524: Cardiac index in pregnancy--friend or foe?
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Body surface area
Cardiac index
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Measurements of cardiac output with the thermodilution technique add to data for clinical decision making and therefore must be valid and reliable. However, the results of studies on the accuracy of values obtained with room-temperature and iced injectates, especially in patients with high or low cardiac output, have been conflicting.To determine the effect of the temperature of the injectate (iced or room temperature) on cardiac output values obtained with the thermodilution technique in critically ill adults with known low cardiac output.A convenience sample of 50 subjects (41 men and 9 women) who had a cardiac index of less than 2.5 (calculated as cardiac output in liters per minute divided by body surface area in square meters) before the study had cardiac output measured by using a closed system and manual injections of room-temperature and iced injectates.A paired t test indicated no significant difference between iced and room-temperature injectates for cardiac output (iced, 3.62 L/min; room temperature, 3.71 L/min; t = 0.99; P = .327) and cardiac index (iced, 1.95; room temperature, 1.99; t = 0.71; P = .482).The findings support the practice of using room-temperature injectate to measure cardiac output in patients with low cardiac output.
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To assess the haemodynamic regulation at rest and during exercise in Fontan patients at a long-term follow-up.Cardiac output was measured with the dye-dilution technique. We examined 15 out of the surviving 20 patients operated upon in Göteborg between 1980 and 1991. Their mean age was 26.4 years. Four patients had to be excluded due to technical reasons.Median maximal oxygen uptake was 1.47 l/min, corresponding to 21.9 ml/kg/min. Cardiac output was lower than expected at all exercise levels, presumably due to a reduced pulmonary blood flow. The median maximal cardiac output value was 8.0 l/min. Stroke volume index was 33 ml/m (2). The subjects compensated for the reduced cardiac output with an increased arteriovenous oxygen difference. They had a normal increase in arterial blood pressure. This was achieved by an increase in total peripheral resistance.The low maximal exercise capacity was due to a reduced cardiac output and a reduced pulmonary blood flow. This was compensated for by an increased arteriovenous oxygen difference
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Cardiac index
Fontan Procedure
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Measurements of the cardiac output utilizing the classical Fick method were carried out in 38 cardiac patients at rest and during exercise. The predicted cardiac output during exercise was calculated by the regression equation derived by Donald et al. ( Clin. Sci. 14: 37, 1955), relating cardiac output to oxygen consumption during the steady state of exercise in normal subjects (cardiac index = 3.708 + 0.00534 x O 2 consumption, ml/min m 2 ). The resting arteriovenous oxygen difference was found to correlate much better with the calculated percentage of predicted cardiac index during exercise (γ = 0.547) than did the resting cardiac index (γ = 0.304). The finding of an arteriovenous oxygen difference greater than 5.16 ml/100 cc indicated a strong probability of subnormal cardiac index during exercise relative to the oxygen consumption. Submitted on June 18, 1962
Arteriovenous oxygen difference
Cardiac index
Fick principle
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Cardiac index
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Data on the cardiac output and circulatory dynamics obtained by cardiac catheter studies in 51 subjects with chronic severe anemia are presented. Patients are divided into two groups: group A consists of 26 subjects with an average hemoglobin value of 3.0 Gm. per 100 ml. (range 1.5 to 3.8 Gm.); group B, 25 patients with a hemoglobin level of 4.0 to 6.5 Gm., average 4.5 Gm. Group A subjects have a somewhat faster heart rate (99 against 92 a minute), higher cardiac index (8.0 versus 6.3 liters per minute per square meter), and stroke index (88 and 68 ml. per beat per square meter) than group B patients. The oxygen consumption values in both groups are normal (average 158 and 160 ml. per minute per square meter), while more oxygen is extracted by the tissue in group A subjects (61 and 53 per cent) whereas less oxygen is transported to the tissue (261 and 321 ml. per minute per square meter). The stroke volume seems to bear a closer relationship to the high cardiac output than such other parameters as heart rate, right heart filling pressure, and velocity of blood flow. Apparently the presence of slow heart rate does not negate high cardiac output. Data also suggest that systemic vascular resistance may play an important role in the high cardiac output as the two are inversely related, and by increasing the peripheral arterial pressure the output can be significantly reduced. Restudy data after the treatment of the anemia (hemoglobin 10.0 to 12.5 Gm. per 100 ml.) show appreciable reduction in the cardiac output and in the right heart filling pressure, increase in the peripheral vascular resistance and oxygen transport values, and widening of the arteriovenous oxygen differences with concomitant decrease in the oxygen extraction by the tissue.
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Hemodynamic indices were determined in 13 anesthetized dogs. In 7 of them,iv injection of endotoxin(E coli 12*10(10)/mL/kg) followed by iv infusion of saline(0.05/ mL/kg/min) increased the vascular resistance, and decreased the mean arterial pressure, the stroke volume, cardiac output and cardiac index. In the other 6 dogs, iv jinfusion of higenamine (dl-demethylcoclaurine) 1 microg/kg/min after iv endotoxin caused no significant changes in blood pressure, decreased the vascular resistance and icreased the stroke volume, cardiac output and cardiac index as compared with those of the control dogs. These results suggest that higenamine improves the circulation of the endotoxin shock dogs.
