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Goldhammer JE, Herman CR. Delining Without Deinforming. J Cardiothorac Vasc Anesth 2018; 32:2503-2504. [DOI: 10.1053/j.jvca.2018.05.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Indexed: 11/11/2022]
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2
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So JS, Yun JH. The Combined Use of Cardiac Output and Intracranial Pressure Monitoring to Maintain Optimal Cerebral Perfusion Pressure and Minimize Complications for Severe Traumatic Brain Injury. Korean J Neurotrauma 2017; 13:96-102. [PMID: 29201841 PMCID: PMC5702765 DOI: 10.13004/kjnt.2017.13.2.96] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 10/12/2017] [Accepted: 10/18/2017] [Indexed: 11/15/2022] Open
Abstract
Objective To show the effect of dual monitoring including cardiac output (CO) and intracranial pressure (ICP) monitoring for severe traumatic brain injury (TBI) patiens. We hypothesized that meticulous treatment using dual monitoring is effective to sustain maintain minimal intensive care unit (ICU) complications and maintain optimal ICP and cerebral perfusion pressure (CPP) for severe TBI patiens. Methods We included severe TBI, below Glasgow Coma Scale (GCS) 8 and head abbreviation injury scale (AIS) >4 and performed decompressive craniectomy at trauma ICU of our hospital. We collected the demographic data, head AIS, injury severity score (ISS), initial GCS, ICU stay, sedation duration, fluid therapy related complications, Glasgow Outcome Scale (GOS) at 3 months and variable parameters of ICP and CO monitor. Results Thirty patients with severe TBI were initially selected. Thirteen patients were excluded because 10 patients had fixed pupillary reflexes and 3 patients had uncontrolled ICP due to severe brain edema. Overall 17 patients had head AIS 5 except 2 patients and 10 patients (58.8%) had multiple traumas as mean ISS 29.1. Overall complication rate of the patients was 64.7%. Among the parameters of CO monitoring, high stroke volume variation is associated with fluid therapy related complications (p=0.043) and low cardiac contractibility is associated with these complications (p=0.009) statistically. Conclusion Combined use of CO and ICP monitors in severe TBI patients who could be necessary to decompressive craniectomy and postoperative sedation is good alternative methods to maintain an adequate ICP and CPP and reduce fluid therapy related complications during postoperative ICU care.
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Affiliation(s)
- Jin Shup So
- Department of Neurosurgery, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Jung-Ho Yun
- Department of Neurosurgery, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
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Affiliation(s)
- Dheeraj Arora
- Institute of Critical Care and Anesthesiology, Medanta The Medicity, Gurgaon, Haryana, India
| | - Yatin Mehta
- Institute of Critical Care and Anesthesiology, Medanta The Medicity, Gurgaon, Haryana, India
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Kapoor PM, Magoon R, Rawat RS, Mehta Y, Taneja S, Ravi R, Hote MP. Goal-directed therapy improves the outcome of high-risk cardiac patients undergoing off-pump coronary artery bypass. Ann Card Anaesth 2017; 20:83-89. [PMID: 28074802 PMCID: PMC5290703 DOI: 10.4103/0971-9784.197842] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: There has been a constant emphasis on developing management strategies to improve the outcome of high-risk cardiac patients undergoing surgical revascularization. The performance of coronary artery bypass surgery on an off-pump coronary artery bypass (OPCAB) avoids the risks associated with extra-corporeal circulation. The preliminary results of goal-directed therapy (GDT) for hemodynamic management of high-risk cardiac surgical patients are encouraging. The present study was conducted to study the outcome benefits with the combined use of GDT with OPCAB as compared to the conventional hemodynamic management. Material and Method: Patients with the European System for Cardiac Operative Risk Evaluation ≥3 scheduled for OPCAB were randomly divided into two groups; the control and GDT groups. The GDT group included the monitoring and optimization of advanced parameters, including cardiac index (CI), systemic vascular resistance index, oxygen delivery index, stroke volume variation; continuous central venous oxygen saturation (ScVO2), global end-diastolic volume, and extravascular lung water (EVLW), using FloTrac™, PreSep™, and EV-1000® monitoring panels, in addition to the conventional hemodynamic management in the control group. The hemodynamic parameters were continuously monitored for 48 h in Intensive Care Unit (ICU) and corrected according to GDT protocol. A total of 163 patients consented for the study. Result: Seventy-five patients were assigned to the GDT group and 88 patients were in the control group. In view of 9 exclusions from the GDT group and 12 exclusions from control group, 66 patients in the GDT group and 76 patients in control group completed the study. Conclusion: The length of stay in hospital (LOS-H) (7.42 ± 1.48 vs. 5.61 ± 1.11 days, P < 0.001) and ICU stay (4.2 ± 0.82 vs. 2.53 ± 0.56 days, P < 0.001) were significantly lower in the GDT group as compared to control group. The duration of inotropes (3.24 ± 0.73 vs. 2.89 ± 0.68 h, P = 0.005) was also significantly lower in the GDT group. The two groups did not differ in duration of ventilated hours, mortality, and other complications. The parameters such as ScVO2, CI, and EVLW had a strong negative and positive correlation with the LOS-H with r values of − 0.331, −0.319, and 0.798, respectively. The study elucidates the role of a goal-directed hemodynamic optimization for improved outcome in high-risk cardiac patients undergoing OPCAB.
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Affiliation(s)
| | - Rohan Magoon
- Department of Cardiac Anaesthesia, Cardio Thoracic Centre, AIIMS, New Delhi, India
| | - Rajinder Singh Rawat
- Department of Cardiac Anaesthesiology, Salalah Heart Center, Salalah, Sultanate of Oman
| | - Yatin Mehta
- Department of Critical Care and Anaesthesiology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - Sameer Taneja
- Department of Cardiac Anaesthesia, Naval Base Hospital, Mumbai, Maharashtra, India
| | - R Ravi
- Department of Statistics, Lady Shri Ram College, University of Delhi, New Delhi, India
| | - Milind P Hote
- Department of Cardiothoracic and Vascular Surgery, AIIMS, New Delhi, India
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Youssef N, Whitlock RP. The Routine Use of the Pulmonary Artery Catheter Should Be Abandoned. Can J Cardiol 2016; 33:135-141. [PMID: 27916322 DOI: 10.1016/j.cjca.2016.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 10/11/2016] [Accepted: 10/11/2016] [Indexed: 11/17/2022] Open
Abstract
The pulmonary artery catheter (PAC) is the most common method of measuring cardiac output in cardiac surgery. However, its use has always been questioned in terms of survival benefit, specifically with regard to the accuracy of its measurements and its invasive nature, with the potential for serious complications. In this review we aimed to develop a clear understanding of the pitfalls of the use of PAC, and discuss its risks and available alternatives. We conclude that there is no indication for the routine use of PAC such that clinicians should carefully consider the clinical risks and benefits on a patient by patient basis.
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Affiliation(s)
- Nayer Youssef
- Division of Anesthesiology, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Richard P Whitlock
- Divisions of Cardiac Surgery and Critical Care Medicine, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
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Hendy A, Bubenek Ş. Pulse waveform hemodynamic monitoring devices: recent advances and the place in goal-directed therapy in cardiac surgical patients. Rom J Anaesth Intensive Care 2016; 23:55-65. [PMID: 28913477 DOI: 10.21454/rjaic.7518.231.wvf] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Hemodynamic monitoring has evolved and improved greatly during the past decades as the medical approach has shifted from a static to a functional approach. The technological advances have led to innovating calibrated or not, but minimally invasive and noninvasive devices based on arterial pressure waveform (APW) analysis. This systematic clinical review outlines the physiologic rationale behind these recent technologies. We describe the strengths and the limitations of each method in terms of accuracy and precision of measuring the flow parameters (stroke volume, cardiac output) and dynamic parameters which predict the fluid responsiveness. We also analyzed the place of the APW monitoring devices in goal-directed therapy (GDT) protocols in cardiac surgical patients. According to the data from the three GDT-randomized control trials performed in cardiac surgery (using two types of APW techniques PiCCO and FloTrac/Vigileo), these devices did not demonstrate that they played a role in decreasing mortality, but only decreasing the ventilation time and the ICU and hospital length of stay.
