This document discusses cardiac output and continuous cardiac output measurement techniques. It describes how cardiac output is measured using a Swan-Ganz catheter via the thermodilution method, injecting cold saline and measuring the temperature change in the pulmonary artery. Continuous cardiac output can be measured minimally invasively using the PiCCO system, which uses a central venous catheter and femoral arterial catheter to inject cold saline and measure the temperature change, allowing beat-to-beat cardiac output monitoring. The document outlines the equipment, accessories, measurement procedures, and parameters provided by both methods.

1. Clinical Differentiators Series
Cardiac Output and Continuous Cardiac Output
Clinical Applications
CMS – India
May 2007

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Cardiac Output
With every ventricular contraction, heart ejects some volume of blood, which is
known as “Stroke Volume”.
Number of contractions in a minute give total amount of blood ejected per
minute, which is known as “Cardiac Output” (measured in lit/min)
Swan-Ganz catheter is used to measure cardiac output
superior vena cava (SVC) – right atrium (RA) – right ventricle (RV) – Pulmonary artery (PA)
SVC
RA
RV
PA
Temp sensor
Cold injectate
path
Swan-Ganz catheter

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Right Heart Method
(M1012A or M3012A : C05 option or M3014A : C05 option)
CO is achieved by using thermo-dilution method, which is GOLD standard
in invasive cardiac output measurement technique.
Swan-Ganz catheter is used to detect CO, which is inserted into the
pulmonary artery (PA) via superior vena cava (SVC) -- right atrium (RA) --
right ventricle (RV)
Known amount of cold solution (saline) is injected into RA and change in
blood temperature is measured at PA (temp sensor is placed at the tip of
Swan-Ganz catheter)

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CO measurement procedure (IntelliVue end) :
Enter into Cardiac Output screen on monitor
Enter height and weight of a patient for getting BSA (body surface area)
Keep 4-5 nos. of cold saline syringes with known temp (preferably less than 8C)
• Inject 10ml of cold temperature into SVC (jugular vein)
• Monitor shall display change in temperature in Pulmonary Artery (temp curve)
• Monitor shall calculate CO and CI
• After repeating the same procedure for 4-5 times, user can select / de-select
the required temperature curves and get average CO results
Once the CO is achieved, haemodynamic calculations can be performed

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Accessories required for performing CO measurement:
M1642A- Cardiac Output cable (from Philips monitor to Swan-Ganz & temp)
23001B : CO set injectate temp probe
23002A : Ice bath temp probe
CO can be performed by using either of the temp probes. Both are different
methods and usage is totally user dependent. However, injectate temp
method is more commonly used and has less error factor due to indirect
handling of the injectate fluid.
Note: Flow through housing from Edwards Lifesciences is recommended
for measurement of in-line injectate temp of saline passing over 23001B
(Ref no. of Flow through housing 93505, from Edward Lifesciences, 3rd party item price Rs. 600-800)

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Continuous Cardiac Output – PiCCO
The PiCCO-Technology is a unique combination of 2 techniques for
advanced hemodynamic and volumetric management without the necessity
of a right heart catheter in most patients
This is minimal invasive technique compared to Right Heart method
CVP line thru Central venous catheter and arterial line thru Femoral
catheter are the only invasive lines used for calculating CCO

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Accessories required for performing CCO measurement:
M1643A- Cardiac Output cable (from Philips monitor to temp probe)
M1646A – PiCCO temperature sensor
Pulsion CCO catheter kit (PV2015L20)
Injectate temperature sensor housing (PV4046)
(available with Philips channel partners)
Pulsion temperature sensor (arterial)
Connection to
M1643A

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Trans-pulmonary thermo-dilution method : CCO
(M1012A : C10 option or M3012A : C10 option or M3014A : C10 option)
CCO is achieved by using trans-pulmonary thermo-dilution method, which is
GOLD standard in invasive cardiac output measurement technique.
PiCCO catheter is used to detect CCO.
CVP line is established (jugular vein) for accessing central venous pressure,
and femoral artery is punctured to measure arterial pressure (ART) by using
PiCCO catheter (pulsiocath)
Once the set-up is done, procedure is very much similar to Right Heart
method

