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A rebreathing method for measuring lung volume, diffusing capacity and cardiac output in conscious small animals.

We developed a multiple gas rebreathing technique for measuring lung diffusing capacity (DL(CO)), lung volume (V(L)) and cardiac output simultaneously in conscious spontaneously breathing small animals. Lung volume was measured from the dilution of methane (CH4) or sulfur hexafluoride (SF6) and verified independently by a helium washout technique. Cardiac output and DL(CO) were estimated from the uptake of acetylene and carbon monoxide, respectively. We tested guinea pigs at two levels of alveolar oxygen tension in order to estimate membrane diffusing capacity and pulmonary capillary blood volume by the Roughton-Forster technique. Results show that measured DL(CO) are consistent with reported values in anesthetized guinea pigs as well as with allometric comparison across species. Lung volume estimated from SF6 dilution agreed closely with that estimated independently from helium washout; however, lung volume estimated from CH4 dilution was systematically lower due to the addition of endogenously produced CH4 to the rebreathing system. We conclude that this technique can be used to measure resting lung function in conscious unsedated small animals.

Animals↗

Two-beam pulsed Doppler cardiac output measurement: reproducibility and agreement with thermodilution.

Two observers used two-beam pulsed Doppler ultrasound, equipped with a suprasternal probe, to measure cardiac output (QtDopp) in 38 ICU patients who had pulmonary artery catheters and in 20 adult volunteers. The two-beam pulsed Doppler method enables one device to measure simultaneously both aortic blood velocity and aortic diameter. Each observer was blind to the other's measurement and to the thermodilution cardiac output measurement (Qttd). Linear regression of the mean of both observer's QtDopp on Qttd showed QtDopp = 0.90.Qttd + 0.01 (see = 1.54 L/min, r = .90). Bias (+/- SD), defined as mean (QtDopp - Qttd) difference, was -0.69 +/- 1.55 L/min. Interobserver agreement was more variable in patients than volunteers; mean (observer 1 - observer 2) difference was 0.14 +/- 1.30 L/min in ICU patients and -0.09 +/- 0.92 L/min in volunteers. Two-beam pulsed Doppler ultrasound is a simpler method of measuring QtDopp than previous pulsed Doppler methods which measure separately the aortic diameter by echocardiography. Although its agreement with Qttd is close to other Doppler methods and has acceptable interobserver reproducibility, its accuracy remains operator-dependent.

Cardiac Output↗

Comparison of changes in transit time ultrasound, esophageal Doppler, and thermodilution cardiac output after changes in preload, afterload, and contractility in pigs.

The purpose of this study was to compare how well changes in cardiac output (CO) measured by esophageal Doppler (Doppler) and thermodilution (TD) followed changes in CO measured by transit time ultrasound (TTU). Simultaneous Doppler, TD, and TTU measurements of CO were made before and after changes in preload, afterload, or contractility in seven piglets. Mean changes in each CO method for each type of change in CO were compared by analysis of variance. Changes in TTU CO, TD CO, and Doppler CO were compared by correlation, linear regression, and bias and precision statistics. Of 86 TTU changes in CO greater than 10%, Doppler changed the same direction as TTU 59 times, changed in an opposite direction 6 times, and changes less than 10% 21 times. Thermodilution changed in the same direction as TTU 72 times, in the opposite direction 4 times, and changed less than 10% 10 times. Changes (% delta) in TTU and TD measurements of CO were not significantly different in any group. Changes in Doppler CO and TTU CO were different for two afterload and contractility groups. Percent changes in Doppler CO had a correlation coefficient (r) = 0.74, m = 0.72, and bias (mean % delta Doppler CO - mean % delta TTU CO) = 6.3 +/- 29.7 with % delta TTU CO. Percent changes in TD CO had an r = 0.90, m = 0.92, and bias = 5.7 +/- 19.1 with % delta TTU CO. Cardiac output measured by Doppler underestimated changes in CO due to changes in preload and contractility and exaggerated changes in CO due to changes in afterload.

Analysis of Variance↗

A model to decrease hepatic blood flow and cardiac output with pressure breathing.