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Affiliation(s)
- Adham Hendy
- Carol Davila University of Medicine and Pharmacy, Bucharest, 1 Department of Cardiovascular Anaesthesia and Intensive Care, C.C. Iliescu Emergency Institute for Cardiovascular Diseases, Bucharest, Romania
| | - Şerban Bubenek
- Carol Davila University of Medicine and Pharmacy, Bucharest, 1 Department of Cardiovascular Anaesthesia and Intensive Care, C.C. Iliescu Emergency Institute for Cardiovascular Diseases, Bucharest, Romania
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7
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Min JJ, Lee JH, Hong KY, Choi SJ. Utility of stroke volume variation measured using non-invasive bioreactance as a predictor of fluid responsiveness in the prone position. J Clin Monit Comput 2016; 31:397-405. [DOI: 10.1007/s10877-016-9859-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 03/02/2016] [Indexed: 02/02/2023]
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Agreement in hemodynamic monitoring during orthotopic liver transplantation: a comparison of FloTrac/Vigileo at two monitoring sites with pulmonary artery catheter thermodilution. J Clin Monit Comput 2016. [PMID: 26884378 DOI: 10.1007/s10877-016-9840-x.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To study agreement in cardiac index (CI), systemic vascular resistance index (Systemic VRI) and stroke volume variation (SV variation) between the FloTrac/Vigileo at radial and femoral arterial cannulation sites, and pulmonary artery catheter (PAC) thermodilution, in patients undergoing orthotopic liver transplantation. A prospective observational study of 25 adult patients with liver failure. Radial and femoral arteries were cannulated with standardised FloTrac/Vigileo arterial transducer kits and a PAC was inserted. CI, SV variation and Systemic VRI were measured four times (30 min after induction of anesthesia, 30 min after portal vein clamping, 30 min after graft reperfusion, 30 min after commencement of bile duct anastomosis). The bias, precision, limits of agreement (LOA) and percentage errors were calculated using Bland-Altman statistics to compare measurements from radial and femoral arterial cannulation sites and PAC thermodilution. Neither radial nor femoral CI achieved acceptable agreement with PAC CI [radial to PAC bias (SD) 1.17 (1.49) L/min/m2, percentage error 64.40 %], [femoral to PAC bias (SD) -0.71 (1.81) L/min/m2, percentage error 74.20 %]. Agreement between radial and femoral sites for CI [mean difference (SD) -0.43 (1.51) L/min/m2, percentage error 70.40 %] and Systemic VRI [mean difference (SD) 0.03 (4.17) LOA ±8.17 mmHg min m2/L] were also unacceptable. Agreement in SV variation between radial and femoral measurement sites approached a clinically acceptable threshold [mean difference (SD) 0.68 (2.44) %), LOA ±4.78 %]. FloTrac/Vigileo CI cannot substitute for PAC thermodilution CI, regardless of measurement site. SV variation measurements may be interchangeable between radial and femoral sites for determining fluid responsiveness.
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9
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Lee M, Weinberg L, Pearce B, Scurrah N, Story DA, Pillai P, McCall PR, P McNicol L, Peyton PJ. Agreement in hemodynamic monitoring during orthotopic liver transplantation: a comparison of FloTrac/Vigileo at two monitoring sites with pulmonary artery catheter thermodilution. J Clin Monit Comput 2016; 31:343-351. [PMID: 26884378 DOI: 10.1007/s10877-016-9840-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Accepted: 02/08/2016] [Indexed: 10/22/2022]
Abstract
To study agreement in cardiac index (CI), systemic vascular resistance index (Systemic VRI) and stroke volume variation (SV variation) between the FloTrac/Vigileo at radial and femoral arterial cannulation sites, and pulmonary artery catheter (PAC) thermodilution, in patients undergoing orthotopic liver transplantation. A prospective observational study of 25 adult patients with liver failure. Radial and femoral arteries were cannulated with standardised FloTrac/Vigileo arterial transducer kits and a PAC was inserted. CI, SV variation and Systemic VRI were measured four times (30 min after induction of anesthesia, 30 min after portal vein clamping, 30 min after graft reperfusion, 30 min after commencement of bile duct anastomosis). The bias, precision, limits of agreement (LOA) and percentage errors were calculated using Bland-Altman statistics to compare measurements from radial and femoral arterial cannulation sites and PAC thermodilution. Neither radial nor femoral CI achieved acceptable agreement with PAC CI [radial to PAC bias (SD) 1.17 (1.49) L/min/m2, percentage error 64.40 %], [femoral to PAC bias (SD) -0.71 (1.81) L/min/m2, percentage error 74.20 %]. Agreement between radial and femoral sites for CI [mean difference (SD) -0.43 (1.51) L/min/m2, percentage error 70.40 %] and Systemic VRI [mean difference (SD) 0.03 (4.17) LOA ±8.17 mmHg min m2/L] were also unacceptable. Agreement in SV variation between radial and femoral measurement sites approached a clinically acceptable threshold [mean difference (SD) 0.68 (2.44) %), LOA ±4.78 %]. FloTrac/Vigileo CI cannot substitute for PAC thermodilution CI, regardless of measurement site. SV variation measurements may be interchangeable between radial and femoral sites for determining fluid responsiveness.
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Affiliation(s)
- Matthew Lee
- Department of Anaesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia.
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia
| | - Brett Pearce
- Department of Anaesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia
| | - Nicholas Scurrah
- Department of Anaesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia
| | - David A Story
- Department of Anaesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Param Pillai
- Department of Anaesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia
| | - Peter R McCall
- Department of Anaesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia
| | - Larry P McNicol
- Department of Anaesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia
| | - Philip J Peyton
- Department of Anaesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia
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Cho YJ, Koo CH, Kim TK, Hong DM, Jeon Y. Comparison of cardiac output measures by transpulmonary thermodilution, pulse contour analysis, and pulmonary artery thermodilution during off-pump coronary artery bypass surgery: a subgroup analysis of the cardiovascular anaesthesia registry at a single tertiary centre. J Clin Monit Comput 2015; 30:771-782. [DOI: 10.1007/s10877-015-9784-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 09/23/2015] [Indexed: 01/24/2023]
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11
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Angappan S, Parida S, Vasudevan A, Badhe AS. The comparison of stroke volume variation with central venous pressure in predicting fluid responsiveness in septic patients with acute circulatory failure. Indian J Crit Care Med 2015; 19:394-400. [PMID: 26180432 PMCID: PMC4502492 DOI: 10.4103/0972-5229.160278] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Purpose: The present study was designed to investigate the efficacy of stroke volume variation (SVV) in predicting fluid responsiveness and compare it to traditional measures of volume status assessment like central venous pressure (CVP). Methods: Forty-five mechanically ventilated patients in sepsis with acute circulatory failure. Patients were not included when they had atrial fibrillation, other severe arrhythmias, permanent pacemaker, or needed mechanical cardiac support. Furthermore, excluded were patients with hypoxemia and a CVP >12. Patients received volume expansion in the form of 500 ml of 6% hydroxyethyl starch. Results: The volume expansion-induced increase in cardiac index (CI) was >15% in 29 patients (labeled responders) and <15% in 16 patients (labeled nonresponders). Before volume expansion, SVV was higher in responders than in nonresponders. Receiver operating characteristic curves analysis showed that SVV was a more accurate indicator of fluid responsiveness than CVP. Before volume expansion, an SVV value of 13% allowed discrimination between responders and nonresponders with a sensitivity of 78% and a specificity of 89%. Volume expansion-induced changes in CI weakly and positively correlated with SVV before volume expansion. Volume expansion decreased SVV from 18.86 ± 4.35 to 7.57 ± 1.80 and volume expansion-induced changes in SVV moderately correlated with volume expansion-induced changes in CI. Conclusions: When predicting fluid responsiveness in mechanically ventilated patients in septic shock, SVV is more effective than CVP. Nevertheless, the overall correlation of baseline SVV with increases in CI remains poor. Trends in SVV, as reflected by decreases with volume replacement, seem to correlate much better with increases in CI.