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Known amount of cold solution (saline) is injected into SVC and change in blood
temperature is measured at Femoral Artery (temp sensor is placed at the tip of
PiCCO catheter)
Enter into Cardiac Output screen (on IntelliVue monitor)
Enter height and weight of a patient for getting BSA (body surface area)
Keep 4-5 nos. of cold saline syringes with known temp (preferably less than 8C)
Inject 10ml of cold temperature into SVC (jugular vein)
Monitor shall display change in temperature (temp curve)
Monitor shall calculate CO and CI
After repeating the same procedure for 4-5 times, user can select / de-select
the required temperature curves and get average CO results

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Once the CO is achieved, perform the calibration of CO over the real time
arterial waveform to achieve continuous cardiac output.
This is Pulse Contour Analysis
Pulse Contour Analysis
CV Bolus
injection
PULSIOCATH
CALIBRATION
Transpulmonary Thermodilution injection
t
T
P
t

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Arterial pulse contour analysis provides continuous Beat by Beat parameters
obtained from the shape of the arterial pressure wave.
t
-∆T
t
-∆T
Calibration
t [s]
P [mm Hg]
SV
Pulse Contour Analysis - Principle
Reference CO value from
thermodilution
Measured blood
pressure(P(t), MAP, CVP)
The algorithm is capable of computing each single stroke volume (SV)
after being calibrated by an initial transpulmonary thermodilution.

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What is the current situation?.………..……..………….Cardiac Output!
What is the preload?.……………….....…Global End-Diastolic Volume!
Will volume increase CO?....………...……….Stroke Volume Variation!
What is the afterload?……………..…..Systemic Vascular Resistance!
Are the lungs still dry?...…….……...…..….Extravascular Lung Water!
PiCCO answers all relevant questions:
CO GEDV SVV SVR EVLW

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Global End-Diastolic Volume, GEDV and Intra-thoracic Blood Volume, ITBV
have shown to be far more sensitive and specific to cardiac preload compared
to the standard cardiac filling pressures CVP + PCWP as well as right
ventricular end-diastolic volume.
The striking advantage of GEDV and ITBV is that they are not adversely
influenced by mechanical ventilation and give correct information of the preload
status under any condition.
Extra-vascular Lung Water, EVLW has shown to have a clear correlation to
severity of ARDS, length of ventilation days, ICU-Stay and Mortality and is
superior to assessment of lung edema by chest x-ray and clearly indicates
fluid overload

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Thermodilution Parameters
• Cardiac Output CO
• Global End-Diastolic Volume GEDV
• Intrathoracic Blood Volume ITBV
• Extravascular Lung Water EVLW
• Pulmonary Vascular Permeability Index PVPI
• Cardiac Function Index CFI
• Global Ejection Fraction GEF
The PiCCO measures the following parameters:
Pulse Contour Parameters
• Pulse Contour Cardiac Output PCCO
• Arterial Blood Pressure AP
• Heart Rate HR
• Stroke Volume SV
• Stroke Volume Variation SVV
• Pulse Pressure Variation PPV
• Systemic Vascular Resistance SVR
• Index of Left Ventricular Contractility dPmx
Parameters measured with the PiCCO-Technology

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Less Invasive Only central venous and arterial access required. No pulmonary artery
catheter required, also applicable in small children
Short Set-up Time Can be installed within minutes
Dynamic, Continuous Measurement Cardiac Output, Afterload and Volume
responsiveness are measured Beat by Beat
No Chest X-ray to confirm correct catheter position
Cost Effective Less expensive than continuous PA catheter, Arterial PiCCO catheter
can be in even place for 10 days, Potential to reduce ICU stay and costs
More Specific Parameters PiCCO parameters are easy to use and interpret even for
less experienced caregivers
Extra-vascular Lung Water Lung edema can be excluded or quantified at the bed-side
What are the advantages of the PiCCO Technology

