean percentage error of 25%. Overall bias between COEPBF and COFick was -0.1 L min-1 (limits of agreement -0.9 and +0.6 L min-1) and a mean percentage error of 25%. The concordance rate was 86% for COEPBF when compared with COTS using a 10% exclusion zone. CONCLUSIONS Estimation of CO with COEPBF results in values very close to the gold standard reference methods COFick and COTS. COEPBF appears to be an accurate tool for monitoring absolute values and changes in CO during hypoxia-induced pulmonary hypertension and inhaled nitric oxide treatment.
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Affiliation(s)
- J Karlsson
- Department of Physiology and Pharmacology (FYFA), C3, Eriksson I Lars Group, Section of Anesthesiology and Intensive Care, Karolinska Institute, Stockholm, Sweden; Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.
| | - M Wallin
- Department of Physiology and Pharmacology (FYFA), C3, Eriksson I Lars Group, Section of Anesthesiology and Intensive Care, Karolinska Institute, Stockholm, Sweden; Maquet Critical Care AB, Solna, Sweden
| | | | - P A Lönnqvist
- Department of Physiology and Pharmacology (FYFA), C3, Eriksson I Lars Group, Section of Anesthesiology and Intensive Care, Karolinska Institute, Stockholm, Sweden; Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
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12
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Karlsson J, Winberg P, Scarr B, Lönnqvist PA, Neovius E, Wallin M, Hallbäck M. Validation of capnodynamic determination of cardiac output by measuring effective pulmonary blood flow: a study in anaesthetised children and piglets. Br J Anaesth 2018; 121:550-558. [PMID: 30115252 DOI: 10.1016/j.bja.2018.02.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 02/27/2018] [Accepted: 03/03/2018] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Effective pulmonary blood flow (COEPBF) has recently been validated as a technique for determining cardiac output (CO) in animals of varying sizes. The primary aim of our study was to investigate this new technique in paediatric surgical patients, compared with suprasternal two-dimensional Doppler (COSSD). METHODS A total of 15 children undergoing cleft lip/palate surgery were investigated. Before the start of surgery, manoeuvres that were anticipated to reduce (increase in PEEP from 3 to 10 cm H2O) and increase (atropine) CO were undertaken. A study in mechanically ventilated piglets was also undertaken under general anaesthesia, measuring COEPBF and pulmonary artery (COTS) flow by ultrasonic probe as the comparator. Bias (Bland-Altman plots) and limits of agreement were assessed for effective pulmonary blood flow and COSSD or COTS. RESULTS In paediatric patients (median age 8.5 months), overall bias was -8.1 (limits of agreement -82 to +66) ml kg-1 min-1, with a mean percentage error of 48% and a concordance rate of 64%. In the piglet model, overall bias was -1 (-36 to +38) ml kg-1 min-1, with a mean percentage error of 31% and a concordance rate of 95%. CONCLUSIONS Under controlled experimental conditions, COEPBF is associated with excellent agreement and good trending ability when compared with the gold standard COTS. In the paediatric clinical setting, COEPBF performs well; by contrast, COSSD, an operator- and anatomy-dependent technology, appears less reliable than COEPBF.
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Affiliation(s)
- J Karlsson
- Karolinska Institute Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care, Stockholm, Sweden; Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.
| | - P Winberg
- Department of Pediatric Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - B Scarr
- Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - P A Lönnqvist
- Karolinska Institute Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care, Stockholm, Sweden; Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - E Neovius
- Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - M Wallin
- Karolinska Institute Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care, Stockholm, Sweden; Maquet Critical Care, Solna, Sweden
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13
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Peyton PJ, Kozub M. Performance of a second generation pulmonary capnotracking system for continuous monitoring of cardiac output. J Clin Monit Comput 2018; 32:1057-1064. [DOI: 10.1007/s10877-018-0110-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 01/31/2018] [Indexed: 11/29/2022]
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Sigmundsson TS, Öhman T, Hallbäck M, Redondo E, Sipmann FS, Wallin M, Oldner A, Hällsjö Sander C, Björne H. Performance of a capnodynamic method estimating effective pulmonary blood flow during transient and sustained hypercapnia. J Clin Monit Comput 2017; 32:311-319. [PMID: 28497180 PMCID: PMC5838142 DOI: 10.1007/s10877-017-0021-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 04/22/2017] [Indexed: 01/04/2023]
Abstract
The capnodynamic method is a minimally invasive method continuously calculating effective pulmonary blood flow (COEPBF), equivalent to cardiac output when intra pulmonary shunt flow is low. The capnodynamic equation joined with a ventilator pattern containing cyclic reoccurring expiratory holds, provides breath to breath hemodynamic monitoring in the anesthetized patient. Its performance however, might be affected by changes in the mixed venous content of carbon dioxide (CvCO2). The aim of the current study was to evaluate COEPBF during rapid measurable changes in mixed venous carbon dioxide partial pressure (PvCO2) following ischemia–reperfusion and during sustained hypercapnia in a porcine model. Sixteen pigs were submitted to either ischemia–reperfusion (n = 8) after the release of an aortic balloon inflated during 30 min or to prolonged hypercapnia (n = 8) induced by adding an instrumental dead space. Reference cardiac output (CO) was measured by an ultrasonic flow probe placed around the pulmonary artery trunk (COTS). Hemodynamic measurements were obtained at baseline, end of ischemia and during the first 5 min of reperfusion as well as during prolonged hypercapnia at high and low CO states. Ischemia–reperfusion resulted in large changes in PvCO2, hemodynamics and lactate. Bias (limits of agreement) was 0.7 (−0.4 to 1.8) L/min with a mean error of 28% at baseline. COEPBF was impaired during reperfusion but agreement was restored within 5 min. During prolonged hypercapnia, agreement remained good during changes in CO. The mean polar angle was −4.19° (−8.8° to 0.42°). Capnodynamic COEPBF is affected but recovers rapidly after transient large changes in PvCO2 and preserves good agreement and trending ability during states of prolonged hypercapnia at different levels of CO.
