Vous êtes sur la page 1sur 9

Topics in Compan An Med 31 (2016) 100–108

Review Article

A Review of Available Techniques for Cardiac Output Monitoring


Kristen Marshall, DVMn, Elizabeth Thomovsky, DVM, MS, DACVECC, Paula Johnson, DVM,
Aimee Brooks, DVM, MS, DACVECC

Keywords: The main objective of fluid therapy is to increase cardiac output (CO). Large, rapidly administered
cardiac output
volumes of fluids are the cornerstone of treating patients in shock to restore circulating volume and
cardiac index
improve tissue perfusion. However, determining exactly how much fluid a given patient requires can be
pulse contour analysis
central venous pressure challenging. If enough fluid is not given, poor tissue perfusion can lead to ischemia, anaerobic
lithium dilution metabolism, and ultimately cell and patient death. Conversely, increased morbidity and mortality
ultrasound associated with excessive intravenous fluid administration has been reported in the human literature in
a wide variety of conditions. This review focuses on types of available CO monitoring, their application in
veterinary medicine as well as current research trends in noninvasive evaluation of CO.
Department of Veterinary Clinical Sciences,
Purdue University College of Veterinary & 2016 Elsevier Inc. All rights reserved.
Medicine, West Lafayette, IN, USA
n
Address reprint requests to: Kristen
Marshall, DVM, Purdue University College
of Veterinary Medicine, 625 Harrison St,
West Lafayette, IN, USA.
E-mail: marsha80@purdue.edu
(K. Marshall)

Administration of intravenous fluids is a critical, life-saving ther- Determining when a patient has gotten to the point where
apy for both human and animal patients. Large, rapidly adminis- further fluids would not improve CO is the clinical problem that
tered volumes of fluids are the cornerstone of initial stabilization directs CO monitoring has been designed to address. A clinician
in most types of shock; the goal is to restore circulating volume wants to give enough fluids to maximize CO and avoid the
and improve tissue perfusion.1 An alternative way of thinking development of ischemia, anaerobic metabolism, and ultimately
about treating these patients is to consider improving the cardiac cell and patient death,5 but not to give such a large volume of fluid
output (CO). that there is increased morbidity and mortality from excessive
Cardiac output is defined as the volume of blood that is intravenous fluid administration.6-9
transferred from the left ventricle to systemic circulation over Knowing that an unstable patient is no longer fluid responsive
time. This is measured in ml/kg/min in veterinary medicine. might also lead a clinician to seek alternate therapies to improve
Normal CO in the dog or cat is 120-200 mL/kg/min. Another way perfusion (inotropes, pressors, blood products, etc.). Several
to think about CO in species of variable size such as dogs and cats methods of assessing fluid responsiveness have been investigated
is to divide the CO by the animal’s body surface area. This is in veterinary medicine.
known as the cardiac index (CI). Surface area is used in this
equation as it is thought to correlate better with the animal’s
metabolic rate than the weight. Cardiac index is measured in Estimation of Preload1
L/min/m2 (Table 1).2
The importance of determining the CO and understanding the Central Venous Pressure
variables involved helps to demonstrate the fact that not every
animal in shock or showing evidence of hypoperfusion requires Although not a direct measure of CO, central venous pressure
fluid therapy. Previous research in human medicine has shown has been used to guide fluid therapy, to assess a patient’s volume
that approximately 50% of critically ill patients are fluid responsive.3 status, and to measure the response to fluid administration in
Fluid responsiveness can be explained by the Frank-Starling (FS) human and veterinary medicine for several decades. Because
principle and curve (Fig 1). central venous pressure is equivalent to the pressure within the
The FS principle states that stroke volume increases as cardiac intrathoracic vena cava, it would approximate right atrial pressure.
end-diastolic volume increases (i.e., as the ventricles fill with more The pressure in the right atrium and vena cava is directly related to
blood, more blood is ejected from the heart). This relationship is the volume of blood in these locations.
built on the fact that more blood means increased stretching of the Blood in the vena cava and right atrium is largely representa-
cardiac myofibrils, which improves contractility.4 However, as the tive of the venous return (blood returning from the peripheral
myofibrils have a maximal amount that they can physically vascular beds into the central venous compartment). This systemic
stretch, this creates a plateau on the curve (Fig 1). As the patient blood presented to the heart is also known as the preload. The
moves toward the flat part of the FS curve, the myofibrils become preload arriving at the right atrium should completely empty into
maximally stretched and CO does not increase, no matter how the right ventricle, thus creating the right ventricular end-diastolic
much more fluid is presented to the heart. volume. Therefore, right ventricular end-diastolic volume is

http://dx.doi.org/10.1053/j.tcam.2016.08.006
1527-3369/ & 2016 Topics in Companion Animal Medicine. Published by Elsevier Inc.
K. Marshall et al. / Topics in Companion An Med 31 (2016) 100–108 101