This randomized, controlled, crossover study evaluated the effect of continuous positive airway pressure (CPAP) breathing on hepatic blood flow (HBF) and cardiac output in 10 healthy male subjects. A CPAP mask was placed on the face and the subject breathed at either CPAP 12.5 cm H2O or ambient airway pressure. The estimated HBF was calculated as the ratio of indocyanine green plasma clearance to one minus the hematocrit. Cardiac output was measured with Doppler ultrasound. CPAP caused HBF to decrease in 8 of 10 subjects (14.1% +/- 15.3%, mean +/- SD, p = 0.033) and cardiac index (CI) to decrease in all subjects (14.1% +/- 5.7%, p = 0.0001). Stroke volume and respiratory rate were significantly decreased; heart rate was unchanged. These results indicate that CPAP at 12.5 cm H2O causes a small, but significant decrease in both HBF and CI.

Adult↗

Continuous measurement of cardiac output by inert gas throughflow: comparison with thermodilution.

OBJECTIVE: The throughflow method is a new technique for continuous and minimally invasive measurement of cardiac output by the Fick principle, which uses ventilation of the 2 lungs with unequal inspired gas concentrations by means of a double-lumen endobronchial tube. It exploits steady-state gas exchange and thus permits rapid repetition of measurement. DESIGN: Comparison of paired measurements by the throughflow method using N(2)O exchange with bolus thermodilution. SETTING: Departments of anesthesiology in 2 university teaching hospitals. PARTICIPANTS: Nine patients undergoing cardiac surgery in the precardiopulmonary bypass period. INTERVENTIONS: Patients intubated with a double-lumen endobronchial tube were ventilated with 45% nitrous oxide (N(2)O) to the left lung (zero to the right lung). Arterial blood gas samples were taken to measure alveolar deadspace to allow correction for the alveolar-arterial N(2)O difference and to correct for the presence of unmeasured shunt perfusion. MEASUREMENTS AND MAIN RESULTS: Throughflow measurements correlated with thermodilution (r = 0.719, p < 0.05) with a mean bias of -0.208 L/min (-5.2%). The standard error of the bias was 0.060 L/min, with 95% confidence limits for the bias of -0.088 L/min and -0.328 L/min. The limits of agreement between the 2 methods were +0.960 L/min and -1.376 L/min. CONCLUSIONS: The throughflow method showed good agreement with thermodilution. It permits continuous cardiac output measurement without the need for sampling of mixed venous blood, using techniques of lung isolation, which are readily available in clinical anesthetic practice.

Bias↗

Mitral Doppler indices are superior to two-dimensional echocardiographic and hemodynamic variables in predicting responsiveness of cardiac output to a rapid intravenous infusion of colloid.

UNLABELLED: We hypothesized that mitral flow (MF) Doppler measurements could be used to predict cardiac output (CO) responsiveness to fluid challenge. Fourteen patients with normal systolic and diastolic function, scheduled for coronary artery bypass graft surgery, were evaluated as part of a pilot study in which preload was varied immediately before the beginning of cardiopulmonary bypass. A Validation group of 36 patients with different levels of systolic and diastolic function received a rapid infusion of 500 mL of 10% pentastarch. By use of transesophageal echocardiography, we measured left ventricular end-diastolic area, pulsed Doppler indices of the MF and pulmonary venous flow, and standard hemodynamic variables during acute volemic variations. A baseline measurement was first recorded, followed by measurements taken after a decrease (211 +/- 87 mL) and then an increase (176 +/- 149 mL) in preload (pilot study) and before and after 500 mL of pentastarch (validation study). In the pilot study, we found that a low velocity/time integral (VTI) E wave/A wave (E/A) ratio was associated with a larger increase in CO secondary to an increase in preload (r = 0.64, P < 0.05). Stepwise linear regression identified Doppler measurements of the mitral VTI E/A ratio as the most important variable to predict the increase in CO after fluid infusion. In the validation study, a mitral E/A ratio <1.26 before fluid infusion best predicted a 20% increase in stroke volume (receiver operating characteristic curve, 71%; P < 0.05), whereas no other hemodynamic or echocardiographic variable predicted preload responsiveness. We conclude that the MF Doppler filling pattern is an important factor to predict the increase in CO after intravascular fluid challenge in patients undergoing coronary artery bypass grafting. IMPLICATIONS: In the presence of low cardiac output, the clinician's ability to identify which patients are more likely to benefit from volume administration to improve hemodynamic status while avoiding fluid overload is important. The analysis of Doppler measurement of the mitral flow as an indirect indicator of the individual diastolic pressure/volume relationship may be useful to predict the intravascular volume responsiveness in patients undergoing coronary artery bypass graft surgery.

Adult↗

Noninvasive monitoring of cardiac output in human neonates and juvenile piglets by inductance cardiography (thoracocardiography).

