A comparison of cardiac output derived from the arterial pressure wave against thermodilution in cardiac surgery patients† J.R.C. Jansen, J.J. Schreuder,

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A comparison of cardiac output derived from the arterial pressure wave against thermodilution in cardiac surgery patients† J.R.C. Jansen, J.J. Schreuder, J.P. Mulier, N.T. Smith, J.J. Settels, K.H. Wesseling British Journal of Anaesthesia Volume 87, Issue 2, Pages 212-222 (August 2001) DOI: 10.1093/bja/87.2.212 Copyright © 2001 British Journal of Anaesthesia Terms and Conditions

Fig 1 Schematic diagram of the three-element non-linear, self-adapting model (right) and input pressure and simulated flow pulse (left). Arterial pressure p is applied to the model input. Z0, characteristic impedance of the proximal aorta; Cw, arterial Windkessel compliance; Rp, total systemic peripheral resistance. The non-linear properties of Z0 and Cw are indicated by a stylized ‘S’ symbol. Rp has an arrow indicating that it adapts to changes in systemic resistance. The result of the model simulation is a flow curve q. Integrated per beat (the area under the curve) it yields stroke volume. British Journal of Anaesthesia 2001 87, 212-222DOI: (10.1093/bja/87.2.212) Copyright © 2001 British Journal of Anaesthesia Terms and Conditions

Fig 2 Trend plot in patient 54. This patient was selected because she had a large ratio between highest and lowest cardiac output. The individual thermodilution measurements, not yet averaged over each series of four, are shown as solid dots. Series are numbered from 1 to 14. Continuous model cardiac output is shown as an eight-beat average, which is uncalibrated until the first thermodilution series is completed, at the arrow. British Journal of Anaesthesia 2001 87, 212-222DOI: (10.1093/bja/87.2.212) Copyright © 2001 British Journal of Anaesthesia Terms and Conditions

Fig 3 Trend plots of cardiac output and cardiac output difference vs time from induction of anaesthesia. Cardiac output is the mean of model and thermodilution values. The data of all patients are pooled per half hour and plotted at the start of each half hour. Data points are plotted only when at least three values were available for that half hour. Cardiac output increases significantly with time and post bypass. Cardiac output difference showed no significant trend. British Journal of Anaesthesia 2001 87, 212-222DOI: (10.1093/bja/87.2.212) Copyright © 2001 British Journal of Anaesthesia Terms and Conditions

Fig 4 The model vs thermodilution cardiac output pairs for the calibration (the first) series in the 54 patients. In the Bland–Altman plot COdif is COmf–COtd, COavg is their mean. The crosses indicate four patients shown in full in Fig. 5. British Journal of Anaesthesia 2001 87, 212-222DOI: (10.1093/bja/87.2.212) Copyright © 2001 British Journal of Anaesthesia Terms and Conditions

Fig 5 Scattergram of uncalibrated model and thermodilution cardiac output in four patients selected for lowest (3.2) and highest (7.6 litre min−1) mean cardiac output and greatest cardiac output (3.0:1) and systemic peripheral resistance (3.4:1) range ratio. Calibration turns the dashed line for patient 31 in the direction of the arrow onto the line of identity. In this patient the other points move below the line of identity which will result in a negative bias after calibration. The solid dot (•) indicates the calibration pair. British Journal of Anaesthesia 2001 87, 212-222DOI: (10.1093/bja/87.2.212) Copyright © 2001 British Journal of Anaesthesia Terms and Conditions

Fig 6 (a) Trendplot of patient 31 with the highest systemic vascular resistance range ratio, and (b) trend plot of patient 45 with a long operation. MF, uncalibrated model cardiac output; TD, thermodilution cardiac output; MAP, mean arterial pressure; HR, heart rate; TPR, total systemic vascular resistance computed as MAP/TD. The + signify correct, the – incorrect indication of thermodilution trend by the model method. The ⊕ signify correct and ⊝ incorrect, trends for thermodilution trends greater than 0.5 litre min−1 between consecutive determinations. (a) The trendscore is 9 trends of which 8 are indicated correctly (9/8), 5 trends greater than 0.5 litre min−1 which are all correct (5/5). (b) These scores are (12/12) and (7/7). British Journal of Anaesthesia 2001 87, 212-222DOI: (10.1093/bja/87.2.212) Copyright © 2001 British Journal of Anaesthesia Terms and Conditions

Fig 6 (a) Trendplot of patient 31 with the highest systemic vascular resistance range ratio, and (b) trend plot of patient 45 with a long operation. MF, uncalibrated model cardiac output; TD, thermodilution cardiac output; MAP, mean arterial pressure; HR, heart rate; TPR, total systemic vascular resistance computed as MAP/TD. The + signify correct, the – incorrect indication of thermodilution trend by the model method. The ⊕ signify correct and ⊝ incorrect, trends for thermodilution trends greater than 0.5 litre min−1 between consecutive determinations. (a) The trendscore is 9 trends of which 8 are indicated correctly (9/8), 5 trends greater than 0.5 litre min−1 which are all correct (5/5). (b) These scores are (12/12) and (7/7). British Journal of Anaesthesia 2001 87, 212-222DOI: (10.1093/bja/87.2.212) Copyright © 2001 British Journal of Anaesthesia Terms and Conditions

Fig 7 Diagrams showing the data pairs in all 54 patients before (top, n=490) and after (bottom, n=490–54=436) calibration on the first series after induction of anesthesia. In the Bland–Altmanplot COdif either COmf–COtd before, or COκ1–COtd after calibration; COavg is their mean. The dashed lines indicate the bias and limits of agreement between methods. British Journal of Anaesthesia 2001 87, 212-222DOI: (10.1093/bja/87.2.212) Copyright © 2001 British Journal of Anaesthesia Terms and Conditions