METHODS

OF MEASSURING
CARDIAC OUTPUT

Yohanes George
THE JUNGLE OF THE CARDIAC OUTPUT
MONITORING
 THE COMMONLY EMPLOYED REFERENCE
TECHNIQUES FOR CO ASSESSMENT
BASED ON INVASIVENESS

Invasive

1. Fick Method 2. Indicator Dilu:on Method

Physiology Clinical Prac/ce
 THE COMMONLY EMPLOYED REFERENCE
TECHNIQUES FOR CO ASSESSMENT
BASED ON THE METHODS

Method

1. Meassurement 2. Calcula:on
•  Direct meassurement Fick’s Method §  Ultrasound
•  Indicator Dilu:on Methods: •  Echocardiography
–  Transcardiac Indicator Dilu:on •  Doppler technology
technique –  Pulse Countour Analysis
–  Transpulmonary Indicator Dilu:on –  Bio-impedance
technique –  Bio-reactance
–  Electrical Cradiometry
CARDIAC OUTPUT ASSESSMENT BASED ON THE
METHODS
Method System Preload and LimitaHons
AddiHonal variable
Transcardiac PA catheter PAOP, PAP, SvO2 Invasiveness,
Thermodilu:on Catheter Ccombo RVEF, RVEDV Training required
Transpulmonary PiCCO GEDV, EVLW, SVV, PPV Invasiveness,
Indicator Dilu:on LiDCO Need for dedicated
(calibrated) catheter
Arterial-pressure Vigileo SVV, dP/dT, CCE, PPV, Need for op:mal arterial
waveform derived MostCare SVV signal
(not calibrated)
Doppler’s principle Esophageal CardiacQ Ftc, peakV Par:al meassurement of
Suprasternal USCOM CO
Es:ma:on of AoCSA
Fick’s principle NiCO Shunt calcula:on Intubated pa:ents
Less reliable in
respiratory failure
Bioimpedance Lifegard, TEBCO None Not applicable in
cardiothoracic surg
MEASSUREMENT:
1. Fick’s
2. Indicator Dilu4on
 1. Fick’s Method
(Invasive Method)

•  1870, Adolf Fick

•  Cardiac output can be computed as follows:

Cardiac output CO = VO2

(CaO2 - CvO2)
2. Indicator DiluHon Method
(Indocyanin green)
•  A cardiac output meassurement by indicator dilu:on has three
principal phases:
a)  an indicator is brought into the circula:on (injecHon)
b)  the indicator mixes with the bloodstream (mixing and diluHon)
c)  the concentra:on of the indicator determined downstream (detecHon)

Researches on the circula:on :me and on the influences which affect it. IV. The output of the heart.
Stewart GN. Physiol 1897; 22: 159-83
 Stewart Hamilton Formula

•  Stewart assumed in his formula that the indicator

concentraHon at the collecHon site rises and declines in a
stepwise manner over the collec:on interval
 ThermodiluHon, 1970’s

Pulmonary Artery Catheter Dr. William Ganz, a

(Swan-Ganz Catheter) cardiologist (1919-2009)
ThermodiluHon method with bolus
injecHon of cold fluid

Following the introduc:on of the pulmonary artery catheter

(PAC) into clinical prac:ce, the single-bolus thermodilu:on
measurement of cardiac output has been widely accepted as
the “clinical standard” for advanced hemodynamic
monitoring.

•  CatheterizaHon of the heart in man with use of a flow-directed balloon-Hpped catheter. Swan HJ, Ganz W,
Forrester J, Marcus H, Diamond G, Chonebe D. N Engl J Med 1970;283: 447-51
•  A new technique for measurement of cardiac output by thermodiluHon in man. Ganz W, Donoso R, Marcus
HS, Forrester JS, Swan HJ. Am J Cardiol 1971; 27: 392-6
 The principle of ThermodiluHon
(TD)
•  The thermodilu:on method adapts the indicator-dilu:on principle to
injectates that cause changes in blood temperature detected
downstream
•  An injectate of known volume and temperature is injected into the right
atrium and the cooled blood traverses a thermistor in a major vessel
branch downstream over a dura:on of :me
•  The cardiac output is inversely propor:onal to the mean blood-
temperature depression and the duraHon of transit of cooled blood (i.e.
area under the curve)
 Methods of ThermodiluHon
Techniques
1.  Transcardiac:
1.  PAC thermodilu:on method with bolus injec:on of cold fluid
2.  PAC conHnuous thermodilu:on method (Edward Ccombo)