PURPOSE: Thoracocardiography has been used in adult patients to noninvasively estimate changes in cardiac output (CO) by analysis of ventricular volume curves recorded by an inductive plethysmographic transducer encircling the chest at the level of the heart. The purpose of this study was to investigate the potential of thoracocardiography to monitor cardiac output in human neonates and in a small animal model, the juvenile piglet. MATERIALS AND METHODS: In 6 human premature neonates weighing 1.0 to 1.6 kg the effect of periodic respiration on CO was studied with thoracocardiography. In 9 piglets weighing 8.5 to 10.2 kg changes in CO were estimated simultaneously by thoracocardiography and thermodilution during fluid loading and rapid atrial pacing. RESULTS: In human neonates, CO during breathing was 136% to 320% of the corresponding value during apneas. In piglets, CO by thermodilution ranged from 0.25 to 3.26 L/min. The mean difference in 40 paired estimates of relative changes in CO by thoracocardiography and thermodilution was 3%, limits of agreement (bias +/- 2 SD) were +/- 30%. CONCLUSIONS: In neonates, increases in CO during respiratory phases of periodic breathing are consistent with expected cardiorespiratory interactions. Thoracocardiography monitored changes in CO in piglets with acceptable accuracy. Thoracocardiography holds promise for noninvasive monitoring in human neonates but further validation is required.

Animals↗

Combined doppler and phased-array echocardiographic estimation of cardiac output.

The capability of a pulsed Doppler flowmeter combined with a phased-array imaging system to measure volume flow was tested in vitro and in patients undergoing cardiac catheterization. The Doppler-phased-array system (DPA) was used to determine vessel diameter and a superimposed cursor was used to locate the range and angle of the Doppler sample volume. DPA estimates of continuous flow through tubing in a water tank correlated strongly (r = 0.99) with measured flow corresponding to physiologic ranges from 3-12 l/min. For pulsatile flow in a water tank, a correlation of r = 0.86 with measured flow was obtained, whereas DPA estimates of cardiac outputs compared with Fick estimates in the 11 patients produced a correlation of r = 0.83. These data indicate that estimates of cardiac output are possible using the DPA approach.

Adult↗

The role of cardiac output response in blood flow distribution during exercise in patients with chronic heart failure.

The relationship between blood flow in the working leg and cardiac output (Q) response was determined for patients with chronic heart failure. The ratio of leg blood flow (LBF) to Q (LBF/Q) at the same workload during submaximal exercise was significantly different in three groups of patients classified by peak cardiac index: it was 0.22 +/- 0.08 in the 'satisfactory' Q group vs 0.33 +/- 0.09 in the moderate Q group, and 0.38 +/- 0.08 in the poor Q group (P < 0.01) in the first stage of exercise. delta LBF/delta Q, the slope of change in leg blood flow to Q from rest to peak exercise, was significantly larger in the poor Q group than in the satisfactory Q group (P < 0.01). The intergroup arteriovenous oxygen difference (AVO2D) in organs other than the leg was large, while that in the working leg was small. Leg vascular resistance at submaximal workload was similar in the three groups, but vascular resistance in other organs was significantly higher in the poor Q group than in the satisfactory Q group (P < 0.001). These findings suggested that metabolic vasodilating stimuli in the working leg attenuated excessive vasoconstriction and caused a shift in blood flow from other organs to the working leg under conditions of severely reduced Q response.

Adult↗

Death due to high-output cardiac failure in fetal sacrococcygeal teratoma.

Fetal sacrococcygeal teratoma (SCT) is being recognized with increasing frequency. Placentomegaly and hydrops fetalis are preterminal events, and it has been suggested that fetal death may be due to high-output cardiac failure from arteriovenous shunting through the tumor. We had a chance to examine this hypothesis when a 21-week fetus presented with a huge sacrococcygeal teratoma. There were marked placentomegaly, cardiomegaly, hyperdynamic ventricles, and a pericardial effusion. Doppler studies showed tremendous flow through the SCT with extreme enlargement of the inferior vena cava, consistent with congestive heart failure from increased flow through the tumor. Hydrops developed, and the fetus was delivered because of placental abruption. This case provides supportive evidence that the teratoma acts as a large arteriovenous shunt, causing high-output cardiac failure. We have now collected 18 more cases of sacrococcygeal teratoma diagnosed in utero. Of the total 45 cases of fetal SCT, 9 had placentomegaly and/or fetal hydrops and all 9 fetuses died in utero or shortly after birth. We conclude that the only hope for survival in these severely affected fetuses is to reduce blood flow to the tumor before birth.