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Affiliation(s)
| | - Satyen Parida
- Department of Anesthesiology and Critical Care, JIPMER, Puducherry, India
| | - Arumugam Vasudevan
- Department of Anesthesiology and Critical Care, JIPMER, Puducherry, India
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12
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Accuracy of Vigileo/Flotrac monitoring system in morbidly obese patients. J Crit Care 2015; 30:562-6. [PMID: 25735614 DOI: 10.1016/j.jcrc.2015.01.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 01/14/2015] [Accepted: 01/17/2015] [Indexed: 11/22/2022]
Abstract
PURPOSE Our goal was to assess the accuracy of measuring cardiac output (CO) by the FloTrac/Vigileo (CO(V)) device in comparison with thermodilution technique through pulmonary artery catheterization (PAC(TD)) in morbidly obese patients. MATERIAL AND METHODS Cardiac output in 8 morbidly obese patients was assessed twice at upright and lying position breathing ambient air. At least 4 consecutive CO measurements with 10 mL of ice-cold saline injections were performed each time. Simultaneous CO measurements were recorded with both single-bolus thermodilution and CO(V). RESULTS One hundred thirty-two CO data pairs were collected. The overall mean single-bolus thermodilution 6.2 ± 1.1 L/min was lower than the overall mean CO(V) 7.8 ± 1.6 L/min (P < .001). Lin concordance coefficient indicated that overall agreement between PAC(TD) and CO(V) was poor, 0.29. Lin concordance coefficient in sitting position was 0.29, 95% confidence interval (0.17-0.40) and in lying position was 0.30, 95% confidence interval (0.15-0.44). The Bland-Altman plot analysis showed systematically higher values from CO(V) in comparison with PAC(TD). These differences increased in presence of high CO measurements. In 3 of 8 patients, the percentage error was lower than 20%, whereas in the other 5, it was higher than 20%. Of these 5, in 2 cases, the percentage error was greater than 50%. CONCLUSION Data obtained using CO(V) vs PAC(TD) measurements showed poor correlation. The results were not interchangeable.
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Affiliation(s)
- Yatin Mehta
- Chairman, Medanta Institute of Critical Care and Anesthesia, Medanta The Medicity, Sector 38, Gurgaon (NCR), Haryana, India
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Kirkeby-Garstad I, Trønnes H, Stenseth R, Sellevold OFM, Aadahl P, Skogvoll E. The Precision of Pulmonary Artery Catheter Bolus Thermodilution Cardiac Output Measurements Varies With the Clinical Situation. J Cardiothorac Vasc Anesth 2014; 29:881-8. [PMID: 25976600 DOI: 10.1053/j.jvca.2014.12.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate the effects of ventilatory mode, injectate temperature, and clinical situation on the precision of cardiac output measurements. DESIGN Randomized, prospective observational study. SETTING Single university hospital. PARTICIPANTS Forty patients undergoing planned cardiac surgery, receiving a pulmonary artery catheter according to institutional routine. INTERVENTIONS Cardiac output was measured at 4 predefined time points during the perioperative patient course, twice during controlled and twice during spontaneous ventilation, using 2 blocks of 8 measurement replications with cold and tepid injectate in random order. MEASUREMENTS AND MAIN RESULTS The data were analyzed using a hierarchical linear mixed model. Clinical precision was determined as half the width of the 95% confidence interval for the underlying true value. The single-measurement precision measured in 2 different clinical situations for each temperature/ventilation combination was 8% to 10%, 11% to 13%, 13% to 15%, and 23% to 24% in controlled ventilation with cold injectate, controlled ventilation with tepid injectate, spontaneous breathing with cold injectate, and spontaneous breathing with tepid injectate, respectively. Tables are provided for the number of replications needed to achieve a certain precision and for how to identify significant changes in cardiac output. CONCLUSIONS Clinical precision of cardiac output measurements is reduced significantly during spontaneous relative to controlled ventilation. The differences in precision between repeated measurement series within the temperature/ventilation combinations indicate influence of other situation-specific factors not related to ventilatory mode. Compared with tepid injectate in patients breathing spontaneously, the precision is 3-fold better with cold injectate and controlled ventilation.
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Affiliation(s)
- Idar Kirkeby-Garstad
- Department of Anesthesiology and Intensive Care, St. Olav University Hospital, Trondheim, Norway.
| | - Håkon Trønnes
- Department of Anesthesiology and Intensive Care, St. Olav University Hospital, Trondheim, Norway
| | - Roar Stenseth
- Department of Anesthesiology and Intensive Care, St. Olav University Hospital, Trondheim, Norway; Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Olav F M Sellevold
- Department of Anesthesiology and Intensive Care, St. Olav University Hospital, Trondheim, Norway; Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Petter Aadahl
- Department of Anesthesiology and Intensive Care, St. Olav University Hospital, Trondheim, Norway; Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Eirik Skogvoll
- Department of Anesthesiology and Intensive Care, St. Olav University Hospital, Trondheim, Norway; Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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Suehiro K, Tanaka K, Matsuura T, Funao T, Yamada T, Mori T, Nishikawa K. The Vigileo-FloTracTM System: Arterial Waveform Analysis for Measuring Cardiac Output and Predicting Fluid Responsiveness: A Clinical Review. J Cardiothorac Vasc Anesth 2014; 28:1361-74. [DOI: 10.1053/j.jvca.2014.02.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Indexed: 02/03/2023]
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Mehta Y, Arora D. Newer methods of cardiac output monitoring. World J Cardiol 2014; 6:1022-1029. [PMID: 25276302 PMCID: PMC4176793 DOI: 10.4330/wjc.v6.i9.1022] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 02/11/2014] [Accepted: 07/15/2014] [Indexed: 02/07/2023] Open
Abstract
Cardiac output (CO) is the volume of blood ejected by each ventricle per minute and is the product of stroke volume and heart rate. CO can thus be manipulated by alteration in heart rate or rhythm, preload, contractility and afterload. Moreover it gives important information about tissue perfusion and oxygen delivery. CO can be measured by various methods and thermodilution method using pulmonary artery catheter (PAC) is till date considered as gold standard method. Complications associated with PAC led to development of newer methods which are minimally or non-invasive. Newer methods fulfil other properties like continuous and reproducible reading, cost effective, reliable during various physiological states and have fast response time. These methods are validated against the gold standard with good level agreement. In this review we have discussed various newer methods of CO monitoring and their effectiveness in clinical use.
