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10. Cardiac Output Handout

# 10. Cardiac Output Handout

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01/25/2014

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Objectives have been taken from The American Physiological Society Medical Curriculum Objectives Projecthttp//:www.the-aps.org/education/MedPhysObj/medcor.htmIn some case, the order of the topics and the objectives have been modify

01. Understand the principles underlying cardiac output measurements made using a) TheFick’s method and b) indicator dilution methods using a Swan-Ganz catheter Calculate CO by using Fick’s method02. Understand the concept of “mean systemic pressure”, its normal value, and how variousfactors can alter its value.Construct a vascular function curve. Identify on the curve the normal central venouspressure and mean circulatory pressure. Predict how the curve is altered by a) changesin resistance to venous return and b) changes in blood volume or vascular compartmentsize.Define venous return. Understand the concept of “resistance to venous return” and knowthat factors determine its value theoretically, what factors are most important in practice,and how various interventions would change the resistance to venous return.03. Know how cardiac function (output) curves are generated and how actors which causehyper effective or hypo effective changes (contractility) in the heart can alter the shape of cardiac function curve.04. Use a combined cardiac output / venous return graph to predict how interventions such ashemorrhage, increase in preload, acute and chronic heart failure, autonomic stimulation or ihibition, and exercise will affect cardiac output and right atrial pressure. Predict howphysiological compensatory changes would alter acute changes.

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I. Cardiac output (CO)
Is the volume of blood pumped into the aorta each minute by the left ventricle.For a 70kg man normal values are HR=70/min and SV=70ml, giving a cardiac output of about5litre/min. . CO can be increased to 20 l/min depending on the body’s demand for O
2
.A. The cardiac index is the cardiac output per square meter of body surface area, normalvalues range from 2.5-4.0 litre/min/m
2
.Body surface area normalizes for different shapes, heights and weights. Tables are availablethat estimate body surface area from weight and height. An average surface area is 1.73 squaremeters (m
2
). Therefore a person with an average cardiac output of 5 l/min would have a CardiacIndex of: 5 l/min ÷ 1.73 m
2
= 2.89 l/min/m
2
.
II. Methods of measuring the Cardiac Output
1. Fick’s principle2. Dye dilution3. Thermodilution4. Doppler techniques
1. The Fick’s Method
Flow can be measured by adding (or removing) a substance to the liquid as it passes throughthe tube.Blood is pumped from the venous system through the lungs to the arterial system. In the lungs,O2 is taken up into the blood stream. The total uptake of O2 by the lung per minute has to beequal to the product of the pulmonary blood flow per min. and the difference in O2 concentrationin pulmonary venous and pulmonary arterial blood.The O2 uptake can be measured by spirometry. Arterial and venous O2 concentrations can bemeasured by withdrawing and analyzing blood from both vessels.Therefore:Cardiac Output = O2 consumption/min ÷ (a
O2
- v
O2
)
2. Indicator-dilution method
A known quantity of a dye is injected into the right atrium via catheter. A measured quantity of an indicator (dye) is injected into a large central vein or into the right side of the heart through acatheter. Arterial blood is continuously drown and passes through a photosensitive device thatmeasures the dye concentration. The resulting curve measures dye concentration as a functionof time.

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The area under the dye-dilution curve can be calculated and approximates the averageconcentration of dye over time. Knowing the quantity of dye injected, the cardiac output can bedetermined by:Cardiac output = Quantity of dye injected ÷ area under the curve
3. Thermo-dilution technique
The procedure is the same, but blood temperature is measured instead of dye color. A colddextrose solution
(2.5-10 ml)
is injected through one part (proximal opening) of a doublelumen catheter which is positioned near right atrium and a small thermistor attached to catheter tip lies in pulmonary artery and measures the profile of temperature change with time.The degree of change in the temperature is inversely proportional to the cardiac output. Then:Increased blood flow (and CO) = Minimal temperature changeDecreased blood flow (and CO) = Pronounced temperature changePlotting this temperature change against the time it took for the cooler fluid to reach thethermistor gives us a thermo dilution curve, a computer built into the monitor calculates andintegrates the area under the thermo dilution curve, and gives a digital readout of the cardiacoutput in L/min
4. Doppler techniques
Is a non-invasive technique. The machines transmit an ultrasonic vibration into the body andrecord the change in the frequency of the signal that is reflected off the red blood cells, soDoppler techniques measure velocity, not flow. The flow could be obtained by integrating thesignal over the cross-sectional area of the vessel.The velocity of blood in the ascending aorta may be measured using the Doppler effect. Thelength of a column of blood passing through the aorta in unit time is estimated and thenmultiplied by the cross-sectional area of the aorta to give stroke volume.
III. Central venous pressure (CVP) monitoring
The central venous pressure (CVP) measures the filling pressure of the right ventricular (RV); itgives an estimate of the intravascular volume status and is an interplay of the (1) circulatingblood volume (2) venous tone and (3) right ventricular function.