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REVIEW

URRENT
C
OPINION

The accuracy of noninvasive cardiac output


and pressure measurements with finger cuff:
a concise review
Koen Ameloot a,b, Pieter-Jan Palmers a,b, and Manu L.N.G. Malbrain c,d

Purpose of review
The present review aims to summarize literature on the accuracy of the finger cuff method to measure
cardiac output (CO) and blood pressure, its ability to track hemodynamic changes, and to predict fluid
responsiveness.
Recent findings
Finger cuff is an easy-to-use hemodynamic monitoring technique. Different devices are currently available,
which provide continuous arterial blood pressure (Finapress), whereas only ClearSight (previously known
as Nexfin; BMEYE) provides an estimate of CO. In most studies, the criteria for clinical interchangeability
(for CO) were not met, when compared with the currently used invasive monitoring systems such as
uncalibrated CO via a radial artery line, and calibrated CO either via a pulmonary artery catheter or a
femoral artery catheter connected to the PiCCO (Pulsion Medical Systems) or VolumeView (Edwards
Lifesciences) devices. In particular, ClearSight obtained CO seems to be less accurate in patients with a
low CO. However, in most patients, ClearSight is able to track hemodynamic changes induced by a fluid
challenge or passive leg raising test. We will discuss in this review the relevant literature with regard to
validation of the finger cuff technique for both arterial blood pressure and CO.
Summary
The finger cuff method provides a reasonable estimate of CO and blood pressure, which does not meet the
criteria for clinical interchangeability with the currently used invasive devices.
Keywords
blood pressure, cardiac output, finger cuff, hemodynamic monitoring, noninvasive, thermodilution

INTRODUCTION
Global hemodynamics may change on a minute-tominute basis in critically ill patients. Therefore,
continuous hemodynamic monitoring is of paramount importance [1]. In addition, continuous
hemodynamic monitoring is crucial for real-time
monitoring of the hemodynamic effects of ongoing
therapeutic interventions. Many intensive care
physicians use either a pulmonary artery catheter
(PAC) in combination with an arterial line or a
device based on transpulmonary thermodilution
with either the PiCCO system (PiCCO2; Pulsion
Medical Systems, Munich, Germany) or the VolumeView (Edwards Lifesciences, Irvine, California,
USA) as golden standard to guide fluid resuscitation
and to adjust inotropic and vasopressive agents
[2,3 ]. However, both PiCCO and PAC require invasive catheters and therefore increase the risk of
iatrogenic complications such as pneumothorax,
&&

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bleeding, catheter sepsis, and deep venous thrombosis [4]. Moreover, the setup of both systems is time
consuming, they are cost intensive, and cannot be
used prehospital or on a regular ward. Currently,
different devices are available using the finger cuff
method to measure arterial blood pressure continuously (CNAP, FinaPress, ClearSight), whereas some
of these devices also have the possibility to monitor

Department of Cardiology, bDepartment of Intensive Care, University


Hospitals Leuven, Leuven, cDepartment of Intensive Care and
d
Department of High Care Burn Unit, Ziekenhuis Netwerk Antwerpen,
ZNA Stuivenberg, Antwerp, Belgium
Correspondence to Dr Manu L.N.G. Malbrain, MD, PhD, ICU and High
Care Burn Unit Director, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, Lange Beeldekensstraat 267, B-2060 Antwerp 6 Belgium. Tel: +32
3 217 7399; fax: + 32 3 217 7574; e-mail: manu.malbrain@skynet.be
Curr Opin Crit Care 2015, 21:232239
DOI:10.1097/MCC.0000000000000198
Volume 21  Number 3  June 2015

Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.

The accuracy of noninvasive cardiac output and pressure measurements with finger cuff Ameloot et al.

