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Changes in cardiac output during the development of renal hypertension in sodium-depleted dogs.

1. Chronic renovascular hypertension developed in uninephrectomized, sodium-depleted dogs in association with a decrease in cardiac output. 2. With sodium and volume repletion of these animals, cardiac output returned to normal but the high level of arterial pressure was unchanged; consequently, the peripheral arterioles dilated. 3. These observations provide evidence against the theory of whole-body autoregulation.

Animals↗

Simultaneous measurement of cardiac output by thermodilution, thoracic electrical bioimpedance and Doppler ultrasound.

To evaluate the accuracy of two non-invasive techniques for cardiac output (CO) measurement, we have measured CO simultaneously by thoracic electrical bioimpedance (TEB), pulsed Doppler ultrasound (DU) and standard thermodilution methods (TD) under different clinical conditions. Measurements were made in 10 patients: (I) during steady state anaesthesia with controlled IPPV ventilation (n = 131), spread over the entire ventilatory cycle; (II) during apnoea (n = 56); (III) during spontaneous breathing (n = 152) in the intensive care unit. Mean (SD) cardiac output values were: (I) COTD 3.5 (1.0) litre min-1, COTEB 3.4 (0.7) litre min-1, CODU 2.8 (0.7) litre min-1; (II) COTD 3.6 (0.6) litre min-1, COTEB 3.5 (0.4) litre min-1, CODU 2.9 (0.7) litre min-1; (III) COTD 7.7 (1.5) litre min-1, COTEB 7.6 (1.9) litre min-1, CODU 5.2 (1.4) litre min-1. The mean percentage deviation of TEB from TD ranged from -2.2% to 1.4% and that of DU from TD was from -16% to -32%. There were no statistically significant differences between TD and TEB, but TD and DU differed significantly during IPPV, apnoea and spontaneous ventilation (P < 0.0001).

Adult↗

An evaluation of a noninvasive cardiac output measurement using partial carbon dioxide rebreathing in children.

Cardiac output (CO) is an important hemodynamic measure that helps to guide the therapy of critically ill patients. Invasive CO assessment in infants and children is often avoided because of the inherent risks. A noninvasive CO monitor that uses partial rebreathing has been recently developed to determine CO via the Fick principle for carbon dioxide. There have been no clinical studies confirming its accuracy in pediatric patients. This is a prospective observational study of 37 children <12 yr of age who underwent cardiac catheterization. Under general anesthesia via an endotracheal tube without a leak, we made multiple CO measurements using thermodilution and compared them with noninvasively determined CO measurements. Paired measurements were analyzed for bias, precision, and correlation via Bland-Altman plot and linear regression. Noninvasive measurements showed a linear correlation with thermodilution CO assessment with an r value of 0.83 (P < 0.03). Bland-Altman analysis yielded a bias of -0.27 L/min and a precision +/-1.49 L/min. Cardiac index measurements demonstrated a decreased r value of 0.67 (P = 0.15) and a bias of -0.18 L . min(-1) . m(-2) and precision of +/-2.13 L . min(-1) . m(-2). Differences between partial rebreathing measurements and thermodilution measurements were largest in children with a body surface area of </=0.6 m(2) ventilated with tidal volumes <300 mL. Based on these findings, noninvasive CO measurement using partial rebreathing may be clinically acceptable in children with >0.6 m(2) body surface area and >300 mL tidal volume.

Anesthesia, General↗

Assessment of cardiac output, intravascular volume status, and extravascular lung water by transpulmonary indicator dilution in critically ill neonates and infants.

