CLINICAL MEASUREMENT

topics

Prof. erban Bubenek MD

1-st. Cardiovascular Anesthesia & Intensive Care Dept

C.C.Iliescu Institute for Cardiovascular Diseases

Bucharest - ROMANIA
TODAY we speak about :
Arterial Pressure Measurement

Cardiac Output Measurement

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Essential requiremets for CLINICAL MEASUREMENT

ACCURACY
- is the difference between the measurements and the real biological signal
- in practice: between a certain technique and a superior 'gold standard technique

PRECISION = reproducibility of repeated measurements of the same biological

signal.

- calibration is important
( against predetermined signals or for absolute measurements to zero)

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 .

MEASUREMENT of ARTERIAL PRESSURE

a wide range of instruments are used to measure pressure :

liquid column manometers : height, zero point, fluid density

mechanical pressure gauges : aneroid manometer

diafragm gauges (coupled to transducers)

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 MEASUREMENT OF ARTERIAL PRESSURE
INDIRECT measurement (non-invasive & not-continous )

- signals generated by the occlusion of a major artery using a cuff

- gives not continous but intermittent measurements

a. palpation method ( Riva Rocci)

b. auscultation of the Korotkoff sounds

c. oscilometry method

DIRECT measurement (invasive and continuous)

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 Indirect Methods of BP measurement (1)

1. Riva Rocci: simplest method of BP measurement, estimating only the

SBP, is by palpating the return of arterial pulse as cuff is deflated.

2. Auscultation of the Korotkoff sounds : both SBP and DBP

on deflation created by the turbulent blood flow in the artery

Mean Arterial Pressure (MAP) = (SBP + 2 DBP) / 3

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 Indirect Methods of BP measurement (2)
3. OSCCILOMETRY
- a microprocessor controlled oscillometer: DINAMAP
- a pressure transducer that digitalizes signals ( microprocesor).
- rapid, accurate, measurements of SBP, DBP, MAP and HR

- SAP = the onset of rapidly increasing oscillations

- MAP = the maximal oscillation at the lowest cuff pressure
- DAP corresponds to the onset of rapidly decreasing oscillations

LIMITATIONS:
- tendency to: overestimate at low pressures and underestimate at high pressures
- errors : movements, arrhythmias or rapid BP fluctuations
- compressive peripheral nerve injuries (repeated measurements )

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 Cuff Size !
Too small cuff will result in false high blood pressure reading

Too large cuff will result in false low blood pressure reading

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 DIRECT Measurement of the BP
invasive : a catheter into the artery

METHODS
1. open Liquid column method : it is obsolete and measures only MAP
13.4 cm. H2O = 10 mm.Hg. !
2. Liquid manometers (obsolete)

3. Electromechanical transducers :
- conversion of mechanic signal into an electric signal
- and then electronically converted and displayed as :
SAP, DAP, MAP

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 Electromechanical transducers
The diaphragm :
- is moved by arterial pulsations which push the saline column
- should be thin, small and rigid !

Transducer :
- based upon strain gauge principle : stretching (by PRESSURE ) a
wire or
silicone crystal changes its electrical resistance

- connected to a wheatstone bridge circuit

the voltage output is proportionate to the pressure applied it !

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 The 3 major problems may occur:
1. Improper zeroing and zero drift

2. Improper transducer / monitor calibration

3. Inadequate dynamic response of system :

a. RF ( resonant or natural frequency)
b. damping

RF = frequency at which a system oscillates when stimulated

- if the frequency of an input signal (i.e., pressure waveform) approaches the RF of

a system : progressive amplification of the output signal occurs,
a phenomenon known as ringing.

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 The ARTERIAL PRESSURE Waveform
ARTERIAL WAVEFORM is a complex sine-wave
The fundamental frequency (FF) or the 1-st harmonic is equal to the HR
( ex: for HR 60 b/min = 1 beat / sec = 1 cycle/sec = 1Hz.)
physiologic peripheral arterial waveforms have a FF = 3 to 5 Hz
( 180 300 beats / min)

The MONITORING SYSTEM ( catheter + transducer + lines)

- RF of the monitoring system should be at least at least 5 times higher than the highest
frequency in the input signal or better : approx.10 times the FF
at least RF > 20 25 Hz to avoid ringing and systolic overshoot

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 The ARTERIAL PRESSURE Waveform
,

Damping Coefficient
(DC): is a measure of how quickly an oscillating system comes to rest

Testing DC: the fast-flush test ( square wave test)

optimal damping

overdamping = underestimates SAP and overestimates DAP

- underdamping = overestimates SAP and underestimates DAP

- in both cases however, MAP is relatively accurate !!!