KEY POINTS
 The finger cuff method provides a reasonable estimate
of cardiac output and blood pressure, which does not
meet the criteria for clinical interchangeability with the
currently used invasive devices.
 ClearSight can be applied for an initial quick
hemodynamic assessment as a bridge to installation of
a more advanced invasive monitoring system.
 ClearSight showed some accuracy to track the
hemodynamic changes induced by fluid loading or
pharmacological interventions.
 ClearSight obtained SVV/PPV shows a correlation with
PiCCO as predictors of volume responsiveness.

cardiac output (CO). The ClearSight (BMEYE,


Amsterdam, the Netherlands) device is the most
widely studied in critically ill patients and is a totally
noninvasive continuous blood pressure and CO
monitor based on finger arterial pressure pulse contour analysis. Potential advantages include its noninvasiveness and ease of use. Questions arose on the
accuracy of ClearSight measurements in critically ill
patients, as there is no initial calibration of the
monitoring system to adjust for the unique mechanical properties of each patients arterial tree.
Moreover, there are concerns about the reliability
of continuous noninvasive finger cuff blood pressure derived pulse contour analysis in critically ill
patients with reduced perfusion of the hand because
of high systemic vascular resistance or hypothermia
or even peripheral edema [5 ,6]. The aims of this
review are to summarize current literature on the
basic principle of finger cuff blood obtained continuous pressure and derived CO via pulse contour
analysis, the feasibility of ClearSight in critically ill
patients, the accuracy of ClearSight to measure CO
and blood pressure, the ability of ClearSight to track
hemodynamic changes, and predict fluid responsiveness and finally to review the potential fields
of application in critically ill patients. We will focus
on the ClearSight device as it has been most
widely studied.
&

BASIC PRINCIPLES OF THE FINGER CUFF


METHOD
The ClearSight (BMEYE) method is based on the
measurement of finger arterial pressure by an inflatable cuff around the middle phalange of the finger
(Fig. 1). The pulsating finger artery is clamped to a
constant volume by applying a varying counter
pressure equivalent to the arterial pressure using a

FIGURE 1. The ClearSight device with wrist unit connected


to the finger cuff with screenshot of arterial blood pressure
curve and trending analysis (circle).

built-in photoelectric plethysmograph and an automatic algorithm (Physiocal). The resulting finger
arterial pressure waveform is reconstructed into a
brachial artery pressure waveform by a generalized
algorithm. CO is calculated by a pulse contour
method (CO-TREK), using the measured systolic
pressure time integral and the hearts afterload
determined from the Windkessel model [7].

FEASIBILITY IN CRITICALLY ILL PATIENTS


ClearSight measurements are feasible in the
majority of ICU and operating room patients
(between 85 and 100%) [5 ,813]. Many authors
reported failure of the device to measure pressure
at any of the fingers in patients with an extreme low
flow in the finger arteries. In addition, we previously
reported a short time to first measurement (<5 min
in 85% of patients), a limited number of repositions
needed to start measuring and high scores on the
nurse questionnaires, illustrating that the device is
very easy to use (plug and play) in the majority of
patients [5 ].
&

&

ACCURACY OF CARDIAC OUTPUT


MONITORING
ClearSight CO has been studied against several
golden standard techniques including PiCCO,

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233

234

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Scientific World
Journal 2013

Anesth Analg
2013

Acta Anesth
Scand 2013

Anesthesia 2012

J Clin Anesth 2012

Br J Anesth 2012

Crit Care 2012

Anaesthesia 2010

BMC Anesthesiol
2009

BubenekTurconi

Fischer

Broch

Chen

Fischer

Monnet

Bogert

Stover

Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.


PiCCO

[15]

[20]

[11]

[12]

[16]

[14]

[18]

[17]

PAC

PAC

PiCCO

PiCCO

TEE

PiCCO

PiCCO

PAC

PiCCO

&

[8]
[5 ]

