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      Accuracy of Estimated Continuous Cardiac Output Monitoring (esCCO) Using Pulse Wave Transit Time (PWTT) Compared to Arterial Pressure-based CO (APCO) Measurement during Major Surgeries

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          A bstract

          Background

          Pulse wave transit time is a novel method of estimating continuous cardiac output (esCCO). Since there are not many studies evaluating esCCO, we compared it with arterial pressure based cardiac output (APCO) method (FloTrac).

          Methods

          In this prospective single-center observational study, we included 50 adult patients planned to undergo supramajor oncosurgeries, where major blood loss and extensive fluid shifts were expected. Cardiac output (CO) measurements were obtained by both methods at five distinct time points, giving us 250 paired readings of stroke volume index (SVI) and cardiac index (CI). We analyzed these readings using Pearson's correlation coefficient and Bland–Altman plots, along with other appropriate statistical tests.

          Results

          There was significant correlation between CI and SVI measured by the esCCO and APCO. Bland–Altman plot analysis for CI showed a bias of −0.44 L/minute/m 2, precision of 0.74, and the limits of agreement of −1.89 and +1.01, while the percentage error was 46.29%. Bland–Altman analysis for SVI showed a bias −5.07 mL with a precision of 9.36, and the limits of agreement to be −23.4 to +13.28. The percentage error was 46.56%.

          Conclusion

          This study demonstrated that esCCO tended to underestimate the CI to a large degree, particularly while estimating the cardiac output in the lower range. We found that the limits of agreement between two methods were wide, which are not likely to be clinically acceptable. Further studies with larger number of data points, obtained in a similar subset of patients, for cardiac output measurement in the perioperative period will certainly help determine if pulse wave transit time (PWTT) is here to stay ( CTRI No.: CTRI/2019/08/020543).

          How to cite this article

          Joshi M, Rathod R, Bhosale SJ, Kulkarni AP. Accuracy of Estimated Continuous Cardiac Output Monitoring (esCCO) Using Pulse Wave Transit Time (PWTT) Compared to Arterial Pressure-based CO (APCO) Measurement during Major Surgeries. Indian J Crit Care Med 2022;26(4):496–500.

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          A meta-analysis of studies using bias and precision statistics to compare cardiac output measurement techniques.

          L Critchley, J A Critchley (1999)
          Bias and precision statistics have succeeded regression analysis when measurement techniques are compared. However, when applied to cardiac output measurements, inconsistencies occur in reporting the results of this form of analysis. A MEDLINE search was performed, dating from 1986. Studies comparing techniques of cardiac output measurement using bias and precision statistics were surveyed. An error-gram was constructed from the percentage errors in the test and reference methods and was used to determine acceptable limits of agreement between methods. Twenty-five articles were found. Presentation of statistical data varied greatly. Four different statistical parameters were used to describe the agreement between measurements. The overall limits of agreement in studies evaluating bioimpedance (n = 23) was +/-37% (15-82%) and in those evaluating Doppler ultrasound (n = 11) +/-65% (25-225%). Objective criteria used to assess outcome were given in only 44% of the articles. These were (i) limits of agreement approaching +/-15-20%, (ii) limits of agreement of less than 1 L/min, and (iii) more than 75% of bias measurements within +/-20% of the mean. Graphically, we showed that limits of agreement of up to +/-30% were acceptable. When using bias and precision statistics, cardiac output, bias, limits of agreement, and percentage error should be presented. Using current reference methods, acceptance of a new technique should rely on limits of agreement of up to +/-30%.
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            Bench-to-bedside review: The importance of the precision of the reference technique in method comparison studies – with specific reference to the measurement of cardiac output

            Maurizio Cecconi, Andrew Rhodes, Jan D Poloniecki … (2009)
            Bland-Altman analysis is used for assessing agreement between two measurements of the same clinical variable. In the field of cardiac output monitoring, its results, in terms of bias and limits of agreement, are often difficult to interpret, leading clinicians to use a cutoff of 30% in the percentage error in order to decide whether a new technique may be considered a good alternative. This percentage error of ± 30% arises from the assumption that the commonly used reference technique, intermittent thermodilution, has a precision of ± 20% or less. The combination of two precisions of ± 20% equates to a total error of ± 28.3%, which is commonly rounded up to ± 30%. Thus, finding a percentage error of less than ± 30% should equate to the new tested technique having an error similar to the reference, which therefore should be acceptable. In a worked example in this paper, we discuss the limitations of this approach, in particular in regard to the situation in which the reference technique may be either more or less precise than would normally be expected. This can lead to inappropriate conclusions being drawn from data acquired in validation studies of new monitoring technologies. We conclude that it is not acceptable to present comparison studies quoting percentage error as an acceptability criteria without reporting the precision of the reference technique.
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              Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study

