Abstract
IntroductionCalibrated arterial pulse contour analysis has become an established method for the continuous monitoring of cardiac output (PCCO). However, data on its validity in hemodynamically instable patients beyond the setting of cardiac surgery are scarce. We performed the present study to assess the validity and precision of PCCO-measurements using the PiCCO™-device compared to transpulmonary thermodilution derived cardiac output (TPCO) as the reference technique in neurosurgical patients requiring high-dose vasopressor-therapy.MethodsA total of 20 patients (16 females and 4 males) were included in this prospective observational clinical trial. All of them suffered from subarachnoid hemorrhage (Hunt&Hess grade I-V) due to rupture of a cerebral arterial aneurysm and underwent high-dose vasopressor therapy for the prevention/treatment of delayed cerebral ischemia (DCI). Simultaneous CO measurements by bolus TPCO and PCCO were obtained at baseline as well as 2 h, 6 h, 12 h, 24 h, 48 h and 72 h after inclusion.ResultsPCCO- and TPCO-measurements were obtained at baseline as well as 2 h, 6 h, 12 h, 24 h, 48 h and 72 h after inclusion. Patients received vasoactive support with (mean ± standard deviation, SD) 0.57 ± 0.49 μg · kg-1 · min-1 norepinephrine resulting in a mean arterial pressure of 103 ± 13 mmHg and a systemic vascular resistance of 943 ± 248 dyn · s · cm-5. 136 CO-data pairs were analyzed. TPCO ranged from 5.2 to 14.3 l · min-1 (mean ± SD 8.5 ± 2.0 l · min-1) and PCCO ranged from 5.0 to 14.4 l · min-1 (mean ± SD 8.6 ± 2.0 l · min-1). Bias and limits of agreement (1.96 SD of the bias) were −0.03 ± 0.82 l · min-1 and 1.62 l · min-1, resulting in an overall percentage error of 18.8%. The precision of PCCO-measurements was 17.8%. Insufficient trending ability was indicated by concordance rates of 74% (exclusion zone of 15% (1.29 l · min-1)) and 67% (without exclusion zone), as well as by polar plot analysis.ConclusionsIn neurosurgical patients requiring extensive vasoactive support, CO values obtained by calibrated PCCO showed clinically and statistically acceptable agreement with TPCO-measurements, but the results from concordance and polar plot analysis indicate an unreliable trending ability.
Highlights
Calibrated arterial pulse contour analysis has become an established method for the continuous monitoring of cardiac output (PCCO)
In neurosurgical patients requiring extensive vasoactive support, CO values obtained by calibrated pulse-contour derived cardiac output (PCCO) showed clinically and statistically acceptable agreement with Transpulmonary thermodilution cardiac output (TPCO)-measurements, but the results from concordance and polar plot analysis indicate an unreliable trending ability
The trial was not registered because it was observational and not randomized. All of these patients were simultaneously included in another observational study with a similar study design, comparing the validity of arterial pressure waveform analysis of cardiac output using the FloTrac/ VigileoTM-device with TPCO [25]
Summary
Calibrated arterial pulse contour analysis has become an established method for the continuous monitoring of cardiac output (PCCO). Data on its validity in hemodynamically instable patients beyond the setting of cardiac surgery are scarce. We performed the present study to assess the validity and precision of PCCO-measurements using the PiCCOTM-device compared to transpulmonary thermodilution derived cardiac output (TPCO) as the reference technique in neurosurgical patients requiring high-dose vasopressor-therapy. Concerns about the inherent risks of pulmonary artery catheterization have driven the development of less invasive devices for monitoring CO [1] of there are a paucity of data on the reliability of PCCO monitoring in situations with significant hemodynamic instability and in settings not related to cardiac surgery. As the total percentage error is a composite of both the tested and the reference method, a true interpretation of validation studies is only possible if the precision of the PCCO technique and the reference method is described separately [12]. To the best of our knowledge, the precision of PCCO measurements has not yet been reported [7,8]
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