Cardiac Output And

Hemodynamic Measurements
Iskander Al-Githmi, MD, FRCSC,
FCCP
Asst. Professor of Surgery
King Abdulaziz University

Adolf Eugen Fick ( 1829 1901)

Historical Perspective

Adolf Fick: 1829- 1901

Born in Sep. 1829, in Kassel, Germany
Earned MD in 1851
1855- Introduced a law of diffusion called
Fick law of diffusion
1870- Was the first one to develop a
technique for measuring cardiac output
Fick was died in Aug. 1901

Cardiac Cycle
Phase 1: Atrial contraction
Phase 2: Isovolum contraction
Phase 3: Rapid ejection
Phase 4: Reduced ejection
Phase 5: Isovolum relaxation
Phase 6: Rapid filling
Phase 7: Reduced filling

Cardiac output
Volume of blood ejected from left ventricle
in one minute
It is the determinant of global oxygen
transport from the heart to the body
It reflects the efficiency of cardiovascular
system
There no absolute value for cardiac output
measurement

Cardiac output influencing factors

Ventricular Preload
- Volume of blood in the ventricle at the end of
diastole
- Any changes in the ventricular preload will affect
the ventricular stroke volume

Cardiac output influencing factors

Ventricular Preload

Frank- Starling Mechanism

The ability of the heart to change its force
of contraction and therefore stroke volume
in response to changes in venous return
I.E ( the greater the diastolic volume or fiber
stretch at the end of diastole the stronger
the force of contraction at systole
The force of contraction will decline once
this physiological limit has reached

Frank-Starlings Mechanism

Cardiac output influencing factors

Preload assessment
It has been very difficult to measure the fiber
length or volume at the bedside
It is clinically acceptable to measure preload as
a pressure.
CVP is used to evaluate right ventricular preload
Pulmonary artery diastolic pressure or PCWP
are used to evaluate the left ventricular preload

Cardiac output influencing factors

Contractility
Increased contractility, will shift Starlings curve
to the left
Decreased contractility will shift Starlings curve
to the right

Cardiac output influencing factors

Assessment of contractility
Stroke volume (SV)
SV = EDV - ESV
Stroke volume index (SVI)

SVI = CI / HR
Left ventricular stroke work index
LVSWI = MAP PCWP x SVI x (0.0136)

Cardiac output influencing factors

Afterload
Related to ventricular wall stress

Laplace Law:
Tension (T)= Pr/t
Afterload per se does not
Alter preload

Clinical Measurement of Afterload

Right ventricular afterload
- Pulmonary vascular resistance (PVR)
- PVR = MPAP- PAWP / CO x 80
- Normal:< 250 dynes/ sec /cm-5

Clinical Measurement of Afterload

Left ventricular afterload
-Systemic vascular resistance (SVR)
-SVR = MAP- RAP / CO x 80
Normal: 800 1200 dynes / sec / cm -5

Ventricular compliance
Compliance = V/P
Given a change in the pressure cause a change
in the volume

Ejection Fraction
Is a fraction of blood ejected by the ventricle
relative to its end-diastolic volume

EF= SV / EDV. 100

Ejection fraction is used as a clinical index to
evaluate the inotropic status of the heart

Methods of calculating and measuring

cardiac output
Simple method:
CO = SV x HR
SV = 2ml x pulse pressure
CO = [2ml x pulse pressure] x HR

Methods of calculating and measuring

cardiac output
Fick Principle: gold standard
CO = VO2 / O2 art O2 ven
Arterial O2 = Hb x 1.34 x O2 sat.
Venous O2 = Mixed venous blood
VO2 = Oxygen consumption

Fick Principle relies on the total uptake of a substances by

peripheral tissue is equal to the product of blood flow to the
peripheral tissue and arterial venous concentration difference of
the substances
Fick cardiac outputs are infrequently used because difficulties in
collecting and analyzing exhaled gas conc. In critically ill patients
because may not have normal VO2 value

Methods of calculating and measuring

cardiac output
Thermodilution Method
Based on how fast the flowing blood can dilute
the substances introduced into the circulation
Stewart-Hamilton Equation:
CO = I x 60 / cm x t x 1/k

Area under the curve is inversely proportion to

the rate of blood flow. This flow is equivalent to
cardiac output in the absence of shunt

Methods of calculating and measuring

cardiac output
Thermodilution Curve

Thermal dilution method

Limitations
Affected by the phase of respiration and should
be measured at the same point of respiratory
cycle
Variations in the speed of cold water injection
can result in altered measurement

Non Invasive Methods

Doppler Method
Based on measuring the length of blood flowvelocity in the ascending aorta in unit time.
Multiplied by the cross- sectional area of the
aorta to give stroke volume. Multiplied to heart
rate to give cardiac output.

Methods of calculating and measuring

cardiac output
Impedance plethysmography
This technique was developed by NASA.
Cardiac output can be measured across
externally electrodes. It measures a changing
impedance in the chest (blood volume). The rate
of change of impedance is a reflection of cardiac
output.
CO = Art. BP / total peripheral vasc. resistance

Questions
Question 1
During a cardiac output reading the thermistor of
the PAC measures the temperature of the:
a. Blood
b. Injectate
c. Pulmonary artery blood
d. Mixing of blood and injectate

Questions

Question 2

Which of the following statements is correct

As it relates to cardiac output curve ?
a. The larger the curve, the larger the output
b. The smaller the curve, the smaller the output
c. The larger the curve, the smaller the output

Questions

Question 3

When patients take a spontaneous breath,

Venous return and cardiac output:
a. Increase
b. Decrease

Questions
Question 4
A 50- year-old male with myocardial ischemia presents with
the following:

HR 128 BPM
CO 6.2 L/min
MAP 88 mmHg
SVO2 51%
CVP 6 mmHg
PAWP 16
SaO2 94%

Is the cardiac output for his tissue is adequate ?

Questions
Question 5
Same patient after treatment with NTG and morphine, his
numbers are as follow:

HR 115 BPM
CO 5.1L/min
MAP 84 mmHg
PAWP 13 mmHg
SVO2 61%
CVP 5 mmHg
SaO2 95%

Is he better or worse ?