Brit. J. Anaesth.

(1969), 41, 751

THE MEASUREMENT OF CARDIAC OUTPUT

BY
C. PRYS-RO3ERTS

"It is a source of regret that the measurement of flow is so much more difficult than the measure-
ment of pressure. This has led to an undue interest in the blood pressure manometer. Most
organs, however, require flow rather than pressure. . ."
Jarisch, 1928

". . . variations in pressure could be due to two factors, power and resistance, and in the absence
of a criterion which allows one to decide with complete surety, many physiologists have chosen
the hypothesis which accords best with their preconceived ideas."
Etienne Jules Marey, 1881

It is still a source of regret that the measurement MEASUREMENT OF VOLUME DISPLACEMENT:

of flow (cardiac output) is so much more difficult
than the measurement of arterial pressure, because
Marey's statement is as true today of the clinical
anaesthetist as it was of the physiologists of his
time. It is certainly true that in the interval many
methods of measuring cardiac output have been
devised, but if we use only such methods as can
be used in intact man under a wide variety of
conditions, then the numbers are limited.
Although reference will be made to a number
of other methods, only those which can reasonably
be applied in both conscious and anaesthetized
man will be considered in detail.
BLOOD FLOW AND VELOCITY
Semantic difficulties arise when these terms are
used in the context of cardiac output measure-
ment, and it would seem expedient to define the
relations. The ventricles accelerate blood from a
static condition, and discharge it into the aorta
or pulmonary artery, and in doing so impart
momentum to the volume of blood ejected. This
momentum carries the blood forward so that
each volume unit travels a certain distance per
unit time, which defines flow velocity. In contrast,
volume displacement is defined as the volume
displaced through some arbitrary reference plane
per unit time (Zierler, 1962). If the cross-sectional
area of the relevant vessel is known, flow velocity
can be simply converted into volume displace-
ment. All methods of measuring cardiac output
measure direct volume displacement or flow
velocity, and will be considered under these
headings.
INDICATOR DILUTION METHODS
All methods of measuring cardiac output directly
as volume displacement are based on the principle
that an indicator incorporated into a unit volume
of flowing blood delineates the position of that
unit volume both in time and space, and dis-
tinguishes it from all other units of volume in the
same system. This concept of indicator dilution
was first used by Hering (1829) to determine the
"circulation time" by injection of potassium
ferricyanide intravenously and collecting timed
samples of blood from a contralateral vein. By
adding ferric chloride to these samples to obtain
the Prussian Blue reaction, he was able to estimate
the time of arrival of the first unit volume contain-
ing indicator. Hering did not realize that all units
of volume do not traverse the circulation at the
same velocity, and the appearance time of his
indicator reflected only the shortest pathway taken
by the blood between the points of injection and
sampling.
Constant rate injection of indicator.
Let us consider the simple analogue of this
situation (fig. 1) in which a fluid flows at a
constant rate (Q ml /sec) into a chamber of known
volume in which complete mixing can occur, and
leaves at the same rate. If to this flow we add
an indicator (dye) at a constant rate (M mg/sec),
then the concentration of the indicator (C mg/ml)
at the outflow will increase as a curvilinear func-
C. PRYS-ROBERTS, M.A., PH.D., M.B., B.S., F.F.A.R.C.S.,
Nuffield Department of Anaesthetics, Oxford Uni-
versity.
 752 BRITISH JOURNAL OF ANAESTHESIA

