Acta Cardiol 2014; 69(2): 167-173 doi: 10.2143/AC.69.2.

3017298 167

Non-invasive cardiac output assessment in critically ill

paediatric patients

Theeranan WONGSIRIMETHEEKUL, MD; Anant KHOSITSETH, MD; Rojjanee LERTBUNRIAN, MD

Dept. of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University Bangkok, Thailand.

Objective Recently, non-invasive methods for cardiac output (CO) assessment have been developed including the ultrasonic cardiac output
monitor (USCOM). This technique uses the same concept as Doppler echocardiography but differs in two aspects including continuous wave (CW) Doppler
and estimated outflow tract diameter (OTD) used in USCOM compared to pulsed wave Doppler and directed measurement of OTD used in echocardiog-
raphy. We sought to assess the agreement between CO assessment by USCOM and echocardiography in critically ill paediatric patients.
Methods Paired measurements of CO in critically ill paediatric patients were simultaneously and independently obtained by USCOM and echocar-
diography. Agreement between OTD, velocity time integral (VTI), CO, and cardiac index (CI) were assessed by percentage error and Bland-Altman analysis.
Results Thirty-four children (aged 7.86 ± 5.78 years, 44.1% male) had a mean OTD (1.47 ± 0.38, 1.41 ± 0.40), VTI (19.13 ± 6.06, 23.53 ± 7.31 cm),
CO (3.88 ± 2.19, 4.41 ± 2.83 l/min) and CI (4.23 ± 1.19, 4.77 ± 1.43 l/min/m2) by echocardiography and USCOM, respectively. Bias ± precision and percentage
of error of OTD, VTI, CO, and CI were -0.07 ± 0.20 cm, 27.80%; -4.40 ± 3.84 cm, 31.99%; –0.53 ± 1.23 l/min, 54.66%; and 0.54 ± 1.03 l/min/m2, 42.32%,
respectively. The bias ± precision and percentage error were more important in patients with septic shock (n = 16).
Conclusion USCOM was an unreliable tool for absolute value measurement of CO and CI due to the errors of VTI by CW Doppler.
Keywords Cardiac output – Doppler echocardiography – diagnostic technique – critically ill – paediatrics.

