Cardiac Output Monitoring

The hard stuff

Mark Vivian
Contents

• Cardiac Output
• The Fick Principle
• PA Catheters
• Thermodilution and dye-dilution
measurement
• (Transoesophageal) Doppler
• LiDCO / PICCO
Cardiac Output, CO
• Volume of blood pumped by heart in a
unit time
• CO is a measurement of FLOW
• Average value of 70kg ♂ is approx 5Lmin-1
• Affected by
– Natural physiology (eg respiration)
– Pathology (organ dysfunction, shock, trauma etc)

• Measured using invasive and non-invasive

techniques
CO

• CO = heart rate (HR, bpm) x stroke

volume (SV, mL)
= volume per unit time

• CO = SBP (systemic BP) ÷ systemic

vascular resistance (SVR)
The Fick Principle
• Adolf Fick (1829-1901)
• German physiologist
• 1870 - Developed principle for measuring
cardiac output

• Can be utilised in variety of clinical

situations
Fick Principle - 1
• blood flow to / from an organ can be measured
using a marker substance
• Relies on observation:
– ‘total uptake/release of a substance by an organ is equal to the
product of bloodflow to that organ and the arterial-venous
concentration gradient of marker substance’

• Several substances can be used

• note -
– Total uptake of substance = Vsub
– Blood flow = CO
– Arterial concentration of substance = CAsub
– Venous concentration = CVsub
Fick Principle - 2
• Can estimate CO if we measure
Substance taken up by organ
per unit time, V

Organ

Concentration of substance Concentration of substance

Supplying organ, CVsub leaving organ, CAsub

• Fick’s principle: Vsub = CO (CAsub – CVsub)

Fick Principle - 3
• Use Oxygen = substance
• Use pulmonary system (receives 100% CO)
Oxygen taken up by organ
per unit time, VO2

Pulmonary LA / aorta /
artery
Lungs arterial system

Concentration of oxygen Concentration of oxygen

Supplying lungs, CVO2 leaving lungs, CAO2
Fick Principle - 4
• Measure VO2 using spirometry
– Approx 250mL O2 min-1

• CVO - from pulmonary artery

2

• CAO – from peripheral artery

2

• From before:
VO2 = CO (CAO2 – CVO2)

• Rearranging to:
CO = VO2 _
(CAO2 – CVO2)
units = mLmin-1
Pulmonary Artery Flotation catheter
• Applies Fick principle when used to
measure CO
• CO measured by Thermodilutional
methods and
• Dye dilutional methods

• Use a known volume / concentration of

substance
• Measure effects at a distal point over time
 Dilutional CO measurement
• Utilises the PA catheter
• Current gold
standard
• 4-5 lumens
• 10cm apart
Dilutional CO measurement - 2
• Discrete volume ‘cold’ fluid or
dye injected in RA
• Temperature/concentration is
measured at a known distance
(usually in PA) and recorded
over time
• CO is calculated from the
resultant concentration or
temperature curve
(‘thermodilution curve’)
Dilutional CO measurement - 3
• CO is calculated using the Stewart-Hamilton equation
• CO is a flow – volume per unit time
• A known ‘mass’ of marker is injected and its’
concentration is measured over time
• The volume into which it was given can be derived using

Vol = Mass ÷ Conc

V = M_
C

• Concentration is measured using an appropriate sensor

Dilutional CO measurement – 4
• The flow of the volume is calculated using
Flow = Mass ÷ (Concentration x change in time)

or CO = M _
C . Δt

• This is the equation used for dyedilutional

measurement of CO

• Thermodilutional method works similarly, with

an adaption
Dilutional CO measurement - 5
• The equation adapted for thermodilutional CO measurement -

CO = Vinj (Tb – Tt). K

Tblood (t) Δt

Where
Vinj = volume of injected fluid (injectate)
Tb = blood temperature
Tt = temperature of injectate
K= constant derived from multiplication of
density and a constant
Tblood (t) Δt = change in blood temperature over time
Dilutional CO measurement - 6
• The (thermo)dilution curve produced

is an inverse ‘hump’ since Temp fall

is recorded versus time

• The graph is usually presented

with temperature decrease on
y-axis so the deflection becomes
positive:
Dilutional CO measurement - 7
• This is an example of a washout curve
• It describes an exponential process:
• the rate of change of a quantity at any time 
the quantity at that time

