Factors on CARDIAC OUTPUT
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CARDIAC OUTPUT (CO)
• A measure of cardiac performance
• The volume of blood pumped out of the
ventricle per unit time indicates the blood
(oxygen) is available to flow into tissues.
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CARDIAC OUTPUT (CO)
Cardiac Output
• Defn: vol of blood pumped by the heart per min
• CO = stroke volume (SV) x heart rate (HR)
• Normally ~ 5 lit/min
• Cardiac index – corrected for body surface area
• Affected by :
– Met. Rate – pregnancy, hyperthyroid, septic
– Preload / contractility / afterload
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CARDIAC OUTPUT
Cardiac Output: Example
• CO (ml/min) = HR (75 beats/min) x SV (70 ml/beat)
• CO = 5250 ml/min (5.25 L/min)
• SV = EDV -ESV
• SV = end diastolic volume (EDV also called preload)
minus end systolic volume (ESV)
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Left Ventricular Volumes - Definitions
End Diastolic Volume (EDV)
Volume at the end of diastole
(end of ventricular filling). In a
healthy heart this is directly
proportional to venous return
NOTE: Resting Ejection
End Systolic Volume (ESV) Fraction (EF) is the best
Volume at the end of systole indicator of both heart
(end of ventricular contraction)
performance and heart
disease prognosis
Stroke Volume (SV) = EDV - ESV
Ejection Fraction (EF) = SV
EDV
Left ventricular norm for EF at Rest: approximately 62%
Left Ventricular norms for Max Exercise:
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Left Ventricular Volumes - Definitions
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Methods of measurement of CO
• Two methods are there for human
1. Direct Fick Method
2. Indicator dilution method
1. Fick principle
• Amount of the substance taken up by an organ per unit
of time is equal to arterial level of substance minus
venous level X blood flow.
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Cardiac Output Measurement
• Methods:
– Fick method
– Dilution techniques – dye / thermal / lithium
– Pulse contour analysis- LiDCO & PiCCO
(PiCCO is a device made by Phillips that enables continuous hemodynamic monitoring using a
femoral or axillary thermodilution a-line (proprietary) and a central venous line
Made by the LiDCO group in London)
– Oesophageal doppler (Trans oesophageal Echograph)
– Transthoracic impedance plethysmography
– Inert gas through flow
– Non-invasive cardiac output measurement
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Cardiac Output Measurement
Transpulmonary thermodilution measurement simply requires the
central venous injection of a cold (< 8°C) or room-tempered (< 24°C)
saline bolus…
CV Bolus
Injection
Lungs
Right Heart Left Heart
PiCCO Catheter
e.g. in femoral artery
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Cardiac Output Measurement
Esophagus
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Pressure in the CVS
Pull out, Betty! Pull out! . . . You’ve hit an artery!
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Pressure in the CVS
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Cardiac Output Measurement
• Clinical indicators of CO imprecise
• Affected by anaesthetic agents used in everyday
practice
• Provides estimate of:
– whole body perfusion
– oxygen delivery
– left ventricular function
• Persistently low CO assoc. with poor outcome
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Cardiac Output Measurement
• Fick Principle: measure volume displacement
– 1st proposed 1870
– “the total uptake or release of a substance by an organ is the product
of the blood flow through that organ and the arteriovenous
concentration difference of the substance”
– CO = O2 consumption (ml/min)
artial – mixed venous O2 conc. (ml/l)
250ml/min
CO = 190ml/L -140ml/l = 250/50 = 5 lit/min
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Measurement of cardiac output
• Fick Method adding 10 beads per minute
adding 10 beads per minute
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Measurement of cardiac output
• Fick Method
adding 10 beads per minute
concentration is 2 beads per litre
Rate added 10 beads/min
Flow = = = 5 litres/min
Concentration 2 beads/litre
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Measurement of cardiac output
• Fick Method
rate of O2 consumption
O2 concentration of O2 concentration of
blood entering lung blood leaving lung
lung
rate of O2 consumption 250 ml/min
Flow = = = 5 litres/min
[O2] leaving – [O2] entering 190 – 140 ml/litre
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Cardiac Output Measurement
•Indicator dilution techniques
• Dye dilution
– Inert dye – indocyanin green
– Injected into pulmonary artery and arterial conc.
measured using a calibrated cuvette densitometer
– Plot indicator dilution curve (see diagram)
– CO derived from area under curve
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Cardiac Output Measurement
Indicator Dilution Curve
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Cardiac Output Measurement
• Swan Ganz Catheter
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Cardiac Output Measurement
Measurement of blood flow
and cardiac output
• Electromagnetic flow meters
– Accurate, but invasive
• Ultrasonic flow meters
• Venous occlusion plethysmography
• Fick method
• Indicator-dilution method
• Doppler echocardiography
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Measurement of cardiac output
Indicator dilution method
inject bolus Sample dye
of dye concentration
Concentration (g/L)
0 Time (min) 22 https://www.nursingsathi.com0.5
Measurement of cardiac output
Indicator dilution method
inject bolus Sample dye
of dye concentration
Concentration (g/L)
0 Time (min) 23 https://www.nursingsathi.com0.5
Measurement of cardiac output
Concentration (g/L)
time of passage (t) = 0.5 min
~
average conc (X) = 2 mg/L
0 Time (min) 0.5
• Amount of dye added = 5 mg
• Average dye concentration = 2 mg/L
• Therefore the volume that diluted the dye = 5mg = 2.5 L
2 mg/L
• Time it took to go past = 0.5 min
• ie flow rate = 2.5 L = 5 L/min
0.5 min
• General equation:
mass of dye (Q g)
Flow rate = ~
average dye conc (X g/L) x time of passage (t min)
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Measurement of cardiac output
• Practical considerations
Concentration (g/L)
0 Time (min) 0.5
Log concentration (g/L)
0 Time (min) 25 https://www.nursingsathi.com0.5
Measurement of cardiac output
• Practical considerations
– dye recirculates in the CVS
– estimate of first transit time is facilitated by
plotting log concentration
– Dye must be non-toxic and not immediately
absorbed eg indocyanine green
– Injected into pulmonary artery
– Measured in brachial artery
– Like the Fick method, is invasive, & discontinuous
• Same principle
– Measure thermodilution of cold saline
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CO in various conditions
• SV is about 70ml in a resting man in supine
position.(70ml of R and L ventricles)
• CO of resting man in supine position is ~5L/min
(70ml X 72 beats/min = 5040ml/min)
• Correlation between CO and body surface area,
CO/min per M2 of body surface is called Cardiac
Index ~ 3.2L
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CO in various conditions
Condition or Factor
No change Sleep
Moderate changes in environmental temperature
Increase Anxiety and excitement (50-100%)
Eating (30%)
Exercise (up to 700%)
High environmental temperature
Pregnancy, Epinephrine
Decrease Sitting or standing from lying position (20-30%)
Rapid arrhythmias
Heart disease
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