Table 1
RAP RV
Comparision of formulas for CO and CI. CVP RAV volume

Cardiac output Cardiac index

CO ¼ HR  SV CO HR  SV
CI ¼ ¼
BSA BSA
LV LA
volume volume

proportional to preload. Additionally, blood in the right ventricle is


the primary determinant of blood presented to the left ventricle,
and thus should create the stroke volume. Therefore, measuring
central venous pressure (CVP) is thought to represent venous
return, preload, and indirectly stroke volume10 (Fig 2). Stroke
volume
The use of central venous pressure measurement has been
recommended in a variety of conditions such as heart failure,
sepsis, and acute kidney injury.11-13 Surveys of human intensivists CVP=central venous pressure, RAP=right atrial pressure, RAV=Right atrial volume,
RV=right ventricle, LA=left atrium, LV=left ventricle
and anesthesiologists from 2007 have shown that approximately
90% of practitioners use CVP to help guide fluid therapy in critical
postoperative and septic patients.14,15 Fig. 2. Relationship between CVP and cardiac output. Central venous pressure
Measuring CVP in veterinary practice first requires placement (CVP) is the pressure of blood in the cranial vena cava near the right atrium of the
of a central venous catheter. Ideally, the catheter tip is within the heart. The CVP is often a good approximation of right atrial pressure (RAP);
however, the 2 terms are not identical. In theory, because the right atrium has little
vena cava just proximal to the right atrium. This location allows
to no resting muscle tone, its pressure is determined almost exclusively by the
for a measurement of central venous pressure that should be the volume within the chamber and the blood within the right atrium comes from the
closest to the pressure in the right atrium. Correct placement of cranial vena cava. Therefore, when measuring the CVP, one is theoretically
the catheter should be confirmed by thoracic radiographs (Fig 3). measuring the volume of blood in the right atrium and as such, the CVP is typically
Once the catheter has been placed, CVP measurements can be used as a surrogate for preload. In a normal heart, the preload should be roughly
equivalent to the volume returning to the left atrium and left ventricle and
obtained with either a water column manometer or an electric
therefore should provide some information about the stroke volume and cardiac
monitor (Fig 4). The measurements obtained can theoretically be output.
used to guide fluid therapy by assessing a patient’s response to a
fluid challenge. Normal CVP measurements are 0 cm H2O-10 cm
H2O.16,17 volume, the CVP should increase by 2-5 cmH20 and return
To perform a traditional fluid challenge, the CVP is measured to baseline in 15-20 minutes. Larger increases in CVP after
and a fluid bolus of 20 mL/kg of crystalloids or 5 mL/kg of colloids fluid administration (4 5 cm H20) is suggestive of poor cardiac
is given as quickly as possible. If the patient has appropriate blood function, fluid overload, or both. A CVP that does not increase or
decreases to baseline quickly after the fluid bolus can reflect the
need for further fluid therapy in that patient. This “5-2” rule was
originally described in the 1970s.18
Unfortunately, central venous pressure monitoring may not be as
accurate a reflection of left ventricular preload in critically ill patients
Preload independent as previously presumed. Increased blood volume, venous tone, and
cardiac tamponade would all increase CVP, whereas hypovolemia
and poor venous tone decrease central venous pressure. Central
venous pressure can also be affected by pressure changes within the
abdomen and the thorax, such as increased intra-abdominal pressure
with diseases such as pancreatitis or increased intrathoracic pressure
in mechanically ventilated patients (Fig 5).

Preload dependent

Preload (cardiac end-diastolic volume)

Fig. 1. The Frank-Starling curve. On the steep portion of the Frank-Starling curve,
stroke volume increases as the preload increases (i.e., as the cardiac end-diastolic
volume increases). In other words, as there is increased ventricular filling, more
blood is ejected from the heart. When the cardiac myofibrils reach maximal
stretch, the ventricles cannot fill any further and no additional blood can be ejected
from the heart. This is depicted by the flat part of the curve. When patients are in
the preload dependent part of the curve, they would likely be fluid responsive. Fig. 3. Correct placement of the jugular catheter for central venous pressure
However, when patients are on the plateau part of the curve (preload independent measurement. Note: The tip of the jugular catheter is immediately cranial to the
portion), they would not be responsive to fluid administration. right atrium.
102 K. Marshall et al. / Topics in Companion An Med 31 (2016) 100–108

Fig. 4. Central venous pressure (CVP) measurement. This picture shows a dog
having his central venous pressure measured. Note, that we are using a manometer
attached to a jugular catheter to evaluate the pressure reading.

More recently, the usefulness of central venous pressure


monitoring has been scrutinized in human medicine and has
been found to correlate poorly with a patient’s volume status
and fluid responsiveness.19 In veterinary medicine, no such
studies or meta-analyses have been performed, but it is
suspected that the correlation is also poor. Therefore, clinical
CVP monitoring is best used to monitor trends rather than
single values. Any CVP value also needs to be interpreted based
on how the patient is doing and what other interventions and
diseases the patient is experiencing. Table 1 shows 2 cases with Fig. 5. Determinants of CVP.

