DESCRIPTION: Because cardiac output is related to the quantity of blood delivered to various parts of the body, it is an important indicator of how efficiently the heart can meet the body's demands fick mein s perfusion. For instance, physical exercise requires a higher than resting-level fick mein s oxygen to support increased muscle activity, where, in the case of heart failureactual CO may be insufficient to support even simple activities of daily living; nor can it increase sufficiently to meet the higher metabolic demands stemming from even moderate exercise. The factors affecting stroke volume and heart rate also affect cardiac output.Jovan Lazic: Many dickheads below hate French girls mostly of the fact that they are feminists.
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Cardiac output is a term used in cardiac physiology that describes the volume of blood being Fick principle; Pulmonary artery thermodilution (trans-right- heart thermodilution) Bian Y, Liu J, Phukan S, Rosman D, Kaklamani V, Baddi L, Siddiqui FS, Frankel W, Prior TW, Schuller DE, Agrawal A, Lang J, Dolan ME. To leßfie do he fyne beqwemicheit erfachj hielt hei vnd treffen vnd flogen fick dem anfiande fchrift de keifer einen Nikequch vth the frankfhort am Mein e jm jare . -Laß fie [peux“., _ r'wnndeft. und'fie lachen- Som mein Heil. bei-'till Wa-s die See(nndLeben'ifinicbt mciik-»n fick bält- muß im Höfe 'allein' iii- dei* mii-'ä.
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Because cardiac output is related to the quantity of blood delivered to various parts of the body, it is an important indicator of how efficiently the heart can meet the body's demands for perfusion.
For instance, physical exercise requires a higher than resting-level of oxygen to support increased muscle activity, where, in the case of heart failureactual CO may be insufficient to support even simple activities of daily living; nor can it increase sufficiently to meet the higher metabolic demands stemming from even moderate exercise.
The factors affecting stroke volume heart rate also affect cardiac output. The figure at the
fick mein s margin illustrates this dependency and lists some of these factors. A detailed hierarchical illustration is provided in a subsequent figure. There are many methods of measuring CO, both invasively and non-invasively; each has advantages and drawbacks as described below. The function of the heart is to drive blood through the circulatory system a cycle that delivers oxygen, nutrients and chemicals to the body's cells and removes cellular waste.
fick mein s out whatever blood comes back into it from the venous systemthe quantity of blood returning to the heart effectively determines the quantity of blood the heart pumps out — its cardiac output, Q.
Cardiac output is classically defined alongside stroke volume SV and the heart rate HR as:. In standardizing what CO values are considered to be within normal range independent of the size of the subject's body, the accepted convention is to further index equation 1 using Body surface area BSAgiving rise to the Cardiac index CI. This is detailed in equation 2 below. There are a number of clinical methods to measure cardiac output, ranging from direct intracardiac catheterization to non-invasive measurement of the arterial pulse.
Each method has advantages and drawbacks. Relative comparison is limited by the absence of a widely
fick mein s "gold standard" measurement. Cardiac output can also be affected fick mein s by the phase of respiration — intra-thoracic pressure changes influence diastolic filling and therefore cardiac output. Cardiac output should be measured at evenly fick mein s points over a single cycle or averaged over several cycles.
Invasive methods are well accepted, but there is increasing evidence that these methods are neither accurate nor effective in guiding fick mein s. Consequently, the focus on development of non-invasive methods is growing.
This method uses ultrasound and the Doppler effect to measure cardiac output. The blood velocity through the heart causes a Doppler shift in fick mein s frequency of the returning ultrasound waves.
This shift can then be used to calculate flow velocity and volume, and effectively cardiac output, using the following equations:. Being non-invasive, accurate and inexpensive, Doppler ultrasound is a routine part of clinical ultrasound; it has high levels of reliability fick mein s reproducibility, and has been in clinical use since the s. Echocardiography is a non-invasive method of quantifying cardiac output using ultrasound.
Two-dimensional 2D ultrasound and Doppler measurements are used together to calculate cardiac output. The result is then multiplied by the heart rate HR to obtain cardiac output. Although used in clinical medicine, it has a wide test-retest variability. Fick mein s alternative that is not necessarily more reproducible is the measurement of the pulmonary valve to calculate right-sided CO. Although it is in wide general use, the technique is consuming and is limited by the reproducibility of its component elements.
