Validation of continuous thermodilution cardiac output in critically ill patients with analysis of systematic errors.
OBJECTIVE
Bolus thermodilution cardiac output (BCO) measurements are affected by variations in injectate volume, rate, and temperature. These variations are eliminated when CO is measured by a continuous automated thermal technique (CCO). Further, CCO eliminates the need for fluid boluses, reduces contamination risk, requires no operator, and provides a continuous CO trend. We prospectively evaluated CCO versus BCO in a population of critically ill adults with low, normal, and high CO states. We sought to discern any systematic effects of temperature fluctuations or signal-to-noise-ratios (SNR) on disparities between BCO and CCO measurements and also sought to assess the relative cost effectiveness of the CCO system.


METHODS
Pulmonary artery catheterizations were performed in a convenience sample of 20 patients over 6 months. BCO data were obtained using a standardized protocol. Three bolus injections of 5% dextrose were given when each CO was within 10% of the median before averaging; otherwise five boluses were given, with the high and low values eliminated before averaging. Injectates were administered randomly through the respiratory cycle and at 1-minute intervals. CCO measurements were recorded from a Vigilance monitor pre and post BCO measurements, yielding an average CCO value. Also recorded were pre- and post-core temperatures and SNR during the first CCO measurement. Cost data included estimates of operator time for BCO determinations as well as costs of Intellicath (Baxter-Edwards, Irvine, CA) pulmonary artery catheters, Vigilance (Baxter-Edwards, Irvine, CA) monitors, conventional catheters, and injectates.


RESULTS
Of the 20 patients, 15 were mechanically ventilated. A total of 306 paired CO values were obtained for analysis. CCO ranged from 2.5 to 14.4 L/min and BCO from 2.4 to 13.3 L/min. Absolute differences between CCO and BCO measurements increased with increasing CO, but percentage differences did not. Of the paired values, 77% were within 1 L/min of one another. Temperature instability and SNR independently had weak correlations with CCO/BCO disparities. The Vigilance system had a slightly higher net cost than conventional BCO, although no economical value was assigned to the clinical usefulness of continuous, as opposed to intermittent, CO monitoring.


CONCLUSIONS
Continuous CO is a reliable and cost-effective alternative to bolus thermodilution CO for critically ill patients in low, normal, and high CO states.
Medin
D L
DL
Critical Care Medicine Department of the Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, MD 20892-1662, USA.
Brown
D T
DT
Wesley
R
R
Cunnion
R E
RE
Ognibene
F P
FP
D000293:Adolescent; D000328:Adult; D000368:Aged; D016477:Artifacts; D015982:Bias; D002302:Cardiac Output; D002407:Catheterization, Swan-Ganz; D003362:Cost-Benefit Analysis; D016638:Critical Illness; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000191:economics / Q000295:instrumentation / Q000379:methods; D011446:Prospective Studies; D015203:Reproducibility of Results; D012815:Signal Processing, Computer-Assisted; D013696:Temperature; D013815:Thermodilution / Q000191:economics / Q000295:instrumentation / Q000379:methods*