title: Major Upper Abdominal Surgery Alters the Calibration of Bioreactance Cardiac Output Readings, the NICOM, When Comparisons Are Made Against Suprasternal and Esophageal Doppler Intraoperatively.
abstract: BACKGROUND
  Minimally invasive continuous cardiac output measurements are recommended for use during anesthesia to guide fluid therapy, but such measurements must trend changes reliably. The NICOM Cheetah, a BioReactance monitor, is being recommended for intraoperative use. To validate its use, Doppler methods, suprasternal USCOM and esophageal CardioQ, were used in tandem to provide reliable estimates of changing trends in cardiac output. Preliminary comparisons showed that upper abdominal surgical interventions caused shifts in the calibration of the NICOM. The purpose of this study was to confirm and measure these calibration shifts.
  
  
  METHODS
  Major surgery patients, aged 58 (32-78) years, 12 males and 15 females, were divided into 4 study groups: (a) controls-lower abdominal or peripheral surgery (n = 9); (b) laparoscopy with abdominal insufflation (n = 6); (c) open upper abdominal surgery with large multiblade retractor placement (n = 6) and (d) head-down robotic surgery (n = 6). Simultaneous NICOM and Doppler readings were taken every 15 to 30 minutes. Within-individual time plots were drawn, and regression analysis between NICOM-USCOM and CardioQ-USCOM readings was performed. Bland-Altman and trend (concordance) analyses were also performed.
  
  
  RESULTS
  Three hundred ninety NICOM comparisons were collected. Duration of surgeries was 4 (1½ to 11) hours, with 7 to 22 sets of readings per case. Mean (SD) cardiac index from USCOM readings was 3.5(1.0) L/min/m. Individual time plots showed shifts in NICOM calibration relative to Doppler (USCOM) in cardiac index of ±0.9 (0.6-1.4) L/min/m during the surgical interventions. In 13 of 18 patients (72%), the shift was downward, but upward shifts did occur. Within-individual correlations between CardioQ-USCOM showed good trending R = 0.87 (range, 0.60-0.97). In the control group, NICOM-USCOM also showed good trending R = 0.89 (0.69-0.97). However, trending was poor in the intervention groups, R = 0.43 (0.03-0.71; P < 0.0001). The Bland-Altman percentage error between NICOM-USCOM (57 [54-60]%) was greater than that between CardioQ-USCOM (42 [40-44]%) (P < 0.0001). Concordance rates were 82 (77-88)% from 101 data pairs and 95 (90-99)% from 72 data pairs, respectively.
  
  
  CONCLUSIONS
  Doppler monitoring used in tandem provided valid trend lines of cardiac output changes against which NICOM readings could be compared. Intraoperatively, the NICOM was shown to track changes in cardiac output reliably in most circumstances. However, surgical interventions to the upper abdomen caused shifts in readings by >1 L/min/m, and the direction of the shifts was unpredictable. Anesthesiologists need to be aware of these calibration shifts and anticipate their occurrence, whenever the NICOM is used intraoperatively.
authors.affiliation: From the Department of Anaesthesia and Surgical Intensive Care, Peking University First Hospital, Beijing, China; and Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR.
authors.forename: Li
authors.initials: L
authors.lastname: Huang
authors.forename: Lester A H
authors.initials: LAH
authors.lastname: Critchley
authors.forename: Jie
authors.initials: J
authors.lastname: Zhang
mesh_terms: D000328:Adult; D000368:Aged; D002138:Calibration / Q000592:standards; D002302:Cardiac Output / Q000502:physiology*; D002307:Cardiography, Impedance / Q000379:methods / Q000592:standards; D015150:Echocardiography, Doppler / Q000379:methods / Q000592:standards*; D004947:Esophagus; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000592:standards*; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods / Q000592:standards*; D012371:Robotics / Q000592:standards; D013249:Sternum