INTRODUCTION Although the invasive method using a pulmonary artery

Cardiac output monitoring in critically ill paediatric
patients is essential for the assessment of cardiac func-
tion. The primary goal is to maintain adequate tissue
perfusion. Currently, there are several methods for the
measurement of cardiac output including invasive, min-
imally invasive, and non-invasive technologies1.To
decide which cardiac output measurements should be
used depends on many factors including knowledge of
technical principles, ability of a convenient routine han-
dling, safety issue for the patients, and validated data2.
Address for correspondence:
Dr. Anant Khositseth ,
270 Rama VI Road, Ratchathewi,
Bangkok 10400, Thailand.
E-mail address: anant.kho@mahidol.ac.th
Received 18 December 2013; accepted for publication 15 January 2014.
catheter (PAC) with thermodilution remains the gold
standard of cardiac output measurement3, it is not rou-
tinely used in paediatric populations. Several studies in
adult patients showed controversies in safety3. Recently,
non-invasive methods of cardiac output assessment have
been developed including Doppler echocardiography4,5
and ultrasonic cardiac output monitor (USCOM, Uscom
Ltd., Sydney, Australia)6,7. However, echocardiography
has been widely used for cardiac output assessment.
It requires a skillful and experienced operator8. USCOM
utilizes transaortic or transpulmonic continuous wave
Doppler ultrasound flow tracing to calculate cardiac
output. This device is designed for rapid, non-invasive
cardiac output assessment. Ideally, the technology for
cardiac output assessment should be non-invasive, accu-
rate, rapid, and compatible in adult and paediatric
patients1. Since USCOM uses the similar technique con-
cept as Doppler echocardiography, we decided to com-
pare the agreement between cardiac output assessment
by Doppler echocardiography and USCOM in critically
ill paediatric patients.
168 T. Wongsirimetheekul et al.
METHODS
This study was a prospective observational study at
a tertiary-based university hospital. Paediatric patients
admitted in the paediatric intensive care unit (PICU)
from 1 May 2012 to 28 February 2013 were enrolled.
The study was approved by the institute’s ethic commit-
tee. The purpose of the study was explained to the
patients’ parents. Informed consent was obtained.
Paediatric patients with a tracheostomy tube, con-
genital heart diseases, and unable to tolerate the supine
position were excluded from the study.
Study protocol
All enrolled patients underwent echocardiography
and USCOM, simultaneously and independently.
Transthoracic echocardiography (TTE)
Using Philips iE33, the left ventricular outflow tract
was measured by 2-dimensional echocardiography from
parasternal long-axis view during diastole for the inner
diameter at the level of the aortic valve annulus, defined
as outflow diameter4,8. From the apical five-chamber
view, a pulsed-wave Doppler echocardiography was
aligned to parallel the flow to measure velocity and
velocity time integral4,8. All echocardiograms were per-
formed by a single operator (AK) following the standard
recommendation8. Cardiac output was calculated with
the following formula8:
Cardiac output = stroke volume × heart rate
Stroke volume = cross-sectional area × velocity time integral
Cross-sectional area = π (radius)2 = π (outflow tract
diameter/2)2
= [π (outflow tract diameter)2]/4
= 0.786 X (outflow tract diameter)2
Cardiac output = 0.786 × (outflow tract diameter)2 × velocity time
integral × heart rate
Finally, the cardiac index is equal to the cardiac out-
put divided by the body surface area.
Ultrasonic cardiac output monitor (USCOM)
The USCOM transducer using 2.2 MHz continuous
wave Doppler was placed on the patient’s suprasternal
notch area and the optimal transaortic flow profile was
obtained just after the corresponding echocardiogram.
Initially, an attempt was made to perform both measure-
ments at the same time but the Doppler signal of
USCOM was interfered by the Doppler from echocar-
diography. USCOM was determined after completion
of the measurement of the cardiac output from the echo-
cardiography in order to minimize the time difference
between the paired sets of measurements. One to three
sets of paired measurements were obtained from each
patient. The USCOM measurements were performed
by a single operator (TW) with no prior echocardio-
graphic or ultrasonographic experience after her train-
ing with supervised measurement of USCOM. This
operator was blinded to the measurements obtained
from echocardiography. The USCOM device reported
cardiac output by using average velocity time integral
measured by continuous wave Doppler and estimated
left ventricular outflow tract diameter. The USCOM
calculates the cross-sectional area using the outflow tract
diameter based on a validated nomogram derived from
height and weight9. Blood velocities were measured from
the suprasternal notch for the aortic valve. The velocity-
time integral is automatically traced and integrated. The
USCOM automatically calculated and reported as stroke
volume, heart rate, cardiac output and cardiac index.
Any complication occurring during the USCOM meas-
urement was recorded. The cardiac output measurement
was terminated if it interfered with the haemodynamics
and/or current treatments of the patient. Cardiac index
was calculated by cardiac output divided by body surface
area which was estimated from the Boyd-West nomo-
gram according to weight and height9. Demographic
data of the patients were recorded including current
medical conditions, underlying diseases, sex, age, body
weight and height. The vital signs including pulse oxygen
saturation were also recorded throughout the time of
cardiac output measurement.
Statistical analysis
Descriptive analyses for continuous data were
described as mean ± SD. A paired t-test was used to detect
any significant difference between the mean of both meas-
urements. Bland-Altman analysis, Pearson’s correlation
coefficient and percentage error were used to analyse the
agreement between each parameter of both measure-
ments. A plot of the difference in each pair of two meth-
ods of measurements for each patient against the mean
of these two methods of measurements was constructed
by Bland-Altman plots10-12. From this plot, the mean dif-
ference between both measurement techniques is the bias,
which is an estimation of how closely these two methods
agree10-12. The SD of the mean difference indicates an
estimation of precision10-12. The limits of agreement are
indicated by the interval of 1.96 SD of the measurement.
The percentage error was calculated as follows13:
Percentage error = (1.96 × SD)/mean value of measurement × 100
When compared with Doppler echocardiography a
percentage error not exceeding 30% was defined as a
clinically useful USCOM13. All statistics were analysed
 Non-invasive cardiac output measurement 169

by MedCalc version 12.4. A P < 0.05 was defined as

statistically significant.

RESULTS

Thirty-four patients admitted to the PICU aged

7.86 ± 5.78 years, 15 males (44.1%) were enrolled. Sixteen
patients (47%) were diagnosed as septic shock. The mean
body weight, body surface area, and BMI were
27.15 ± 18.23 kg, 0.93 ± 0.47 m2, and 17.26 ± 3.33 kg/m2.
A
There were no complications observed and all measure-
ments were finished without interruption.
Overall, the outflow tract diameter estimated from
USCOM was not significant ly different from that meas-
ured from 2-dimensional echocardiography whereas the
velocity time integral measured by continuous wave Dop-
pler from USCOM was significantly greater than that
measured by pulsed wave Doppler from echocardiogra-
phy (table 1). Using both parameters to calculate cardiac
output and cardiac index, cardiac output and cardiac
index from USCOM were significantly greater than those
from echocardiography (table 1). However, the correlation B
coefficients of the outflow tract diameter, velocity time
Fig. 1 Bland-Altman plots for cardiac output and cardiac index
integral, cardiac output and cardiac index from these two
in all patients (n = 34): plot between the difference of cardiac
methods had good correlations (table 1). Using a Bland- output calculated by echocardiography (COECHO) and by ultrasonic
Altman plot, the difference between outflow tract diam- cardiac output monitor (COUSCOM) versus the average difference
eter, velocity time integral, cardiac output and cardiac between these two methods with 95% limits of agreement (1A).
Plot between the difference of cardiac index calculated by
index from both methods had a bias (mean) and precision
echocardiography (CIECHO) and by ultrasonic cardiac output
(SD) as shown in table 1 and figure 1. Importantly, the monitor (CIUSCOM) versus the average difference between these two
percentage errors of cardiac output and cardiac index methods with 95% limits of agreement (1B).