• The rate at which the injectate is removed is

equal to the flow of blood x concentration of the
injectate in the blood
Q = V x [inj]
note: V is flow; Q = rate of
removal of injectate
Dilutional CO measurement - 8
• However, V is constant, therefore
Q (rate of removal injectate)  [inj]
V is the flow, or volume of blood between the injection site and the thermistor
sensor ie the parts of the heart and vasculature = constant

• And, the actual amount of injectate in the

blood volume at any time is proportional
to its’ concentration, so
Mass injectate  injectate concentration
- an exponential.
 Dilutional CO measurement – 9
• This exponential (proportional) relationship
is exploited to derive the CO

• The graph is converted by a semi-log

transformation
• log10 Temp decrease y axis
• time x axis
• Area under the curve is
used to measure CO
 Dilutional CO measurement - 10
• The Area under the curve is calculated to give the
CO
CO = _dose injectate_ = __mass___

area under curve = concn . Time

• Similar techniques for both Dye and thermodilutional

methods
• a computer works the values out!
• Remember, CO = flow = volume per unit time
Doppler measurement of CO
• Probe in oesophagus
• Anatomically close to aorta
• Measures velocity of blood in descending aorta
• Velocity enables calculation of volume per unit
time, ie CO

• Some additional data is needed, such as

diameter of aorta (calculated via normograms)
Doppler Effect
• CO measurement relies on Doppler Effect
• phenomenon by which frequency of
transmitted sound is altered as it is reflected
from a moving object -

there is an increase in the observed frequency of a signal

when the signal source approaches the observer

e.g. ambulance siren

Doppler Effect - 2
• Electromagnetic wave equation:
v=f.λ
Where v = velocity of wave motion, f = frequency, λ = wavelength

• Doppler effect:

Wavelength ↓ = Wavelength ↑ =
frequency ↑ = frequency ↓ =
pitch ↑ pitch ↓
Doppler Effect - 3
• Doppler effect represented by:
V = _ΔF . c _
2 F0 cos θ
Where V = velocity of object
ΔF = frequency shift
c = speed of sound in medium (body tissue here)
F0 = frequency of emitted sound
cos θ = angle between sound wave and flow (RBC)

• To measure CO transoesophageally, we
need to know the diameter of the aorta
 Doppler Effect - 4
• F0 = frequency emitted
• FR = frequency reflected off RBCs
moving at u m/s
• Θ = angle of incidence (transmitter to
direction of flow)

Frequency (phase) shift =

FR – F0 = ΔF

and ΔF  velocity of RBCs

If a measurement – or estimate (by normogram) – of the

cross-sectional area of the aorta is known,
flow can be derived as area x velocity
(m2.m.s-1 = m3s-1)

i.e. a volume per unit time = CO

Doppler output
PiCCO / LiDCO

• Continuous CO analysis

• PiCCO – pulse contour cardiac output

• LiDCO – Lithium dilution cardiac output

• Both systems employ very complicated
algorithms based on the Fick principle
LiDCO
• Bolus isotonic LiCl (150mM) injected
peripheral/central vein

• CLiCl over time is monitored via an ion selective

electrode on the arterial line manometer

• CO is calculated from the Li dose and the area

under the concentration-time curve prior to
recirculation using:
CO = Li dose (mmol) x 60
Area x (1-PCV) (m mol/sec)

Where PCV = packed cell volume = Hb (g/dL) /34

LiDCO -2
• Blood flows into the sensor assembly at the rate
of a peristaltic pump.

• Beat to beat CO by calibrating an arterial BP

trace algorithm

• Additionally, LiDCO can be used in conjunction

with another device to calibrate and provide
continuous arterial waveform CO analysis
PiCCO
• Cold bolus as described previously
• Injected via central line
• Injectate travels through multiple compartments

• Variables are indexed according to patient parameters

• Complicated algorithms used to calculate CO
PiCCO - 2
• Pulse contour continuous cardiac output
• Displayed following calibration
• SV is calculated
from AUC from
arterial trace

• CO calculated from SV (CO = HR . SV)

Summary
• Invasive, semi-invasive methods
• Based on the Fick and Doppler Principles
• Fick Principle is gold standard but practically
hard to measure
• Dilutional methods give CO via washout curves
and analysis of ‘area under the curve’ (i.e. mass
 concentration)
• Doppler and LiDCO / PiCCO methods provide
continuous waveform analysis
• CO = flow = volume per unit time!