cardiac output monitoring monica morosan. typical value end diastolic volume (edv)120 ml (65 - 240...
TRANSCRIPT
Cardiac Output Monitoring
Monica Morosan
Typical value End diastolic volume (EDV)120 ml (65– - 240 ml) End systolic volume (ESV)50 ml(16 - –143 ml) Stroke volume (SV)70 ml (55 - 100 ml) Stroke volume index (33-47 ml/m2/beat) Ejection Fraction (Ef)58% (55 to 70%) Cardiac output (CO)4.9 L/minute (4.0 - 8.0 L/min) Cardiac index CI (2.6-4.2)L/min/m2
SVR=80x(MAP-CVP)/CO (800-1200dynes/sec/cm5) SVRI (1970-2390dynes/sec/cm5/m2)
Cardiac output monitoring
Invasive
PA catheter Non invasive
TOE, Echo
Oesophageal Doppler
Transthoracic impedance
Arterial pulse contour analysis (PiCCO)
Arterial pulse power analysis (LiDCO)
Fick principle or indicator dilution technique
PA catheter
PA catheter
Measures: Intracardiac pressures PA pressures Cardiac output Oxygen saturation
Indications: IHD, Cardiogenic shock RV failure Septic shock ARDS Periop: high risk
cardiac surgery or neurosurgery
Contraindications: Tricuspid or pulm valve
mechanical prosthesis Right heart mass
(Tumour or thrombus) Tricuspid or pulmonary
endocarditis
PAOP (PCWP) significance
Estimates Left sided preload Left ventricular end diastolic pressure Extravascular lung water Miocardial O2 consumption
Thermodilution: Stewart Hamilton equation
Oesophageal Doppler
Oesophageal Doppler
Measures:
Blood flow velocity in the descending aorta
CO=VTIxCSAxHR
Parameters:
CO, SV, FTc, PV (peak velocity), HR
CO: 86% agreement between measured CO with Doppler vs PAC
Normovolaemia Hypovolaemia
LiDCO Lithium indicator dilution Continous, real time pulse power analysis rather than pulse
contour Assumption than pulse power has a linear relationship with
flow, uses an algorithm to det CO Minimally invasive
Safe Uses the CVP catheter
and A line Injectate 0.15-0.3 mmol
Lithium Chloride
Contraindications
-If already on Lithium
-Muscle relaxant drugs
-Weight less then 40 kg
-First 3 months pregnancy
PiCCO
Pulse contour analysis with intermittent thermodilution measurement
Good agreement with PAC
Thermistor tipped A lineRelies on good A line
trace ( arrythmias, AoR, Ao baloon, SVR up): innaacuracies
PiCCO
Pulse contour analysis:-Continuous pulse contour
cardiac analysis (PCCO)
-Arterial blood pressure (AP)
-Heart rate (HR)
-Stroke volume (SV)
-Stroke volume variation (SVV)
-Systemic vascular resistance (SVR)
-Index of left ventricular contractility
Intermittent thermodilution:
Transpulmonary cardiac output (CO)
Intrathoracic blood volume (ITBV)
Extravascular lung water (EVLW)
Cardiac function index (CFI)
Impedance plethysmography
2 sets circular wire electrodes around chest and neck
Current passed between outer two( high frec, low magnitude), with measurement of potential difference between the inner two
Maximal rate of change of impedance occurs with peak Ao flow
Movement, arrythmias and diathermy: innacuracies More evidence in haemodynamically unstable
Thoracic bioreactance NICOM
Modification of impedance technology To improve the signal to noise ratio Phase shift in voltage across thorax 4 electrodes across thorax CO for L and R side and then averages Also averages over 60s
Penaz technique Continous pulse contour analysis of NIBP ( also
known as vascular unloading technique) Finger cuff applies pressure Infrared light assesses the light absorbtion (artery
diameter) Alters the pressure in the cuff to keep the diameter
constant (this pressure=BP) Trace compared to oscillometric derived systolic and
diastolic values Limitations: oedema or hypeperfusion, low CO, low
SVR
Others
Pulse wave transit time: continous, derived from ECG, sats probe trace and Art pressure
Radial artery tonometry ECHO: LVEF, IVC collapsibility index All might have a place in low/intermediate risk
patients, non-invasive haemodyn optimisation, ED department and diagnostic procedures