              Jan Benes, Ivan Chytra, Pavel Altmann … (2010)
              Introduction Stroke volume variation (SVV) is a good and easily obtainable predictor of fluid responsiveness, which can be used to guide fluid therapy in mechanically ventilated patients. During major abdominal surgery, inappropriate fluid management may result in occult organ hypoperfusion or fluid overload in patients with compromised cardiovascular reserves and thus increase postoperative morbidity. The aim of our study was to evaluate the influence of SVV guided fluid optimization on organ functions and postoperative morbidity in high risk patients undergoing major abdominal surgery. Methods Patients undergoing elective intraabdominal surgery were randomly assigned to a Control group (n = 60) with routine intraoperative care and a Vigileo group (n = 60), where fluid management was guided by SVV (Vigileo/FloTrac system). The aim was to maintain the SVV below 10% using colloid boluses of 3 ml/kg. The laboratory parameters of organ hypoperfusion in perioperative period, the number of infectious and organ complications on day 30 after the operation, and the hospital and ICU length of stay and mortality were evaluated. The local ethics committee approved the study. Results The patients in the Vigileo group received more colloid (1425 ml [1000-1500] vs. 1000 ml [540-1250]; P = 0.0028) intraoperatively and a lower number of hypotensive events were observed (2[1-2] Vigileo vs. 3.5[2-6] in Control; P = 0.0001). Lactate levels at the end of surgery were lower in Vigileo (1.78 ± 0.83 mmol/l vs. 2.25 ± 1.12 mmol/l; P = 0.0252). Fewer Vigileo patients developed complications (18 (30%) vs. 35 (58.3%) patients; P = 0.0033) and the overall number of complications was also reduced (34 vs. 77 complications in Vigileo and Control respectively; P = 0.0066). A difference in hospital length of stay was found only in per protocol analysis of patients receiving optimization (9 [8-12] vs. 10 [8-19] days; P = 0.0421). No difference in mortality (1 (1.7%) vs. 2 (3.3%); P = 1.0) and ICU length of stay (3 [2-5] vs. 3 [0.5-5]; P = 0.789) was found. Conclusions In this study, fluid optimization guided by SVV during major abdominal surgery is associated with better intraoperative hemodynamic stability, decrease in serum lactate at the end of surgery and lower incidence of postoperative organ complications. Trial registration Current Controlled Trials ISRCTN95085011.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Indian J Crit Care Med
                Journal ID (iso-abbrev): Indian J Crit Care Med
                Journal ID (publisher-id): IJCCM
                Title: Indian Journal of Critical Care Medicine : Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine
                Publisher: Jaypee Brothers Medical Publishers
                ISSN (Print): 0972-5229
                ISSN (Electronic): 1998-359X
                Publication date (Print): Summer 2022
                Volume: 26
                Issue: 4
                Pages: 496-500
                Affiliations
                [1,2 ]Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India
                [3 ]Division of Critical Care Medicine, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
                [4 ]Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
                Author notes
                Atul P Kulkarni, Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India, Phone: +91 9869077526, e-mail: kaivalyaak@ 123456yahoo.co.in
                Author information
                https://orcid.org/0000-0001-5051-9474
                https://orcid.org/0000-0003-1403-3658
                https://orcid.org/0000-0002-0290-0526
                https://orcid.org/0000-0002-5172-7619
                Article
                DOI: 10.5005/jp-journals-10071-24158
                PMC ID: 9067478
                SO-VID: 127002c3-b5ba-4c86-96ee-6cf6d1ac4775
                Copyright © Copyright © 2022; Jaypee Brothers Medical Publishers (P) Ltd.
                License:

                © The Author(s). 2022 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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                Subject: Original Research

                ScienceOpen disciplines: Emergency medicine & Trauma
                Keywords: arterial pressure-based cardiac output,bias,estimated continuous cardiac output,limits of agreement,percentage error,precision,pulse wave transit time
                Data availability:
                ScienceOpen disciplines: Emergency medicine & Trauma
                Keywords: arterial pressure-based cardiac output, bias, estimated continuous cardiac output, limits of agreement, percentage error, precision, pulse wave transit time

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