Measuring Cardiac Output: Intermittent Bolus Thermodilution Method

Anna Gawlinski

Crit Care Nurse. 2004;24: 74-78

© 2004 American Association of Critical-Care Nurses
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Critical Care Nurse is the official peer-reviewed clinical journal of the American
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 ProtocolsforPractice

by a computer and converted into a

Measuring Cardiac measurement of cardiac output. Car-
diac output is inversely proportional

Output: Intermittent Bolus to the area under the curve.

The normal cardiac output curve
has a rapid smooth upstroke and a
Thermodilution Method gradual downstroke (Figure 1). A
small area under the curve indicates
Anna Gawlinski, RN, DNSc, CS-ACNP a high cardiac output. The faster
blood flows through the heart, the
earlier the peak and sharper the drop,
because the catheter senses temper-

Q What are the physiological

principles underlying the intermittent
bolus thermodilution (TDCO) method
of determining cardiac output?
The TDCO method is the one clini-
cians use most often to measure cardiac
output. It is based on the principles of
dilution. A known quantity of an indi-
cator (ie, a contrast agent) is injected
into the bloodstream. Blood flow and
blood volume are calculated by meas-
uring the concentration of the indica-
tor downstream at a distal arterial site
at selected times. The TDCO method
uses a cold solution to create a thermal
proximal port of a pulmonary artery
catheter located in the right atrium.
In the atrium, the injectate mixes with
the blood and passes through the tri-
cuspid valve into the right ventricle.
A thermistor within the catheter
senses the change in blood tempera-
ture as the blood passes the catheter
tip located in the pulmonary artery.1
A curve that shows the change in
temperature over time is calculated
Decreasing temperature
ature change over a short period. A
low cardiac output results in a larger
area under the curve. When blood
flows slowly (low cardiac output), the
area under the curve (temperature
change over time) is greater because
the catheter senses changes in tem-
perature over a longer period. The
curves vary according to the patient’s
clinical condition and according to
deviations in technique (Figure 2).
Concerns about contamination
of prefilled syringes of injectate and
Peak
80%

deficit as a variant of the indicator-dilu-

tion method. A bolus of sterile solution Curve onset 30%
(ie, the injectate) that is colder than
the patient s blood is injected into the
Baseline Downslope Extrapolated area

Author
Anna Gawlinski is a clinical nurse spe-
cialist in the cardiac care unit and car-
diac observation unit at UCLA Medical
Center and is an assistant professor of
nursing at the UCLA School of Nursing,
Los Angeles, Calif.
To purchase reprints, contact The InnoVision Group,
101 Columbia, Aliso Viejo, CA 92656. Phone, (800)
809-2273 or (949) 362-2050 (ext 532); fax, (949)
362-2049; e-mail, reprints@aacn.org.
Time
Figure 1 An ideal thermodilution curve. Administration of the injectate is charac-
terized by a rapid upslope to a peak, a gradual downslope, and an exponential
decay of the thermal signals. The cardiac output computer begins integration of
the area under the thermodilution curve at the instant of injection and terminates
integration when the exponential decay reaches a value of about 30%. The com-
puter then extrapolates the exponential decay to baseline. In this way, any artifact
introduced by recirculation of indicator is minimized.

74 CRITICALCARENURSE Vol 24, No. 5, OCTOBER 2004

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warming of injectate due to handling
led to the design of closed delivery sys- Normal curve
tems (Figure 3). The closed system is Injection Smooth upstroke to peak,

Temperature
designated for use with a pulmonary then gradual downslope
to baseline
artery catheter and a cardiac output Computer looks for a
computer or with iced and room-tem- smooth curve
Time
perature injectate. The closed system
also incorporates a flow-through tem- Variation in normal curve Computer extrapolates
perature probe that measures the tem- Curve downslope to calculate

Temperature
Injection area under curve
extrapolated
perature of the injectate near the site Respiratory variation
of injection. The obvious advantages Increase baseline from
recirculation of injectate
are that closed systems do not require
Time Respiratory variation
preparation of individual syringes,
eliminate inefficiencies, and reduce A
Normal high cardiac output
multiple entries into a sterile system.2
Small area under the
Temperature

Injection
curve is typical of a
Q: How accurate is the TDCO high cardiac output
method? (small change in injectate
temperature over time)
Time
The accuracy of the method is
Normal low cardiac output
related to how closely the observed
signal (ie, measurement of cardiac
Temperature