V ml

Q ml/ sec C mg/ ml -Kt

yt • y

max

time — time time -—

(a) (b) (c)
FIG. 1
Top: Simple hydraulic analogue of indicator dilution in the circulation. Fluid flows at a constant
rate (Q ml/sec) into a chamber in which complete mixing occurs, and then leaves at the same rate.
Indicator is added at a known rate (M mg/sec).
(la) Change of indicator concentration (C) with time during constant rate infusion of indicator.
No indicator in fluid input.
(lb) Change of indicator concentration (C) with time during constant rate infusion of indicator,
over and above a known concentration of the same indicator (Co) in the fluid input.
(lc) Change of indicator concentration (C) following sudden injection of indicator into a constant
flow stream.
tion of time to reach a maximum value C maI was that involving the physiological gases, oxygen
(fig. la). When this occurs, the rate at which and carbon dioxide as indicators. In this case, the
indicator leaves the system must equal the rate indicators are diffusible at the intravascular
at which it is introduced, and is the product of boundaries at the lungs and the tissues, but
the fluid flow and the maximum concentration: exemplify the conditions of figure lb, where Q
M=QxCmax . . . [i] is the cardiac output traversing the lungs, M is
the uptake of oxygen (Vo2) and C ^ and C o
If the flowing liquid already contains a known represent the oxygen content of arterial (CaO2) and
constant concentration of the same indicator mixed venous (Cv02) blood respectively:
(Co mg/ml), and we add to this the same indicator
at M mg/sec, a new 0 ^ will be reached, and Vo2 = Qx(Ca O 2 -Cv O 2 ) . . [Hi]
(fig. lb): If the "direct" Fick method using either oxygen
M=Qx(CmaI-C0) . . .[iij or carbon dioxide as an indicator is employed,
certain assumptions are implicit in the comparison
THE FICK PRINCIPLE with the model in figure 1. It is assumed that both
This apparently simple concept is the basis of Q and M remain constant during the period where
all indicator dilution methods, and in its second a constant difference exists between Cm^ and Co.
form [ii] is typified by the principle postulated Applied to the physiological circumstances in
by Adolph Fick (1870). Although he never applied which either Fick method is used, the underlying
his principle in practice, the example chosen by assumption is that both cardiac output and gas
Fick, and probably the only one he thought of, uptake are constant for a finite period, and that
THE MEASUREMENT OF CARDIAC OUTPUT 753