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Semi-invasive measurement of cardiac output based on pulse contour: a review and analysis. Can J Anaesth 2014; 61:452-79. [PMID: 24643474 DOI: 10.1007/s12630-014-0135-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 02/18/2014] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The aim of this review was to provide a meta-analysis of all five of the most popular systems for arterial pulse contour analysis compared with pulmonary artery thermodilution, the established reference method for measuring cardiac output (CO). The five investigated systems are FloTrac/Vigileo(®), PiCCO(®), LiDCO/PulseCO(®), PRAM/MostCare(®), and Modelflow. SOURCE In a comprehensive literature search through MEDLINE(®), Web of Knowledge (v.5.11), and Google Scholar, we identified prospective studies and reviews that compared the pulse contour approach with the reference method (n = 316). Data extracted from the 93 selected studies included range and mean cardiac output, bias, percentage error, software versions, and study population. We performed a pooled weighted analysis of their precision in determining CO in various patient groups and clinical settings. PRINCIPAL FINDINGS Results of the majority of studies indicate that the five investigated systems show acceptable accuracy during hemodynamically stable conditions. Forty-three studies provided adequate data for a pooled weighted analysis and resulted in a mean (SD) total pooled bias of -0.28 (1.25) L·min(-1), percentage error of 40%, and a correlation coefficient of r = 0.71. In hemodynamically unstable patients (n = 8), we found a higher percentage error (45%) and bias of -0.54 (1.64) L·min(-1). CONCLUSION During hemodynamic instability, CO measurement based on continuous arterial pulse contour analysis shows only limited agreement with intermittent bolus thermodilution. The calibrated systems seem to deliver more accurate measurements than the auto-calibrated or the non-calibrated systems. For reliable use of these semi-invasive systems, especially for critical therapeutic decisions during hemodynamic disorders, both a strategy for hemodynamic optimization and further technological improvements are necessary.
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18
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Slagt C, Malagon I, Groeneveld ABJ. Systematic review of uncalibrated arterial pressure waveform analysis to determine cardiac output and stroke volume variation. Br J Anaesth 2014; 112:626-37. [PMID: 24431387 DOI: 10.1093/bja/aet429] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
UNLABELLED The FloTrac/Vigileo™, introduced in 2005, uses arterial pressure waveform analysis to calculate cardiac output (CO) and stroke volume variation (SVV) without external calibration. The aim of this systematic review is to evaluate the performance of the system. Sixty-five full manuscripts on validation of CO measurements in humans, published in English, were retrieved; these included 2234 patients and 44,592 observations. RESULTS have been analysed according to underlying patient conditions, that is, general critical illness and surgery as normodynamic conditions, cardiac and (post)cardiac surgery as hypodynamic conditions, and liver surgery and sepsis as hyperdynamic conditions, and subsequently released software versions. Eight studies compared SVV with other dynamic indices. CO, bias, precision, %error, correlation, and concordance differed among underlying conditions, subsequent software versions, and their interactions, suggesting increasing accuracy and precision, particularly in hypo- and normodynamic conditions. The bias and the trending capacity remain dependent on (changes in) vascular tone with most recent software. The SVV only moderately agreed with other dynamic indices, although it was helpful in predicting fluid responsiveness in 85% of studies addressing this. Since its introduction, the performance of uncalibrated FloTrac/Vigileo™ has improved particularly in hypo- and normodynamic conditions. A %error at or below 30% with most recent software allows sufficiently accurate and precise CO measurements and trending for routine clinical use in normo- and hypodynamic conditions, in the absence of large changes in vascular tone. The SVV may usefully supplement these measurements.
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Affiliation(s)
- C Slagt
- Department of Anaesthesiology and Intensive Care, Zaans Medical Centre, Koningin Julianaplein 58, 1502 DV Zaandam, The Netherlands
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Suehiro K, Tanaka K, Funao T, Matsuura T, Mori T, Nishikawa K. Systemic vascular resistance has an impact on the reliability of the Vigileo-FloTrac system in measuring cardiac output and tracking cardiac output changes. Br J Anaesth 2013; 111:170-7. [DOI: 10.1093/bja/aet022] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Cardiac output monitoring in septic shock: evaluation of the third-generation Flotrac-Vigileo®. J Clin Monit Comput 2013; 27:273-9. [DOI: 10.1007/s10877-013-9431-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 01/10/2013] [Indexed: 02/03/2023]
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Park SY, Kim DH, Joe HB, Yoo JY, Kim JS, Kang M, Hong YW. Accuracy of cardiac output measurements during off-pump coronary artery bypass grafting: according to the vessel anastomosis sites. Korean J Anesthesiol 2012; 62:423-8. [PMID: 22679538 PMCID: PMC3366308 DOI: 10.4097/kjae.2012.62.5.423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 09/28/2011] [Accepted: 09/28/2011] [Indexed: 11/24/2022] Open
Abstract
Background During beating heart surgery, the accuracy of cardiac output (CO) measurement techniques may be influenced by several factors. This study was conducted to analyze the clinical agreement among stat CO mode (SCO), continuous CO mode (CCO), arterial pressure waveform-based CO estimation (APCO), and transesophageal Doppler ultrasound technique (UCCO) according to the vessel anastomosis sites. Methods This study was prospectively performed in 25 patients who would be undergoing elective OPCAB. Hemodynamic variables were recorded at the following time points: during left anterior descending (LAD) anastomosis at 1 min and 5 min; during obtuse marginal (OM) anastomosis at 1 min and 5 min: and during right coronary artery (RCA) anastomosis at 1 min and 5 min. The variables measured including the SCO, CCO, APCO, and UCCO. Results CO measurement techniques showed different correlations according to vessel anastomosis site. However, the percent error observed was higher than the value of 30% postulated by the criteria of Critchley and Critchley during all study periods for all CO measurement techniques. Conclusions In the beating heart procedure, SCO, CCO and APCO showed different correlations according to the vessel anastomosis sites and did not agree with UCCO. CO values from the various measurement techniques should be interpreted with caution during OPCAB.
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Affiliation(s)
- Sung Yong Park
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea
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Lavi R, Cheng D. Pro: continuous cardiac output and SvO₂monitoring should be routine during off-pump coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth 2012; 26:1131-5. [PMID: 22633742 DOI: 10.1053/j.jvca.2009.06.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Indexed: 11/11/2022]
Affiliation(s)
- Ronit Lavi
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, Ontario, Canada
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Marik PE. Noninvasive cardiac output monitors: a state-of the-art review. J Cardiothorac Vasc Anesth 2012; 27:121-34. [PMID: 22609340 DOI: 10.1053/j.jvca.2012.03.022] [Citation(s) in RCA: 204] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Indexed: 12/26/2022]
Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA 23507, USA.
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Porhomayon J, Zadeii G, Congello S, Nader ND. Applications of minimally invasive cardiac output monitors. Int J Emerg Med 2012; 5:18. [PMID: 22531454 PMCID: PMC3353182 DOI: 10.1186/1865-1380-5-18] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Accepted: 04/24/2012] [Indexed: 11/10/2022] Open
Abstract
Because of the increasing age of the population, critical care and emergency medicine physicians have seen an increased number of critically ill patients over the last decade. Moreover, the trend of hospital closures in the United States t imposes a burden of increased efficiency. Hence, the identification of devices that facilitate accurate but rapid assessments of hemodynamic parameters without the added burden of invasiveness becomes tantamount. The purpose of this review is to understand the applications and limitations of these new technologies.