differing CVP findings and PE findings to show the importance of


evaluating the entire patient before making clinical decisions Consumption Methods
(Table 2).
Concerns with its accuracy aside, one of the reasons CVP Fick’s Method (The Original Gold Standard)
continues to be used in both human and veterinary medicine is Cardiac output measurement was originally described in 1870
that central venous pressure is one of the few easily available, by Adolph Fick, a German physician and physiologist. The Fick’s
relatively easy to perform, bedside methods of estimating pre- method of CO assessment is the oldest and original gold standard
load. It is also easy to understand that a high CVP most likely of CO monitoring. The Fick’s method assumes that the rate of
reflects hypervolemia or poor cardiac function, whereas a low oxygen consumption is determined by the rate of blood flow and
CVP most likely reflects hypovolemia. As long as CVP is used in the rate of oxygen uptake by the tissues. In states of decreased CO
the context of the patient (i.e., in conjunction with other patient and decreased blood flow to tissues, the rate of blood flow is
parameters such as body weight, urine output, mentation, and decreased and more time exists for oxygen to be extracted from
heart rate) along with following trends, it may provide some the blood.20 The equation for the Fick’s method is as follows:
information regarding the efficacy of fluid therapy as well as
VO2
some information about a patient’s volume status. CO ¼
Ca O2 Cv O2
In this equation, oxygen consumption (VO2) is divided by the
Measurement of Cardiac Output difference between arterial oxygen content (CaO2) and venous
oxygen content (CvO2). The tissues take up oxygen presented to
There are several methodologies for directly monitoring CO them by arteries, with any excess oxygen not used by tissues being
that have been used in veterinary medicine. The advantage of found in the veins. Taking this a step further, the arterial oxygen
these methods over CVP or the other approximations discussed comes from inspired oxygen, and the unused oxygen in the venous
in the first article of this series is that these methods attempt to circulation is related to the oxygen exhaled. To perform CO
enumerate the actual CO. However, most of these methods are calculation using the Fick’s method, a patient is intubated and
used in research settings or in a tertiary referral centers. This oxygen consumption is determined by comparing the oxygen
section would provide brief descriptions of these methods and concentration in the air that they inhale vs. the oxygen concen-
their applications in veterinary medicine. tration of the air that the patient exhales. This usually takes place
K. Marshall et al. / Topics in Companion An Med 31 (2016) 100–108 103

Table 2
A comparison of Central Venous Pressure (CVP) Monitoring With Serial Examinations

Patient 1: 3-year-old male castrated Golden Retriever Patient 2: 5-year-old female spayed000 Yorkshire Terrier

8AM: QAR, HR ¼ 120, RR ¼ 12, mm-pink, CRT o2, good pulse quality, 8AM: Obtunded, HR ¼ 180, RR ¼ 36, mm-pale, CRT 4 2, weak femoral pulses,
CVP ¼ 0, and Doppler BP ¼ 90 CVP ¼ 1, and Doppler blood pressure ¼ 40
Fluid bolus given Fluid bolus given
12AM: QAR, HR ¼ 90, RR ¼ 12, mm-pink, CRT o2, good pulse quality, 12PM Obtunded, HR ¼ 160, RR ¼ 24, mm-pale, CRT  2 s, weak femoral pulses,
CVP ¼ 2, and Doppler blood pressure ¼ 120 CVP ¼ 2, and Doppler blood pressure ¼ 70
Fluid bolus given
4PM: BAR, HR ¼ 70, RR ¼ 12, mm-pink, CRT o2, good pulse quality, 4PM: QAR, HR ¼ 160, RR ¼ 16, mm-light pink, CRT o 2 s, weak femoral pulses,
CVP ¼ 5, and Doppler blood pressure ¼ 110 CVP ¼ 2, and Doppler blood pressure ¼ 90
Fluid bolus given
8PM: BAR, HR ¼ 60, RR ¼ 10, mm-pink, CRT o 2 s, good pulse quality 8PM: QAR, HR ¼ 100, RR ¼ 12, mm-light pink, CRT o 2 s, improved femoral pulses,
CVP ¼ 0, and Doppler blood pressure ¼ 120 CVP ¼ 5, and Doppler blood pressure ¼ 100

Both patients presented with a 2-day history of severe watery diarrhea, vomiting, and lethargy. Note, that patient 1 has persistently low CVP values; however, the remainder
of his physical examination parameters are improving over time. In this case, it is unlikely that CVP measurements accurately reflect volume status in this clinically stable
patient. In contrast, patient 2 appears to be in shock based on her physical examination findings. Her CVP numbers are suggestive of hypovolemia. The CVP values used along
with her examination findings suggest that fluid therapy may be beneficial to this patient. BAR, bright, alert, and responsive; QAR, quiet, alert, and responsive; CRT, capillary
refill time; mm, mucous membrane color; HR, heart rate; RR, respiratory rate.