the measured gas contents of the arterial and from the corresponding movements of oxygen and
mixed venous blood samples are representative carbon dioxide, so the nitrogen balance method
of the same period. Therefore we must assume [iv] for estimating the inspired minute volume
that a steady state exists during such a period, cannot be applied. This problem may be over-
the duration of which depends on the method come by using box-bag spirometry (Nunn and
employed for measuring gas uptake or elimination Pouliot, 1962), a technique which has been suc-
(Visscher and Johnson, 1953). The method cessfully applied during uptake and elimination
commonly used when the subject breathes room of nitrous oxide (Bay, Nunn and Prys-Roberts,
air consists of collecting a timed sample of expired 1968). A steady state for tissue production and
gas in a suitable container such as a Douglas lung elimination of carbon dioxide is more difficult
bag or Tissot spirometer, accurately measuring to obtain than that for oxygen because of large
the volume (VE) and reducing it to STPD and carbon dioxide stores, but during prolonged
measuring the fractional concentrations (or partial artificial ventilation, the "direct" Fick procedure
pressures) of oxygen ( F E 0 2 ) and carbon dioxide may be applied using directly measured CO 2
(FE C O 2 ) in the sample. To allow reasonable contents of arterial and mixed blood samples.
accuracy in measuring the gas volume, the
sampling period is usually between one and three
Inert diffusible gases may be used in preference
minutes. The inspired fractional concentration of
to the respiratory gases and were introduced in
oxygen (Fi 02 ) is either measured or assumed.
principle by Krogh and Lindhard (1912) who
Oxygen uptake (VO2 ml/min, standard tempera-
used a single-breath method using nitrous oxide
ture and pressure dry: STPD) is calculated from
as indicator. By measuring the uptake of an inert
the difference between the volume of oxygen
gas from the lungs, and knowing its mean alveolar
inspired and that expired:
concentration and its solubility in whole blood at
body temperature, pulmonary blood flow can be
Vo, = ( v i . Fi O 2 )-(VE . F E 0 2 ) estimated by the general method described by
Correcting for differences between inspired and Lee and Dubois (1955). These authors developed
expired minute volumes by assuming that there a particularly valuable application using the body
is no net volume exchange of nitrogen: plethysmograph to estimate the uptake of nitrous
oxide from the lungs, and their technique has
been further modified to estimate pulmonary
V i-Fio capillary blood flow and stroke volume on a beat-
-(VE.FI02) • • • [iv] by-beat basis in man (Bosman et al., 1964). The
cumbersome body plethysmograph limits the use-
where
fulness of the method, and of course it is par-
VI = inspired minute volume ticularly inapplicable during nitrous oxide anaes-
VE=expired minute volume both at STPD thesia. Acetylene has also been used as an inert
Samples of blood simultaneously withdrawn from gas (Grollman, 1929) but following a brief period
a peripheral artery and the pulmonary artery or of popularity, the method was shown to be
right ventricle are analyzed for oxygen content systematically in error (Hamilton et al., 1932).
(ml/litre blood at STPD), and cardiac output can
be calculated from equation [iii].
SUDDEN INJECTION OF INDICATOR
This method, when correctly applied either
during spontaneous or artificial ventilation, can Let us return to the model system and consider
produce reproducible results in conscious man the decay of indicator concentration from the
(Cournand et al., 1945, 1948; Visscher and time at which addition of indicator to the system
Johnson, 1953). Difficulties arise however, if the is stopped (fig. la). At any time after this event,
direct Fick method is applied during anaesthesia the concentration of indicator (Q) will bear some
with gaseous or volatile agents (Prime and Gray, relationship to the maximum concentration Cm**
1952). Uptake or elimination of anaesthetic agents as a function of the relevant time interval (t).
or nitrogen exchange are difficult to distinguish This relationship was found empirically to be an
754
exponential decay (Kinsman, Moore and
Hamilton, 1929) and can be expressed:
Ct=C m a i e- k t . . . [v]
where:
e=2.718 (the Naperian logarithm base);
k is the decay constant of the exponential.
If we consider a further situation where, rather
than using a constant rate infusion of indicator, a
bolus containing a known mass of indicator is
suddenly introduced into the flow at the inlet of
the system, we can visualize that the concentra-
tion of indicator at the outflow will follow some
curvilinear function with time C (t) to reach a
peak concentration, and thereafter decay according
to equation [v]. At any given moment in time,
denoted by the infinitely small time interval (dt),
the rate at which indicator leaves the system is
given by the product of the flow (Q) and its
concentration at that time C (t) dt. Since all the
indicator must leave the system eventually, if the
products of Q and C (t) dt are summated by
mathematical integration, this must equal the
amount (M) of indicator injected.
M=<> c (t) dt [vi]
Rearranged we thus have an expression for volume
displacement (flow) which is the basis of all the
dilution methods involving sudden injection of
indicator:
M of the light pathway. Converting and taking
. . . . [vii]
The integral term 1 c (t) dt is the product of
o-J
concentration and time, and thus represents the
area beneath the curve in figure lc.
This principle may be applied to the measure-
ment of cardiac output using a sudden injection
of a suitable indicator. The criteria for such an
indicator used in man are that it should be non-
toxic even in large doses, that it should not diffuse
out of the intravascular space during its first
circulation, that a known quantity can be intro-
duced into the venous segment, and that its
concentration downstream from the mixing
BRITISH JOURNAL OF ANAESTHESIA
chamber (the heart) can be detected and quantified
instantaneously. A number of indicators can
satisfy these criteria, notably dyes, electrolytes,
acids, cold, heat and radioactive tracers. At the
present time, dye dilution, thermodilution (cold)
and radioactive tracer dilution seem to have stood
the test of time and each method has both
advantages and disadvantages.
Application of the sudden-injection of dye dilution
method in man.
Credit for the first application of dye dilution
for the measurement of cardiac output in man
is due to Hamilton and his colleagues (1932)
although Stewart (1897) applied the same
principle, but using an electrolyte as indicator
and electrical conductivity of blood as the method
of detection. The dye used by Hamilton was
Brilliant Red, and he measured its concentration
in individual timed samples of arterial blood by
visual colorimetry. The advent of transmission
oximetry and its quantification by Matthes (1936)
led to the development of the oximeter to deter-
mine the change in optical density of blood by
addition of dye (Wood, 1950). This application
is based on the Lambert-Beer Law:
I = I 0 e - Ecd . . . . [viii]
where: I and I o are the amounts of transmitted
and impingent light respectively, E is the extinc-
tion coefficient, c the concentration of the light
transmitting fluid, and d is the layer thickness
logarithms of both sides of [viii]:
log, (I/I 0 ) = E.c.d. . . . [ix]
Since E and d are constant for any given system,
and Io can be kept constant, it follows that the
amount of transmitted light is proportional to
the concentration of the specific transmitting
medium. The amount of light is detected by
photosensitive cells whose current output is thus
proportional to the concentration of dye in blood.
Choice of dye. Most of the dyes which have
been introduced for this purpose have been
"blue" dyes which have their peak spectral
absorption in the red region of the visual
spectrum, that is between 600 and 700 nano-
metres (nm) wavelength. In this range there is
a marked difference between the spectral absorp-
tion of oxyhaemoglobin (HbO2) and that of
THE MEASUREMENT OF CARDIAC OUTPUT 755