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Affiliation(s)
- Jahan Porhomayon
- VA Western New York Healthcare System, Division of Critical Care and Pain Medicine, Department of Anesthesiology, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY, USA.
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Porhomayon J, El-Solh A, Papadakos P, Nader ND. Cardiac output monitoring devices: an analytic review. Intern Emerg Med 2012; 7:163-71. [PMID: 22147648 DOI: 10.1007/s11739-011-0738-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2010] [Accepted: 11/22/2011] [Indexed: 10/14/2022]
Abstract
To evaluate cardiac output (CO), both invasive and semi-invasive monitors are used in critical care medicine. The pulmonary artery catheter is an invasive tool to assess CO with the major criticism that the level of its invasiveness is not supported by an improvement in patients' outcomes. The interest in a lesser invasive techniques is high. Therefore, alternative techniques have been developed recently, and are used frequently in critical care medicine. Cardiac output can be monitored continuously by different devices that analyze the stroke volume and CO. The purpose of this review is to understand these new technologies and their applications and limitations.
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MESH Headings
- Cardiac Catheterization/instrumentation
- Cardiac Catheterization/methods
- Cardiac Output/physiology
- Cardiology/instrumentation
- Cardiology/methods
- Critical Care/methods
- Echocardiography, Doppler/instrumentation
- Echocardiography, Doppler/methods
- Echocardiography, Transesophageal/instrumentation
- Echocardiography, Transesophageal/methods
- Electric Impedance
- Equipment Design
- Equipment Safety
- Extracorporeal Membrane Oxygenation/instrumentation
- Extracorporeal Membrane Oxygenation/methods
- Female
- Hemodynamics/physiology
- Humans
- Lithium
- Male
- Monitoring, Physiologic/instrumentation
- Monitoring, Physiologic/methods
- Sensitivity and Specificity
- Ultrasonography, Doppler, Pulsed/instrumentation
- Ultrasonography, Doppler, Pulsed/methods
- Ultrasonography, Interventional/instrumentation
- Ultrasonography, Interventional/methods
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Affiliation(s)
- Jahan Porhomayon
- Department of Anesthesiology, VA Western New York Healthcare System, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY 14215, USA.
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Mclean AS, Huang SJ, Kot M, Rajamani A, Hoyling L. Comparison of Cardiac Output Measurements in Critically Ill Patients: Flotrac/Vigileo Vs Transthoracic Doppler Echocardiography. Anaesth Intensive Care 2011; 39:590-8. [DOI: 10.1177/0310057x1103900409] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Measurement of cardiac output is an integral part of patient management in the intensive care unit. FloTrac/Vigileo is a continuous cardiac output monitoring device that does not need re-calibration. However, its reliability has been questioned in some studies, especially involving surgical patients. In this study, we evaluated the comparability of FloTrac/Vigileo and transthoracic Doppler echocardiography in 53 critically ill patients requiring continuous cardiac output monitoring. Most of these patients had septic or cardiogenic shock. Cardiac output was measured by both FloTrac/Vigileo and transthoracic Doppler echocardiography. The bias and precision (mean and SD) between the two devices was 0.35±1.35 l/minute. The limits of agreement were -2.3 to 3.0 l/minute (%error=49.3%). When patients with irregular heart rhythms and aortic stenosis were excluded, the bias and precision was 0.02±0.80 l/minute (n=42). The limits of agreement were -1.55 to 1.59 l/minute (%error=29.5%). Patient demographics (body surface area, gender and age) did not affect the bias, but there was a mild tendency for FloTrac/Vigileo to register a higher cardiac output at high heart rates. Changes in cardiac output for two consecutive days correlated well between the two methods (r=0.86; P <0.001). In summary, with the exceptions of patients with irregular heart rhythms and significant aortic stenosis, FloTrac/Vigileo is clinically comparable to transthoracic Doppler echocardiography in cardiac output measurements in critically ill patients.
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Affiliation(s)
- A. S. Mclean
- Intensive Care Unit, Nepean Hospital, Sydney Medical School, Penrith, New South Wales, Australia
- Department Head
| | - S. J. Huang
- Intensive Care Unit, Nepean Hospital, Sydney Medical School, Penrith, New South Wales, Australia
| | - M. Kot
- Intensive Care Unit, Nepean Hospital, Sydney Medical School, Penrith, New South Wales, Australia
| | - A. Rajamani
- Intensive Care Unit, Nepean Hospital, Sydney Medical School, Penrith, New South Wales, Australia
| | - L. Hoyling
- Intensive Care Unit, Nepean Hospital, Sydney Medical School, Penrith, New South Wales, Australia
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Evaluation of a new software version of the FloTrac/Vigileo (version 3.02) and a comparison with previous data in cirrhotic patients undergoing liver transplant surgery. Anesth Analg 2011; 113:515-22. [PMID: 21680855 DOI: 10.1213/ane.0b013e31822401b2] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Reliable cardiac output monitoring is particularly useful in the cirrhotic patient undergoing liver transplant surgery, because cirrhosis of the liver is associated with a vasodilated and high output state, known as cirrhotic cardiomyopathy, that challenges the reliability of pulse contour cardiac output technology. The contractility of the ventricle in cirrhosis is impaired, which is tolerated even though the ejection fraction and cardiac output are elevated because of the low peripheral resistance. However, during surgery the cirrhotic patient can decompensate because of the physiological changes and stress of surgery. Recently, we showed that the FloTrac/Vigileo™ failed to perform in cirrhotic patients undergoing transplant surgery. In response, the company upgraded their software. Therefore, we have assessed the accuracy and reliability of this new third-generation (version 3.02) FloTrac/Vigileo algorithm software in the same setting. METHODS The cardiac index was measured simultaneously by single-bolus thermodilution (CI(TD)), using a pulmonary artery catheter, and pulse contour analysis, using the FloTrac/Vigileo (CI(V)). Readings were made at 10 time points during and after liver transplant surgery in 21 patients. Comparisons with data from our 2009 study, which used second-generation (version 01.10) software, were also made. RESULTS Our new data show that version 3.02 software significantly reduced the adverse effect on pulse contour cardiac output reading bias in low peripheral resistance states, and thus improves the overall precision and trending ability of the system. Regression analysis between CI(TD) and CI(V) showed that the correlation was moderate (r =0.67, 95% confidence interval, 0.40 to 0.86). The Bland and Altman analysis showed that bias was 0.4 L.min(-1) · m(-2), and the percentage error was 52% (95% confidence interval, 49% to 55%). Trending ability of the new software also was improved but was still well below the current benchmarks. CONCLUSION The new software (version 3.02) provided substantial improvements over the previous versions with better overall precision and trending ability. Further algorithm refinements will increase this technology's reliability to be extensively used in the highly complex setting of cirrhotic patients undergoing liver transplantation.
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Singh S, Taylor MA. Con: the FloTrac device should not be used to follow cardiac output in cardiac surgical patients. J Cardiothorac Vasc Anesth 2011; 24:709-11. [PMID: 20673749 DOI: 10.1053/j.jvca.2010.04.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Indexed: 11/11/2022]
Affiliation(s)
- Saket Singh
- Department of Anesthesiology, The Western Pennsylvania Hospital, Temple University School of Medicine, Pittsburgh, PA 15224, USA.
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Geerts BF, Aarts LP, Jansen JR. Methods in pharmacology: measurement of cardiac output. Br J Clin Pharmacol 2011; 71:316-30. [PMID: 21284692 DOI: 10.1111/j.1365-2125.2010.03798.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Many methods of cardiac output measurement have been developed, but the number of methods useful for human pharmacological studies is limited. The 'holy grail' for the measurement of cardiac output would be a method that is accurate, precise, operator independent, fast responding, non-invasive, continuous, easy to use, cheap and safe. This method does not exist today. In this review on cardiac output methods used in pharmacology, the Fick principle, indicator dilution techniques, arterial pulse contour analysis, ultrasound and bio-impedance are reviewed.