over approximately a 3-minute period (Fig 6) An arterial blood thermodilution. In transpulmonary thermodilution, a patient
sample can be compared with a mixed arteriovenous (usually receives an injection of a predetermined amount of an indicator
from the pulmonary artery) blood sample as an alternative to the (dye, lithium, or cold saline) into the bloodstream (usually the
respiratory gas analysis.2 jugular vein), and this indicator is sampled and measured in blood
Although the Fick’s method was considered the original downstream from the original injection site (usually the femoral
gold standard for CO monitoring, it has several disadvantages artery). The amount of the indicator found in the downstream
that prevent it from being clinically useful. First, it is not a blood is used to generate a time-dilution curve that in turn can be
real-time measurement of CO, because the respiratory gases and used to derive CO (Fig 8). However, in pulmonary artery thermo-
arterial blood gases require laboratory analysis, which takes time dilution, a pulmonary artery catheter is placed and a predeter-
before acquiring results. It also requires that the patient be mined amount of indicator is injected into the catheter and is
intubated to obtain accurate collection of inhaled and exhaled detected by a thermistor located in the pulmonary artery. Inter-
respiratory gases. Finally, this method can only be used in a mittent transpulmonary thermodilution has acceptable agreement
patient who is hemodynamically stable because the results are with pulmonary artery thermodilution but is not as accurate in
less accurate if shunting of blood is occurring in an unstable monitoring trends.25
patient.21 These 2 methods have recently been compared in patients with
fluid overload and were found to show good agreement and an
accurate assessment of CO.26
Noninvasive CO Monitoring
Noninvasive CO monitoring is a method that calculates CO by
carbon dioxide (CO2) rebreathing using a modified Fick’s equation.
An intubated patient is connected to a proprietary rebreathing
system that contains CO2 and flow sensors. A rebreathing exercise
using a “rebreathing loop” is performed to assess CO. (Fig 7). The
comparative value of the CO2 concentration can be used to
calculate CO.
When CO is low, the exhaled CO2 is similar to inhaled CO2
because less blood is traveling to tissues and bringing waste CO2
from the tissues back to the lungs to be exhaled. When the CO is
high, more blood is circulating through the tissues and bringing
CO2 back to the lungs, so the exhaled CO2 is significantly higher
than inhaled CO2. The change in CO2 after the rebreathing circuit
is activated for a predefined period of time and is used to
estimate CO.
This method of CO monitoring is less invasive than the Fick’s
method and has been found to work well in dogs and foals.22,23
Limitations include the need for an intubated and preferably
ventilated patient, which is not always practical in a clinical
setting.

Indicator Dilution Methods (The New Gold Standard)

Indicator dilution methods were originally described by Stew-


art in the late 1800s.24 These methods of CO monitoring have Fig. 6. The Fick's method of cardiac output measurement. This shows a graphic
description of the Fick's method. Both the inhaled and exhaled gases from an
evolved since their first description, but the principle remains the intubated patient are analyzed by the gas analyzer, and the difference in oxygen
same. There are 2 types of indicator dilution methods such concentration between the inhaled and exhaled gas is used to calculate cardiac
as pulmonary artery thermodilution and transpulmonary output.
104 K. Marshall et al. / Topics in Companion An Med 31 (2016) 100–108

Fig. 7. Noninvasive Cardiac Output (NICO). This diagram shows the setup for using NICO. The NICO device analyzes the CO2 exhaled by the patient through an endotracheal
tube. Typically, this is done during a rebreathing exercise. During the rebreathing exercise, a rebreathing valve (pictured earlier) is opened and the patient breathes in their
own exhaled gases. This exercise increases the concentration of inhaled CO2. Then when the rebreathing loop is closed, the CO2 sensor measures the patient's inhaled CO2
concentration and compares it with the exhaled CO2. The rebreathing loop is simply used to increase the magnitude of CO2 delivered to the patient for ease of measurement.
(Adapted with permission from http://frca.mikrocom.co.uk/Anaesthetics/Presentations/CardiacOutput/index.php).

Indicator dilution methods have replaced Fick’s method as the rupture, pulmonary thrombosis, and arrhythmias making them
current gold standard of CO monitoring because of their high level less practical for clinical patients.
of accuracy and ease of use. However, most indicator dilution
methods are relatively invasive, requiring a pulmonary artery Pulse Contour Analysis
catheter, central venous catheterization, or central arterial cathe-
terization or all of these. Pulmonary artery catheters have been More recently, the dilution methods described earlier have
associated with serious side effects such as pulmonary artery been combined with pulse contour analysis. In addition to

Fig. 8. Indicator dilution method for cardiac output monitoring. This method of cardiac output monitoring involves injecting an indicator, usually lithium, room temperature
saline, or a dye into the venous side of circulation. A known concentration of indicator is typically injected into the jugular vein. Blood samples are then removed from the
arterial side of circulation, and the difference in concentration of the indicator is measured and used to calculate cardiac output in a method similar to the Fick's method.
RAEDV, right atrial end-diastolic volume; LAEDV, left atrial end-diastolic volume; PBV, Pulmonary blood volume; LAEDV, left atrial end-diastolic volume; LVEDV, left
ventricular end-diastolic volume. (Image adapted with permission from derangedphysiology.com).
K. Marshall et al. / Topics in Companion An Med 31 (2016) 100–108 105

