The relationship between alfentanil distribution kinetics and cardiac output.

The relationship between cardiac output and the tissue distribution of alfentanil was investigated in seven healthy volunteers. Subjects were given 10 micrograms/kg alfentanil and 0.5 mg/kg indocyanine green. Arterial blood samples were obtained at baseline, 1 minute, every 1/2 minute until 5 minutes, and then every minute until 15 minutes after the drug injection was begun. Subsequent samples were collected to 6 hours. Cardiac output was measured continuously by use of thoracic bioimpedance. Alfentanil pharmacokinetics were modeled with both a standard three-compartment model and a four-compartmental model based in part on the two-compartmental pharmacokinetics of indocyanine green. The sum of intercompartmental clearances for both the three- and four-compartment models were significantly correlated with the measured cardiac outputs, r = 0.93 and r = 0.88, respectively. These findings indicate that the intercompartmental clearance (i.e., tissue distribution) of alfentanil is largely determined by cardiac output (i.e., tissue blood flow).     

Systemic cardiac output and distribution during high-frequency oscillation

High-frequency oscillation (HFO) appears to be an alternate, less traumatic mode of ventilating surfactant-deficient patients, because conventional (mechanical) pressure-limited ventilation (CMV) compromises cardiac function at high mean airway pressures. We compared systemic cardiac output and its distribution during HFO and CMV in ten adult rabbits rendered surfactant deficient by repeated pulmonary saline lavage. Cardiac output and organ blood flow were measured using the radionucleotide-labeled microsphere technique during ventilation at a mean airway pressure of 15 cm H2O and an inspired oxygen concentration of 100%. Both cardiac output and organ perfusion were similar during both modes of ventilation.     

Beta-adrenergic blockade affects initial drug distribution due to decreased cardiac output and altered blood flow distribution

Beta-adrenergic receptor blockers decrease intravenous anesthetic dose requirements. The present study determined the effect of propranolol on indocyanine green and antipyrine disposition from the moment of rapid intravenous injection. Anti-pyrine is a physiological marker that distributes to a volume as large as total body water in a blood flow-dependent manner and is a pharmacokinetic surrogate for many lipophilic drugs, including intravenous anesthetics. Antipyrine and indocyanine green disposition were determined twice in five healthy adult males in this Institutional Review Board-approved study, once during propranolol infusion. After rapid indocyanine green and antipyrine injection, arterial blood samples were collected frequently for 2 min and less frequently thereafter. Plasma indocyanine green and antipyrine concentrations were measured by high-performance liquid chromatography. Indocyanine green and antipyrine disposition were characterized, using SAAM II, by a recirculatory pharmacokinetic model that describes drug disposition from the moment of injection. Parameters were compared using the paired t test. The disposition of indocyanine green demonstrated that propranolol decreased cardiac output at the expense of the fast peripheral (nonsplanchnic) intravascular circuit. The area under the antipyrine concentration versus time relationship was doubled for at least the first 3 min after injection due to both decreased cardiac output and maintenance of nondistributive blood flow at the expense of a two-thirds reduction of blood flow (intercompartmental clearance) to the rapidly equilibrating (fast, splanchnic) tissue volume. The increase in antipyrine area under the curve due to propranolol-induced alteration of initial antipyrine disposition could explain decreased intravenous anesthetic dose requirements in the presence of beta-adrenergic receptor blockade.     

Fetal cardiac abnormalities identified prior to 14 weeks' gestation.