Cardiac index
Mean arterial pressure
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This study compared the accuracy of a formula calculating cardiac output utilizing a patient size modification of a pulse pressure formula of Starr with that measured with a standard thermal dilution technique. During a six-month period 111 patients in the intensive care unit (ICU) on the cardiothoracic and vascular surgical services had comparison of their cardiac output by these two methods. The basic formula of Starr for stroke volume was converted to a stroke volume index by dividing by 1.7 and the empirically derived average body surface area in meters square. The stroke volume index was multiplied by the body surface area (BSA) of the patient to determine the patient's stroke volume in ml. Thus the modified stroke volume formula was 100-0.6 age-0.6 Diastolic Pressure + 0.5 Pulse Pressure x Patients BSA (m2)" over 1.7. Cardiac output was calculated by multiplying the stroke volume by heart rate. Nearly 60% of the patients had less than a 5% difference between the two methods, and over 90% had less than a 10% variance. In this particular population the highest variation was 18%. Thus, using only a carefully measured sphygmomanometer blood pressure, stroke volume and cardiac output can be determined with sufficient accuracy for clinical use.
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Sphygmomanometer
Cardiac index
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A technique for measuring cardiac output by the Fick method in small infants during cardiac catheterization is described. Data on resting oxygen consumption, arteriovenous oxygen difference and systemic cardiac output is presented for a group of 126 subjects composed mainly of infants and young children with congenital heart disease. It was found that (a) there was no significant difference in mean resting cardiac index for patients with body surface area under 1.0 square meter regardless of the presence of, or the severity of, heart disease, and (b) patients with heart disease who were larger than 1.0 square meter had significantly lower mean cardiac indices and higher arteriovenous oxygen differences than the control patients. An excellent linear correlation of cardiac output to body surface area was found. There was also a close correlation between index and regression lines for cardiac output leading support to the validity of the cardiac index concept for comparing cardiac outputs in various sized patients. The normal increase in cardiac output during exercise is greater for children than for adults. Forty-seven per cent (8 of 17) children with heart disease showed low cardiac output response to exercise.
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Arteriovenous oxygen difference
Cardiac catheterization
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Objective
To study the hemodynamic effects of Milrinone in patients with sepsis and low cardiac output.
Methods
The study was conducted on 13 patients with sepsis and low cardiac output recruited at the surgical intensive care unit(SICU)of Beijing Hospital from March 2011 to June 2012.Continuous IV infusion of Milrinone was made at 0.25-0.50μg·kg-1·min-1.Hemodynamic variables were monitored by PiCCO, and data at baseline, 10 min, 2 h, and 24 h after infusion were analyzed.
Results
No statistical differences were found between measurements at baseline and 10min after milrinone infusion in variables such as systolic pressure, diastolic pressure, mean arterial pressure(MAP), heart rate, central venous pressure(CVP), global end diastolic volume index(GEDI), cardiac index(CI), cardiac function index CFI), stroke volume index(SVI)and systemic vessel resistance index(SVRI). Increased CI(2.73±0.62, 2.93±0.49 vs.2.33±0.57), CFI(3.59±0.84, 3.85±0.84 vs.3.12±0.93)and SVI(28.62±10.32, 28.77±9.85 vs.25.31±9.09)and decreased SVRI(2 269±615.3, 2 094±542.2 vs.2 946±1 417.0)were observed at 2 h and 24 h after Milrinone infusion, compared with baseline data.
Conclusions
Continuous IV infusion of low dose milrinone can increase cardiac output and decrease systemic vascular resistance in patients with sepsis and low cardiac output.
Key words:
Milrinone; Sepsis; output low cardiac; Hemodynamics
Milrinone
Cardiac index
Mean arterial pressure
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Hemodynamic monitoring is an important step in the management of critically ill children despite the difficulty in measuring preload indices continuously. The aim of the study was to analyze cardiac output parameters and preload indices after acute changes in mean airway pressure and volemia.Twenty-three children treated at our unit were enrolled in a prospective non randomized cohort study. Respiration was supported by controlled mechanical ventilation with positive expiratory-end pressure (PEEP), peak inspiratory pressure <20 cm H(2)O and mean airway pressure <10 cm H(2)O, and hemodynamic monitoring using the PiCCO system. Hemodynamic parameters were measured at T0 (base line), T(1) (after an increase in PEEP of 5 cm H(2)O for 10 min), and T(2) (after fluid challenge). The statistical analysis (BMPD New System software package) comprised comparison of changes at T(0) vs T(1), T(1) vs T(2) and T(0) vs T(2), construction of 3 correlation matrices and multiple linear regression analysis.Sixty-nine hemodynamic parameters were measured in the 23 patients. A comparison between T(0) and T(1) showed no significant changes; differences between T(0) and T(2) were found for cardiac index (CI), (p=0.003); between T(0) and T(2) significant differences were found for CI (p=0.0015), intrathoracic blood volume index (ITBVI) (p=0.04) and stroke volume index (SVI) (p=0.06). The analysis of the correlation matrices yielded ITBVI with CI (p=0.0006), ITBVI with SVI (p=1 x 10(-5)), CI with SVI (p=0.002); a significant correlation between CI and extravascular lung water index (EVLWI) was found only at T(1). Multiple linear regression analysis showed that ITBVI and SVI were predictive for variance of CI at each time point.ITBVI measured by a volumetric monitoring system such as the PiCCO may be considered a sensitive preload indicator also in critically ill children.
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