Non invasive cardiac output

monitoring
• Adolph Fick described the first method of CO
estimation in 1870.
• Thermodilution PAC is used till a decade ago for
continuous real time cardiac output monitoring.
• CO measurement with a PAC using the bolus
thermodilution method has become the gold
standard for measuring CO and is the reference
standard to compare non invasive technologies.
• 1997 , a consensus statement concluded that there is
no basis for pulmonary catheter use .

• Complications associated with invasive techniques led

to development of newer non invasive means of
hemodynamic monitoring.

• Bland Altman method is frequently used to evaluate

these methods against to a reference.
• Correlation coefficient , ROC , 4 quadrant plot are other
methods.
 Ficks principle
• Total uptake or release of a substance by an
organ is the product of the blood flow to the
organ and the AV concentration difference of
the substance.
• Vo2 = CO x Cao2 – Cvo2
• CO = Vo2
Cao2 – Cvo2
 CO measurement by Rebreathing
technique
• CO = Vco2
Cvco2 – Caco2
• Vco2 is simply measured by ETco2.
• Caco2 by ABG.
• Cvco2 is difficult to measure . By using partial
rebreathing technique and law of ratios ,
Cvco2 in the equation gets cancelled, so no
need to measure it .
• Rebreathing is done by introducing additional
150 ml of dead space into the ventilator circuit
for a brief period of 50 seconds.
• NICO – Respironics is the device that
measures CO based on this principle.
NICO - Respironics
 CO2 difference during Rebreathing
and Non rebreathing.
• Indirect Fick equation with rebreathing (r) and
with out rebreathing (n) .
• CO = Vco2
Cvco2 – Caco2
• CO = Vco2n – Vco2r
(Cvco2n – Caco2 n) – (Cvco2r – Caco2r)

• CO = Change in Vco2
Change in Caco2
 Several technical problems exist with
this method ...
• Difference between venous and arterial CO2 is
only about 6 , small errors in measurement of
these values leads to large change in calculated
CO.

• It only measures pulmonary capillary blood flow .

Intrapulmonary shunt and Qs/Qt must be added
to get total CO.
• NICO system estimates Qs/Qt using shunt fraction
algorithm using spo2 and fio2.
 Other limitations
• Validated in deeply sedated mechanically ventilated
patients , even in whom , the agreement with
thermodilution CO varied from poor to acceptable.

• In spontaneously breathing patients , rebreathing is

associated with increase in minute ventilation ,
reducing the accuracy of CO estimation.

• Animal Studies on injured lungs showed poor

correlation in comparison with standard technique.
• Routine use of this method is not recommended.
 Pulse Contour Analysis
• Wessling and colleauges in 1983 , developed
an algorithm to continually monitor CO ,based
on analysis of contour of arterial pressure
waveform.
• This Contour is proportional to stroke volume ,
estimated by integral of change in pressure
from end diastole (t0) to end systole (t1) over
time . t1
SV = dP/dt
t0
Z
• Z is dependent on CO and individual elastic
properties of aorta at that particular time.

• To determine the individual impedance at any

one point , CO must be determined by
another method and is used to calibrate the
pulse contour device.
 Categories of pulse contour analysis
systems
1. Those requiring an indicator dilution CO
measurement to calibrate – LIDCO system ,
PiCCO system .
2. Those requiring patient demographic and
physical characteristics for arterial
impedance estimation – FloTrac system .
3. Those that do not require calibration or
preloaded data – Most Care system
• Important factor when using pulse contour
systems – site where BP is measured .
• Picco manufacturer recommends axillary or
femoral artery .
• Radial artery use has not been validated and it
may not truly reflect aortic pressures causing
falsely low CO values.
 LIDCO system
• Lithium chloride is injected into central/peripheral
vein and lithium is measured with a sensitive
electrode in the peripheral arterial system .