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Affiliation(s)
- Bart F Geerts
- Departments of Anaesthesiology Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands.
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Monitoring Cardiac Output Trends With End-Tidal Carbon Dioxide Pressures in Off-Pump Coronary Bypass. Ann Thorac Surg 2011; 91:e81-2. [DOI: 10.1016/j.athoracsur.2010.12.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Revised: 11/23/2010] [Accepted: 12/20/2010] [Indexed: 11/18/2022]
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Jo YY, Song JW, Yoo YC, Park JY, Shim JK, Kwak YL. The uncalibrated pulse contour cardiac output during off-pump coronary bypass surgery: performance in patients with a low cardiac output status and a reduced left ventricular function. Korean J Anesthesiol 2011; 60:237-43. [PMID: 21602972 PMCID: PMC3092957 DOI: 10.4097/kjae.2011.60.4.237] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 10/08/2010] [Accepted: 10/26/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We compared the continuous cardiac index measured by the FloTrac/Vigileo™ system (FCI) to that measured by a pulmonary artery catheter (CCI) with emphasis on the accuracy of the FCI in patients with a decreased left ventricular ejection fraction (LVEF) and a low cardiac output status during off-pump coronary bypass surgery (OPCAB). We also assessed the influence of several factors affecting the pulse contour, such as the mean arterial pressure (MAP), the systemic vascular resistance index (SVRI) and the use of norepinephrine. METHODS Fifty patients who were undergoing OPCAB (30 patients with a LVEF ≥ 40%, 20 patients with a LVEF < 40%) were enrolled. The FCI and CCI were measured and we performed a Bland-Altman analysis. Subgroup analyses were done according to the LVEF (< 40%), the CCI (≤ 2.4 L/min/m), the MAP (60-80 mmHg), the SVRI (1,600-2,600 dyne/s/cm(5)/m(2)) and the use of norepinephrine. RESULTS The FCI was reliable at all the time points of measurement with an overall bias and limit of agreement of -0.07 and 0.67 L/min/m(2), respectively, resulting in a percentage error of 26.9%. The percentage errors in the patients with a decreased LVEF and in a low cardiac output status were 28.2% and 22.3%, respectively. However, the percentage error in the 91 data pairs outside the normal range of the SVRI was 40.2%. CONCLUSIONS The cardiac output measured by the FloTrac/Vigileo™ system was reliable even in patients with a decreased LVEF and in a low cardiac output status during OPCAB. Acceptable agreement was also noted during the period of heart displacement and grafting of the obtuse marginalis branch.
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Affiliation(s)
- Youn Yi Jo
- Department of Anesthesiology and Pain Medicine, Gachon University of Medicine and Science, Gil Medical Center, Incheon, Korea
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De Backer D, Marx G, Tan A, Junker C, Van Nuffelen M, Hüter L, Ching W, Michard F, Vincent JL. Arterial pressure-based cardiac output monitoring: a multicenter validation of the third-generation software in septic patients. Intensive Care Med 2010; 37:233-40. [PMID: 21153399 PMCID: PMC3028067 DOI: 10.1007/s00134-010-2098-8] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2009] [Accepted: 09/29/2010] [Indexed: 12/18/2022]
Abstract
Purpose Second-generation FloTrac software has been shown to reliably measure cardiac output (CO) in cardiac surgical patients. However, concerns have been raised regarding its accuracy in vasoplegic states. The aim of the present multicenter study was to investigate the accuracy of the third-generation software in patients with sepsis, particularly when total systemic vascular resistance (TSVR) is low. Methods Fifty-eight septic patients were included in this prospective observational study in four university-affiliated ICUs. Reference CO was measured by bolus pulmonary thermodilution (iCO) using 3–5 cold saline boluses. Simultaneously, CO was computed from the arterial pressure curve recorded on a computer using the second-generation (COG2) and third-generation (COG3) FloTrac software. CO was also measured by semi-continuous pulmonary thermodilution (CCO). Results A total of 401 simultaneous measurements of iCO, COG2, COG3, and CCO were recorded. The mean (95%CI) biases between COG2 and iCO, COG3 and iCO, and CCO and iCO were −10 (−15 to −5)% [−0.8 (−1.1 to −0.4) L/min], 0 (−4 to 4)% [0 (−0.3 to 0.3) L/min], and 9 (6–13)% [0.7 (0.5–1.0) L/min], respectively. The percentage errors were 29 (20–37)% for COG2, 30 (24–37)% for COG3, and 28 (22–34)% for CCO. The difference between iCO and COG2 was significantly correlated with TSVR (r2 = 0.37, p < 0.0001). A very weak (r2 = 0.05) relationship was also observed for the difference between iCO and COG3. Conclusions In patients with sepsis, the third-generation FloTrac software is more accurate, as precise, and less influenced by TSVR than the second-generation software. Electronic supplementary material The online version of this article (doi:10.1007/s00134-010-2098-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium.
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Pugsley J, Lerner AB. Cardiac output monitoring: is there a gold standard and how do the newer technologies compare? Semin Cardiothorac Vasc Anesth 2010; 14:274-82. [PMID: 21059611 DOI: 10.1177/1089253210386386] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
As a principal determinant of oxygen delivery and of blood pressure, cardiac output (CO) represents an important hemodynamic variable. Its accurate measurement, therefore, is important to the clinician caring for critically ill patients in a variety of care environments. Though the first clinical measurement of CO occurred 70 years ago, it was the introduction of the pulmonary artery catheter (PAC) with thermodilution-based determination of CO in the 1970s that set the stage for practical and widespread clinical measurement of CO. Although the usefulness and accuracy of this technique have justified its consideration as a "practical" gold standard in CO measurement, its drawbacks have driven the search for newer, less invasive measurement techniques. The last decade has seen the introduction of several such devices into the clinical arena. This article will serve to give a brief review of the history of CO measurement, to provide a discussion of the measurement of accuracy as it relates to CO measurement, and to discuss some of the newer methods and devices for CO measurement and how they have fared against a "practical" gold standard.