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REDUCING ARTIFACTS IN A-LINES
Lines free of kinks and clots

avoid Air Bubbles : small amount may augment systolic pressure reading, while
large amount cause an over-damped system
One stopcock per line
Heparinized saline flushed maintaining patency

Transducer should be electronically balanced or re-zeroed because the zero point

may drift if the room temperature changes

to have an adequate damping = flushing TEST !

The catheter and lines: short and rigid

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MEASUREMENT OF BLOOD FLOW:
CARDIAC OUTPUT

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Potential Methods able to measure the Cardiac Output

Fick method
Indicator dilution
Pulse waveform ( pulse contour) methods
Ultrasounds ( 2D-Echo and Doppler techique)
Bioimpedance

ANGIOGRAPHY
MRI

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 Ideal Cardiac Output Monitoring Technique
Precise and No bias
Non-invasive
Continous and instantaneous
Automatic
Operator independent
Cheap
Easy available in OR the ICU
Leads to treatment changes / improvement in outcome

IT DOES NOT EXIST !

Use the Best Compromise : feasibility precision patient !

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 The FICK principle

defines flow by: the ratio of the uptake or clearance of a tracer within
an organ to the arterio-venous difference in concentration

CO = VO2 / ( CaO2 CvO2)

VO2 is measured by: a spirometer + Douglas bag

CvO2 is taken from the pulmonary artery

CaO2 is taken from a catheter in a peripheral artery

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 The FICK method
considered to be the most accurate method for CO

but : - invasive, time consuming

- accurate VO2 samples are difficult to acquire

discontinous CO : Deltatrac (Datex)

continous CO : possible, but no integrated system available

modified Fick equation : continous CO by NICO2 apparatus !

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 INDICATOR DILUTION

CO measurement by indicator dilution has 3 phases :

(a) an indicator is brought into the circulation (injection)

(b) the indicator mixes with the bloodstream

(mixing and dilution)

(c) the concentration of the indicator is measured downstream

(detection)

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 INDICATOR DILUTION
Chemical indicator dilution (dye)

Thermal indicator dilution

( Thermodilution )

the widest used : PAC = Swan-Ganz

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 Chemical indicator dilution
The Stewart-Hamilton formula (time-concentration curve)

using indocyanine green was the conventional indicator dilution method used to
measure CO in ICU until the 1970s.
Indocyanine green :
- nontoxic, inert, safe
- short half-life
- not affected by arterial saturation

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 The Thermodilution (TD) method
Thermodilution = the indicator is the change in blood temperature

a known volume of injectate at low temperature is injected into

the right atrium and the cooled blood traverses a thermistor in a
major vessel branch downstream over a duration of time.

TD Methods :

1. PULMONARY Thermodilution (P-TD) : PAC

2. TRANSPULMONARY Thermodiution (TP-TD)

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The CLINICAL STANDARD is the PAC !
Pulmonary -TD

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 PAC-Thermodilution

The change of the bloods temperature in is measured in the pulmonary artery using
the PAC thermistor and then,the monitor electronically displays a temperature/time
curve.
The CO is inversely proportional to
- the temperature change
- the area under the curve
PAC measures the Pulm.CO = Global CO if no intra-cardiac shunt !

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 Sources of error for P-TD

Loss of indicator

Variation of injectate temperature and volume

Recirculation - IC shunts : false high CO values

Tricuspid regurgitation : false low CO values

Fluctuations in baseline temperature

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 ...........................

10 ml.
cold saline (4 - 6 C)
optimal < 4 sec.
> 4-5 sec. false low CO
during the same respiratory phase

-at least 3 measurements with less than < 10 % between them !

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 Advantages of P-TD
the standard method for clinical CO measurement
simple and repeated measurements possible

The modified PAC may provide CCO

- thermal indicator : intermitent heating of a resistance
- 44C for 1-4 sec, each 30-60 sec
- Not really continuous : mean of 3-4 min !
- expensive

The PAC provides not only CO, SV, .. but also PA pressures, PCWP, SvO2, and
optionally RVEF and RVEDV.

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 TRANSPULMONARY Thermodiution (TPTD)

- TD

- TD

The TPTD femoral artery curve appears later and has a lower peak temperature
than the pulmonary artery TD curve.
The TPTD was shown to be as accurate and precise as P-TD is !

TP-TD is less invasive than P-TD, but does not offer: SvO2, PCWP and PAP values

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 The Clinical USE of TP-TD

Mainly : as a calibration method for other systems :

PiCCO, EV-1000

PiCCO and EV-1000 are able after the initial calibration by TPTD,
to measure in a continuous manner ( beat by beat ) the C.C.O, using

the Pulse Contour method !

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 CCO by the Pulse contour method

The area under the systolic part of the AP waveform correlates :

- directly with Left Ventricular STROKE VOLUME
- inversely with aortic impedance (Z)

SV = Systolic Area / Z

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 The Pulse Contour method
C.C.O.

