1. Cardiac Output Monitoring
Monica Morosan

2. Typical value
End diastolic volume (EDV)120 ml (65– ml)
End systolic volume (ESV)50 ml(16 - –143 ml)
Stroke volume (SV)70 ml ( ml)
Stroke volume index (33-47 ml/m2/beat)
Ejection Fraction (Ef)58% (55 to 70%)
Cardiac output (CO)4.9 L/minute ( L/min)
Cardiac index CI ( )L/min/m2
SVR=80x(MAP-CVP)/CO ( dynes/sec/cm5)
SVRI ( dynes/sec/cm5/m2)

3. Cardiac output monitoring
Invasive
PA catheter
Non invasive
TOE, Echo
Oesophageal Doppler
Transthoracic impedance
Arterial pulse contour analysis (PiCCO)
Arterial pulse power analysis (LiDCO)

4. Fick principle or indicator dilution technique

5. PA catheter

6. PA catheter Measures: Intracardiac pressures PA pressures
Cardiac output
Oxygen saturation

8. 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

9. PAOP (PCWP) significance
Estimates
Left sided preload
Left ventricular end diastolic pressure
Extravascular lung water
Miocardial O2 consumption

10. Thermodilution: Stewart Hamilton equation

11. Oesophageal Doppler

12. 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

13. Normovolaemia Hypovolaemia

14. 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

15. Safe
Uses the CVP catheter and A line
Injectate mmol
Lithium Chloride
Contraindications
-If already on Lithium
-Muscle relaxant drugs
-Weight less then 40 kg
-First 3 months pregnancy

16. PiCCO
Pulse contour analysis with intermittent thermodilution measurement
Good agreement with PAC
Thermistor tipped A line
Relies on good A line trace ( arrythmias, AoR, Ao baloon, SVR up): innaacuracies

17. PiCCO Pulse contour analysis: Intermittent thermodilution:
-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)

18. 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

19. 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

20. 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

21. 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