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Why your customer should buy PiCCO module?
Clinically useful data
• Beat to beat cardiac output
• Continuous SVR
• Intra-Thoracic Blood Volume – Shows the volume of blood in the chest
• Extra-Vascular Lung Water – Shows the amount of fluid in the lung
Fluid Management
• Doctors can calculate amount of blood loss and give the correct volume of fluid
using ITBV
• Fluid overload can be prevented by keeping an eye on EVLW
Less traumatic and cost effective
• PiCCO uses only CVP line and femoral artery line – less invasive
• Can be used for 8-14 days (Other methods can be only used for max 3 days)
• Cost less than other CCO methods in the market
GE had no PiCCO module, while Drager is planning to introduce a PiCCO soon. Philips has launched
PiCCO Plus in March 2007

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PiCCO plus (new introduction from IntelliVue Rev E.0)
New improved measurement algorithms
New measurements:
• GEF (Global Ejection Fraction)
• PVPI (Pulmonary Vascular Permeability Index)
New continuous PiCCO measurement with PPV
Right-Left shunt detection
SVV, PPV, dPmax can be measured prior to CCO calibration

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New measurements:
• GEF (Global Ejection Fraction)
This reflects the ejection fraction of Global End-Diastolic Volume of the heart.
GEF can be used to detect myocardial insufficiency
• PVPI (Pulmonary Vascular Permeability Index)
This shows the relationship between EVLW and PBV and can help to
Discriminate between permeability type of pulmonary edema
Pulse Pressure Variation (PVV) are used for the direct estimation of volume
responsiveness in mechanically ventilated patients.

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CCO measurement:
30 year old male accident case with internal haemorrhage

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Typical CCO screen designed for KLE hospital, Belgaum, Karnataka
CCO data

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Continuous Cardiac Output – PiCCO
Monitor used to measure CCO : Philips IntelliVue MP20
Necessary Software for CO/CCO : C30
Minimum IBP required : 2 pressure lines (ART and CVP)
Server : M3012A with C10 option (CCO with IBP, Temp and IBP/Temp)
M3001A
Basic server
M3012A
Hemodynamic server
M1643A Cardiac Output cable
M1634A IBP cable for ART
IBP port for CVP measurement

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Continuous Cardiac Output – PiCCO
Philips accessories in action
M1643A CCO cable
To PULSION catheter
To M1646A temp probe

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Accessories required for performing CCO measurement:
M1646A – PiCCO temperature sensor
Pulsion CCO catheter kit (PV2015L20)
Injectate temperature sensor housing (PV4046)
(available with Philips channel partners)
Pulsion temperature sensor
Connection to
M1643A
Connection to ART

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Pulsion kit is used to measure CCO.
Patient preparation :
• Subclavien vein is used to measure CVP as well as injecting COLD injectate solution
• Connect pressure transducer and get CVP waveform and value on the monitor
• Connect Philips M1646A temperature sensor to Subclavien puncture
• Connect Pulsion PV4046 in line temperature housing on M1646A for injecting cold saline
M1646A
PV4046
Pulsion housing
Subclavien puncture
Cold injectate port

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• Puncture Femoral Artery and insert Pulsion catheter.
• Connect Blood pressure transducer to one end on Pulsion catheter
• Get ART waveform and value on the monitor
• Connect other end of Pulsion catheter to Philips M1643A Cardiac Output cable
Femoral puncture
Pulsion Catheter
ART pressure
measurement
To M1643A for
T blood
measurement
IBP transducer
connection

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• Check for good trace of ART and CVP on the monitor
• Keep max 6 nos (10 ml) syringes ready with saline water (temp should be less than 8C)
(greater the injectate volume and colder the temp – more accurate is the measurement)
• Press Cardiac Output soft key on the monitor and enter in CO measurement page
CO measurement

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Enter into Cardiac Output screen (on IntelliVue monitor)
Enter height and weight of a patient for getting BSA (body surface area)
BSA = Height x Weight of patient
BSA

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Press START CO
Inject the 10ml solution into the subclavien vein. Optimal injection rate is 2.5ml / sec
Approximate time to inject 10ml solution should not be more than 4 sec.

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• Repeat the same procedure with time delay of 2 min
• Repeat the same procedure for maximum 6 times.

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• User have a choice of selecting or deselecting the procedure results and average the CO

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• Once the good averaged CO is achieved, user can calibrate the CO value on contour of
Arterial Waveform to measure continuous cardiac output (CCO)

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• Related Hemodynamic parameters can be calculated from CCO values

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