2.  Transpulmonary:
1.  bolus thermodilu:on method (PiCCO)
2.  lithium bolus dilu:on method (LiDCO)
1. Transcardiac
1.  Transcardiac PAC thermodiluHon method with
bolus injecHon of cold fluid

The introduc:on of the cold injectate causes a rapid upslope to a peak, a gradual
downslope, and an exponen:al decay of the thermal signal. The CO computer begins
integraHon of the area under the TD curve un:l the exponen:al decay reaches a value
of about 30%, and extrapolates the exponen:al decay to baseline in order to minimize
ar:facts due to recircula:on of the indicator.
 Hemodynamic Data Provided by
Pulmonary Artery Catheter

Direct Derived
Cardiac output Vascular resistance:
-  Pulmonary
-  systemic
Mixed venous O2 sat Stroke-work index
Vascular Pressure: Arterio-venous O2 content
-  Right Atrium differences
-  Right ventricle
-  Pulmonary Artery
-  Baloon occlusion (wedge)

 Shock classificaHon has
dramaHcally change
MAP PAWP CO SVR

HYPODYNAMIC

- Hypovolemic: hemorrhage, dehydration ↓↔ ↓ ↓ ↑

- Cardiogenic: myocardial infarction ↓ ↑ ↓ ↑
- Obstructive: pulmonary embolism, pericardial ↓ ↔↑ ↓ ↑
tamponade, tension pneumotoraks
HYPERDYNAMIC

- Distributive sepsis, adrenal insuficiency, ↓ ↔↓ ↔↑ ↓

anaphylaxis
How to do ThermodiluHon CO
Post CABG with PA Catheter inserted through Internal
Jugular Vein
Injecting…
2. Transpulmonary
 2. Transpulmonary bolus thermodiluHon method
(PiCCO & LiDCO)
Transpulmonary thermodilu:on measurement simply requires the central venous
injec:on of a cold (< 8°C) or room-tempered (< 24°C) saline bolus…

CV Bolus
InjecHon
Lungs
Right Leo Heart
Heart
PiCCO Catheter
e.g. in femoral artery
(thermosensor)
The difference between PiCCO and PAC

(PAC) (PiCCO)
 DETERMINATION OF CARDIAC OUTPUT PICCO
USING THE STEWART HAMILTON EQUATION

Aoer central venous injec:on of the indicator, the thermistor in the :p of

the arterial catheter measures the downstream temperature changes
The cardiac output is calculated by analysis of the thermodiluHon curve
using a modified Stewart-Hamilton algorithm:

-Tb InjecHon (Tb − Ti ) ⋅ Vi ⋅ K

C.O. =
∫ ΔTb ⋅ dt

t
 TRANSPULMONARY BOLUS
Configuration
THERMODILUTION METHOD
CV
1.  Central venous line (CV)
A
2.  Thermodilution catheter with B
lumen for arterial pressure
measurement
I.  Axillary (A)
II.  Brachial (B) R
III.  Femoral (F)
IV.  Radial (R), long catheter F

3.  Arterial pressure transducer

PiCCO catheter
PiCCO Catheter
T1
Thermistor/Temp.
Sensor
T2
PiCCO catheter
inserted
How to do PiCCO
ThermodiluHon
 T1 =
ThermodiluHon
sensor in distal
lumen of CVC

Inject the cold

Injectate 15 ml
within 3 second

T2 = Thermistor
PiCCO catheter at
Brachial artery
 PiCCO 1
Installed
Philips
Monitor 3 trials

PiCCO
Cardiac Output
ThermodiluHon
Curve
PICCO THERMODILUTION IN ICU
PICCO THERMODILUTION
INTRAOPERATIVE
DETERMINATION OF CARDIAC OUTPUT LiDCO
USING THE STEWART HAMILTON EQUATION

-Tb InjecHon (Tb − Ti ) ⋅ Vi ⋅ K

C.O. =
∫ ΔTb ⋅ dt

t
 CALCULATION:

Minimally Invasive Monitoring Cardiac
Output
 Arterial-pressure
waveform derived
Cardiac Output
(Pulse Contour Method = PCM)
Arterial Pulse Contour Analysis as a basis for Cardiac
Output measurement

1.  Arterial pulse contour analysis provides con:nuous beat-by-beat parameters

obtained from the shape of the arterial pressure wave.
2.  The algorithm is capable of compu:ng each single stroke volume (SV)

