Measurement of cardiac output

Dr Kavitha Lakshman
University College of Medical Sciences & GTB
Hospital, Delhi
Methods used for measurement of
Cardiac Output

Invasive
PA catheter
- Ficks cardiac output measurement
- Thermodilution Technique
- Mixed venous oximetry pulmonary catheter


Minimally invasive
Doppler Ultrasound
Lithium dilution cardiac output monitoring
Pulse contour cardiac output monitoring
Transpulmonary thermodilution


Non-invasive
Bio impedence cardiac output monitoring
Partial carbon dioxide re breathing cardiac output monitoring



INVASIVE METHODS OF CARDIAC
OUTPUT MEASUREMENT (PAC)
PULMONARY ARTERY CATHETERISATION
First used by Swan, Ganz for hemodymamic
monitoring of patients

PAC can be placed from any central venous
cannulation sites, but right internal jugular
vein is most commonly used.

Standard PAC is 7.0 to 9.0 Fr in circumference,
110 cm long, has 4 internal lumens


PHYSIOLOGICAL CONCEPTS OF
CARDIAC OUTPUT MEASUREMENT






INDICATOR DILUTION TECHNIQUE
Tracer substance is injected into the bloodstream concentration change
measured at a downstream site
Indocyanin green most commonly used dye

Stewart Hamilton Equation

I
Q =
C
I
dt
Where
Q = CO
I = Amount of indicator

C
I
dt = Integral of indicator concentration over time

Drawbacks of indicator dilution method
Limited to cardiac catheterization laboratories
Continuous withdrawal of arterial blood to plot the dye concentration curve
Dye needs regular injections (can accumulate)


Other guidelines for placement & waveforms
were already discussed
Complication of PA catheterisation-
Infection, endocarditis
Thrombo embolism
Endocardial damage, valve injury
PA infarction
PA rupture
Catheter knotting
Ventricular fibrillation, arrhythmia, RBBB

Bolus - Thermodilution Cardiac Output
Monitoring

Variant of indicator dilution technique
Iced indicator/ room temperature indicator (bolus)-
10 ml or 0.15ml/kg in children
Advantages
Performed quickly, repeatedly
Does not require advanced diagnostic or technical skills
Uses non-toxic, non-accumulative indicator
Stewart Hamilton equation is modified
(T
B
T
I
) x K
Q =
T
B
(t) dt
Where
Q = CO
T
B


= Blood temp.
T
I


= Injectate temp.
K = Computational constant
T
B
(t) dt = Integral of temp. change over time




Method
Volume of ice cold or room temperature fluid is injected as
bolus

Change in pulmonary artery blood temperature is recorded
Source of error
Intra or extra-cardiac shunt
Tricuspid or pulmonary valve regurgitation
Inadequate delivery of indicator
Thermister malfunction
Unrecognised blood temperature fluctuation
Respiratory cycle influence
Continuous - Thermodilution CO
monitoring

Warm or cold thermal indicator
Methods
Release of small quantity of heat from a 10 cm thermal filament incorporated
into right ventricular portion of a PAC approx. 15-20 cm from catheter tip

Heating filament is cycled on & off

Thermal signal measured

CO derived from cross-correlation of measured pulmonary artery temp.

Displayed value of CO is updated every 30-60 sec & represents the average
value for cardiac output measured over 3-6 min
Advantages
External system for cold fluid injection is not required
Fewer measurement error
Less risk of fluid overload and infection
Measures average CO value - derived over several
mins
Beat-to-beat variation in SV that occur during single
respiratory cycle are equally represented

In contrast bolus technique measures cardiac output
values depending on phase of respiration

MINIMALLY INVASIVE METHODS OF
CARDIAC OUTPUT MEASUREMENT
Doppler Ultrasound

Doppler principle
When USG waves strike moving objects, these
waves are reflected back to their source at a
different frequency, termed the Doppler shift
frequency that is directly related to the velocity
of moving object and the angle at which the
USG beam strikes these objects
Red blood cells serve as moving object target
2
Where
f = Doppler shift frequency
v = Velocity of red blood cell targets
f
0
= Transmitted USG beam frequency
0 = Angle b/w the USG beam and the vector of
RBC flow
C = Velocity of USG in blood (approx. 1570
m/sec)

Cosine 0 = 1 as long as angle of insonation is small
SV = v x ET x CSA

Where
SV = Stroke volume
v = Spatial average velocity of blood
flow (cm/sec)
ET = Systolic ejection time
CSA = Cross-sectional area of vessel

-Estimated CSA close to the mean value during systole
obtained from a nomogram stored in the computer
-Measured CSA using an M mode echo transducer
incorporated in the probe

Types of probe-Suprasternal(Ascending aorta)
Esophageal(Descending aorta)
Suprasternal probe position instability limited
their use for extended period of time
Esophageal probes have 2 advantage over the
suprasternal probe
- Smooth muscle tone of the oesophagus
maintains the probe position
- Its in close proximity to the aorta; thereby
minimizing signal interference
The shape of the waveform allows
Assessment of the
venticular preload,
afterload and contractility
PULSE CONTOUR CARDIAC OUTPUT
MONITORING

Cardiac output is determined through analysis of
arterial pressure wave form obtained from an
arterial catheter or from a non invasive finger
blood pressure waveform
CO is measured on a beat to beat basis
Wesseling and colleagues devised an algorithm
for the calculation of SV from aortic impedence
and changes in arterial pressure during systole
SV= dP/dt
Z

Advantage-
It has the potential for continuous, beat to
beat monitoring of cardiac output
Disadvantage-
Baseline calibration with known cardiac
output is required
Recalibration is required every 8 to 12 hrs
Require calibration to compensate for the
algorithms inability to independently assess
the ever changing effects of vascular tone
A well defined arterial pressure waveform is
needed
Pulse contour cardiac output estimation without
external calibration(Flo Trac)
- Doesnt require external calibration
- The algorithm works on the principle that SV is
directly proportional to pulse pressure and
inversely proportional to aortic compliance
- The aortic pressure is sampled at 100Hz analysed
and updated every 20 sec
- SV =K(SdAP)
- The standard deviation-SdAP is proportional to
the pulse pressure, which is proportional to SV. K
is the constant derived from patient
characteristics as described by Langewouler and
co workers
NON INVASIVE CARDIAC OUTPUT
MEASUREMENT
BIOIMPEDENCE CARDIAC OUTPUT
MONITORING
Developed by Kubiceck and NASA researchers in
1960s
Based on changes in electrical resistance of the
thoracic cavity occurring with change in aortic
blood volume during systole & diastole
4Pairs -Each pair of electrode consists of a
transmitting and a sensing electrode
Two pairs are applied to the base of the neck on
opposite sides, two pairs are applied to the
lateral aspect of the thorax at the level of the
xiphoid process on opposite sides

The electrodes mark the upper and lower
boundaries of the thorax
An alternating current of low amplitude and
high frequency is applied which is sensed by
electrodes placed over the neck & lateral
aspect of the chest.
Volume of thorax is calculated according to
the height, weight and gender


Advantage-
Non invasive, continuous monitoring
Measures thoracic fluid content, left
ventricular ejection time, cardiac index
Disadvantage-
Susceptibility to electrical interference
Relies on correct placement of the electrodes

References
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THANK YOU