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Affiliation(s)
- Jacob Pugsley
- Beth Israel Deaconess Medical Center, Boston, MA, USA
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Critchley LA, Lee A, Ho AMH. A Critical Review of the Ability of Continuous Cardiac Output Monitors to Measure Trends in Cardiac Output. Anesth Analg 2010; 111:1180-92. [DOI: 10.1213/ane.0b013e3181f08a5b] [Citation(s) in RCA: 380] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Manecke GR. Pro: The FloTrac Device Should Be Used to Follow Cardiac Output in Cardiac Surgical Patients. J Cardiothorac Vasc Anesth 2010; 24:706-8. [DOI: 10.1053/j.jvca.2010.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2010] [Indexed: 11/11/2022]
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Effects of on-pump and off-pump coronary artery bypass grafting on left ventricular relaxation and compliance: a comprehensive perioperative echocardiography study. Curr Opin Anaesthesiol 2010; 22:71-7. [PMID: 20421229 DOI: 10.1097/aco.0b013e32831f44d0] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIMS The short-term effect of coronary artery bypass grafting (CABG) on diastolic function is only moderately investigated. Furthermore, it remains unknown whether avoidance of cardioplegic arrest by an off-pump CABG procedure has advantages over on-pump procedure regarding diastolic relaxation and compliance. We investigated whether components of diastolic function would be improved the day after CABG depending on the type of the surgical procedure. METHODS AND RESULTS Spontaneously breathing on-pump (n = 20) and off-pump CABG (n = 12) patients underwent a comprehensive transthoracic echocardiography examination the day before and the day after elective CABG, including transmitral and pulmonary vein flow parameters, colour M-mode flow propagation velocity (Vp) and tissue Doppler assessment of the average mitral annulus diastolic velocity (Em). Isovolumic relaxation and E-wave deceleration time were corrected for heart rate (IVRTcHR and DTcHR). Left ventricular (LV) relaxation time (τ) and LV operating stiffness (LVOS) were calculated. Overall and independent from operation type and preload, CABG decreased IVRTcHR (107 ± 20 vs. 93 ± 15 ms) (P < 0.01) and τ (54 ± 10 vs. 45 ± 10 ms) (P < 0.01), increased Vp (49 ± 22 vs. 75 ± 37 cm/s) (P < 0.01), and increased Em (6.6 ± 2.0 vs. 7.3 ± 1.3 cm/s, P = 0.06), indicating improved relaxation. LVOS increased (0.13 ± 0.06 vs. 0.22 ± 0.05 mmHg/mL) (P < 0.01), compatible with an impaired compliance. A similar improvement in relaxation and impairment in compliance were observed in both groups. CONCLUSION Myocardial relaxation improved the day after CABG irrespective of the use of cardiopulmonary bypass with cardioplegic arrest. Impairment in compliance could not be prevented by the avoidance of cardioplegia.
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Jeong YB, Kim TH, Roh YJ, Choi IC, Suh JH. Comparison of uncalibrated arterial pressure waveform analysis with continuous thermodilution cardiac output measurements in patients undergoing elective off-pump coronary artery bypass surgery. J Cardiothorac Vasc Anesth 2010; 24:767-71. [PMID: 20399114 DOI: 10.1053/j.jvca.2010.02.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Monitoring of cardiac output is required during anesthesia for off-pump coronary artery bypass (OPCAB) surgery. Recently, FloTrac, a new device for arterial pressure waveform analysis for cardiac output (APCO) monitoring without external calibration, was developed. The authors have compared APCO with STAT-mode continuous cardiac output (SCCO) in patients undergoing OPCAB surgery. DESIGN A clinical study. SETTING A university hospital (single institution). PARTICIPANTS Thirty consecutive patients undergoing elective OPCAB surgery. INTERVENTIONS Arterial pressure measurement with FloTrac, pulmonary arterial catheter insertion. MEASUREMENTS AND MAIN RESULTS APCO and SCCO measurements were recorded after pulmonary artery catheter insertion (T1), after sternotomy (T2), after heart positioning for left anterior descending artery anastomosis (T3, T4), after heart positioning for obtuse marginal artery anastomosis (T5, T6), after heart positioning for posterior descending artery anastomosis (T7, T8), and after sternal closure (T9). APCO and SCCO were compared using the Bland-Altman method and the percentage error by Critchley's criteria. SCCO and APCO ranged from 2.1 to 6.9 L/min and 1.2 to 7.4 L/min, respectively, and showed low correlation (r = 0.29). The overall bias by the Bland-Altman method between SCCO and APCO was -0.23 L/min, with a precision of -1.4 to 0.9 L/min, and the overall limits of agreement were -2.5 to 2.0 L/min. The overall mean CO was 4.0 ± 0.95 L/min. The overall percentage error between SCCO and APCO measurements was 57%. CONCLUSIONS Uncalibrated APCO values do not agree with thermodilution SCCO and significantly overestimated the SCCO in patients undergoing OPCAB surgery. Further evaluation is required to verify the clinical acceptance of FloTrac APCO in OPCAB surgery.
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Affiliation(s)
- Yong Bo Jeong
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
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Hofer CK, Button D, Weibel L, Genoni M, Zollinger A. Uncalibrated Radial and Femoral Arterial Pressure Waveform Analysis for Continuous Cardiac Output Measurement: An Evaluation in Cardiac Surgery Patients. J Cardiothorac Vasc Anesth 2010; 24:257-64. [DOI: 10.1053/j.jvca.2009.06.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2009] [Indexed: 11/11/2022]
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Schramm S, Albrecht E, Frascarolo P, Chassot PG, Spahn DR. Validity of an Arterial Pressure Waveform Analysis Device: Does the Puncture Site Play a Role in the Agreement With Intermittent Pulmonary Artery Catheter Thermodilution Measurements? J Cardiothorac Vasc Anesth 2010; 24:250-6. [DOI: 10.1053/j.jvca.2009.05.029] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Indexed: 11/11/2022]
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Hamm JB, Nguyen BV, Kiss G, Wargnier JP, Jauffroy A, Helaine L, Arvieux CC, Gueret G. Assessment of a Cardiac Output Device using Arterial Pulse Waveform Analysis, VigileoTM, in Cardiac Surgery Compared to Pulmonary Arterial Thermodilution. Anaesth Intensive Care 2010; 38:295-301. [DOI: 10.1177/0310057x1003800211] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Many devices are available to assess cardiac output (CO) in critically ill patients and in the operating room. Classical CO monitoring via a pulmonary artery catheter involves continuous cardiac output (CCO) measurement. The second generation of Flotrac/VigileoTM monitors propose an analysis of peripheral arterial pulse waves to calculate CO (APCO) without calibration. The aim of our study was to compare the CO between the Swan Ganz catheter and the VigileoTM. In this observational study, nine patients undergoing coronary artery bypass grafting were prospectively included. APCO, mean (CCO) and instantaneous CO (ICO) were measured. Perioperative and postoperative assessments were performed up to 24 hours post-surgery. Measurements were recorded every minute, resulting in the collection of 6492 data pairs. Comparison of APCO and ICO showed a limited bias of -0.1 l/min but an important percentage error of 48%. Corresponding values were -0.1 l/min and 46% for the APCO versus CCO comparison, and 0 and 17% for ICO versus CCO comparison. Large inter-individual variability does exist. During cardiac surgery and after leaving the operating room, VigileoTM is not clinically equivalent to continuous thermodilution by pulmonary artery catheter. Nevertheless, the connection between CCO and ICO relates the difference between APCO and CCO more to the different algorithms used. Further efforts should be concentrated on assessing the ability of this device to track changes in cardiac output.