It uses anthropometry to calculate aortic and pulmonary valve diameters and CSAs, allowing right-sided and left-sided Q measurements. In comparison to the echocardiographic method, USCOM significantly improves reproducibility and increases sensitivity of the detection of changes in flow.
Real-time, automatic tracing of the Doppler flow profile allows beat-to-beat right-sided and left-sided Q measurements,
fick mein s operation and reducing the time of acquisition compared to conventional echocardiography. USCOM has been validated from 0. USCOM the only method of cardiac output measurement to have achieved equivalent accuracy to the implantable flow probe.
Transoesophageal Doppler includes two main technologies; transoesophageal echocardiogram —which is primarily used for diagnostic purposes, and oesophageal Doppler monitoring—which is primarily used for the clinical monitoring of cardiac output. The latter uses continuous wave Doppler to measure blood velocity in the descending aorta. An ultrasound probe is inserted either orally or nasally into the oesophagus to mid-thoracic level, at which point the oesophagus lies alongside the descending thoracic aorta.
Because the transducer is close to the blood flow, the signal is clear. The probe may require re-focussing to ensure an optimal signal.
This method has good validation, is widely used for fluid management during surgery with evidence for improved patient outcome,
fick mein s        and has been recommended by the UK's National Institute for Health and Clinical Excellence NICE. This method generally requires patient sedation and is accepted for use in both adults and children. Pulse pressure PP methods measure the pressure in an artery over time to derive a waveform and use this information to calculate cardiac performance.
However, any measure from the artery fick mein s changes in pressure associated with changes in arterial function, for example compliance and impedance.
Physiological or therapeutic changes in vessel diameter are assumed to reflect changes in Q. PP methods measure the combined performance of the heart and the blood vessels, thus limiting their application for measurement of Q. This can be partially compensated for by intermittent calibration of the waveform to another Q measurement method then monitoring the PP waveform.
Ideally, the PP waveform should be calibrated on a beat-to-beat basis. There are invasive and non-invasive methods of measuring PP. The principle of the volume clamp method is to dynamically provide equal pressures, on either side of an artery wall. By clamping the artery to a certain volume, inside pressure—intra-arterial pressure—balances outside pressure—finger cuff pressure. The use of finger cuffs excludes the device from application in patients without vasoconstriction, such as in sepsis or in patients on vasopressors.
Inscientists at BMI-TNO, the research fick mein s of Netherlands Organisation for Applied Scientific Research at the University of Amsterdaminvented and patented a series of additional key elements that make the volume clamp work in clinical practice.
These methods fick mein s the use of modulated infrared light in the optical system the sensor, the lightweight, easy-to-wrap finger cuff with velcro fixation, a new pneumatic proportional control valve principle, and a set point strategy for the determining and tracking the correct volume at which to clamp the finger arteries—the Physiocal system.
An acronym for physiological calibration of the finger arteries, this Physiocal tracker was found to be accurate, robust and reliable. The Finapres methodology was developed to use this information calculate arterial pressure from finger cuff pressure data. A generalised algorithm to correct for the pressure level difference between the finger and brachial sites in patients was developed.
This correction worked under all of the circumstances it was tested in—even when it was not designed for it—because it applied general physiological
fick mein s. This innovative brachial pressure waveform reconstruction method was first implemented in the Finometer, the successor of Finapres that BMI-TNO introduced to the market in The availability of a continuous, high-fidelity, calibrated blood pressure waveform up the perspective of beat-to-beat computation of integrated haemodynamics, based
fick mein s two notions: At the proximal aortic site, the 3-element Windkessel model of this impedance can be modelled with sufficient accuracy in an individual patient with known age, gender, height and weight.
According to comparisons of non-invasive peripheral vascular monitors, modest clinical utility is restricted to patients with normal and invariant circulation.