Cardiac Output↗

Maximum cardiac output during incremental exercise by first-pass radionuclide ventriculography.

STUDY OBJECTIVE: To validate a noninvasive first-pass radionuclide ventriculographic (FPRV) measurement of maximum cardiac output (Qv) during exercise. DESIGN: Comparison of Qv to that measured by the Fick principle (Qf) at peak exercise. SETTING: Academic cardiopulmonary exercise laboratory. PATIENTS: Seventy-eight consecutive patients without a history of septal defect undergoing clinically indicated maximum incremental cardiopulmonary exercise testing with pulmonary arterial catheterization and FPRV. MEASUREMENTS AND RESULTS: Ventilation and gas exchange were measured breath-by-breath or by a mixing chamber/mass spectrometer system. Arterial and mixed venous O2 content were measured each minute during exercise. When patients without left-to-right ventricular stroke count ratio evidence for left-sided regurgitation were isolated, peak Qv was linearly related to Qf (r=0.75, p=0.0001). To account for a small systematic overestimation (bias) of Qf by Qv, the linear equation for the Qv/Qf relation was derived for patients studied between 1990 and 1993 and applied to those studied subsequently. The resulting corrected peak Qv was tightly related to peak Qf (r=0.90, p<0.001) with confidence intervals for slope and intercept overlapping identity. CONCLUSION: FPRV can reasonably estimate maximum cardiac output during incremental exercise in patients for whom the technique has ruled out left-sided cardiac regurgitant lesions.

Cardiac Catheterization↗

Hemodynamic monitoring in obese patients: the impact of body mass index on cardiac output and stroke volume.

OBJECTIVE: Interpreting hemodynamic parameters in critically ill obese patients can be difficult as the effects of body mass index (BMI) on cardiac output (CO) and stroke volume (SV) at the extremes of body size remains unknown. We examined the relationship between BMI and both CO and SV for patients with varying body sizes. DESIGN: Retrospective cohort analysis. SETTING: A large tertiary care academic medical center. PATIENTS: A total of 700 consecutive adults who were found to have disease-free coronary arteries and a cardiac output measurement (thermodilution or Fick method) during coronary angiography between July 1, 2000, and July 31, 2004. MEASUREMENTS AND RESULTS: We examined the relationship between BMI (mean, 28 kg/m(2); range, 10.6-91.6 kg/m(2)) and cardiac hemodynamics after adjusting for demographic (age, sex) and clinical (diabetes, smoking status, valvular heart disease, medications, indications for catheterization) characteristics using multivariable regression. Body mass index was positively correlated with CO and SV. Each 1 kg/m increase in BMI was associated with a 0.08 L/min (95% confidence interval [CI], 0.06-0.10; p < .001) increase in CO and 1.35 mL (95% CI, 0.96-1.74; p < .001) increase in SV. There was no significant association between BMI and both cardiac index (0.003 L/min/m(2); 95% CI, -0.008-0.014; p = .571) and stroke volume index (0.17 mL/m(2); 95% CI, -0.03-0.37; p = .094). CONCLUSION: Variations in BMI translate into predictable but only modest differences in CO and SV, even at the extremes of body size. Indexing hemodynamic measurements to body surface area attenuates the effects of BMI. Body habitus should not appreciably complicate the interpretation of hemodynamic measurements.

Aged↗

Action of endogenous atrial natriuretic peptide in calves with experimental acute central venous congestion and low cardiac output.