OBJECTIVE: To assess cardiac output, intrathoracic blood volume, global end-diastolic volume, and extravascular lung water in critically ill neonates and small infants using transpulmonary indicator dilution. DESIGN: Prospective, observational, clinical study. SETTING: Pediatric intensive care unit in a university hospital. PARTICIPANTS: Critically ill neonates and small infants suffering from severe heart failure, respiratory failure, or sepsis (n = 10). INTERVENTIONS: A total of 194 transpulmonary indicator dilution measurements were done. Global end-diastolic volume, intrathoracic blood volume, and stroke volume were measured and compared with standard hemodynamic parameters during the clinical course and before and after volume loading (16 +/- 3.7 mL/kg of 10% albumin solution) in 8 of 10 patients. MEASUREMENTS AND MAIN RESULTS: A positive correlation was found for stroke volume index versus global end-diastolic volume (r = 0.76, p < 0.001) and intrathoracic blood volume (r = 0.56, p < 0.001). In contrast, no correlation was observed for stroke volume index versus central venous pressure. Volume loading resulted in significant increases in stroke volume index (p < 0.01), global end-diastolic volume (p < 0.01), and intrathoracic blood volume (p < 0.01); whereas central venous pressure, heart rate, mean arterial pressure, and extravascular lung water remained unchanged. CONCLUSION: Transpulmonary indicator dilution enables measurement of cardiac output and intravascular volume status in critically ill neonates and infants at the bedside. The effects of volume loading on cardiac preload and effective change in stroke volume can be monitored by this technique, whereas central venous pressure was not indicative of changes in intravascular volume status.

Blood Volume↗

Thermodilution method for measuring cardiac output.

The thermodilution technique has been shown to measure cardiac output accurately. The technique violates ideal conditions for indicator dilution methods and is liable to gross errors unless certain requirements are strictly adhered to. The quantity of injectate must be accurately measured and injected rapidly. The dilution curve must be available for inspection and show a smooth rapid ascent and monoexponential decline.

Blood Flow Velocity↗

Correction for cardiac output calculations by the nitrous oxide technique.

Calculations of cardiac output using the N2O technique as described by Becklake et. al. (J. Appl. Physiol. 17: 579, 1962) result in spurious values when barometric pressure or body temperature deviates from 760 Torr or 37.0 degrees C, respectively. Nitrous oxide (N2O) uptake (VN2O) must be corrected to standard pressure, dry at 37.0 degrees C.

Cardiac Output↗

Measurement of hepatocellular function, cardiac output, effective blood volume, and oxygen saturation in rats.

The available techniques do not permit the measurement of hepatocellular function, cardiac output, effective blood volume, and oxygen saturation in small animals without the need of blood or tissue sampling. We present methodology that permits us to measure the above variables in the rat. Multiple doses of indocyanine green (ICG; 0.16-2.6 mg/kg) were given to pentobarbital-anesthetized rats, and [ICG] was continuously measured by an in vivo hemoreflectometer. Initial velocity of clearance (Vo) was determined from the [ICG] vs. time plot for each dose by nonlinear regression. The maximal velocity of clearance (Vmax; indicating hepatocellular function) was calculated. Vmax was 1) accurately determined using two, three, or four doses of ICG; 2) it was 1.09 +/- 0.16 mg.kg-1.min-1, not different from the Vo of the near-saturating dose of 25 mg/kg; and 3) it decreased after partial hepatectomy. Cardiac output was 41.89 +/- 1.46 ml.100 g-1.min-1, effective blood volume was 6.12 +/- 0.34 ml/100 g, and oxygen saturation was 92 +/- 2%. These methodologies may prove useful in the evaluation of hepatocellular dysfunction and hemodynamic parameters in the rat during and after various diseased states.

Animals↗

Effect of betaxolol on the hemodynamic, gas exchange, and cardiac output response to exercise in chronic atrial fibrillation.

BACKGROUND: beta-blockade controls the ventricular response to exercise in chronic atrial fibrillation (AF), but the effects of beta-blockers on exercise capacity in AF have been debated. METHODS: Twelve men with AF (65+/-8 years) participated in a randomized, double-blind, placebo-controlled study of betaxolol (20 mg daily). Patients underwent maximal exercise testing with ventilatory gas exchange analysis, and a separate, submaximal test (50% of maximum) during which cardiac output was measured by a CO2 rebreathing technique. RESULTS: After betaxolol therapy, heart rate was reduced both at rest (92+/-27 vs 62+/-12 beats/min; p < 0.001) and at peak exercise (173+/-22 vs 116+/-24 beats/min; p < 0.001). Maximal oxygen uptake (VO2) was reduced by 19% after betaxolol (21.8+/-5.3 with placebo vs 17.6+/-5.1 mL/kg/min with betaxolol; p < 0.05), with similar reductions observed for maximal exercise time, minute ventilation, and CO2 production. VO2 was reduced by a similar extent (19%) at the ventilatory threshold. Submaximal cardiac output was reduced by 15% during betaxolol therapy (12.9+/-2.3 vs 10.9+/-1.3 L/min; p < 0.05), and stroke volume was higher (88.0+/-21 vs 105.6+/-19 mL/beat; p < 0.05). CONCLUSION: Betaxolol therapy in patients with AF effectively controlled the ventricular rate at rest and during exercise, but also caused considerable reductions in maximal VO2 and cardiac output during exercise. The observed increase in stroke volume could not adequately compensate for reduced heart rate to maintain VO2 during exercise.