OBJECTIVE: An increasing number of patients are presenting at early gestational age as being at high risk for congenital heart disease, as a result of ultrasound screening by nuchal translucency. The feasibility and accuracy of fetal echocardiography was assessed in a series of pregnancies studied before 14 weeks' gestation. METHODS: Echocardiography was attempted in 478 fetuses of crown-rump length 40.0-85.0 mm (median, 60.3 mm) with increased nuchal translucency, suspected abnormalities on routine scan or a family history of heart defect. The findings were related to results of autopsy, karyotyping, later scans and postnatal follow-up. RESULTS: Satisfactory images were obtained transabdominally in 402/478 (84.1%) and transvaginally in a further 13 patients. Cardiac defects were confidently identified in 60 fetuses and abnormalities of uncertain significance (isolated ventricular or great artery disproportion, or tricuspid regurgitation) were observed in a further 49. Defects were suspected in an additional 20 fetuses, and 286 were passed as normal. The karyotype was subsequently demonstrated to be abnormal in 70/286 (24.5%) fetuses with normal echocardiograms, and in 94/129 (72.9%) with abnormal or suspicious cardiac findings. Validation of the scan findings was possible in 241 fetuses. Normal heart structure was confirmed in 204 fetuses, and previously unsuspected cardiac abnormalities revealed in nine. Heart defects were verified in 28 fetuses, but five of these had important additional findings. There were false positive findings in three fetuses. CONCLUSIONS: Fetal echocardiography is feasible prior to 14 weeks' gestation. Cardiac defects, when present, may be identified or suspected in the majority of cases. In the risk group studied, heart defects were frequently a manifestation of chromosomal abnormality.     

Comparison of cardiac output determined by bioimpedance, thermodilution, and the Fick method.

BACKGROUND: Cardiac output can be determined by using a variety of methods. OBJECTIVES: To determine the precision and bias between 3 methods for determining cardiac output: bioimpedance, thermodilution, and the Fick method. METHODS: Cardiac output was determined by using bioimpedance via neck and thorax patches and thermodilution via pulmonary artery catheter in 46 patients in the intensive care unit. A subset of 15 patients also had cardiac output determined by using the Fick method. RESULTS: Mean (SD) cardiac output in all patients was 6.3 (2.2) L/min by thermodilution and 5.6 (2.0) L/min by bioimpedance. In the 15 patients in whom all 3 methods were used, mean cardiac output was 6.0 (1.7) L/min by thermodilution, 5.3 (1.7) L/min by bioimpedance, and 8.6 (4.5) L/min by the Fick method. Bias and precision (mean difference +/- 2 SDs) were 0.7 +/- 2.9 L/min between thermodilution and bioimpedance, 1.7 +/- 3.8 L/min between the Fick method and thermodilution, and 2.4 +/- 4.7 L/min between the Fick method and bioimpedance. CONCLUSION: Bioimpedance, thermodilution, and Fick determinations of cardiac outputs are not interchangeable in a heterogeneous population of critically ill patients.     

Normal cardiac output in relation to age and body size.

The resting cardiac output was measured in 151 healthy persons (109 males and 42 females) of 4 to 78 years of age by the earpiece dye-dilution method by using an automatic calibration device of dye concentration. Cardiac index had a significantly inverse correlation to age in 105 cases with the age higher than 20 years: r=-0.491 and y=-4.874-0.023x, where y is cardiac index (liters/min/m2) and x is age (years). Stroke index also decreased linearly by aging throughout all ages: r=-0.426 and y=71.0-0.26 x, where x is stroke index (ml/m2) and x is age. There is no significant difference between males and females. A significant difference was found between the young group below 14 years of age and the other group older than 15 years when cardiac output was correlated to body sizes such as height, weight and surface area. The former which is corresponding to the growth age showed significantly higher cardiac output than the latter. From these results, age-matched normal predicted values were presented. It is suggested that the measured cardiac index and stroke index should be taken as abnormal if those values deviate from the normal value by 30% or more.     

Assessment of the accuracy of continuous cardiac output and pulse contour cardiac output in tracking cardiac index changes induced by volume load.