PAC

ICU, surgical

ICU, postcardiac

ICU, mixed

ICU, postcardiac

ICU, noncardiac

OR, elective cardiac

ICU, postcardiac

ICU, postcardiac

ICU, mixed

ICU, postcardiac

OR, elective
cardiac

Golden
standard Setting

365

10

25

38

44

25

40

37

28

45

20

53

Bias

NA

NA

NA

NA
7.2  2.3 0.91

5.5  1.4

6.8

5.0  1.2 0.56

4.7  1.8 0.91

4.8  1.2 0.82

4.9  1.1 0.71

6.2  2.1 0.82

NA

0.71

0.10

0.33

0.23

0.44

0.4

0.02

0.88

0.2

0.21

0.05

0.4

0.26

5.2  0.8 0.53 0.35

1094 5.4  1.6 0.79

80

25

76

120

66

80

74

47

135

20

371

Patients Pairs Average


(n)
(n)
CO

29

29

57

50

37

24

56

39

36

39

58

PE

1.22

44

1.15 41.3

1.05

0.81

2.00

1.2

0.86

0.6

1.29

1.05

1.16

1.1

1.5

SD
bias

0.67

0.01

1.18 56

0.14

1.35 55
0.31 1.70 62

3.9  1.4 0.89

After phenylefrine

0.74
5.4  1.7 0.92

5.3

0.9

NA

NA

Baseline

After CPBP

5
4.3

After fluid
Before CPBP

4.1

Baseline

0.7

5.6  1.3

After fluid

1.05

0.75

0.2

0.2

0.01

0.4

0.00

0.1

38

33

26

23

0.83 42

0.9

0.7

0.5

1.45 58

1.12 55

1.1

1.00 39

7.0  2.1 0.76 0.48 1.49 43


4.9  1.1 0.71

8h
Baseline

6.6  2.3 0.84 0.22 1.84 56

0.51 0.01 1.38 51

0.4

0.51

0.46 0.91 1.33 44

0.35 0.78 1.42 47

4h

5.4

1 day postoperative

SD
bias PE

6.1  2.0 0.83 0.05 1.23 40

5.5

Before extubation

Bias

0.49 0.18 1.11 52

0h

6.0
4.9

Arrival ICU

After CPBP
After protamine

4.2
6.0

Before CPBP

4.3

Average
CO

Baseline

Condition

Per condition (if data available)

CO, cardiac output; CPBP, cardiopulmonary bypass; OR, operating room; PAC, pulmonary artery catheter; PE, percentage error; R, Pearson correlation coefficient; SD, standard deviation; TEE, transesophageal
echocardiography.

Weighted
average

Statistics

J Crit Care 2014

Ameloot

&

Ref

J Cardiothorac Vasc [19 ]


Anesth 2014

Hofhuizen

Maass

First author Journal

Average per study

Table 1. Overview of studies on the validation of cardiac output measurements by ClearSight

Cardiopulmonary monitoring

Volume 21  Number 3  June 2015

The accuracy of noninvasive cardiac output and pressure measurements with finger cuff Ameloot et al.

PAC, and transesophageal cardiac ultrasound in 10


studies, including a total of 365 patients [5 ,8,11,12,
1418,19 ,20] (Table 1). For the purpose of this
review, we calculated a weighted average correlation, bias, and percentage error. A new CO
monitoring technique is considered to be clinically
interchangeable if the squared Pearson correlation
coefficient (R2) of the linear regression equation is
larger than 0.6 (R > 0.77), if the bias and its standard
deviation are clinically acceptable and if the percentage error is below 30% [5 ,21,22]. Some authors
reported their research in terms of cardiac index. To
allow an easier comparison for the purpose of this
review, cardiac index was converted to CO. In general, most authors reported a moderate-to-good correlation between ClearSight obtained CO and the
golden standard with a weighted average R of 0.71.
This reflects only the relationship between ClearSight and the golden standard in relative terms. In
absolute values, most authors reported a very low
systematic bias (weighted average 0.10 l/min) with a
considerable standard deviation (weighted average
1.22 l/min). This should be interpreted in the light
of the observed average CO. To take this into
account, the percentage error can be calculated by
taking two times the standard deviation of the bias
normalized by the observed average CO with the
golden standard used [22]. Almost all authors
reported a percentage error that is clinically unacceptable (weighted average 44%). Given a measured
CO with ClearSight of 5 l/min and a weighted average bias of 0.10  1.22 l/min, there is a 95% chance
that the true CO is between 2.7 and 7.5 l/min. In
this way, the added value of the obtained ClearSight
CO for the treating physicians is limited. ClearSight
obtained CO showed to be less accurate in patients
with a lower baseline CO, high peripheral resistance,
hypothermia, or peripheral edema of the fingers
[5 ]. On the contrary, ClearSight seems to perform
better in patients with a higher CO (e.g., medical
ICU, sepsis). The major reason for this is probably
mathematical (a larger denominator will result in a
lower percentage error). Critics will argue that the
added value of CO monitoring is limited in patients
with a high CO. However, because tissue perfusion
and oxygen delivery are determined directly by CO
and only indirectly by mean arterial pressure (MAP),
we strongly believe that with the development and
future fine tuning of noninvasive CO measurement
devices such as ClearSight, determination of target
therapy guidelines for CO should be considered.

