Pulse contour analysis after normothermic cardiopulmonary bypass in cardiac surgery patients

Sander Michael, Von, Foer Achim, Grosse Joachim, Dushe Simon, Konertz, Spies

Description

Monitoring of the cardiac output by continuous arterial pulse contour (CO PiCCOpulse ) analysis is a clinically validated procedure proved to be an alternative to the pulmonary artery catheter thermodilution cardiac output (CO PACtherm ) in cardiac surgical patients. There is ongoing debate, however, of whether the CO PiCCOpulse is accurate after profound hemodynamic changes. The aim of this study was therefore to compare the CO PiCCOpulse after cardiopulmonary bypass (CPB) with a simultaneous measurement of the CO PACtherm . Methods After ethical approval and written informed consent, data of 45 patients were analyzed during this prospective study. During coronary artery bypass graft surgery, the aortic transpulmonary thermodilution cardiac output (CO PiCCOtherm ) and the CO PACtherm were determined in all patients. Prior to surgery, the CO PiCCOpulse was calibrated by triple transpulmonary thermodilution measurement of the CO PiCCOtherm . After termination of CPB, the CO PiCCOpulse was documented. Both CO PACtherm and CO PiCCOtherm were also simultaneously determined and documented. Results Regression analysis between CO PACtherm and CO PiCCOtherm prior to CPB showed a correlation coefficient of 0.95 ( P < 0.001), and after CPB showed a correlation coefficient of 0.82 ( P < 0.001). Bland-Altman analysis showed a mean bias and limits of agreement of 0.0 l/minute and -1.4 to +1.4 l/minute prior to CPB and of 0.3 l/minute and -1.9 to +2.5 l/minute after CPB, respectively. Regression analysis of CO PiCCOpulse versus CO PiCCOtherm and of CO PiCCOpulse versus CO PACtherm after CPB showed a correlation coefficient of 0.67 ( P < 0.001) and 0.63 ( P < 0.001), respectively. Bland-Altman analysis showed a mean bias and limits of agreement of -1.1 l/minute and -1.9 to +4.1 l/minute versus -1.4 l/minute and -4.8 to +2.0 l/minute, respectively. Conclusion We observed an excellent correlation of CO PiCCOtherm and CO PACtherm measurement prior to CPB. Pulse contour analysis did not yield reliable results with acceptable accuracy and limits of agreement under difficult conditions after weaning from CPB in cardiac surgical patients. The pulse contour analysis thus should be re-calibrated as soon as possible, to prevent false therapeutic consequences.

Informations

• Publié par: biomed
• Publié le: 01 janvier 2005
• Nombre de lectures: 21
• Langue: English

Extrait

Available onlinehttp://ccforum.com/content/9/6/R729

Vol 9 No 6 Open Access Research Pulse contour analysis after normothermic cardiopulmonary bypass in cardiac surgery patients 1 11 11 Michael Sander, Christian von Heymann, Achim Foer, Vera von Dossow, Joachim Grosse, 2 2 1 Simon Dushe, Wolfgang F Konertzand Claudia D Spies

1 Department of Anesthesiology and Intensive Care Medicine, University Hospital Charité, Campus Charité Mitte, University Medicine, Schumannstrasse 20/21, 10098 Berlin, Germany 2 Department of Cardiovascular Surgery, University Hospital Charité, Campus Charité Mitte, University Medicine, Schumannstrasse 20/21, 10098, Berlin, Germany

Corresponding author: Michael Sander, [e-mail]

Received: 1 Aug 2005Revisions requested: 30 Aug 2005Revisions received: 7 Oct 2005Accepted: 13 Oct 2005Published: 4 Nov 2005

Critical Care2005,9:R729R734 (DOI 10.1186/cc3903) This article is online at: http://ccforum.com/content/9/6/R729 © 2005 Sanderet al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract Introduction Monitoringof the cardiac output by continuous arterial pulse contour (CO) analysis is a clinically PiCCOpulse validated procedure proved to be an alternative to the pulmonary artery catheter thermodilution cardiac output (CO) in PACtherm cardiac surgical patients. There is ongoing debate, however, of whether the COis accurate after profound PiCCOpulse hemodynamic changes. The aim of this study was therefore to compare the COafter cardiopulmonary bypass (CPB) PiCCOpulse with a simultaneous measurement of the CO. PACtherm Methodsethical approval and written informed consent, After data of 45 patients were analyzed during this prospective study. During coronary artery bypass graft surgery, the aortic transpulmonary thermodilution cardiac output (CO) PiCCOtherm and the COwere determined in all patients. Prior to PACtherm surgery, the COwas calibrated by triple PiCCOpulse transpulmonary thermodilution measurement of the CO .After termination of CPB, the COwas PiCCOtherm PiCCOpulse documented. Both COand COwere also PACtherm PiCCOtherm simultaneously determined and documented.

Introduction Measurement of cardiac output (CO) is widely used in cardiac surgical patients. Over recent decades the main device for determination of CO has been the pulmonary artery catheter (PAC). The use of the PAC has been decreasing over recent years in surgical and cardiac surgical patients, however, as the benefit of guiding therapy with this device is unclear and the use of the PAC might even lead to increased morbidity, as

Resultsandanalysis between CO Regression PACtherm CO priorto CPB showed a correlation coefficient of PiCCOtherm 0.95 (P< 0.001), and after CPB showed a correlation coefficient of 0.82 (P< 0.001). BlandAltman analysis showed a mean bias and limits of agreement of 0.0 l/minute and 1.4 to +1.4 l/minute prior to CPB and of 0.3 l/minute and 1.9 to +2.5 l/minute after CPB, respectively. Regression analysis of CO versusCO andof COversus PiCCOpulse PiCCOthermPiCCOpulse CO afterCPB showed a correlation coefficient of 0.67 PACtherm (P< 0.001) and 0.63 (P< 0.001), respectively. BlandAltman analysis showed a mean bias and limits of agreement of 1.1 l/ minute and 1.9 to +4.1 l/minute versus 1.4 l/minute and 4.8 to +2.0 l/minute, respectively. Conclusionobserved an excellent correlation of We CO andCO measurementprior to CPB. Pulse PiCCOtherm PACtherm contour analysis did not yield reliable results with acceptable accuracy and limits of agreement under difficult conditions after weaning from CPB in cardiac surgical patients. The pulse contour analysis thus should be recalibrated as soon as possible, to prevent false therapeutic consequences.

shown in one large trial [1]. Other randomized studies indicate no clear evidence of benefit or harm by managing critically ill patients with a PAC [2,3].

Aortic transpulmonary thermodilution, a less invasive tech nique for determination of the CO, was therefore developed and has gained increasing acceptance in clinical practice [4 6]. Only an arterial line and a central venous line are needed to

CO = cardiac output; CO= pulmonary artery catheter thermodilution cardiac output; CO= continuous arterial pulse contour analysis PACtherm PiCCOpulse cardiac output; CO= aortic transpulmonary thermodilution cardiac output; CPB = cardiopulmonary bypass; LOA = limits of agreement; PAC PiCCOtherm = pulmonary artery catheter. R729