1. CALIBRATED techniques
PiCCO TP-TD
EV-1000
LiDCO Pulse CO (TP- Lithium dilution)

2. NON-CALIBRATED techniques
Flow-Track VIGILEO
Pro-AQT
Nexfin ( Clear-Sight)

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 PiCCO & EV-1000

C.C.O.( mean 5 -15 sec.) with intermittent TP-TD calibration.

Enables continuous hemodynamic monitoring using:

- a femoral / axilary artery catheter

+
- a central venous catheter (CVC)

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 LiDCO Pulse CO

the calibration technique is : Lithium indicator Dilution

safe and minimally invasive : peripheral venous and arterial

catheters

the PulseCO algorithm used by LiDCO is based on pulse power

analysis !

Continuous, real-time cardiovascular monitoring

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 Pulse Contour NON-CALIBRATED techniques

Flow-Track VIGILEO
PulsioFlex- ProAQT

LiDCO-rapid

- demographics
- only an arterial line + a proprietary sensor in line

NEXFIN (Clear-Sight)
- totally non-invasive !

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 BIOIMPEDANCE
bio tissues (bone, muscle,blood, etc) have different electric proprieties
blood is the most conductive tissue ( Na+ and Cl-)
pulsatile modifications of ITBV TB

TB ~ stroke volume

SV = K x (dZ / dt) / Zo x TEV

TB is measured by : producing and transmiting electricity

( high = 70 kHz low A = 2,5 mA ) between 2 pairs of electrodes

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 Echocardiography (ultrasounds)
for measuring the CO

2 D method

Doppler - method

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 Ultrasounds
US techniques can detect : the shape, size and movement of tissue
interfaces, especially soft tissues and blood (RBC)

US are defined by :
- amplitude of oscillation (dB)
- the wavelength (distance between successive peaks)
- frequency (inversely proportional to wavelength) nr. of cycles / second

human ear can detect frequencies : 20-20,000 Hz.

US have frequencies > 20,000 cycles /sec ( 20 KHz)
diagnostic US uses frequencies in the range of 1-10 MHz. !!!!!

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 2-D Method

SV = EDV ESV

LV volumes (Simpsons method): the summation of the volume of stacked

cylinders within the LV at end-diastole and end-systole

SV = 150 ml - 52 ml = 98 ml

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 Doppler Effect
Doppler effect represented by:

V= _F . c _
2 F0 cos

where V = velocity of object

F = frequency shift
c = speed of sound in medium (body tissue here)
F0 = frequency of emitted sound
cos = angle between sound wave and flow (RBC)
cos 90 = 0 so the US beam should be parallel to RBC

Maximum angle = 20 !

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 Doppler Method for CO measurements
Principle
SV =Area x Velocity
Flow Velocity at LVOT
Area of left ventricular outflow tract
PW Doppler at LVOT in apical 5 chamber view
Obtain LVOT dimension in parasternal long axis view

D=2.1 cm
Simplified formula= (2.1cm)2 * 0.785 Velocity time integral 25 cm

SV = 3.46cm 2
X 25 cm = 87 cm3
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 OESOPHAGEAL DOPPLER
Measurement of blood flow velocity in the descending aorta at the tip of
the flexible probe

4 MHz continuous or 5 MHz pulsed wave

DAF
FTc (corrected flow time)
PV (peak velocity)
MD (minute distance)
HR (heart rate)

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 n

Methods:
ESICM invited 12 experts to form a Task Force to update a
previous consensus (Antonelli et al.: Intensive Care Med 33:575
590, 2007)

Conclusions
This consensus provides 44 statements that can be used at the
bedside to diagnose, treat and monitor patients with shock.

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 Monitoring - KEY MESSAGES (1)

NOT routine for measuring CO 1C

In non-responders to initial therapy, CO or SV should be

measured to evaluate response to fluid or inotropes 1C

Serial measurements of blood LACTATE 1C

Not only lactate, but ScvO2 and CO2-gap 2B
the commonly used preload measures (such as CVP, PAOP or LVEDAi or GEDV) alone should not be used
to guide fluid resuscitation 1 B
use: dynamic over static variables to predict fluid responsiveness 1B

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 Hemodynamic Monitoring
We do NOT recommend the routine use of PAC for patients in shock.
1A
In complex pts. we suggest to use additionally to ECHO:
PAC or TPTD to determine type of shock 2C

We suggest PAC in patients with refractory shock + RV

ECHO is first ! dysfunction. 2 C

We suggest the use of PAC or TPTD with in pts. severe shock

especially in the case of associated ARDS 2 C

We recommend that less invasive devices are used, instead of

more invasive devices, only when they have been validated in
shock pts. UG-BP

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THANKS for your attention !
&
GOOD LUCK !

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