105 mg in 24 hours (30 individual dye curves

using 3.5 mg each) and this produced no detect-
able undesirable effects.
Injection of dye. The only requirement con-
cerning the injection and sampling points in the
circulation is that there should be adequate
mixing of the dye with the blood stream in
transit, and this can be satisfactorily achieved by
interposing one atrium and ventricle between
these points. Thus injection into the left atrium
and sampling from the aorta will produce steeply
peaked dye curves whose downslopes are usually
complete before significant recirculation occurs.
In practice, this is rarely possible in intact man,
and injection into the pulmonary arterial trunk
is a satisfactory alternative. The greater the dis-

700 SOD 900 1000

Wavelength ~ nanometers

FIG. 2
Spectral absorption of oxygenated and reduced haemo-
globin, and the peak absorption wavelengths of some
dyes used in the measurement of cardiac output.

reduced haemoglobin (HHb) (fig. 2). Conse-

quently the oximeter photocell cannot differentiate
a dye such as Evans Blue (T1824) which has a
peak absorption at 640 run, from reduced haemo-
globin. The only blue dye which does not fall into
this category is Coomassie Blue (Taylor and
Thorp, 1959) which has a peak absorption at
585 nm, a region in which both HbO 2 and HHb
have a very low spectral absorption. From figure
2, it can be seen that the region of 800 nm is an
isobestic wavelength for both HbO2 and HHb,
that is their spectral absorption is equal and fairly
high, so that a dye having a peak absorption in
this region would be ideal. Indocyanine Green
(ICG) was introduced in 1957 by Fox and his
colleagues at the Mayo Clinic (Fox et al., 1957; FIG. 3
Fox and Wood, I960), and has a peak absorption Left: Self-loading, constant volume syringe for dye
at 805 nm, is non-toxic and is rapidly removed injection (a) attached by tap system to low-pressure
range transducer (Elema-Schonander, EMT 33) and
from the circulation by the parenchymal cells of right heart float catheter (b).
the liver (Hunton, Bollman and Hoffman, 1960) Right: Arterial pressure transducer (c: Statham
and its half-life in the circulation is approximately P23De) attached to controlled high-pressure perfusion
system (d) with lead from pressurized, boiled saline
10 minutes (Fox and Wood, 1960). Repeated dye reservoir (e) and withdrawal/infusion pump (f). Cuvette
curve estimations can be made at 2-minute densitomeier (g: Waters XC-302) and mixing loop (h)
intervals (Kelman and Prys-Roberts, 1967) and attached to arterial cannula (i: Becton-Dickinson
Teflon cannula 8" X18 G). Dye is injected into the
the maximum dose as yet used by the author is rubber sleeve from a micro-syringe.
756 BRITISH JOURNAL OF ANAESTHESIA