Adrenergic beta-Antagonists↗

The clinical application of pulse contour cardiac output and intrathoracic volume measurements in critically ill patients.

Cardiac output (CO) determination by pulmonary artery (PA) catheter has increasingly been criticised within the literature due to its invasive nature and poor correlation between the pressure measurements and intravascular volume status in mechanically ventilated patients. Consequently, alternative less invasive technologies to PA catheterisation are emerging within intensive care. One such novel technology are pulse contour CO (PCCO) systems. They establish comprehensive and continuous haemodynamic monitoring utilising a central venous catheter (CVC) and an arterial line. Furthermore, a key feature of this technology is its ability to produce intrathoracic volume measurements which may provide a better estimation of cardiac preload as well as indicate the presence and severity of pulmonary oedema. This article aims to discuss the theoretical basis and clinical application of PCCO systems, how PCCO systems differ from PA catheters and how the intrathoracic volume measurements are derived. Understanding these advanced concepts will ensure that clinicians are able to employ this innovative monitoring technology more effectively.

Cardiac Output↗

Atriopeptin II lowers cardiac output in conscious sheep.

Atrial natriuretic peptides cause natriuresis, kaliuresis, diuresis, and hypotension. They relax vascular smooth muscle in vitro, and they dilate renal vessels in vivo. Hence, we tested the hypothesis that they produce hypotension by lowering total peripheral resistance. The studies were performed in conscious chronically instrumented sheep standing quietly in their cages. Atriopeptin II (AP II) was infused into the right atrium for 30 min at 0.1 nmol X kg-1 X min-1. Atriopeptin II lowers arterial pressure (9%, P less than 0.05) by lowering cardiac output (18%, P less than 0.05), stroke volume (28%, P less than 0.05), and right atrial pressure (2.3 mmHg, P less than 0.05). Heart rate and total peripheral resistance increase (16 and 13%, respectively, P less than 0.05). Partial ganglionic blockade with trimethaphan camsylate during AP II infusion prevents the increases in heart rate and total peripheral resistance. The changes in right atrial pressure, stroke volume, and cardiac output persist, and arterial pressure falls further (27%, P less than 0.05). These hemodynamic data are consistent with direct AP II-induced relaxation of venous smooth muscle with reduction of venous return, right atrial pressure, stroke volume, cardiac output, and arterial pressure, followed by reflex activation of the sympathetic nervous system to increase heart rate and total peripheral resistance. Because partial ganglionic blockade alone and AP II alone cause similar reductions in right atrial pressure (2.1 and 2.3 mmHg, respectively) but AP II causes a greater fall in stroke volume (28 vs. 13%), it is possible that AP II also causes coronary vasoconstriction.

Animals↗

Endothelin-1 blockade corrects mesenteric hypoperfusion in a porcine low cardiac output model.