several authors with conflicting results [813,15,


2326] (Table 2). In the absence of validation
criteria for continuous blood pressure monitoring
systems, all authors used the Association for the
Advancement of Medical Instrumentation criteria
designed for intermittent noninvasive blood pressure monitoring devices [27]. According to these
criteria, the bias (difference between ClearSight
and golden standard) should be less than 5 mmHg
with a standard deviation less than 8 mmHg to allow
two techniques to be used interchangeably. Most
authors reported a rather small bias (weighted average was 2 mmHg) with an almost acceptable standard deviation (weighted average of 9 mmHg). Our
calculated weighted average percentage error (22%)
is slightly above the previous suggested cutoff for
clinical interchangeability (18%). Therefore, in summary, these results indicate that the accuracy of
ClearSight obtained MAP is slightly insufficient
for full clinical interchangeability. However, at least
three authors reported a good accuracy with ClearSight obtained MAP [6,9,12]. Conflicting results
were previously explained by differences in the
study populations included and the reference techniques used. In particular, it was hypothesized that
ClearSight would not be reliable when applied in
patients with a reduced perfusion of the hand
caused by severe hypotension, a high peripheral
resistance, high dose of vasopressors, hypothermia
or peripheral edema. Disproving these concerns,
extensive subgroup analysis by our group showed
that blood pressure measurements were reliable even in the above-mentioned subgroups [6]. This is in
contrast, however, with a study by Hohn et al. [10]
that showed a poor correlation between invasive
and ClearSight MAP in patients treated with norepinephrine. Future research should focus on patient
characteristics that influence the accuracy of
ClearSight to phenotype a patient group in which
ClearSight may be used with sufficient accuracy.
Several authors also reported results about the
accuracy of ClearSight for SBP and DBP monitoring
[9,13,15,24,26]. In general, ClearSight obtained DBP
may be used interchangeably with invasive DBP
(weighted average bias 0.6  7 mmHg). Although
the bias of SBP is very low (weighted average bias
2 mmHg), the standard deviation is too high to be
clinically acceptable (weighted average standard
deviation 13 mmHg).

ACCURACY OF BLOOD PRESSURE


MONITORING

Global hemodynamics may change on a minute-tominute basis and a continuous hemodynamic


monitor should be able to track hemodynamic
changes over time to assess the effect of ongoing

&

&

&

&

Previously, the accuracy of ClearSight was evaluated


against invasive blood pressure monitoring by

ACCURACY TO TRACK HEMODYNAMIC


CHANGES

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Br J Anaesth 2013

Minerva Anestesiol
2013

Hohn et al.

Broch et al.

Radial artery

Anesthesiology 2012

Am J Emerg Med 2011 [26] Noninvasive

BMC Anesthesiol 2009 [15] Radial artery

Martina et al.

Nowak et al.

Stover et al.

ICU, mixed

[13] Radial artery

[12] Radial artery

ICU, surgical

ER, mixed

OR, cardiac

ICU, postcardiac

504

10

40

50

44

41

38

50

25

29

20

112

45

(n)

77  13

101  27

63  9

74  12

77  17

77  16

71  13

76  12

84  9

NA

82  11

83  17

(mmHg)