performing traditional dilution techniques, an arterial blood


pressure waveform is also measured from the patient. This arterial
waveform is furthermore analyzed by proprietary software to
derive the CO from the area under the curve of the arterial
waveform (pulse contour analysis). The dilution described in the
previous section serves as a calibration for the pulse contour
calculation of CO (Fig 9).
Typical dilution þ pulse waveform methods are called lithium
dilution (LiDCO) or thermodilution (PiCCO), which have been
evaluated and found to have a good correlation with traditional
thermodilution in many veterinary species.27,28 However, more
recently dilution þ pulse waveform methods were found to
correlate poorly with transpulmonary thermodilution and have
poor trending ability.24 Fig. 10. Arterial waveform for pulse pressure analysis. The curve represents the
Disadvantages to pulse contour methods are the need for arterial pressure waveform in the patient. Stroke volume is mathematically derived
arterial and venous catheterization to facilitate the dilution from the area under the curve and multiplied by the heart rate to yield the cardiac
technique, the need for normal vasculature (i.e., no shunts and output. The purple area indicates the area under the curve.
arteriovenous fistulas), normal vascular tone, and decreased accu-
racy in patients with arrhythmias.29 An additional disadvantage of
LiDCO is that lithium must be administered to the patient for essentially is the area under the arterial waveform30 (Fig 10). The
the initial calibrating dilution studies. Lithium is not a problem resulting stroke volume is then multiplied by heart rate to
in larger species including humans but could cause toxicity in calculate CO continuously.
smaller veterinary patients. Pulse pressure analysis methods are less invasive than other CO
techniques, although they still require placement of an arterial
catheter. They can be used continuously.
Pulse Pressure Analysis
However, these methods do have several limitations making
them unsuitable for use in animals at this time. First, pulse
In an effort to find less invasive ways to estimate CO, pulse
pressure analysis correlates poorly with thermodilution methods
pressure analysis was developed. Vigileo FloTrac and PRAM are
and is less accurate in patients with arrhythmias and decreased
based on pulse pressure analysis similar to LiDCO and PiCCO
systemic vascular resistance. This decreased accuracy is because of
described earlier. The difference is that they do not use any
the fact that pulse pressure analysis methods require a good
dilution technique for calibration. Stroke volume is calculated
arterial signal and waveform to calculate CO; both arrhythmias
from the variations in pulsatility of the arterial waveform and
and poor blood pressure would reduce the arterial signal quality.29
In fact, FloTrac has been investigated in veterinary medicine and
been found to be unsuitable for use in dogs, overestimating CO
Normal Cardiac output
with a high rate of error.31,32 Additionally, pulse pressure analysis
methods have recently been found to be unsuitable for monitoring
trends in anesthetized dogs compared with transpulmonary and
Time
pulmonary artery thermodilution.24

Ultrasonographic Methods
Temperature

Transthoracic Echocardiography
Low cardiac output Transthoracic echocardiography has long been used to estimate
CO. Stroke volume is calculated from echocardiographic measure-
Time
ments of the velocity of blood flow in the left ventricular outflow
multiplied by the cross-sectional area of the left ventricular
Temperature
outflow tract. This product equals stroke volume, and CO is then
calculated by multiplying the stroke volume by the patient’s heart
rate.29
This method is noninvasive, requiring only the use of an
High cardiac output ultrasound probe to perform the echocardiogram. However, it is
Time technically difficult to get the correct measurements, typically
requiring a trained cardiologist. Additionally, this method cannot
continuously report the CO, and any arrhythmias would affect the
Temperature
accuracy.

Fig. 9. Time vs. indicator curves created during PiCCO (thermodilution) or LiDCO
Esophageal Doppler
(lithium dilution) pulse contour analysis techniques. Curve 1 represents the curve
seen with normal cardiac output. In low cardiac output states, such as depicted in Esophageal Doppler (ED) is used to measure blood flow
curve 2, the curve is taller and wider because it takes a longer time to detect the velocity in the descending aorta. The Doppler probe is placed
dye or temperature change in low cardiac output states. The opposite is true for orally into the esophagus and inserted to the level of the
curve 3—the high output cardiac state—where the indicator is detected sooner. descending aorta. Aortic flow velocity combined with aortic
This is represented by a smaller and steeper curve. The cardiac output is measured
by the area under the curve. In PiCCO annd LiDCO methods, the computer used to
diameter is used to calculate stroke volume and then CO (Fig 11).
measure these images is initially calibrated by comparing its measured CO with the This method is minimally invasive. However, correct
CO measured by thermodilution or lithium techniques, respectively. probe placement is essential to obtain accurate measurements.
106 K. Marshall et al. / Topics in Companion An Med 31 (2016) 100–108

Fig. 11. Diagram of esophageal Doppler technique for cardiac output monitoring. The Doppler probe is inserted through the mouth to the level of the descending aorta. The
probe has 2 parts, a transmission crystal and a receiving crystal. The ultrasound waveform detects the velocity and peak flow of blood through the descending aorta through
the crystals and uses this information to calculate the stroke volume, which in turn is used to calculate cardiac output (i.e., by multiplying it by heart rate).

