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Clinical validation of the non-invasive cardiac output monitor USCOM-1A in

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Article  in  European Journal of Anaesthesiology · November 2008

DOI: 10.1017/S0265021508004882 · Source: PubMed

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Validation of the USCOM-1A cardiac output

monitor in hemodynamic unstable intensive
care patients

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Lenneke Van Lelyveld-Haas David H T Tjan

Diakonessenhuis Utrecht Gelderse Vallei Hospital
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Arthur R H Van Zanten

Gelderse Vallei Hospital
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Retrieved on: 10 August 2015
 ABSTRACT

Validation of the USCOM-1A cardiac output monitor

in hemodynamic unstable intensive care patients

L.E.M. Haas, D.H.T. Tjan, J. van Wees, A.R.H. van Zanten,
Department of Intensive Care, Gelderse Vallei Hospital, Ede, The Netherlands

Introduction
Since the introduction of the pulmonary artery catheter (PAC) in the 1970s, thermodilution CO
measurement is widely used and considered the gold standard. The use of the PAC has its
inherent risks and has never convincingly been shown to improve the outcome of the critically
ill patient [1]. Therefore, less invasive methods for CO monitoring have been developed.
The ultrasonic cardiac output monitor (USCOM Pty Ltd, Coffs Harbour, NSW, Australia) was
developed in 2001 and has been introduced for clinical use in the Netherlands in 2005 (figure
1). It measures CO non-invasively by continuous wave Doppler ultrasound with a transducer
(2.2 or 3.3 MHz) placed supra- or parasternally (figure 2&3). It has been demonstrated that the
USCOM-1A is accurate in cardiac surgery patients [2].
The aim of this study is to evaluate the accuracy of the USCOM-1A (COUSC) in ICU patients
compared to the continuous thermodilution technique (using a PAC; COPAC).

Methods
Twenty-five adult ventilated ICU patients on vasoactive drugs, that required a PAC (CCO
PAC, 7.5 F, Edwards Lifesciences, LLC, Irvine, CA, USA) to the discretion of the attending
physician, were included. The protocol was approved by the hospital institutional review board.
After a hands-on training five intensive care physicians and five intensive care nurses
performed several series of 5 COUSC measurements on consecutive days. Means of these 5
measurements were paired with actual COPAC data. These COPAC data were blinded for the
operator and filed by an independent observer. As the data followed a lognormal distribution, a
logarithmic transformation was used. The systematic error and the various random error
components were estimated using a linear random effects model. Finally, the results were
retransformed to percentages.

Results
Twenty-five sedated and mechanically ventilated patients were included and studied between
September and December 2005. Demographics, co-morbidities and outcomes are shown in
tables 1, 2 and 3, respectively.
We obtained 1315 USCOM measurements and based on means, 263 paired measurements were

Presented: February 2006, Annual Intensive Care Society Congress, the Netherlands 1
analysed for bias, precision and correlation. We measured CO in a range of 1.1-11.0 l/min
(mean CO 6.0 ± 1.9, median 5.8 l/min). The correlation over the CO range between the two
techniques is shown in figure 4. Correlation of COPAC vs. COUSC is good (correlation
coefficient r = 0,8024 and r2 = 0,6438).
The accuracy is depicted in figure 5 using Bland-Altman analysis. Individual comparisons are
shown in figure 6. The overall coefficient of variation is 17%. This means that 95% of errors are
less than 34%. Random effect model error comprises a inter-operator variability of 7.7%, a
inter-patient variability of 8.8% and residual variability of 14%. Further correction for the
systematic error was performed, but did not change results. The error is greatest at high flows,
where USCOM underestimated the CO (by up to 30%), but is acceptable in the clinically
important range. Temperature and gender did not influence the correlation. We found a
significant relation of the CO with the body mass index (BMI) (p=0.03). A single point increase
of BMI corresponds with 1% increase of COUSC. Correction for BMI only marginally reduces
the total error from 17% to 16%. In all patients similar circulatory profiles were found with
PAC and USCOM

Patients (Pts) and Methods:

We studied 7 pts with CRT (mean age 70±8) with the mean EF (24±9%) at recruitment. A VO
was first performed by an echo physician using the Ritter’s formula. After determining the
optimal AV interval, the highest Doppler trans-aortic flow determined CO and the highest MD
from the aortic Doppler at 11 VV intervals (RV80, RV60, RV40, RV20, RV12, 0 LV12, LV20,
LV40, LV60 and LV80) in random sequence by the same echo physician and a nurse who
were blind to the sequence.

Results:
The Doppler and USCOM determined VVI were all within 20ms. 5 pts (71%) had 100%
concordant in VV interval, the remaining 2 pts had VVI difference within 20ms. The USCOM
determined VVI were well correlated with the Doppler determined VVI. (r2 0.92, p<0.01).
However, the mean durations for USCOM were significantly shorter than trans-aortic Doppler
determined CO. (47±14 min vs 89±8 min p<0.001)

Conclusion
• Measuring CO non-invasively with the USCOM method is simple, rapid, safe, well-tolerated
and cost-effective.
• USCOM is a reliable method of measuring CO in critically ill patients
• Systematic and variable errors in measurements were detected.
• The non-invasive USCOM provided adequate data to distinguish different shock types in ICU
patients.

Presented: February 2006, Annual Intensive Care Society Congress, the Netherlands 2
Figure 1: USCOM monitor

Figure 2: Anatomic position for USCOM CO measurements

Presented: February 2006, Annual Intensive Care Society Congress, the Netherlands 3
Figure 3: Flow profile

Presented: February 2006, Annual Intensive Care Society Congress, the Netherlands 4
Table 2: Co-morbidities (N = 25)

Table 1: Demographics (N = 25)

Table 3: Outcome (N = 25)

Presented: February 2006, Annual Intensive Care Society Congress, the Netherlands 5
Figure 4: Correlation between the COUSC monitor and COPAC

Figure 5: Bland-Altman plot of errors of COUSC monitor vs. COPAC

Presented: February 2006, Annual Intensive Care Society Congress, the Netherlands 6
Figure 6: Cardiac Output in individual patients comparing PAC vs. USCOM

Figure 7: Diagnosis of shock states comparing clinical suspicion with PAC vs. USCOM

Presented: February 2006, Annual Intensive Care Society Congress, the Netherlands 7
 References
1 Harvey S, Harrison DA, Singer M, Ashcroft J, Jones CM, Elbourne D, Brampton W, Williams D,
Young D, Rowan K; PAC-Man study collaboration. Assessment of the clinical effectiveness of
pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised
controlled trial. Lancet 2005; 366:472-77.
2 Tan HL, Pinder M, Parsons R, Roberts B, Heerden PV. Clinical evaluation of USCOM ultrasonic
cardiac output monitor in cardiac surgical patients in intensive care unit. Br J Anaesth 2005; 94:
287-91.

Presented: February 2006, Annual Intensive Care Society Congress, the Netherlands 8

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