• Lithium dilution curve is constructed and CO is

calculated acc. To
• CO = LiCl x 60
Area x (1 – PCV)
• This CO value is used to calibrate the pulse
contour device.
 LIDCO system
• LIDCO system combines pulse contour analysis
with lithium indicator dilution for continuous SV
and SVV monitoring .

• Arterial pressure waveform is interpreted as a

continuous curve describing in arbitrary units to
make it into a standardised volume waveform.
• Effective value of this wave form is determined
using root mean square to obtain nominal SV
which is then calibrated to give actual SV.
LIDCO
 LIDCO validation

• CO values derived from LIDCO correlate well

with PA thermodilution and transpulmonary
thermodilution measurements.
PiCCO
 PICCO – Pulse index Continuous
Cardiac output monitor
• Measures and integrates wide array of
hemodynamic variables by combining pulse
contour analysis with transpulmonary
thermodilution method.

• 3 main components – Arterial catheter with

thermistor tip , injection device connected to
distal lumen of central venous catheter , user
interface monitor.
• Femoral artery and IJV/SC vein preferred sites.
• SV by continuous pulse contour is derived
from Area under systolic portion of arterial
wave form . In addition , shape of arterial
wave form , arterial compliance , SVR , and
patient specific calibration factor are taken
into account .
• Trans pumonary thermo dilution CO
measurement is used for Picco calibration.
Pulse contour analysis - PiCCO
 Transpulmonary thermodilution
• Cold 0.9 NS , 15 – 30 ml , optimal temperature of
<8oC.

• Cold injectate is delivered via central venous

catheter and mixing of thermal indicator occurs
as it passes from right atrium till aorta.

• Thermister in the femoral arterial line quantifies

the change in temperature over time. On plotting
both , Area under this curve derives CO.
 Transpulmonary thermo dilution
• Like PA thermodilution technique , this method
uses Stewart Hamilton equation , to estimate CO .
• CO = (Ta – Tb) x Vi x K
dT/dt

• Ta = temperature before injection ,

Tb = temperature after injection , K = constant
Vi = volume of injectate ,
dT/dt = change in temperature per change in time .
 Transpulmonary thermodilution
• It measures left sided CO , versus PA
thermodilution technique , which measures
the right sided CO.

• This method is less affected by respiratory

variation and results had good correlation
with PA method on validation.
• Calibration repeated every 8 hours or
following a major change in clinical condition
Picco parameters
 PICCO parameters
• Trans pumonary thermodilution indicator time
curve measures these parameters
intermittently –
CO , EVLW , GEDV , ITBV , CFI , GEF .

• Pulse contour analysis provides continuous

estimation of Stroke volume , CO , SVR, PPV ,
SVV , LV contractility index ., Scvo2.
PICCO Parameters
 PiCCO - Goal directed use
• In an attempt to provide an appropriate
response to the displayed values , A decision tree
model has been proposed by the manufacturers .

• Clinical response is divided into – Expectant ,

volume loading , volume reduction , use of vaso
active medication.
• This structured approach couples standardised
interventions to specific data patterns , but needs
to be correlated in clinical context.
 Picco Validation
• Most studies showed excellent correlation
with PA thermodilution , including in patients
with ARDS.

• With significant change in hemodynamics ,

however , values by both these methods
diverged , suggesting the need for frequent
recalibration while using Picco ,during times of
hemodynamic instability , to minimise errors.
FloTrac system
 Flotrac system
• SV = SD (AP) x X .
• Arterial pressure waveform is sampled each
20 seconds at 100 Hz resulting in 2000 data
points .
• SD(AP) is the standard deviation of these data
points ,reflecting pulse pressure.
• Factor X is conversion factor depending on
arterial compliance , MAP , wave form
characteristics ( skewness , kurtosis ) .
 Limitations
• Does not track changes in SV accurately after a
volume challenge or after vasopressors .

