Measurement of Cardiac Function Cardiac Output/Cardiac Index Establishing the absolute value of a patient's cardiac output is a relatively difficult

task. It is, however, possible to estimate the relative change in a patient's cardiac output between two situations from the changes in heart rate (HR) and arterial pressure that occur. Recall (from Figure 31) that arterial pulse pressure (Pp) is defined as the difference between the arterial systolic (Ps) and diastolic (Pd) pressures. For reasons that will be explained in Chapter 6, acute changes in pulse pressure occur primarily because of changes in stroke volume (SV). If one assumes a linear relationship between changes in stroke volume and pulse pressure, then one can reason that since CO = HR x SV, the fractional change in CO that occurs in going from situation 1 to situation 2 is approximately equal to the product of the fractional changes in HR and Pp between these situations. For example, if heart rate increased by 10% and pulse pressure increased by 10%, one would estimate that cardiac output increased by 21% (1.1 x 1.1 = 1.21). One of the most accurate methods of measuring cardiac output makes use of the Fick principle, which is discussed in detail in Chapter 6. Briefly, this principle states that the amount of a substance consumed by the tissues, Xtc, is equal to what goes in minus what goes out [which is the arterial-venous concentration difference in the substance ([X]a [X]v) times the blood flow rate, ]. This relationship can be algebraically arranged to solve for blood flow:

A common method of determining cardiac output is to use the Fick principle to calculate the collective flow through the systemic organs from (1) the whole body oxygen consumption rate ( tc), (2) the oxygen concentration in arterial blood ([X]a), and (3) the concentration of oxygen in mixed venous blood ([X]v). Of the values required for this calculation, the oxygen content of mixed venous blood is the most difficult to obtain. Generally, the sample for venous blood oxygen measurement must be taken from venous catheters positioned in the right ventricle or pulmonary artery to ensure that it is a mixed sample of venous blood from all systemic organs. The calculation of cardiac output from the Fick principle is best illustrated by an example. Suppose a patient is consuming 250 mL of O2 per minute when his or her systemic arterial blood contains 200 mL of O2 per liter and the right ventricular blood contains 150 mL of O2 per liter. This means that, on the average, each liter of blood loses 50 mL of O2 as it passes through the systemic organs. In order for 250 mL of O2 to be consumed per minute, 5 L of blood must pass through the systemic circulation each minute: Dye dilution and thermal dilution (dilution of heat) are other clinical techniques commonly employed for estimating cardiac output. Usually a known quantity of indicator (dye or heat) is

rapidly injected into the blood as it enters the right heart and appropriate detectors are arranged to continuously record the concentration of the indicator in blood as it leaves the left heart. It is possible to estimate the cardiac output from the quantity of indicator injected and the time record of indicator concentration in the blood that leaves the left heart. The normal cardiac output for an individual is obviously dependent on his or her size. For example, the cardiac output of 50-kg woman will be significantly lower than that of a 90-kg man. It has been found, however, that cardiac output correlates better with body surface area than with body weight. Therefore, it is common to express the cardiac output per square meter of surface area. This value is called the cardiac index; at rest it is normally approximately 3 (L/min)/m2.