OBJECTIVE: To study the importance of endothelin-1-induced vasoconstriction in a model of acute and maintained low cardiac output, by investigating regional changes within the mesenteric and particularly the intestinal mucosal circulation. DESIGN: Prospective, controlled animal study. SETTING: University-affiliated research laboratory. SUBJECTS: Thirteen fasted, anesthetized, mechanically ventilated landrace pigs. MEASUREMENTS AND MAIN RESULTS: Cardiac output, portal venous blood flow, renal arterial flow, jejunal mucosal microcirculation by laser Doppler flowmetry, jejunal capnotonometry (Pco2 gap), and jejunal mucosal oxygenation (tPo2) were monitored. Cardiac tamponade was established to reduce portal venous blood flow to a preset end point at two thirds of baseline. Measurements were made at baseline, after 90 mins of cardiac tamponade, and 90 mins after the administration of the combined endothelinA/endothelinB antagonist tezosentan at 1 mg.kg-1.hr-1 during tamponade in seven animals. Six animals served as time controls and received only the vehicle. Cardiac tamponade decreased portal venous blood flow, renal arterial flow, and laser Doppler flowmetry, whereas the Pco2 gap increased. The change in tPo2 failed to gain statistical significance (p =.08). Administration of tezosentan during tamponade restored portal venous blood flow and laser Doppler flowmetry to baseline values, increased tPo2 above baseline, and decreased Pco2 gap. No effect on renal arterial flow was observed. Investigated variables remained unchanged in control animals after induction of cardiac tamponade. CONCLUSIONS: Endothelin-1 blockade in acute cardiac failure improves mesenteric, but not renal, perfusion, illustrating the regional importance of endothelin-1-induced vasoconstriction. Importantly, endothelin-1 blockade restored mucosal blood flow and oxygenation, which might be particularly interesting considering the implications for maintenance of mucosal barrier integrity in low output states.

Animals↗

Measurement of cardiac output by transoesophageal echocardiography: a comparison of two Doppler methods with thermodilution.

This study assessed the agreement between three methods of cardiac output (CO) measurement, thermodilution, the current clinical standard, and two transoesophageal echocardiographic techniques. Measurements were performed in 37 patients using thermodilution, continuous wave Doppler across the aortic valve and pulsed wave Doppler positioned in the left ventricular outflow tract. The aortic valve area was measured by direct planimetry, and the left ventricular outflow tract area was calculated from its diameter. Weighted least products regression analysis was employed to detect bias, and standard deviation of the difference (SDdiff) was calculated. There was no fixed bias but there was proportional bias between continuous wave Doppler and thermodilution methods (SDdiff 0.92 l/min). There was fixed bias but not proportional bias between pulsed wave and thermodilution methods (SDdiff 1.1 l/min). There was neither fixed nor proportional bias between pulsed wave and continuous wave Doppler methods (SDdiff 1.1 l/min). The transoesophageal Doppler methods described can be clinical alternatives to thermodilution cardiac output measurement.

Aortic Valve↗

Stroke volume and cardiac output in juvenile elephant seals during forced dives.

The aim of this study was to examine the effect of forced diving on cardiac dynamics in a diving mammal by evaluating cardiac output and heart rate. We used MR Imaging and phase contrast flow analysis to obtain accurate flow measurements from the base of the aorta. Heart rate (fh) and cardiac output (Q) were measured before, during and after dives in four restrained juvenile northern elephant seals, Mirounga angustirostris, and stroke volume (Vs) was calculated (Vs=Q/fh). Mean Q during diving (4011+/-387 ml min(-1)) and resting (6530+/-1018 ml min(-1)) was not significantly different (paired t-test; P<0.055). Diving was accompanied by a 20% increase in Vs over the pre-dive level. Pre-dive, post-dive or diving fh was not significantly correlated with Vs during any state. Diving Vs correlated negatively with the bradycardic ratio (diving fh to pre-dive fh). In this study, the degree of bradycardia during diving was less than in previous pinniped studies, suggesting that the reduction in vagal input may contribute to the observed increase in Vs.

Animals↗

A computer program for the on-line computation of cardiac output from thermodilution curves.

An accurate, rapid calculation of Cardiac Output is of great importance during the treatment of critically ill patients. This paper describes a complete, self-contained mini-computer system, based on a Data General NOVA 1220 which can accurately sample data and compute the results in about 30 sec. The system uses the thermodilution method with a Swan-Ganz catheter to collect data and a weighted least-squares technique to compute the results.

Cardiac Catheterization↗

Role of the pulmonary circulation in the distribution of human fetal cardiac output during the second half of pregnancy.