• Comparison studies are not very satisfactory ,

though 3 rd generation software devices claim
to be better .
Pressure recording analytic method
(PRAM)
Comparison of pulse contour devices
• Hadian et al have done cross comparison of
Lidco , Picco , FloTrac systems , compared with
Pac Thermodilution technique. , which
showed Lidco , picco performances were
adequate while FloTrac was suboptimal .

• Picco system accurately tracked changes in

volume and Norepinephrine induced cardiac
index.
 Esophageal Doppler
• A doppler transducer placed at the tip of a
flexible probe is introduced into esophagus .
• Probe is rotated ,so that transducer faces
descending aorta and a characteristic aortic
velocity signal is obtained.
• This technique measures blood flow velocity
in the descending aorta.
• Descending aorta is similar to a cylinder .
• Flow in cylinder = cross sectional area x velocity of
fluid in cylinder .
• Area is given by aortic diameter , measured or
estimated value based on age .
• Velocity is integral of volume change ( dV/dt) from T1
to T2 ( onset of flow to end of flow)
• Termed as Velocity time integral ( VTI ) .

• SV = Cross sectional area x VTI

• CO = SV x HR
• Problems –
• Descending aorta receives only a portion of CO ,
so its only an estimate.
• Positioning of probe to obtain optimal signal –
poor positioning leads to underestimation.

• Assumption that a fixed percentage of CO is

directed to the head and descending aorta ,
which may not be true always with varying
hemodynamics.
 USCOM
• Completely Non invasive , uses trans aortic or
transpulmonary doppler U/s flow tracings .

• Aortic outflow tract area is calculated from a

proprietary anthropometric algorithm based on
height.
• Stroke distance = distance an RBC travels per
systolic stroke . Measured as VTI of doppler flow
profile of each systolic stroke .
• CO = Area x VTI x HR.
• Comparison studies showed mixed results .
• Operator dependent .
• Good flow signal has to be obtained , and
properly interpreted or it will lead to sub
optimal VTI measurements.
 Thoracic Bioimpedence systems
• High frequency electric current of known
amplitude is applied across thorax and
electrical resistance of thorax is measured,
TEB – Thoracic electrical bioimpedence (Zo)

• TEB is inversely proportional to the content of

thoracic fluids . Instantaneous rate of change
of impedance is related to the blood flow in
the aorta.
• SV is proportional to the product of rate of
change of Zo and Ventricular ejection time .

• However , readings are inaccurate in patients

with increased lung water , significant electric
noise and body motion .
• It is sensitive to placement of electrodes on
body , variations in body size , temperature ,
humidity .
 Validation of Bio impedence

• Poor correlation between TEB derived CO

and PAC thermodilution.

• Because of limitations of bioimpedance

devices , newer methods of processing the
impedance signal have been developed.
 BIOREACTANCE
• NICOM device – measures bioreactance or the
phase shift in voltage across the thorax.

• Thorax is an electrical circuit with a resistor (R)

and a capacitor (C) which create thoracic
impedance (Zo) .

• R and C determine the amplitude and phase of

impedance . Pulsatile ejection of blood from
heart modifies R &C leading to instantaneous
changes in amplitude and phase of Zo.
• Phase shifts can occur only because of pulsatile
flow , that stems from aorta.

• Since underlying thoracic fluid is static , it will not

induce any phase shift and do not contribute to
NICOM signal .

• SV = C x VET x rate of phase shift .

• Unlike Bioimpedence , result does not depend on
distance between electrodes .
Bioreactance
 Bioreactance
• Can be used in ventilated or nonventilated
patients , can compute CO inpatients with
arrythmias , easy to set up and use.
 NICOM
monitor
algorithm -
Hemodynamic
management
of peri
operative
patients
Algorithm
for Septic
patients
 Validation
• Highly correlated with values measured by
thermodilution and pulse contour analysis .

• Good concordance was found regarding fluid

responsivenes in comparison with carotid flow
dopper and esophageal doppler.
Echo - Plax view
Plax view
Plax view
Cardiac out put measurement by echo
Apical 5 chambered view
Apical 5 chambered view
Echocardiography
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