Additionally, to tolerate the placement of the probe, general a current encounters as it travels through a circuit; in this
anesthesia is required. ED has been evaluated in dogs, cats, and case, the circuit is the thorax. The impedance of the curr-
horses with variable results. Specifically, ED was not accurate in ent varies in relation to the amount of fluid within the thorax
measuring CO in dogs33,34 but may be useful to monitor trends in and specifically owing to changes in blood flow within the aorta.
cats.35 In horses, ED was found to give accurate CO data but was This method is noninvasive and requires the application of
difficult and time consuming to use.36 sensor pads to the thorax that detect changes of the amplitude of
the electric current as it passes through the thorax. In both human
and veterinary medicine, TEB has had variable correlation com-
Ultrasound CO Monitor pared with thermodilution methods of CO monitoring, making it
Ultrasound CO monitor (USCOM) is a noninvasive ultrasound unreliable to predict CO.41,42 Another potential drawback of TEB in
monitor that uses transaortic or transpulmonary blood flow veterinary medicine is its decreased accuracy in awake, moving
tracings to calculate CO and stroke volume (Fig 12). The USCOM patients and loud environments, reducing its use in an ICU setting
machine uses a proprietary mathematical formula to calculate on awake patients.
stroke volume from the waveform tracings. Bioreactance (NICOM) is similar to TEB in that an electric
However, as a standard aortic diameter measurement is pre- current of a known frequency is applied across the thorax
loaded into the machine for adult and pediatric human patients for (Fig 13). However, in bioreactance, the frequency or phase shift
stroke volume calculation, this presents a problem in veterinary of the electric current is measured. A delay in phase shift (i.e., a
medicine given the wide variety of patient sizes encountered. decrease in frequency of the electric current) is associated with an
Therefore, before using the USCOM, an echocardiogram would increase in stroke volume.
need to be performed to determine aortic diameter and incorpo- Bioreactance is noninvasive and only requires the application
rate this into the machine’s software. Only then would there be a of adhesive sensor pads to the thorax. Unlike bioimpedance,
chance for appropriate calculation of the animal’s CO with this bioreactance has been shown to correlate well with thermodilu-
method. tion methods of CO monitoring in a variety of human patients.43,44
Although USCOM is noninvasive, it has had mixed results Bioreactance has been evaluated experimentally in dogs and had
compared with thermodilution in animals and is not a continuous an excellent correlation with thermodilution but has not been
monitoring device.37 Recent human studies have shown that used clinically.45
USCOM can detect decreases in stroke volume because of blood
loss in conscious patients, making USCOM potentially useful
in an emergency setting to assess human patients with Conclusions
hypovolemia.38 USCOM has been found to be accurate in sheep
and beagles39,40; however, it is has not been used clinically in Direct CO monitoring is the most ideal way to assess fluid
veterinary patients. responsiveness and to guide fluid therapy in critically ill patients.
However, there is no one good way to measure CO in veterinary
medicine. Many methods used to evaluate CO are invasive, poorly
Bioimpedance and Bioreactance researched in veterinary medicine, or impractical to use clinically.
Additionally, the most commonly used objective clinical estimate
Thoracic bioimpedance (TEB) applies a high-frequency elect- of volume status—central venous pressure—does not reliably
ric current of known amplitude and frequency across the thorax correlate with preload in the heart and is a poor predictor of fluid
(Fig 13). Impedance is defined as the amount of resistance responsiveness.
K. Marshall et al. / Topics in Companion An Med 31 (2016) 100–108 107

Fig. 12. USCOM. This image shows proper placement of the ultrasound probe and typical waveform on the USCOM display.

An ideal CO monitoring device for use in veterinary and human


medicine would be minimally to completely noninvasive, easy to
use, and able to provide continuous, accurate CO information.
Right now, research has shown that the dilution techniques of CO
monitoring (PiCCO and LiDCO) are the most accurate in veterinary
patients; however, their invasiveness has limited their use to
research settings.
Of the newer noninvasive techniques that have been developed
recently in human medicine, most have not been validated in
veterinary patients. Perhaps the most promising is bioreactance as
it is completely noninvasive and has been found to correlate well
with thermodilution methods in single veterinary study. However,
additional research is needed to assess bioreactance and other
minimally invasive CO monitoring modalities in veterinary
patients.
Ideally, one day there would be a widely available noninvasive
Fig. 13. Bioimpedance and bioreactance. The circular areas indicate the placement continuous way to accurately assess CO in veterinary species,
of sensor pads for bioimpedance and bioreactance. Chest pads are placed on both
sides of the thorax. The outer orange pads apply the electric current through the
allowing the administration of fluid therapy with greater accuracy
thorax, whereas the inner blue pads are the sensor pads for the changes in and resulting in fewer deleterious effects from excessive fluid
electrical signal across the thorax. therapy.
108 K. Marshall et al. / Topics in Companion An Med 31 (2016) 100–108