Average
MAP

2
4.2
6

4.6

-2.6

0.82
0.79

2.1

4.3

-2

0.81 -2.05

0.96

0.87

NA

NA

0.53 10.9

0.7

18

PE
0.77

22

NA

NA

26

34

39

NA

NA

5.8

NA

NA

NA

0.53 11.4 17.1

NA

NA

NA

22

15

PE

20

30

19

17

0.7

NA

0.83

0.96

9.4

22

0.73

9.3 22.7 0.73

15

6.3

NA

23

14

NA
NA

NA
4.9

NA

29

NA

NA

32

13

25

-8.9

-0.2

NA

13

NA

NA

NA

0.75 -1.24

0.93

0.8

NA

NA

0.48

NA

2.1 13.1

22

0.73 0.6

5.3 12.9 21.5 0.72 6.6

NA

0.8

5.7

NA

38

24

25

NA

NA

47

NA

9.2

NA

NA

23

17

PE

7.6

29

8.1 27.7

NA

15

6.5

NA

13.5

NA

5.2

6.8

NA

SD
Bias bias

0.74 -9.4

0.77

7.8 0.64 -7.0

2.7 11.1 NA

NA

8.2 0.76 -7.6

NA

8.3 13.5

SD
Bias bias

7.5 19.5 NA -13.5 12.5 NA

10

13

15

5.1

4.7

2.3 12.4 14.7 0.62

SD
Bias bias

0.76 -6.9

NA

NA

0.94

0.77

10988 78.6  14.2 0.80

80

344

9000

220

41

76

100

117

NA

20

765

225

(n)

Patients Pairs

AAMI, Association for the Advancement of Medical Instrumentation; LVAD, left ventricular assist device; MAP, mean arterial pressure; OR, operating room; PE, percentage error; SD, standard deviation.

Weighted
average

Statistics

Br J Anaesth 2012

Fischer et al.

[11] PiCCO

Garnier et al.

OR, cardiac

ICU, surgical

ICU, post-LVAD

ICU, postcardiac

ICU medical
surgicalburns
OR elective

Setting

[25] Invasive arterial ICU, pediatric

Crit Care 2012

Br J Anaesth 2012

Monnet et al.

[24] Radial artery

[10] Radial artery

[9]

ASAIO J 2014

Martina et al.

Radial artery

[23] Radial artery


[8]

Hofhuizen et al. J Crit Care 2014

Vos et al.

Ameloot et al.

PiCCO

[6]

Authors

Minerva Anestesiol
2014
Br J Anaesth 2014

Golden
Ref standard

MAP SAP DAP

Table 2. Overview of studies on the validation of blood pressure measurements by ClearSight (according to AAMI criteria)

Cardiopulmonary monitoring

Volume 21  Number 3  June 2015

Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.

The accuracy of noninvasive cardiac output and pressure measurements with finger cuff Ameloot et al.

&

90
1.0

&

0.8

135

0.6
0.4

45

CO (%)

therapeutic interventions. Eight studies addressed


the accuracy of ClearSight to track changes in CO
over time [5 ,11,14,1618,19 ,27]. The level of concordance can be calculated as the percentage of pairs
with the same direction of change. On the basis of
previous reports, the concordance should be greater
than 90% when pairs with less than 15% of change
are excluded for analysis [5 ]. In general, ClearSight
performs well with reported levels of concordance
between 84 and 100% [5 ,11,16,17]. One smaller
study showed a more limited concordance when
compared with transesophageal echocardiography
as a golden standard [28]. This means that, in a
majority of cases, ClearSight changed in the same
direction as the golden standard, which would
suggest a good trending ability. Nonetheless, this
four-quadrant analysis only takes into account the
direction of CO changes and not their magnitude.
For clinical practice, not only the direction but also
the amplitude of CO changes might be important.
Therefore, Critchley et al. [29] suggested converting
the xy values to polar coordinates, in which agreement is shown by the angle the vector makes with
the line of identity (y x) and magnitude of change
by the length of the vector (example in Fig. 2). In
this way, ClearSight also showed an acceptable
trending capability with 8489% of the data points
lying within the 1.0 l/min (or 10%) limits of
agreement lines [5 ,19 ]. Five studies used a prespecified hemodynamic intervention, such as a fluid
challenge [11,17,18], administration of phenylefrine [16], or a passive leg raising test [14] to assess the
dynamical tracking ability. Results are conflicting
with reported levels of concordance between 94 and
100%, but varying correlation coefficients between
0.39 and 0.94. Three studies addressed the accuracy
of ClearSight to track changes in MAP over time and
generally a high level of concordance (between 85
and 100%) is reported [6,8,24].
&