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Affiliation(s)
- J.-B. Hamm
- Departments of Anesthesiology and Critical Care Medicine and Cardiac Surgery, University Hospital la Cavale Blanche, Boulevard Tanguy Prigent, Brest, France
- Resident in Anaesthesiology, Departments of Anaesthesiology and Critical Care Medicine
| | - B.-V. Nguyen
- Departments of Anesthesiology and Critical Care Medicine and Cardiac Surgery, University Hospital la Cavale Blanche, Boulevard Tanguy Prigent, Brest, France
- Resident in Anaesthesiology, Departments of Anaesthesiology and Critical Care Medicine
| | - G. Kiss
- Departments of Anesthesiology and Critical Care Medicine and Cardiac Surgery, University Hospital la Cavale Blanche, Boulevard Tanguy Prigent, Brest, France
- Anaesthetist, Departments of Anaesthesiology and Critical Care Medicine
| | - J.-P. Wargnier
- Departments of Anesthesiology and Critical Care Medicine and Cardiac Surgery, University Hospital la Cavale Blanche, Boulevard Tanguy Prigent, Brest, France
- Anaesthetist, Departments of Anaesthesiology and Critical Care Medicine
| | - A. Jauffroy
- Departments of Anesthesiology and Critical Care Medicine and Cardiac Surgery, University Hospital la Cavale Blanche, Boulevard Tanguy Prigent, Brest, France
- Resident in Anaesthesiology, Departments of Anaesthesiology and Critical Care Medicine
| | - L. Helaine
- Departments of Anesthesiology and Critical Care Medicine and Cardiac Surgery, University Hospital la Cavale Blanche, Boulevard Tanguy Prigent, Brest, France
- Anaesthetist, Departments of Anaesthesiology and Critical Care Medicine
| | - C. C. Arvieux
- Departments of Anesthesiology and Critical Care Medicine and Cardiac Surgery, University Hospital la Cavale Blanche, Boulevard Tanguy Prigent, Brest, France
- Professor, Anaesthesiology and Critical Care Medicine Department
| | - G. Gueret
- Departments of Anesthesiology and Critical Care Medicine and Cardiac Surgery, University Hospital la Cavale Blanche, Boulevard Tanguy Prigent, Brest, France
- Consultant, Anaesthesiology and Critical Care Medicine Department
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The FloTrac™ System—Measurement of Stroke Volume and the Assessment of Dynamic Fluid Loading. Int Anesthesiol Clin 2010; 48:45-56. [DOI: 10.1097/aia.0b013e3181b48a1b] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Zimmermann A, Steinwendner J, Hofbauer S, Kirnbauer M, Schneider J, Moser L, Pauser G. The Accuracy of the Vigileo/FloTrac System Has Been Improved—Follow-up After a Software Update: A Blinded Comparative Study of 30 Cardiosurgical Patients. J Cardiothorac Vasc Anesth 2009; 23:929-31. [DOI: 10.1053/j.jvca.2008.12.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Indexed: 11/11/2022]
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Mayer J, Boldt J, Poland R, Peterson A, Manecke GR. RETRACTED: Continuous arterial pressure waveform-based cardiac output using the FloTrac/Vigileo: a review and meta-analysis. J Cardiothorac Vasc Anesth 2009; 23:401-406. [PMID: 19464625 DOI: 10.1053/j.jvca.2009.03.003] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2009] [Indexed: 12/11/2022]
Affiliation(s)
- Jochen Mayer
- Department of Anesthesiology and Intensive Care Medicine, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Joachim Boldt
- Department of Anesthesiology and Intensive Care Medicine, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Reagan Poland
- Department of Anesthesiology, University of California San Diego School of Medicine, San Diego, CA
| | - Amanda Peterson
- Department of Anesthesiology, University of California San Diego School of Medicine, San Diego, CA
| | - Gerard R Manecke
- Department of Anesthesiology, University of California San Diego School of Medicine, San Diego, CA.
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Senn A, Button D, Zollinger A, Hofer CK. Assessment of cardiac output changes using a modified FloTrac/Vigileo algorithm in cardiac surgery patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R32. [PMID: 19261180 PMCID: PMC2689464 DOI: 10.1186/cc7739] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2008] [Revised: 12/29/2008] [Accepted: 03/04/2009] [Indexed: 11/10/2022]
Abstract
INTRODUCTION The FloTrac/Vigileo (Edwards Lifesciences, Irvine, CA, USA) allows pulse pressure-derived cardiac output measurement without external calibration. Software modifications were performed in order to eliminate initially observed deficits. The aim of this study was to assess changes in cardiac output determined by the FloTrac/Vigileo system (FCO) with an initially released (FCOA) and a modified (FCOB) software version, as well as changes in cardiac output from the PiCCOplus system (PCO; Pulsion Medical Systems, Munich, Germany). Both devices were compared with cardiac output measured by intermittent thermodilution (ICO). METHODS Cardiac output measurements were performed in patients after elective cardiac surgery. Two sets of data (A and B) were obtained using FCOA and FCOB in 50 patients. After calibration of the PiCCOplus system, triplicate FCO and PCO values were recorded and ICO was determined in the supine position and cardiac output changes due to body positioning were recorded 15 minutes later (30 degrees head-up, 30 degrees head-down, supine). Student's t test, analysis of variance and Bland-Altman analysis were calculated. RESULTS Significant changes of FCO, PCO and ICO induced by body positioning were observed in both data sets. For set A, DeltaFCOA was significantly larger than DeltaICO induced by positioning the head down. For set B, there were no significant differences between DeltaFCOB and DeltaICO. For set A, increased limits of agreement were found for FCOA-ICO when compared with PCO-ICO. For set B, mean bias and limits of agreement were comparable for FCOB-ICO and PCO-ICO. CONCLUSIONS The modification of the FloTrac/Vigileo system resulted in an improved performance in order to reliably assess cardiac output and track the related changes in patients after cardiac surgery.
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Affiliation(s)
- Alban Senn
- Institute of Anaesthesiology and Intensive Care Medicine, Triemli City Hospital Zurich, Birmensdorferstrasse 497, 8063 Zurich, Switzerland
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Chatti R, de Rudniki S, Marqué S, Dumenil AS, Descorps-Declère A, Cariou A, Duranteau J, Aout M, Vicaut E, Cholley BP. Comparison of two versions of the Vigileo-FloTrac system (1.03 and 1.07) for stroke volume estimation: a multicentre, blinded comparison with oesophageal Doppler measurements. Br J Anaesth 2009; 102:463-9. [PMID: 19244262 DOI: 10.1093/bja/aep020] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Our aim was to evaluate the validity of stroke volume measurements obtained using the Vigileo-FloTrac system in comparison with those obtained using oesophageal Doppler considered as a reference. METHODS Prospective, multicentre study (four university hospitals), in which investigators were blinded to stroke volume values acquired simultaneously with the other technique. Two different versions of the Vigileo software (1.03 and 1.07) were studied and compared over two consecutive periods of time. Forty critically ill patients (three ICUs) and 20 high-risk surgical patients (one operating theatre) were studied over a 6-month period. RESULTS Two hundred and forty paired stroke volume values obtained using the second version of the Vigileo (1.07) yielded better correlation and agreement (R=0.48, P<0.001; bias=4 ml, limits of agreement: +/- 41 ml) than the 207 paired values obtained using version 1.03 (R=0.12, P=0.1; bias=1 ml, limits of agreement: +/- 75 ml). However, even with the second version, the percentage error in stroke volume measurement was 58%, a value still above the range considered clinically acceptable (30%). CONCLUSIONS The precision of stroke volume estimation using Vigileo-FloTrac has improved with the second version of the software (1.07), but remains insufficient to allow the replacement of the reference technique in the population studied.
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Affiliation(s)
- R Chatti
- Département d'Anesthésie-Réanimation, AP-HP, Hôpital Lariboisière, Paris, France
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Compton F, Schäfer JH. Noninvasive cardiac output determination: broadening the applicability of hemodynamic monitoring. Semin Cardiothorac Vasc Anesth 2009; 13:44-55. [PMID: 19147529 DOI: 10.1177/1089253208330711] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Although cardiac output (CO) monitoring is usually only used in intensive care units (ICUs) and operating rooms, there is increasing evidence that CO should be determined and optimized as early as possible, even before admission to the ICU, in the care of hemodynamically compromised patients. A variety of different minimally or noninvasive CO determination techniques have been developed, but not all of them are suitable for early hemodynamic monitoring outside the ICU. In this review, the different available methods for CO monitoring are presented and their potential for early hemodynamic assessment is discussed.
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Affiliation(s)
- Friederike Compton
- Department of Nephrology, Campus Benjamin Franklin, Charité University Medicine Berlin, Germany.
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