Cardiac Output Measurement

Introduction Cardiac output is the amount of blood ejected from the left ventricle in one minute and is measured in liters per minute. Under normal circumstances, the outputs of the left and right ventricles must be equal in the absence of abnormal shunts between the pulmonary and systemic circulatory systems. Physiology Along with left ventricular filling pressures (pulmonary capillary wedge pressure), the cardiac output is one of the few hemodynamic parameters that with today's technology requires the placement of a pulmonary artery catheter. Cardiac output is the product of heart rate and stroke volume. Heart rate is determined by both intrinsic pacemaker function and modulation by the autonomic nervous system. Stroke volume is dependent upon the degree of diastolic ventricular filling coupled with the degree of contraction sometimes expressed as ejection fraction. Disease states can alter all of these components of cardiac output. Normally, as heart rate increases, the cardiac output increases proportionately. As heart rate increases however, the time available for ventricular filling to occur decreases and in each patient, there is a heart rate, above which, ventricular filling will decrease enough that further increases in heart rate will result in a lowered cardiac output. In a normal person, this cut-off occurs somewhere between 180-200 beats per minute while in disease states such as congestive heart failure secondary to cardiomyopathy, this cut-off may be reached at rates as low as 120 beats per minute. Uncontrolled atrial fibrillation or atrial flutter frequently result in heart rates that are too high for adequate cardiac output and a major part of the treatment of these arrythmias is to give the patient digoxin to help slow the abnormally high heart rate. Measurement Methods Two main methods are used to measure cardiac output today. These are the Fick method and dilution methods (either dye or thermal). Fick Method The Fick method requires that you be able to measure the A-V oxygen content difference and requires that you be able to measure the oxygen consumption. An arterial blood gas from a peripheral artery provides the blood for the CaO2 measurement or calculation while blood from the distal PA port of a Swan-Ganz catheter provides the blood for the CvO2 measurement or calculation. Oxygen consumption is obtained by measuring the inspired oxygen concentration and the expired oxygen concentration along with the expired minute volume. Small errors in the oxygen concentration measurements can result in large mathematical errors therefore these measurements should be made with a calibrated blood gas machine equipped for measurement of gas samples (such as the ABL 300, IL, or Corning blood gas machines). Note the Fick cardiac output formula from a previous lecture. Fick cardiac outputs are infrequently used mainly because of the inconvenience of collecting and analyzing exhaled gas concentrations. It's not as difficult to do as one might think but nonetheless Fick cardiac outputs are seldom used today. You may see mention of an estimated Fick cardiac output method where you just assume that oxygen consumption is normal by plucking a value off of a nomagram corrected for weight and height but in patients in whom a cardiac output determination is really needed, the oxygen consumption is seldom normal and these estimated cardiac output measurements can do more harm than good.

Dilution Methods Dilution methods mathematically calculate (using calculus) the cardiac output based on how fast the flowing blood can dilute a marker substance introduced into the circulation normally via a pulmonary artery catheter. The marker must be distinguishable from the blood and must be able to be measured quickly and with a high degree of accuracy. Early dilution methods used dye solutions which were administered upstream and then drawn off in blood samples downstream from the infusion port where they could be analyzed for concentration. Cardiac output was inversely related to the downstream dye concentration. Dye dilution cardiac outputs are seldom used today outside of cardiac catheterization labs and even most of them use the more automated thermal dilution method. In thermal dilution, cold or room temperature water or D5W is used as the marker solution and distal concentration is determined by measuring the temperature downstream from the infusion port. Since water is non-toxic, multiple measurements can be made as often as needed and the downstream concentration (i.e. temperature) can be measured in situ without having to withdraw any blood from the circulation for analysis. Errors Cardiac output measurement is not precise using today's technology. For clinical use, we don't need 100% accuracy to 5 significant digits but to avoid big errors it is important to know the limitations of the measurement techniques. Fick cardiac output errors result from leaky gas collection apparatus, from inaccuracies in the measurement of inhaled and exhaled oxygen concentrations (these are particularly common when high levels of oxygen are used), an from errors in the calculations and/or measurements of blood oxygen contents (such as might be caused by using a bogus hemoglobin level or assuming the absence of carbon monoxide affecting oxygen saturation). Thermal dilution cardiac outputs are affected by the phase of respiration, particularly during mechanical ventilation and should thus always be measured at the same point in the respiratory cycle (normally end-expiratory) where the effect of breathing (either spontaneous or mechanical) is least. Small errors can result from using the wrong fluid (something other than D5W) as the injectate. Variations in the speed of cold water injection can result in altered measurements and devices to automatically inject the fluid are available to eliminate this source of variation. While there are lots of things that can result in cardiac output measurements not exactly equaling the true cardiac output, the most important concept here is to make the measurements reproducible and the errors consistent from one measurement to the next. It is the change in cardiac output, up or down, that allows the practitioner to determine the effects of therapy and disease and not the absolute value but to accurately detect changes, the output measurement errors must be consistent.