References 26. Itami T, Endo Y, Hanazono K, et al. Comparision of cardiac output measure-
ments using transpulmonary thermodilution and conventional thermodilution
techniques in anaesthetized dogs with fluid overload. Vet Anaesth Analg. http://dx.
1. Shock deLaforcade A. In: Silverstein D, Hopper K, editors. Small Animal Critical
doi.org/10.1111.vaa.12331
Care Medicine. 2nd ed. St Louis, MO: Elsevier; 2014. p. 26–30
27. Shih A, Maisenbacher HW, Bandt C, et al. Assessment of cardiac output by
2. Mellema MS, McIntyre RL. Cardiac output monitoring. In: Silverstein D, Hopper K,
transpulmonary pulse contour analysis. J Vet Emerg Crit Care 21:321–327, 2011
editors. Small Animal Critical Care Medicine. 2nd ed. St Louis, MO: Elsevier; 2014.
28. Morgaz J, del Mar Granados M, Munoz-Rascon P, Fernandez-Sarmiento JA,
p. 962–967
Gomz-Villamandos RJ, et al. Comparision of thermodilution, lithium dilution,
3. Marik PE, Cavallazzi R, Vasu T, Hirani A. Dynamic changes in arterial waveform
and pulse contour analysis for the measurement of cardiac output in 3 different
derived variables and fluid responsiveness in mechanically ventilated patients:
hemodynamic states in dogs. J Vet Emerg Crit Care 24:562–570, 2014
A systematic review of the literature. Crit Care Med 37:2642–2647, 2009
29. Lee AJ, Cohn JH, Ranasinghe JS. Cardiac output assessed by invasive and
4. Boulpaep EL. Regulation of arterial pressure and cardiac output. In: Boron W,
minimally invasive techniques. Anesth Res Pract:1–17, 2011
Boulpep E, editors. Medical Physiology. 2nd ed. St Louis, MO: Elsevier; 2012.
30. Porhomayon J, El-Solh A, Papadakos P, Nader ND. Cardiac output monitoring
p. 554–576
5. Pearson JD, Round JA, Ingram M. Management of shock in trauma. Anaesth devices: An analytic review. Intern Emerg Med 7:163–171, 2012
Intensive Care Med 12:387–389, 2011 31. Bektas RN, Kutter AP, Hartnack S, Jud RS, Schnyder M, Matos JM, et al.
6. Barmparas G, Liou D, Lee D, et al. Impact of positive fluid balance on critically ill Evaluation of a minimally invasive non-calibrated pulse contour cardiac output
surgical patients: A prospective observational study. J Crit Care 29:936–941, monitor (FloTrac/Vigileo) in anaesthetized dogs. Vet Anaesth Analg 39:464–471,
2014 2012
7. Boyd J, Forbes J, Nakada T, Walley K, Russell J. Fluid resuscitation in septic 32. Valverde A, Gianotti G, Rioja E, Hathaway A. Comparision of cardiac output
shock: A positive fluid balance and elevated central venous pressure are determined by arterial pulse pressure waveform analysis method (FloTrac/
associated with increased mortality. Crit Care Med 39:259–265, 2011 Vigileo) versus lithium dilution in anesthetized dogs. J Vet Emerg Crit Care
8. Bouchard J, Soroko S, Chertow G, et al. Fluid accumulation, survival and 21:328–334, 2011
recovery of kidney function in critically ill patients with acute kidney injury. 33. Canfrán S, Cediel R, Sández I, Caro-Vadillo A, Gomez de Segura IA. Evaluation of
Kidney Int 76:422–427, 2009 an oesophageal Doppler device for monitoring cardiac output in anaesthetised
9. Kasotakis G, Sideris A, Yang Y, et al. Aggressive early crystalloid resuscitation healthy normotensive dogs. J Small Anim Pract 56:450–455, 2015
adversely affects outcomes in adult blunt trauma patients: An analysis of the 34. Day TK, Boyle CR, Holland M. Lack of agreement between thermodilution and
Glue Grant database. J Trauma Acute Care Surg 74:1215–1221, 2013 echocardiographic determination of cardiac output during normovolemia and
10. Mohrman DE, Heller LJ. Central venous pressure, In: Cardiovascular Physiology acute hemorrhage in clinically healthy, anesthetized dogs: Original study. J Vet
7th ed. New York, NY: McGraw-Hill; 2010:148-162. Emerg Crit Care 17:22–31, 2007
11. Uthoff H, Thalhammer C, Potocki M, et al. Central venous pressure at 35. Rezende ML, Pypendop BH, Ilkiw JE. Evaluation of transesophageal echo-
emergency room presentation predicts cardiac rehospitalization in patients Doppler ultrasonography for the measurement of aortic blood flow in anes-
with decompensated heart failure. Eur J Heart Fail 12:469–476, 2010 thetized cats. Am J Vet Res 69:1135–1140, 2008
12. Schrier RW. Fluid administration in critically ill patients with acute kidney 36. Linton RA, Young LE, Marlin DJ, Blissitt KJ, Brearley JC, Jonas MM, et al. Cardiac
injury. Clin J Am Soc Neph 5:733–739, 2010 output measured by lithium dilution, thermodilution, and transesophageal
13. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the doppler echocardiography in anesthetized horses. Am J Vet Res 61:731–737,