Invasive PP monitoring involves inserting a manometer pressure sensor into an artery—usually the radial or femoral artery —and continuously measuring the PP waveform. This is generally done by connecting the catheter to a signal processing device with a display. The PP waveform can then be analysed to provide measurements of cardiovascular performance. Changes in vascular function, the position of the catheter tip or damping of the pressure waveform signal will affect the accuracy of the readings.
Invasive PP measurements can be calibrated
fick mein s uncalibrated. In both cases, an independent technique is required to provide calibration of continuous Q analysis because arterial PP analysis cannot account for unmeasured variables such as the changing compliance of the vascular bed. Recalibration is recommended after changes in patient position, therapy or condition. In PiCCO, transpulmonary thermodilution, which uses the Stewart-Hamilton principle but measures temperatures changes from central venous line to a central arterial line, i.
The Q value derived from cold-saline thermodilution is used to calibrate the arterial PP contour, which can then provide continuous Q monitoring. The PiCCO algorithm is dependent on blood pressure fick mein s morphology mathematical analysis of the PP waveformand it calculates continuous Q as described by Wesseling and colleagues.
Transpulmonary thermodilution allows for less invasive Q calibration but is less accurate than PA thermodilution and requires a central venous and arterial line with the accompanied infection risks. Lithium chloride dilution uses a peripheral vein and a peripheral arterial line. It estimates cardiac output Q using a standard arterial catheter with a manometer located in the femoral or radial artery. The device consists of a high-fidelity pressure transducer, which, when used with a monitor Vigileo or EV monitorderives left-sided cardiac output Q from a sample of arterial pulsations.
The device uses an algorithm based on the Frank—Starling law of the heartwhich states pulse pressure PP is proportional to stroke volume SV. The equation in simplified is: Khi is designed to reflect arterial resistance; compliance is a multivariate polynomial equation that continuously quantifies arterial compliance and vascular resistance.
Khi does this by analyzing the morphological changes of arterial pressure waveforms on a bit-by-bit basis, based on the principle that changes in compliance or resistance affect the shape fick mein s the arterial pressure waveform. By analyzing the shape of said waveforms, the effect of vascular tone is assessed, allowing the calculation of SV.
fick mein s derived using equation 1. Only perfused beats that generate an arterial waveform are counted for in HR. This system estimates Q using an existing arterial catheter with variable accuracy. These arterial monitors do not require intracardiac catheterisation from a pulmonary artery catheter. They require an arterial line and are therefore invasive. As with other arterial waveform systems, the short set-up and data fick mein s times are benefits of this technology.
Disadvantages include its inability to provide data regarding right-sided heart pressures or mixed venous oxygen saturation. It is used for managing fluid optimisation in high-risk surgical or critically ill patients.
A physiologic optimization program based on haemodynamic principles that incorporates the data pairs SV and SVV has been published. Arterial monitoring systems are unable to predict changes in vascular tone; they estimate changes in vascular compliance.
The measurement of pressure in the artery to calculate the flow in the heart is physiologically irrational and of questionable accuracy,  and of unproven benefit. Pressure Recording Analytical Method PRAMestimates Q from the analysis fick mein s the pressure wave profile obtained from an arterial catheter—radial or femoral access.
This PP waveform can then be used to determine Q. Unlike FloTrac, neither constant values of impedance from external calibration, nor form pre-estimated in vivo or in vitro data, are needed. PRAM has validated against the considered gold standard methods in stable condition  and in various haemodynamic states.
Generally monitored haemodynamic values, fluid responsiveness parameters and an exclusive reference are provided by PRAM: It is expressed by a pure number ranging from 1 best to -1 worst and it indicates the overall heart-vascular response coupling. The ratio between heart performance and consumed energy, represented as CCE "stress index", can be of fick mein s importance in understanding the patient's present and future courses. Impedance cardiography often abbreviated as ICG, or Thoracic Electrical Bioimpedance TEB measures changes in electrical impedance across the thoracic region over the cardiac cycle.
Lower impedance indicates greater intrathoracic fluid volume blood flow.
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fick mein soutputs from both sides of the heart work partly in parallel by the foramen ovale and ductus arteriosuswhich directly supply the systemic circulation. Current Opinion in Cardiology. Anaesthesia and Intensive Care.
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