0.2

&

&

&

ACCURACY TO PREDICT FLUID


RESPONSIVENESS
In fully sedated and mechanically ventilated
patients (in sinus rhythm), pulse pressure (PPV)
and stroke volume variation (SVV) can be considered as a golden standard for the prediction of
fluid responsiveness [30,31]. The ability of SVV and
PPV obtained with ClearSight to predict fluid
responsiveness was assessed in two studies showing
conflicting results. Fischer et al. [18] reported that
PPV and SVV given by ClearSight were not able to
predict fluid responsiveness [areas under receiver
operating characteristics curves 0.57 (95% confidence interval 0.400.73) and 0.50 (0.330.67)].
On the contrary, Lansdorp et al. [32] compared

180
1.0

0.8

0.6

0.4

0.0
0.2 0.0
0.2

0.2

0.4

0.6

0.8

0
1.0

0.4
0.6
225

315

0.8
1.0
270

FIGURE 2. Example of a polar plot. The distance from the


center of the plot represents the mean change in cardiac
output (DCO, expressed as %, with 1.0 referring to 100%
change from baseline) and the angle u with the horizontal
(08 radial) axis represents agreement. The less the
disagreement between CO measurements, the closer data
pairs will lie along the horizontal radial axis. Data with
good trending will lie within 10% limits of agreement.
However, data with poor trending will be scattered
throughout the plot and lie outside the limits of good and
acceptable agreement (i.e., 10 and 20%, respectively). The
polar plot shows 90 paired measurements of mean DCO
(%), calculated as absolute value of (DNeX CO
Dthermodilution CO)/2. From the 90 initial data, 98.9% of
the data points lie within the 20% lines and 89% within the
10% lines, suggesting acceptable trending capabilities.
Reproduced with permission from [5 ].
&

ClearSight obtained SVV/PPV with invasive SVV/


PPV in post-CABG ICU patients. They found a good
correlation (R 0.95) with a low mean bias (0.95%
for PPV and 0.22% for SVV) and a good correlation
between changes in PPV and SVV as a result of
volume expansion (R 0.88). On the basis of these
results, these authors concluded that ClearSight
SVV/PPV is accurate.

POTENTIAL FIELDS OF APPLICATION


Based on extensive review of the literature, we conclude that ClearSight is an easy-to-use hemodynamic monitor that provides a reasonable
estimate of CO and blood pressure; however, both
do not meet the criteria for clinical interchangeability with the currently used invasive techniques. We
believe the ClearSight device can be applied in ICU,

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237

Cardiopulmonary monitoring

operating room, or emergency room patients,


potentially also on the regular wards and even out
of hospital (if the manufacturer could provide a
battery), for an initial quick hemodynamic assessment as a bridge to installation of a more advanced
invasive monitoring system. Differentiation of the
different types of shock on a clinical basis showed to
be a major challenge and often inaccurate, even in
hands of experienced ICU physicians [33]. Also,
ClearSight showed some accuracy to track the
hemodynamic changes induced by fluid loading
or pharmacological interventions and ClearSight
obtained SVV/PPV shows a correlation with PiCCO
as predictors of volume responsiveness. Finally, the
finger cuff method can be applied when catheter
placement is problematic, for instance in patients
with active catheter infections after removal of the
previously infected arterial line.
On the contrary, in our opinion there are five
main reasons why ClearSight cannot always be used
as a first choice in the general ICU population with
good intravenous and intraarterial access requiring
prolonged advanced hemodynamic monitoring.
Obviously, in general, the accuracy of ClearSight
to measure CO and MAP is slightly above the
suggested cutoffs for clinical interchangeability.
Of note however, in a recent meta-analysis, none
of the four tested methods achieved satisfactory
agreement with bolus thermodilution within the
expected 30% percentage error limits [34]. Therefore, questions are raised on the feasibility of the
current validation criteria for uncalibrated CO and a
fortiori other noninvasive devices. Second, many
studies showed that ClearSight obtained CO is less
accurate in patients with a reduced baseline CO.
Third, ClearSight cannot entirely replace (less) invasive monitoring with an arterial line because arterial
blood gas analysis and follow-up of arterial lactate
will always be one of the cornerstones of critical care
management. Fourth, in some unstable patients and
especially those with changing conditions of preload, afterload or contractility it may be advisable to
calibrate the CO device in relation to the new hemodynamic situation. Finally, ClearSight is not always
feasible in patients with an extreme low flow in the
finger arteries, hypothermia, or peripheral edema.