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Affiliation(s)
- Thorir Svavar Sigmundsson
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden. .,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
| | - Tomas Öhman
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | | | - Eider Redondo
- Department of Intensive Care Medicine, Hospital de Navarra, Pamplona, Spain
| | - Fernando Suarez Sipmann
- Hedenstierna's laboratory, Section of Anaesthesiology and Critical Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.,CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Mats Wallin
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.,Maquet Critical Care AB, Solna, Sweden
| | - Anders Oldner
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Caroline Hällsjö Sander
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Håkan Björne
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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15
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Sander CH, Sigmundsson T, Hallbäck M, Sipmann FS, Wallin M, Oldner A, Björne H. A modified breathing pattern improves the performance of a continuous capnodynamic method for estimation of effective pulmonary blood flow. J Clin Monit Comput 2016; 31:717-725. [PMID: 27251701 DOI: 10.1007/s10877-016-9891-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 05/25/2016] [Indexed: 12/15/2022]
Abstract
In a previous study a new capnodynamic method for estimation of effective pulmonary blood flow (COEPBF) presented a good trending ability but a poor agreement with a reference cardiac output (CO) measurement at high levels of PEEP. In this study we aimed at evaluating the agreement and trending ability of a modified COEPBF algorithm that uses expiratory instead of inspiratory holds during CO and ventilatory manipulations. COEPBF was evaluated in a porcine model at different PEEP levels, tidal volumes and CO manipulations (N = 8). An ultrasonic flow probe placed around the pulmonary trunk was used for CO measurement. We tested the COEPBF algorithm using a modified breathing pattern that introduces cyclic end-expiratory time pauses. The subsequent changes in mean alveolar fraction of carbon dioxide were integrated into a capnodynamic equation and effective pulmonary blood flow, i.e. non-shunted CO, was calculated continuously breath by breath. The overall agreement between COEPBF and the reference method during all interventions was good with bias (limits of agreement) 0.05 (-1.1 to 1.2) L/min and percentage error of 36 %. The overall trending ability as assessed by the four-quadrant and the polar plot methodology was high with a concordance rate of 93 and 94 % respectively. The mean polar angle was 0.4 (95 % CI -3.7 to 4.5)°. A ventilatory pattern recurrently introducing end-expiratory pauses maintains a good agreement between COEPBF and the reference CO method while preserving its trending ability during CO and ventilatory alterations.
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Affiliation(s)
- Caroline Hällsjö Sander
- Department of Anaesthesiology, Surgical Services and Intensive Care Medicine, Karolinska University Hospital, 171 76, Solna, Stockholm, Sweden. .,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
| | - Thorir Sigmundsson
- Department of Anaesthesiology, Surgical Services and Intensive Care Medicine, Karolinska University Hospital, 171 76, Solna, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | | | - Fernando Suarez Sipmann
- Hedenstierna's Laboratory, Department of Surgical Sciences, Section of Anaesthesiology and Critical Care, Uppsala University, Uppsala, Sweden.,CIBER de enfermedades respiratorias (CIBERES), Instituto Carlos III, Madrid, Spain
| | - Mats Wallin
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.,Maquet Critical Care AB, Solna, Sweden
| | - Anders Oldner
- Department of Anaesthesiology, Surgical Services and Intensive Care Medicine, Karolinska University Hospital, 171 76, Solna, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Håkan Björne
- Department of Anaesthesiology, Surgical Services and Intensive Care Medicine, Karolinska University Hospital, 171 76, Solna, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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16
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Minimally invasive monitoring of cardiac output and lung gas exchange: taking it mainstream. J Clin Monit Comput 2016; 30:749-751. [PMID: 27008589 DOI: 10.1007/s10877-016-9866-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 03/20/2016] [Indexed: 10/22/2022]
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