tance between injection and detection, the greater
the chance that significant recirculation occurs
before the downslope of the first dye curve is
complete, particularly at low cardiac outputs
(Oriol, Sekelj and McGregor, 1967) and in
patients with chronic lung disease (Oriol,
Anthonisen and McGregor, 1968). To obtain
consistent dosage with repeated injection, a self-
loading syringe with an adjustable stop should
be used (fig. 3) to displace dye through a catheter
filled with the same dye solution. The dose may
be predetermined and checked by weighing
aliquots of ejected fluid.
Detection of dye. The photoelectric device com-
monly used for detecting the change in optical
density of blood is a cuvette densitometer which
consists of a variable light source, a light path-
way through which blood from an arterial source
may be withdrawn at a constant rate, and a filter
and double photocell assembly (fig. 3g). This
type of densitometer (XC-302, Waters Co.,
Rochester, Minn., U.S.A.) is dichromatic, in that
the transmitted light is split into two beams, one
of specifically 805 nm, and the other containing
the full light spectrum emitted by the lamp. The
outputs of the two photocells are balanced to
give zero current when blood is withdrawn
through the cuvette prior to dye injection. The
extravascular circuit between the blood vessel used
for sampling and the cuvette densitometer must
be kept to an absolute minimum in order to avoid
catheter distortion effects (Scheel, Langill and
Millhorn, 1966), but if these are unavoidable, an
on-line analogue electronic device may be used
to correct the dye curve according to the physical
characteristics of the system (Melbin, 1967).