OBJECTIVE: To assess the ability to track changes in cardiac index (DeltaCI) induced by volume loading using continuous pulsed heat thermodilution (CCO), and pulse contour (PCCO) cardiac output (CO) with transpulmonary thermodilution (TD(tp)) CO as reference. DESIGN: Prospective observational clinical trial. SETTING: Intensive care unit. PATIENTS: Twelve ventilated and sedated post-operative cardiac surgery patients. MEASUREMENTS AND RESULTS: Each patient had a 7.5F CCO pulmonary artery catheter (Edwards Lifesciences) and a 5F, 20cm PCCO femoral artery catheter (Pulsion Medical Systems). Forty-five data sets were taken before and after 25 volume loadings of 5mL/kg of 4% albumin. Volume loading resulted in an increase in CI (2.84L/(minm(2)) versus 3.12L/(minm(2)), p<.05) although only nine volume loadings changed CI (DeltaCI)>/=14%. The change in CI using PCCO (DeltaPCCI) was correlated with DeltaCI (TD(tp)) (R(2)=.50, p<.0001), whilst DeltaCI using CCO (DeltaCCI) was not (R(2)=.14). The bias and limits of agreement (LOA) between DeltaTD(tp)CI and DeltaPCCI was 6.2% (95% CI, +/-5.8%) and 28.4% (95% CI, +/-38.2%) respectively. DeltaTD(tp)CI and DeltaCCI has a bias of 2.6% (95% CI, +/-8.3%) and LOA of 39.6% (95% CI, +/-63%). Both DeltaPCCI and DeltaCCI reliably tracked DeltaCI>/=14%. CONCLUSION: In this small group of patients the continuous cardiac output methods tracked changes in CI, although, in individual cases they did not change in the same direction as the thermodilution method. Critical care nurses need to critically appraise the accuracy and clinical relevance of continuous CO data within the clinical context.     

Fetal cardiac development and hemodynamics in the first trimester.

OBJECTIVE: To describe fetal cardiac and hemodynamic development in the first trimester of pregnancy. SUBJECTS AND METHODS: Forty-eight pregnancies were prospectively studied with transvaginal ultrasound and color Doppler. Fetal heart rate and size were documented together with the presence of inflow and outflow wave-forms and valve signals. RESULTS: Heart rate and size showed a positive correlation with gestational age. At 6 weeks of gestation, 20% of the cardiac cycle was occupied by the isovolumic contraction time (ICT); the isovolumic relaxation time (IRT) occupied 16% and remained unchanged, while the ICT progressively shortened and was not measurable after 12 weeks. The peak inflow velocities had changed from monophasic to biphasic by 10 weeks of gestation. At 7 weeks of gestation, semilunar valves were detected in 10% of examinations and the atrioventricular valves in 3%. The detection rate for both valves at 12 weeks was > or = 90%. In pregnancies that miscarried, the detection rate for both was < 25%. CONCLUSIONS: The Doppler signals that characterize the heart during the first trimester suggest effective heart compliance by 12 weeks. Normal valve development can be inferred from non-invasive Doppler recordings.     

Comparison of the ability of two continuous cardiac output monitors to measure trends in cardiac output: estimated continuous cardiac output measured by modified pulse wave transit time and an arterial pulse contour-based cardiac output device

Estimated continuous cardiac output (esCCO), a noninvasive technique for continuously measuring cardiac output (CO), is based on modified pulse wave transit time, which in turn is determined by pulse oximetry and electrocardiography. However, its trending ability has never been evaluated in patients undergoing non-cardiac surgery. Therefore, this study examined esCCO’s ability to detect the exact changes in CO, compared with currently available arterial waveform analysis methods, in patients undergoing kidney transplantation. CO was measured using an esCCO system and arterial pressure-based CO (APCO), and compared with a corresponding intermittent bolus thermodilution CO (ICO) method. Percentage error and statistical methods, including concordance analysis and polar plot analysis, were used to analyze results from 15 adult patients. The difference in the CO values between esCCO and ICO was ?0.39 ± 1.15 L min^?1 (percentage error, 35.6 %). And corrected precision for repeated measures was 1.16 L min^?1 (percentage error for repeated measures, 36.0 %). A concordance analysis showed that the concordance rate was 93.1 %. The mean angular bias was ?1.8° and the radial limits of agreement were ±37.6°. The difference between the APCO and ICO CO values was 0.04 ± 1.37 L min^?1 (percentage error, 42.4 %). And corrected precision for repeated measures was 1.37 L min^?1 (percentage error for repeated measures, 42.5 %). The concordance rate was 89.7 %, with a mean angular bias of ?3.3° and radial limits of agreement of ±42.2°. This study demonstrated that the trending ability of the esCCO system is not clinically acceptable, as judged by polar plots analysis; however, its trending ability is clinically acceptable based on a concordance analysis, and is comparable with currently available arterial waveform analysis methods.     

Fetal and placental power Doppler imaging in normal and high-risk pregnancy.