STUDY OBJECTIVE: The aim of the study was to investigate plasma concentrations of atrial natriuretic peptide, aldosterone, and renin during experimentally induced acute central venous congestion. DESIGN: Two experimental calf models were used: (1) right heart failure due to pulmonary artery obstruction; (2) inferior vena cava syndrome produced by inferior vena caval obstruction. Hormonal responses and haemodynamic variables were measured over 6 h. SUBJECTS: Experiments were performed on three female "Schwarzbund" calves, age 3 months, weight 92 +/- 8 kg. MEASUREMENTS AND MAIN RESULTS: In the pulmonary artery obstructed group there was an increase of plasma aldosterone from 6.5(SEM 1.6) to 22.1(3.2) ng.dl-1 (p less than 0.05), of renin from 0.7(0.1) to 2.5(0.3) Goldblatt units x 10(-4).ml-1 (p less than 0.05), and of atrial natriuretic peptide from 22.1(4.5) to 141.4(27.8) pmol.litre-1 (p less than 0.05). During inferior vena caval obstruction, aldosterone increased from 2.4(0.4) to 20.9(2.0) ng.dl-1 (p less than 0.05), and renin increased from 0.4(0.05) to 2.0(0.20) Goldblatt units x 10(-4).ml-1 (p less than 0.05). In this experiment, atrial natriuretic peptide remained unchanged. Cardiac output decreased in both groups. There was significant fluid and electrolyte retention during both experiments, with urine volume decreasing from 87.7(11.6) to 35.0(1.2) ml-h-1 in experiment (1), and from 185(14) to 95.7(8.6) ml.h-1 in experiment (2). CONCLUSIONS: The study suggests (1) that in an experimental acute state of reduced cardiac output due to pulmonary artery stenosis with constantly increased right heart pressures, raised endogenous atrial natriuretic peptide failed to induce diuresis and natriuresis; (2) that in acute right heart failure, renin and aldosterone secretion could not be suppressed by raised atrial natriuretic peptide concentrations; and (3) atrial natriuretic peptide secretion seemed to be exhausted after 6 h continuous atrial distension.

Acute Disease↗

Effects of streptozotocin-induced diabetes and noradrenaline infusion on cardiac output and its regional distribution in pithed rats.

46Sc-and 99mTc-labelled microspheres were used to measure the effects of noradrenaline infusion on cardiac output and its regional distribution in 10 control and 10 streptozotocin-diabetic pithed rats. Plasma noradrenaline concentrations during the infusion were similar in both groups. Pressor responses were significantly smaller in the diabetic animals (controls: + 79, diabetic: + 44 mmHg; p less than 0.001). Cardiac output remained similar in both groups before and during the noradrenaline infusion. Total peripheral resistance was similar in both groups before noradrenaline but the noradrenaline-mediated increase was significantly smaller in the diabetic animals (controls: + 150%, diabetic: + 76%; p less than 0.05). Noradrenaline-mediated resistance increases were significantly reduced in several tissues of the diabetic rats including the small intestine (controls: + 132%, diabetic: -4%; p less than 0.005), the large intestine (controls: + 150%, diabetic: + 39%; p less than 0.05) and the kidneys (controls: + 180%, diabetic: + 27%; p less than 0.05), but were very similar in other areas, e.g. in the hindlimbs and tails.

Animals↗

[Interest of prehospital use of cardiac output monitoring with partial CO2 rebreathing technique: a case report].

We report the case of a 68-year-old man with severe hypoxemic pneumopathy having cardiac output monitoring with the NICO system in prehospital medicine. This monitoring permitted the diagnosis of a compressive pneumothorax during the transfer to the intensive care unit. This ease of use technique based on partial carbon dioxide rebreathing, allows non-invasive, continuous and reliable cardiac output monitoring. We discuss the interest of this device in prehospital medicine.

Aged↗

Reference sample microsphere method: cardiac output and blood flows in conscious rat.

Validation of the reference sample method (RSM) in the rat was accomplished by: 1) simultaneous measurement of cardiac output (CO) by the RSM and electromagnetic flowmetry method in ether-anesthetized open-chest Wistar rats, and 2) determination of systemic and regional hemodynamic reproducibility in conscious rats following three serial injections of microspheres. The optimal sampling time and sampling rate were determined in several CO states. The results indicate that: 1) 200 or more microspheres contained in the reference sample result in an accurate determination of CO, 2) almost 100% of the microspheres are trapped by tissues with in 20 s of cessation of the microsphere injection, 3) the hemodynamic steady state is affected only under low cardiac output conditions at a high sampling rate (1.211 ml/min), 4) three repeated injections of microspheres in conscious animals do not alter systemic hemodynamis, and 5) the reproducibility of regional blood flow distribution is good in all organs except the liver, stomach, spleen, and skin (third application). These data indicate that the RSM is reliable, providing reasonable accuracy and reproducibility of systemic and regional hemodynamics in the rat.

Animals↗

Cardiac output monitoring during the acute phase of myocardial infarction: accuracy and precision of the thermodilution method.

A triple human catheter was used for the determination of cardiac output during the acute phase of moycardial infarction in 23 patients. The correlation coefficient between thermodilution and the Fick method was 0.91. Precision of the method assessed by multiple repeated determinations was 4.8 or 5.6%. Quadruplicate determinations allowed to detect variations of cardiac output in the range of 0.465 1/min. Variation between two successive determinations of more than 9.4% can probably be attributed to a technical error.

Acute Disease↗