100

50-

2.303

C 3 6 9 12 time in sees.
12 18 time in sees.
FIG. 4
Dye dilution curve obtained after injection of 3.5 mg Indocyanine Green into human pulmonary
artery, sampling from aortic root (left).
Replotting of the downslops of the same curve on semi-logarithmic paper (right), with method
of estimating the decay constant of the exponential function.
THE MEASUREMENT OF CARDIAC OUTPUT
Analysis of dye curves. Figure 4 shows a con-
centration/time curve recorded from a Waters
XC-302 densitometer and amplifier and inscribed
on a potentiometric chart recorder (Model M.R.,
E. H. Sargent & Co., Chicago, 111., U.S.A.). The
curve has the acceptable criteria of a flat stable
baseline before and after injection of dye, a
smooth contour including a sharp peak, and the
obvious recirculation peak occurs after the down-
slope has fallen below 20 psr cent of the peak
height of the curve.
The methods available for estimating the area
under the inscribed dye curve are numerous, and
have been assessed and their accuracy defined by
Kelman (1965). The method described below has
the merit not only of accuracy in determining this
area but also of being quick and simple. Measur-
ing the area under a function such as that in
figure lc is relatively simple, but the area under
the curve in figure 4 is complicated by the recir-
culation peak, the effect of which has to be
eliminated. This is achieved by replotting the
downslope on semilogarithmic paper, thus pro-
ducing a function linear with time up to the
point of recirculation (Kinsman, Moore and
Hamilton, 1929). It has been traditional to
extrapolate the line beyond this point to zero con-
centration and then transpose the relevant values
to the original plot before estimating the total area
under extrapolated curve.
The method of manual analysis of dye curves
is to divide the curve into two areas as in figure 4,
the dividing line being arbitrarily determined by
the point C* which is the last point on the
originally inscribed curve which is included in
the exponential decay. This ordinate is used to
calculate the area A2 by the expression: A2 = C*/k,
where k is the decay constant of the previously
determined exponential (Appendix I). The area
under the preceding part of the curve (Aj) is
determined by application of the trapezoid rule
(Kelman, 1965) as in Appendix I. This method is
particularly suitable for digital computerization,
either on a large multi-purpose computer, or a
small desk-top computer (Wang Laboratories,
Model 370, Tewksbury, Mass., U.S.A.) as used in
the author's laboratory.
Calibration. Static calibration of dye curves is
achieved by drawing blood containing known
dye concentrations through the densitometer, and
757
although potentially inaccurate, is the method
commonly used. Dynamic calibration is achieved
by injecting a known mass of dye (ML) into the
subject's blood withdrawn through a mixing loop
(fig. 3) at a constant rate (QL), thus inscribing a
non-recirculating dye curve having a known area
(AL). Thus from the mixing loop: QL = M L / A L .
When a known mass of dye (MP) is injected into
the patient having an unknown cardiac output
(QP) and using the same system a dye curve is
inscribed having an area (AP), then the ratio of
the flows
QP/QL=MP.AJML.AP. . . [x]
(Shinebourne, Fleming and Hamer, 1967)
Since QL, ML, M P , AL are constant, the unknown
cardiac output can be calculated from the above
expression. This relationship is particularly useful
if the relevant dye curve areas can be calculated
by an analogue computer (Hara and Bellville,
1963; Glassman, Bailiff and Herrera, 1967; Taylor
et al., 1967).
THERMODILUTION
The principle of thermodilution methods is
identical to that described for dye dilution, the
indicator being either hot or cold injected fluid,
and the sensor of temperature change being an
intravascular thermistor probe. Various techniques
have been described in animals (Fegler, 1954;
Evonuk et al., 1961; Hosie, 1962) and in man
(Branthwaite and Bradley, 1968). In this last
method, a miniature cardiac catheter carrying a
thermistor at its tip is floated into the pulmonary
artery, its location being determined by visualiza-
tion of the pressure waveform at its tip (Bradley,
1964). Saline or dextrose at room temperature is
injected through a separate catheter into the
right atrium, and the change of temperature in
the pulmonary artery is inscribed as a tempera-
ture/time dilution curve. Cardiac output is calcu-
lated from the expression in the footnote below.
Branthwaite and Bradley (1968) found that this
method agreed well with tie direct Fick method,
V. D x . Sx . C T B - T I ) = Q . dT . t . D B . S B (1000/60)
[xi]
where: Q is the cardiac output, Dj, D B are the
densities, S r , SB the specific heats, and T x and T B the
temperatures of the injected fluid and blood respectively.
V is the volume of injected fluid, dT the mean tem-
perature change and t its duration.
758 BRITISH JOURNAL OF ANAESTHESIA

and stress that frequently repeated injections of of pressure in the region of the ascending aorta,
indicator are relatively innocuous and no blood it might seem that these methods would be ideal
sampling is required. for continuous measurement of stroke volume
and cardiac output in intact man. There has been
RADIOACTIVE TRACER DILUTION
a fairly general inability on the part of workers
(RADIOCARDIOGRAPHY)
other than the original authors to validate the
Continuous recording of radioactivity using methods, which accounts in some way for the
external counting apparatus has been used in an lack of acceptance in the clinical field, and the
attempt to avoid sampling of blood (Huff et al., number of alternative methods. The stringent
1955). The indicator used by these authors was requirements for fidelity in reproduction of the
radioiodinated (I131) human serum albumin (RISA) pressure waveform can now be more easily met,
injected intravenously and detected with a colli- and the application of on-line digital computation
mated beam scintillation counter placed over an to calculate stroke volumes on a beat-to-beat basis
intercostal space to one side of the sternum. This in real time, makes this "Philosopher's stone" of
application has been extended by Cournand and cardiovascular physiology almost tangible (Warner,
his colleagues (1960) who, using a highly volatile Gardner and Toronto, 1968; Kouchoukos et al.,
radioactive indicator (KrS5) injected in the right 1968). All these methods are empirical and the
atrium, obtained a dilution curve for the right computed values of stroke volume are in arbitrary
heart alone, and by injection of RISA into the units which have to be multiplied by an appro-
pulmonary artery, were able to obtain a similar priate proportionality constant determined from
curve for the left ventricle. The limitations of simultaneous dye dilution measurements.
radioactive tracer methods in general are mainly
concerned with the calibration techniques, the APPENDIX I
inadvisability of repeated estimations and the Calculation of area under inscribed dye-dilution curve
radiation hazard, particularly to the thyroid when in figure 4.
I 131 labelled indicators are used. Area A, is calculated by the trapezoid rule (Kelman,
1965):
MEASUREMENT OF FLOW VELOCITY fc=n fc=n _
Methods which measure mean flow velocity in c(t)dt= (c,+c2 + c, + ...+ ^ ) At
either pulmonary artery or the ascending aorta c=o-) c=oJ L