Injection
Large area under the curve
output) matches an accepted standard seen in patients with low
value. Forrester et al3 found a corre- cardiac output (greater
lation coefficient of 0.993 between a change in temperature
over time)
mechanical pump with a known flow Time
and TDCO measurements. In other Uneven injection technique
Temperature

studies4-6 with flowmeters, correlation

coefficients were 0.97 to 1.0. Other Injection
researchers have used the direct Fick Uneven upstroke on curve
method as the gold standard for meas-
Temperature

urement of cardiac output. The Fick Time

Injection
principle states that the amount of a Severe artifact on both
substance taken up by the body per upstroke and downstroke
of curve
unit of time is equal to the arterial
Time
level of the substance minus the B
Prolonged injection time
venous level of the substance multi-
Temperature

plied by the flow.6,7 Cardiac output
can be calculated by the Fick method
by dividing the amount of oxygen
consumed by the body by the arterial-
venous oxygen difference.8 Numerous
studies4,9-14 have addressed the corre-
lation between the direct Fick method
and the TDCO method. In all but 2
studies,15,16 the correlations between
Injection
Injectate delivered in over
4 seconds
10
seconds
Time
Figure 2 A, Variations in the normal cardiac output curve seen in certain
clinical conditions. B, Abnormal cardiac output curves that will produce an
erroneous cardiac output value.
Reprinted with permission from Love M, Lough ME, Bloomquist J. Cardiovascular laboratory
assessment and diagnostic procedures. In: Thelan LA, Davie JK, Urden LD. Textbook of Critical Care
Nursing: Diagnosis and Management. St Louis, Mo: CV Mosby;1990:246.

values obtained with the 2 methods

CRITICALCARENURSE Vol 24, No. 5, OCTOBER 2004 75

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ProtocolsforPractice

Q: Is the continuous cardiac out-

put (CCO) method as accurate is the
IV solution
TDCO method?
container
Clinical studies have also com-
pared the accuracy of the CCO and
IV spike
the TDCO methods. These studies
Snap Clamp are synthesized and critiqued in the
“Annotated Bibliography” section of
To continuous the research-based protocol on meas-
flush solution
urement of cardiac output.19 Although
Thermodilution the studies report good correlations
Injectate
catheter
temperature probe (0.84 to 0.94) between measurements
obtained with the 2 methods, com-
parisons between CCO and TDCO
Syringe barrel
with thermal shield
values have intrinsic methodologi-
cal issues. The TDCO method itself
is not a gold standard for measure-
ment of cardiac output. Under ideal
Right atrial Syringe plunger with circumstances, TDCO measurements
injection hub contamination sheath have a 10% error rate related to oper-
check
3-Way valve ator error, temperature transduction,
stopcock Flow-through housing
Reusable and instrument inaccuracies. Studies
injectate that compare values obtained with
probe
assembly the CCO method with values obtained
with an inaccurate gold standard such
as the TDCO method may lead to
erroneous estimation of the accuracy
Cardiac output cable of the CCO device. Further studies
Figure 3 Schematic illustration of the closed injectate delivery system for use are necessary to compare CCO values
with iced injectate for determination of cardiac output. with more precise measurement of
Reprinted with permission from Abbott Critical Care, Mountain View, Calif. cardiac output (such as those obtained
by using the Fick or the indicator-
dilution method) in a variety of criti-
were 0.91 to 0.98.6 The TDCO Several technical considerations must cally ill patients. Such confirmatory
method is an acceptable substitute be understood in order to minimize studies are necessary to verify the
for the Fick method or the indicator- the potential for error. These include accuracy of CCO technology.
dilution method. the position of the pulmonary artery Other methodological problems
Many of the derived hemody- catheter, volume and temperature of limit the generalizability of these
namic indexes and the clinical thera- the injectate, the phase in the respi- studies to other critically ill popula-
pies for critically ill patients depend ratory cycle for administration of the tions. The majority of the studies
on accurate measurement of cardiac injectate, the patient’s body position, were done during periods of hemo-
output. Critical care nurses routinely effects of concomitant intravenous dynamic stability in patients who had
use the TDCO method to measure infusions, and the effect of positive had coronary artery bypass graft sur-
cardiac output in critically ill patients end-expiratory pressure. Even under gery. Many of these studies used
and are responsible for the accuracy ideal circumstances, TDCO measure- small sample sizes (N = 12 to 35) and
and analysis of the obtained values. ments have a 10% error.17,18 multiple observations. Therefore,