BACKGROUND: By using Doppler echocardiography, we determined the normal distribution of human fetal combined cardiac output (CCO) from the left and right ventricles. We also established weight-indexed pulmonary and systemic vascular resistances (Rpi and Rsi, respectively) and changes during the second half of pregnancy. METHODS AND RESULTS: Blood flows at the aortic and pulmonary valve annuli (LVCO and RVCO, respectively), right and left pulmonary arteries (QP), and ductus arteriosus (QDA) were calculated in 63 normal fetuses. Foramen ovale blood flow (QFO = LVCO-QP) was estimated. From 20 to 30 weeks of gestation, the proportion of QP of the CCO increased (from 13% to 25%, P < .001), while the proportion of QFO decreased (from 34% to 18%, P < .001). After 30 weeks, the proportions of QP and QFO were unchanged. At 38 weeks, the proportion of RVCO (60%) was higher (P < .05) than that of LVCO (40%). The proportion of QDA did not change significantly. The correlation between RVCO calculated from blood flow through the pulmonary valve and from QDA and QP was good (r = .97, P < .0001). RPi (P < .001) decreased from 20 to 30 weeks of gestation. From 30 to 38 weeks, RPi increased (P < .0001). Rsi increased (P < .001) from 20 to 38 weeks. The ratio of RPi to RSi decreased (P < .01) from 20 to 30 weeks and later remained unchanged. CONCLUSIONS: The human fetal pulmonary circulation has an important role in the distribution of cardiac output.

Blood Pressure↗

Decreased cardiac output: case for a collaborative diagnosis.

The nursing diagnosis Cardiac Output, Alteration in: Decreased (COAD) continues to be challenged as an appropriate nursing diagnostic category. Two areas of concern are the interdependent interventions associated with this physiologic diagnosis and the potential misuse of the diagnosis due to incomplete refinement of the diagnostic category. A new conceptual framework is suggested for dealing with physiologic diagnostic categories and ways to refine the definition, the etiologies, and the defining characteristics of COAD for use as a collaborative diagnosis are discussed.

Cardiac Output, Low↗

Simultaneous cardiac output measurements by transtracheal Doppler, electromagnetic flow meter, and thermodilution during various hemodynamic states in pigs.

The transtracheal Doppler (TTD) method of cardiac output (CO) measurement was compared with thermodilution (TDL) and aortic electromagnetic flow meter (EFM). Simultaneous CO measurements with the three methods were obtained during various hemodynamic states in eight pigs. Cardiac output ranged from 1 to 3 L/min during the study. For 128 measurements, the mean difference +/- SD between TTD-TDL and TTD-EFM measurements was -0.037 +/- 0.24 L/min and -0.055 +/- 0.23 L/min, respectively. TDL-EFM mean difference +/- SD was -0.017 +/- 0.15 L/min. The limits of the agreement between TTD and the reference methods were 0.4 to -0.5 L/min. The limits of agreement between the reference methods were 0.3 to -0.3 L/min. Regression analysis yielded TTD = 0.383 + 0.779 TDL (r = 0.86); TTD = 0.351 + 0.788 EFM (r = 0.87); TDL = 0.077 + 0.95 EFM (r = 0.95). Only a change greater than 0.6 L/min in TTD CO could predict with 95% confidence a change in TDL or EFM CO. These results suggest that, in the CO range of this study, the TTD method does not accurately reproduce the CO measurements obtained by TDL or EFM.

Adrenergic beta-Antagonists↗

Intestinal infarction complicating low cardiac output states.

Nonocclusive mesenteric ischemia, leading into intestinal infarction, frequently complicates and causes the fatal outcome in otherwise treatable instances of low cardiac output states. Once intestinal necrosis occurs in these patients, the mortality is almost 100 per cent. A high risk group of patients in whom intestinal infarction occurs because of low cardiac output can be readily identified. A high index of suspicion for the occurrence of intestinal ischemia in these patients should facilitate recognition of the disease during its early stages. The disastrous results experienced by us and others warrant the use of more aggressive methods for the diagnosis and treatment of patients with this condition. A high index of suspicion in a recognizable group of patients observed by selective mesenteric arteriography affords a method for confirmation of the diagnosis of mesenteric vasoconstriction. Once the diagnosis is established, a patient management protocol program should be followed. Sustained infusion of papaverine into the mesenteric artery is useful in reversing mesenteric vasoconstriction. Additionally, the judicious use of celiotomy and intestinal resection, preceded and followed by the sustained infusion of papaverine into the superior mesenteric artery, offers hope for the survival of some of these patients and warrants further use.

Aged↗