CONCLUSION
The finger cuff method provides a reasonable estimate of CO and blood pressure, which does not meet
the criteria for clinical interchangeability with the
currently used invasive devices. More studies are
needed to identify specific patient populations that
could benefit from the use of this promising and
totally noninvasive technique.
238

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Acknowledgements
None.
Financial support and sponsorship
The present study was not financially supported.
Conflicts of interest
MLNGM is a member of the medical advisory board of
Pulsion Medical Systems. The remaining authors have no
conflicts of interest.

REFERENCES AND RECOMMENDED


READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
&
of special interest
&& of outstanding interest
1. Michard F. Do we need to know cardiac preload? In: Vincent JL, editor.
Yearbook of intensive care and emergency medicine. Heidelberg, Berlin:
Springer-Verlag; 2004. pp. 694701.
2. Palmers PJ, Vidts W, Ameloot K, et al. Assessment of three minimally invasive
continuous cardiac output measurement methods in critically ill patients
and a review of the literature. Anaesthesiol Intensive Ther 2012; 44:188
199.
3. Hofkens PJ, Verrijcken A, Merveille K, et al. Common pitfalls and tips and tricks
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to get the most out of your transpulmonary thermodilution device: results of a
survey and state-of-the-art review. Anaesthesiol Intensive Ther 2014. [Epub
ahead of print]
A must read for everyone involved with the use of transpulmonary thermodilution in
the critically ill, nice overview of the technique with a practical approach and focus
on 10 simple steps for the nurses, followed by 10 steps for the doctors, and finally
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4. Belda FJ, Aguilar G, Teboul JL, et al. PICS Investigators Group. Complications
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106:482486.
5. Ameloot K, Van De Vijver K, Broch O, et al. Nexfin noninvasive continuous
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intermittent transpulmonary thermodilution derived cardiac output in critically
ill patients. ScientificWorldJournal 2013; 2013:519080.
Compares CO obtained by Nexfin with transpulmonary thermodilution CO obtained by PiCCO in a large sample of critically ill patients. Focus on subgroup
analysis to identify the population in which Nexfin performs best.
6. Ameloot K, Van De Vijver K, Van Regenmortel N, et al. Validation study of
Nexfin1 continuous noninvasive blood pressure monitoring in critically ill
adult patients. Minerva Anestesiol 2014; 18:12941301.
7. Wesseling KH, Jansen JR, Settels JJ, et al. Computation of aortic flow from
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8. Hofhuizen C, Lansdorp B, van der Hoeven JG, et al. Validation of noninvasive
pulse contour cardiac output using finger arterial pressure in cardiac surgery
patients requiring fluid therapy. J Crit Care 2014; 29:161165.
9. Martina JR, Westerhof BE, de Jonge N, et al. Noninvasive arterial blood
pressure waveforms in patients with continuous-flow left ventricular assist
devices. ASAIO J 2014; 60:154161.
10. Hohn A, Defosse JM, Becker S, et al. Noninvasive continuous arterial pressure
monitoring with Nexfin does not sufficiently replace invasive measurements in
critically ill patients. Br J Anaesth 2013; 111:178184.
11. Monnet X, Picard F, Lidzborski E, et al. The estimation of cardiac output by the
Nexfin device is of poor reliability for tracking the effects of a fluid challenge.
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pressure and cardiac index monitoring with Nexfin after cardiac surgery. Br
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output measurements using the Nexfin monitoring device and the esophageal
Doppler. J Clin Anesth 2012; 24:275283.

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The accuracy of noninvasive cardiac output and pressure measurements with finger cuff Ameloot et al.
17. Bubenek-Turconi SI, Craciun M, Miclea I, Perel A. Noninvasive continuous
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The largest study so far, including fifty-three consecutive patients scheduled for
elective, nonemergent cardiac surgery that showed that Nexfin lacked reliability
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undergoing cardiac surgery. Minerva Anestesiol 2013; 79:248256.

25. Garnier RP, van der Spoel AG, Sibarani-Ponsen R, et al. Level of agreement
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