treatment of severe sepsis and septic shock. N Engl J Med 345:1368–1377, 2001 2000
14. Kastrup M, Markewitz A, Spies C, et al. Current practice of hemodynamic 37. Gregory SD, Cooney H, Diab S, Anstey C, Thom O, Fraser JF. In vitro evaluation
monitoring and vasopressor and inotropic therapy in post-operative cardiac of an ultrasonic cardiac output monitoring (USCOM) device. J Clin Monit
surgery patients in Germany: Results from a postal survey. Acta Anaesthesiol Comput
Scand 51:347–358, 2007 38. O’Loughlin E, Ward M, Crossley A, Hughes R, Bremner AP, Corcoran T.
15. McIntyre LA, Hébert PC, Fergusson D, Cook D, Aziz A. A survey of Canadian Evaluation of the utility of the Vigileo FloTrac, LiDCO, USCOM and CardioQ to
intensivists’ resuscitation practices in early septic shock. Crit Care:11–16, 2007 detect hypovolaemia in conscious volunteers: A proof of concept study.
16. Oakley RE, Olivier B, Eyster GE, et al. Experimental evaluation of central venous Anaesthesia 70:142–149, 2015
pressure monitoring in the dog. J Am Anim Hosp Assoc 339:77–82, 1997 39. Phillips RA, Hood SG, Jacobson BM, West PA, Wan L, May CN. Pulmonary artery
17. Waddell LS, Brown AJ. Hemodynamic Monitoring. In: Silverstein D, Hopper K, catheter (PAC) accuracy and efficacy compared with flow probe and trans-
editors. Small Animal Critical Care. 2nd ed. St Louis, MO: Elsevier; 2014. cutaneous doppler (USCOM): An ovine cardiac output validation. Crit Care Res
p. 957–962
Pract. http://dx.doi.org/10.1155/2012/621496
18. Weil MH, Henning RJ. New concepts in the diagnosis and fluid treatment of
40. Critchley LA, Peng ZY, Fok BS, Lee A, Phillips RA. Testing the reliability of a new
circulatory shock. Anesth Analg 58:124–132, 1979
ultrasonic cardiac output monitor, the USCOM, by using aortic flowprobes in
19. Marik PE, Cavallazzi R. Does the central venous pressure predict fluid
anesthetized dogs. Anesth Analg 100:748–753, 2005
responsiveness? An updated meta-analysis and a plea for some common sense
41. Kamath SA, Drazner MH, Tasissa G, Rogers JG, Stevenson LW, Yancy CW.
Crit Care Med 41:1774–1781, 2013
Correlation of impedance cardiography with invasive hemodynamic measure-
20. Thiele RH, Bartels K, Tong JG. Cardiac output monitoring: Contemporary
ments in patients with advanced heart failure: The BioImpedance CardioG-
assessment and review. Crit Care Med 43:177–185, 2015
raphy (BIG) substudy of the Evaluation Study of Congestive Heart Failure and
21. Ehlers KC, Mylrea KC, Waterson CM, Calkins JM. Cardiac output measurements.
A review of current techniques and research. Ann Biomed Eng 14:219–239, 1986 Pulmonary Artery Catheterization Effectiveness (ESCAPE) Trial. Am Heart J
22. Gunkel CI, Valverde A, Morey TE, Hernandz J, Robertson SA. Comparision of 158:217–223, 2009
non-invasive cardiac output measurement by partial carbon dioxide rebreath- 42. Yamashita K, Ueyama Y, Miyoshi K, Igarashi R, Kushiro T, Umar MA. Minimally
ing with the lithium dilution method in anesthetized dogs. J Vet Emerg Crit Care invasive determination of cardiac output by transthoracic bioimpedance,
14:187–195, 2004 partial carbon dioxide rebreathing, and transesophageal doppler echocardiog-
23. Giguere S, Bucki E, Adin DB, Valverde A, Estrada AH, Young L. Cardiac output raphy in beagle dogs. J Vet Med Sci 69:43–47, 2007
measurement by partial carbon dioxide rebreathing, 2 dimensional echocar- 43. Raval NY, Squara P, Cleman, Yalamanchili K, Winklmaier M, Burkhoff D.
diography, and lithium dilution methods in anesthetized neonatal foals. J Vet Multicenter evaluation of a noninvasive cardiac output measurement by
Intern Med 19:737–743, 2005 bioreactance technique. J Clin Monit Comput 23:113–119, 2008
24. Kutter A, Wolfensberger R, Romagnoli N, Bektas R. Evaluation of agreement 44. Keren H, Burkoff D, Squara P. Evaluation of a noninvasive continuous cardiac
and trending ability between transpulmonary thermodilution and calibrated output monitoring system based on thoracic bioreactance. Am J Physiol
pulse contour and pulse power cardiac output monitoring methods against 293:583–589, 2007
pulmonary artery thermodilution in anesthetized dogs. J Vet Emerg Crit Care 45. Heerdt PM, Wagner CL, DeMais M, Savarese JJ. Noninvasive cardiac output
26:531–540, 2016 monitoring with bioreactance as an alternative to invasive instrumentation for
25. Stewart GN. Researches on the circulation time and on the influences which preclinical drug evaluation in beagles. J Pharmacol Toxicol Methods 64:111–118,
offset it IV: The output of the heart. J Physiol. 22:159–183, 1897 2011

Vous aimerez peut-être aussi