Stroke Volume Stroke Volume

Area Under
Curve (AUC)
P [mm Hg]

t [s]

SV x HR = Cardiac Output
The Methods of Pulse Contour
Technique
1.  Requiring external calibra:on:
1.  LiDCO (Lithium indicator CO)
2.  PiCCO (Pulse indicator Con:nuous CO)
2.  Without external calibra:on:
1.  Vigileo
2.  MostCare
The CalibraHon
every 8 hours
 1. PCM requiring
external calibration

LiDCO PiCCO
EV1000 – Edwards lifescience

Similar with PiCCO system

Transducer
“VolumeView”
Set
“VolumeView”
Catheter
EV1000 Monitor
2. PCM without external calibraHon

Vigileo MostCare
(Flotrac) (PRAM)
 1. Vigileo
FlowTrack System
 THE FLOTRAC SYSTEM

Vigileo Monitor FloTrac Sensor

2. MostCare
 CALCULATION:

Non-Invasive Monitoring Cardiac
Output
Impedance Cardiography (ICG)
•  Current is Transmised Through the
Chest
•  Current Seeks Path of Least Resistance:
The Blood Filled Aorta
•  ICG Measures the Baseline Impedance
(Resistance) to this Current
•  With Each Heartbeat, Blood Volume and
Velocity in the Aorta Change
•  ICG Measures the Corresponding Change
in Impedance
•  ICG Uses the Baseline and Changes in
Impedance to Measure and Calculate
Hemodynamic Parameters
Esophageal Doppler Technology
 USCOM Monitor
Suprasternal Doppler Parasternal Doppler

HR, SV,
CO, SVR
FTc, PV, SD,
Bio-reactance Cardiography, Cheetah
NICOM
Cardiac Output Using
Echocardiography:

1. 2-D Method
2. Doppler Method
 1. CO using 2-D Method
Principle:
Stroke volume= End diastolic volume – End systolic volume

EDV (150 ml) – ESV (52 ml) = SV 98 ml

 2. CO using Doppler Method
Principle
Flow (stroke volume)=Area * Velocity Flow Velocity at LVOT
CO=Stroke volume * Heart rate Pulsed wave Doppler at LVOT in
Area of leo ventricular ouulow tract (LVOT) apical 5 chamber view
Obtain LVOT dimension in parasternal long axis view

D=2.1 cm
Velocity :me integral 25 cm
Simplified formula= (2.1cm)2 * 0.785

3.46cm X 25cm = 87 cm3

2
LimitaHon of Echocardiography

•  Volume Measurement Dependent Upon Endocardial

Visualiza:on
•  Doppler Flow measurement less accurate if Aor:c
Regurgita:on
•  Not validated in pa:ents with shock
•  Strong operator dependence
Electrical Cardiometry
CO using Cardiometry
CO USING CARDIOMETRY
The Parameters
 HOW TO USE GDT WITH
CARDIOMETRY
Cardiac index

SVRI Aperload

FTc Preload

(SI) Stroke Volume

(ICON) ContracHlity
71 THN, POST HEMORAGIK SHOCK KRN GI BLEEDING EC ULKUS
DUODENUM. HARI KE 3 SETELAH GASTROSKOPI, DILAPORKAN
HIPOTENSI, TANPA TOPANGAN KATEKOLAMIN.
 Hypovolemia
state

Very low cardiac

index
Overshoot SVRI à high blood
pressure
Low FTc/preload

Low Stroke Volume

Normal index of
contracHlity
Male 60 yo, admibed to coronary care unit due to severe
hypertension immediate post stenHng at Lcx and didn’t response to
Nitroglycerine iv 30 and captopril 12.5. No dyspnea, conscious.

CXR pre-procedure; No lung edema,

Cardiomegaly
 Meassuring cardiac
output non-invasively
 Very low cardiac
index

Overshoot SVRI à high

blood pressure

Slightly low
preload

Very low Stroke

Volume

Very low index

of contracHlity
 Normal cardiac
index

Very low SVRI

Vasopressor
Normal preload
No fluid loading

Low Stroke
Volume

Normal index of
contracHlity
 Conclusion
•  Monitors associate with inaccuracies, misconcep:ons and
poorly documented benefits.
•  A good understanding of the pathophysiological
underpinnings for its effec:ve applica:on across pa:ent
groups is required.
•  Func:onal hemodynamic monitors are superior to
conven:onal filling pressure.
•  The goal of treatments based on monitoring is to restore the
physiological homeostasis.
Thank you