may be used to estimate cardiac output if either [i]

where c15 c2, etc., are the concentration values of the
the cross-sectional area of the relevant vessel is ordinates at time interval At (0.6 sec in figure 4).
known or if an alternative method of measuring Area A2 is calculated by estimating the area under
volume displacement (e.g. dye dilution) can be
the extrapolated exponential decay:
used to calibrate the velocity method (see
McDowall (1969), in this issue). cdt = c * e - « . dt [ii]
oj
PRESSURE PULSE CONTOUR METHODS at t=o, c=c*
Erlanger and Hooker (1904) first suggested that
the stroke volume of the heart could be quantified
from the pulse pressure, and many methods have =
c*
[e-kv!_e-ko] [i v ]
subsequently been devised utilizing various mathe- k
matical treatments of the central arterial pressure since: e- k > -=o, and e- k o = l,
waveform (Remington, Hamilton and Dow, 1945; A2 = c*/k [v]
Warner et al., 1953; Fry, Mallos and Casper,
1956; Womersley, 1955; Kouchoukos et al., 1968). k is the decay constant of the exponential decay and is
calculated from figure 4:
Most of the early techniques were claimed to loge (y,-y s )
give excellent results in both dogs and man k= [vi]
when compared with the dye dilution under a t2-t,
variety of conditions. Since the measurement Total area = f c(t) dt=A! + A [vii]
usually involves no more than accurate recording
j
THE MEASUREMENT OF CARDIAC OUTPUT
FURTHER READING
Guyton, A. C. (1963). Circulatory Physiology: Cardiac
output and its regulation. London: Saunders.
Hamilton, W. F. (1962). Measurement of cardiac out-
put; in Handbook of Physiology: Circulation, Sect.
2, Vol. I, Chap. 17, pp. 574-584. Washington,
D.C.: Amer. Physiol. Soc.
ACKNOWLEDGEMENTS
I am grateful to Mr. R. H. Salt and his staff, and the
Longworth Scientific Instrument Co. Ltd., Abingdon,
for the construction of the transducer table depicted in
figure 3.
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REGISTRARS PRIZE (ANAESTHETICS)

Applications are invited by the Royal Society of Medicine, Section of Anaesthetics, for
a prize of £50 provided by Messrs. May & Baker Ltd., for a paper written by a medical
practitioner of Senior Registrar or Registrar status, holding an appointment in anaes-
thesia in a department or hospital, or in the armed forces of the Commonwealth or of
the Republic of South Africa or Eire. Fellowship of the Royal Society of Medicine is
not necessary for entry. The subject will be of the author's choice, but must be connected
with anaesthesia. All papers for the 1970 award must be submitted in triplicate oy
1 January, 1970.

Further details and rules of the prize can be obtained from

T H E ROYAL SOCIETY OF MEDICINE, 1 WIMPOLE STREET, LONDON, W1M 8AE