OBJECTIVE: Computer analysis of organ power Doppler (PD) imaging has recently become available. The aim of the study was to evaluate gestational trends in placenta-, fetal lung-, liver- and kidney-blood flow in normal pregnancies and relate it to signals in high-risk pregnancies. METHODS: PD signals were recorded in normal singleton pregnancies between 26 and 42 weeks of gestation. Signals were also recorded in 63 high-risk pregnancies. Fixed preinstalled PD system installations for each organ were used during examinations. Images from PD scan were recorded on video tape and off-line analysed by computer. Mean flow signal intensity was calculated for each organ. Umbilical and uterine artery Doppler velocimetry were also recorded in high-risk pregnancies. RESULTS: PD signals from the four organs indicated increasing organ blood flow until approximately 34 weeks of gestation, from where the organ signals seemed to decrease. High-risk pregnancies seemed to have lower PD signal intensity, which was more pronounced in cases with signs of placental vascular resistance. CONCLUSION: The results suggest that a decrease in fetal organ blood flow might indicate a centralisation of fetal circulation in normal pregnancy at term, as a physiological response to a decrease in placental perfusion. In the high-risk pregnancies the placental and fetal organ blood flow seem to be even further reduced, suggesting a more intense centralisation of circulation.     

Effects of nifedipine on total cardiac output distribution in conscious rat

The purpose of this study was to determine the effects of the "calcium channel blocker" nifedipine (NF) on cardiocirculatory dynamics and the total distribution of cardiac output in the conscious rat preparation. Animals were instrumented for right atrial, left ventricular, arterial and venous pressure recordings and the radioactive microsphere technique was used to measure regional blood flow and cardiac output before (control) and during the i.v. infusion of either NF at three dosage levels [0.1, 0.6 and 1.5 mg (kg X hr)-1] or vehicle (ethyl alcohol and polyethylene glycol) at rates matching those of the NF protocol [0.015, 0.1 and 0.5 ml(min)-1]. The maximum rate of infusion represented approximately a 2% increase in blood volume per minute. Systemic vascular resistance, stroke volume, regional vascular resistances and the regional percentage of distribution of total cardiac output were calculated. In the experimental group (N = 7), NF at the highest dosage level lowered mean arterial pressure by 20% and resulted in a significantly lower systemic vascular resistance and left ventricular end diastolic pressure compared with the parallel vehicle control data. The parallel vehicle only slightly but significantly lowered heart rate. The most predominant circulatory effect of NF was a significant 64% reduction in coronary vascular resistance also reflected in a substantial increase in coronary blood flow. NF also dilated the hepatic arterial circulation. The net effects of NF on cardiac output distribution involved a significant fractional shift away from the cutaneous and splenic circulatory beds in favor of the coronary, hepatic arterial and gastrointestinal circulations.(ABSTRACT TRUNCATED AT 250 WORDS)     

Non-invasive determination of the distribution of cardiac output in man at rest and during exercise

Summary. The distribution of cardiac output, as expressed by the regional uptake of thallium-201 following injection, has been studied by whole body scanning with a gamma-camera in six healthy persons and eight patients with aortic valvular disease. In the patients, cardiac output at rest and during exercise was also measured by the dye dilution technique. Combining the values of cardiac output and regional thallium uptake enabled the calculation of organ blood flow. The myocardial uptake of thallium at rest was 3·2 ± 0·32% in the control group, which is significantly lower than 8·3 ± 1·52%, found in the patients. The corresponding values measured in the kidneys were 12·5 ±1·91% in the healthy subjects and 7·1 ± 0·50% in the patient material. Myocardial uptake increased and kidney uptake decreased in both groups following injection at peak exercise. Thallium uptake in the legs increased from about 13% at rest to about 39% at exercise in both groups. Distribution of thallium after injection at peak exercise did not, however, vary significantly between the two groups in the kidneys, abdominal area or the legs. Further methodological work is required before it can be ascertained to what extent the regional thallium uptake reflects the distribution of cardiac output. We nevertheless propose that the technique should be explored further, since it appears to be a simple non-invasive means of visualizing the distribution of the cardiac output in man under certain conditions.