How to optimize cardiac output
by using USCOM
Kawewan Limprayoon MD
Division of Pediatric Critical Care
Department of Pediatrics
Faculty of Medicine, Siriraj Hospital
Cardiac output measurement
Invasive
– Thermodilution technique: Swan-Gantz
Less-invasive
– Modified themodilution± pulse contour
analysis: PiCCO, LidCCO
– Pulse contour analysis :Flo-trac
Noninvasive
– Ultrasound: Echocardiogram, USCOM,
Esophageal Doppler
– Phase shift of ECG or bioimpedance:
NICOM, ICON
Doppler measures blood flow
Suprasternal CW Doppler
(left heart output)
Parasternal CW Doppler
(right heart output)
Non-invasive cardiac output
monitoring : USCOM
Copyright of Siriraj
Hospital
CW Doppler Ultrasound
Quantitative
Safe
Sensitive
Fast
Accurate
Reproducible
Economical
Accurately measures blood flow
Doppler for measuring blood flows has been the standard for 50 years
Measuring Blood Flow Velocity
time
velocity
diastole
systole
• Frequency shift indicates flow direction and
velocity (v= f λ).
Calculating Flow Volume
Stroke Volume = Stroke Distance x Flow Area
x
vti (stroke OTD
distance)
(directly measured by
USCOM)
Cardiac Output = Stroke Volume x HR
Outflow Tract Area (OTD, or CSA)
OT Diameter determined by Uscom Algorithm
• Linear relationship with Height*
• Neonates (<50cm/20ins) Weight
Height → Area
* Nidorf et al New perspectives in the assessment of cardiac chambers
dimensions during development and adulthood. JACC Vol 19, No 5.
April 1992:983-8
Also note, the CSA is typically constant for the period of a typical patient
care (e.g. few days / weeks), such as in ICU, ED, OR…
D
C
A B C D
Variables by USCOM
velocity time integral (Vti)
stroke volume (SV)
stroke volume index (SVI)
cardiac output (CO)
cardiac output index (CI)
systemic vascular resistance (SVR)
systemic vascular resistance index (SVRI)
Variables by USCOM (cont.)
flow time (FT)
corrected flow time(FTc)
peak velocity (Vpk)
minute distance (MD)
oxygen delivery(DO2)
Inotropy
Potential Energy
PE= ΔP x ΔV.
ΔP= MAP-CVP, ΔV = SV
Kinetic Energy
KE = ½mV2
Inotropy
Applying this to the heart, where the mass
of blood is SV x Density, we get
Inotropy (Watts) = P.E./Flow Time +
K.E./Flow Time
= BPm x SV x 10-3 + D x SV x 10-6 x Vm2
7.5 x FT 2 x FT
(The Smith-Madigan formula)
Where BPm = (mean arterial pressure – central venous pressure) in
mmHg, SV = stroke volume in ml, D = density, Vm = mean velocity,
FT = systolic flow time. The factors 7.5, 10-3 and 10-6 are required
to convert mmHg and ml to kPa and m3 to conform to SI values.
The unit of inotropy is therefore the Watt, the SI unit of power.
Normal INO (all age) = 1.35-2.24
British Journal of Anaesthesia 111 (4): 580–8 (2013)
Normal value
Normal value
www.app.uscom.com.au
How to interpret
Hemodynamic parameter Variables from USCOM
Preload SV, FTc (short), SVV(optional)
After load SVR, MBP
Inotropy Vpk, SV, FTc(long), INO (SMII)
Cardiac output CO, CI, SV, HR
Oxygen delivery CO, SpO2, DO2
How to optimum preload
Fluid -- preload
• SV
• FTc (short)
• SVV
(optional)
only intubated &
sedated
Inotropy
• Vpk
• SV
• FTc(long)
• INO (SMII)
Vasopressor
• ↓SVR &
↓SVRI
• MBP
How to optimum inotropy and SVR
CASE SAMPLE
Case 1
A 5 8/12 year old Thai boy
Presented with vomiting and diarrhea 10+ times/day
for 2 days
Last voiding about 3 h ago
PE
– V/S: Afebrile, P111/min, BP 102/66 mmHg,
MAP 98 mmHg
– GA: Dry lips, cold extremities, capillary refill < 2 secs
Imp: Acute gastroenteritis with moderate dehydration
Fast HR, SVRI ↑, short FTc, CI-normal,
USCOM parameter Prior to fluid Post fluid bolus
bolus
SV (1.25-2.2) 1.54 ml/kg 1.75 ml/kg
Vpk (1.1-1.6) 1.3 m/s 1.5 m/s
HR ↓, CI ↑, FTc ↑, SVRI ↓
FTc (325-400) 311 ms 317 ms
SVR (1200-1800) 2364 d.s./cm-5 1887 d.s./cm-5
SVRI (1000-2000) 1697 d.s./cm-5 1354 d.s./cm-5
/m2 /m2
CO (2.8-5.0) 3.0 l/min 3.2 l/min
CI (3.5-5.0) 3.7 l/min/m2 4.4 l/min/m2
Case sample 2
A 13-year-old boy presented with high
graded fever with alteration of
consciousness
Dx: Septic shock suspected meningitis
Clinical signs:
– Stuporous, intubated
– wide pulse pressure,
– capillary refill 4 secs
www.app.uscom.com.au
Short FTc, Low SVI, normal CI
SVV in intubated > 12-15%
Stroke volume variation (SVV)
Short FTc ≡ Fluid depletion
Fluid responsiveness
– Intubated/ventilated
– SVV ≥ 12-15%
Fluid bolus X 2
Repeat USCOM
Slightly low SVRI, High CI, High INO
Start small dose vasopressor
– Norepinephrine 0.05-0.1 mcg/kg/min then
titration
Repeat USCOM
Repeat study
FTc ↑, SV ↑, CI →, HR ↓
Case sample 3
A 9-year-old boy admitted
• Dengue Shock Syndrome
• Shock on day 4
• Multiple fluid bolus > 40ml/kg
• Hct 40%, poor urine output
• No bleeding observed
• Signs of massive positive fluid balance
CI 2.9 (l/min/m )
2
FTc 416 (ms)
Vpk 1 (m/s)
SVI 28 (ml/m2)
SVRI 2450 (ds-cm5/m2)
INO 1.1 (W/m ) 2
Low CI, slow Vpk, long FTc, High SVRI
Low SMII (INO)
Echocardiogram –pre
Echocardiogram -pre
Start dobutamine 5 titrate to 10
mcg/kg/min
Repeat USCOM
INO increased from 1.1 to 1.5
Dobutamine 10 mcg/kg/min
Echocardiogram -post
Echocardiogram -post
Before
After
Frank Starling curve
3
Frank Starling curve
Inotropic agent and fluid filling
Summary
USCOM can help to make decision how to
adjust: preload, afterload and contractility
USCOM can monitor to keep CO as high as
the goal: CI = 3.3 - 6.0 L/ min./m2
Clinical assessment and specific organ
support are also important.