76 CRITICALCARENURSE Vol 24, No. 5, OCTOBER 2004

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measurements within each study
were not completely independent
of one another. For example, if a
subject in a study had some charac-
teristic that led to errors in measure-
ment, multiple measurements in
that subject would lead to overrepre-
sentation and possibly negative bias
in the results. Using larger sample
sizes and limiting the number of
data points per patient would con-
trol for this possible variation.
Power analysis was not used to
determine appropriate sample size
(see the “Annotated Bibliography”
in the protocol19 for more details).
Rigorous studies that control for the
issues just described are needed in
critically ill patients to establish the
accuracy of newer technologies of
noninvasive measurements of car-
diac output.
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Q: What is the procedure for
obtaining a TDCO measurement?
For accurate TDCO curves, the
signal-to-noise ratio must be ade-
quate for the cardiac output moni-
tor to sense a change in temperature
over time. The signal is the tempera-
ture difference between the injectate
and the patient’s blood; the noise is
the cycling variation in blood tem-
perature. The difference between
the temperature of the injectate and
the temperature of the patient’s
blood should be 10˚C.2 Theoretically,
10 mL of iced injectate produces a
greater signal-to-noise ratio than does
10 mL of room-temperature injectate
or smaller volumes (eg, 5 mL) of
either iced or room-temperature
injectate. Use of room-temperature
injectate or smaller volumes of injec-
tate may decrease the temperature
difference (signal) and may yield erro-
neous values for cardiac output. In
most normothermic patients, 5 mL
of iced injectate can be used if fluid
restriction is warranted. Before
using a smaller volume, clinicians
must verify that the values obtained
with the smaller volume are compa-
rable to values obtained with a
larger volume.
• To ensure the validity and reli-
ability of the measurement, check
the following:
– position of the pulmonary
artery catheter,
– computation constant,
– catheter size,
– temperature of the
injectate,
– volume of injectate, 10 mL
(or 5 mL if iced), and
ProtocolsforPractice
– patient’s body position.
• Use appropriate TDCO tech-
nique:
– Inject 10 mL within 4
seconds; 5 mL, within 2 seconds.
– Administer the injectate
when the patient is at end-
expiration.
– Obtain 3 measurements.
– Assess the cardiac output
curve.
– Average values that are
within 10% of the median value.
– Starting at baseline, a
normal cardiac output curve has
a smooth rapid upstroke and a
gradual downstroke.
Q: What further research on meas-
urement of cardiac output is needed?
Although many research studies
have been done on measurement of
cardiac output and on newer meth-
ods, additional investigation and
replication are needed. Further
research is needed to do the following:
• Describe chronobiological fluc-
tuations in cardiac output.
• Determine the validity and
reliability of noninvasive methods of
measuring cardiac output, such as
Doppler flow imaging and echocar-
diography and thoracic electric bioim-
pedence, in various populations of
critically ill patients.
• Determine the validity and reli-
ability of values obtained by using
the CCO method in various popula-
tions of critically ill patients.
• Determine the effect on clinical
outcomes and cost of using CCO
versus TDCO methods in critically
ill patients.
• Replicate studies with iced and
room-temperature injectate in sub-
groups of critically ill patients, such
78 CRITICALCARENURSE Vol 24, No. 5, OCTOBER 2004
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as patients who have low ejection
fraction, low cardiac output, high
cardiac output, or hypothermia.
• Replicate studies with small
volumes of injectate in subgroups of
critically ill patients, such as patients
who have low ejection fraction, low
cardiac output, high cardiac output,
or hypothermia.
• Replicate studies comparing
the accuracy of closed system of
injectate delivery with the accuracy
of using prefilled syringes in sub-
groups of critically ill patients.
• Replicate studies in patients with
cardiac conditions in which the TDCO
method is considered less accurate but
for which cardiac output and other
hemodynamic measurements are
used, such as valvular disease (tricus-
pid regurgitation), dysrhythmias, and
dilated heart chambers with increased
ventricular dimensions.
• Replicate studies of the effects
of the patient’s body position on
TDCO measurements in critically ill
patients.
References
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J Crit Illness. 1996;11:249-256.
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Josephson ME. Multiple cardiac output meas-
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17. Moore FA, Haenel JB, Moore EE. Alterna-
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18. Burchell SA, Yu M, Takiguchi SA, Ohta RM,
Myers SA. Evaluation of a continuous car-
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Note
This article was first published in
Critical Care Nurse April 2000.
This article is based on the protocol
Cardiac Output Monitoring by
Anna Gawlinski. It was taken from
the Hemodynamic Monitoring series
(Product #170709) of AACN’s
Protocols for Practice. Protocols can
be obtained from AACN, 101
Columbia, Aliso Viejo, CA 92656-
1491, (800) 899-AACN, (949) 362-
2000. Product #170704: $11, AACN
members; $14, nonmembers.