Table 1 Outflow tract diameter, velocity time integral, cardiac output and cardiac index compared with echocardiography and
the ultrasonic cardiac output monitor in all patients (n = 34)

Parameters Echocardiography USCOM* P value Agreement between echocardiography and USCOM*

Correlation Bias ± precision Percentage error†
coefficient (r) (%)
OTD‡ 1.47 ± 0.38 1.41 ± 0.40 0.06 0.87 –0.07 ± 0.20 27.80
(cm) (0.76-0.94)
P < 0.0001
VTI§ 19.13 ± 6.06 23.53 ± 7.31 < 0.0001 0.85 –4.40 ± 3.84 31.99
(cm) (0.72-0.92)
P < 0.0001
CO¶ 3.88 ± 2.19 4.41 ± 2.83 0.02 0.91 –0.53 ± 1.23 54.66
(l/min) (0.83-0.96)
P < 0.0001
CI** 4.23 ± 1.19 4.77 ± 1.43 0.005 0.70 –0.54 ± 1.03 42.32
(l/min/m2) (0.48-0.84)
P < 0.0001

Values are mean ± standard deviation.

*USCOM, ultrasonic cardiac output monitor; †percentage error, 100 × 1.96 × SD/mean; ‡OTD, outflow tract diameter; §VTI, velocity time integral; ¶CO, cardiac output;
**CI, cardiac index.
170 T. Wongsirimetheekul et al.

measured by USCOM were high, when compared to those
measured by echocardiography (table 1).
Subgroup analysis into patients with non-septic
shock (n = 18) and patients with septic shock (n = 16)
were analysed (table 2 and table 3). The correlation
coefficients of cardiac output and cardiac index from
these two methods in patients with non-septic shock
had better correlations than those with septic shock.
Bias ± precision of cardiac output and cardiac index
tended to be less in patients with non-septic shock
(figure 2) than in patients with septic shock (figure 3).
The percentage errors of cardiac output and cardiac
index measured by USCOM when compared to those
measured by echocardiography were higher in patients
with septic shock than in patients with non-septic shock
(table 2 and table 3).
DISCUSSION
Pulmonary artery catheter (PAC) with thermo-
dilution is still the gold standard of cardiac output

Table 2 Outflow tract diameter, velocity time integral, cardiac output and cardiac index compared between those from echocardiography
and those from ultrasonic cardiac output monitor in subgroup of patients with non-septic shock (n = 18)

Parameters Echocardio- USCOM* P value Agreement between echocardiography and USCOM*

graphy
Correlation Bias ± precision Percentage error†
coefficient (r) (%)
OTD‡ 1.44 ± 0.38 1.38 ± 0.38 0.06 0.95 0.06 ± 0.12 33.41
(cm) (0.88-0.98)
P < 0.0001
VTI§ 19.09 ± 6.17 23.50 ± 6.21 < 0.0001 0.82 –4.41 ± 3.70 30.86
(cm) (0.58-0.93)
P < 0.0001
CO¶ 4.00 ± 2.47 4.50 ±2.86 0.02 0.97 –0.50 ± 0.79 34.41
(l/min) (0.91-0.99)
P < 0.0001
CI** 4.30 ± 1.18 4.81 ± 1.37 0.02 0.80 –0.52 ± 0.84 33.82
(l/min/m2) (0.53-0.92)
P < 0.0001

Values are mean ± standard deviation.

*USCOM, ultrasonic cardiac output monitor; †percentage error, 100 × 1.96 × SD/mean; ‡OTD, outflow tract diameter; §VTI, velocity time integral; ¶CO, cardiac
output; **CI, cardiac index.

Table 3 Outflow tract diameter, velocity time integral, cardiac output and cardiac index compared between those from echocardiography
and those from ultrasonic cardiac output monitor in subgroup of patients with septic shock (n = 16)

Parameters Echocardiography USCOM* P value Agreement between echocardiography and USCOM*

Correlation Bias ± precision Percentage error†
coefficient (r) (%)
OTD‡ 1.51 ± 0.39 1.43 ± 0.44 0.06 0.80 0.08 ± 0.27 37.00
(cm) (0.50-0.93)
P < 0.0002
VTI§ 19.18 ± 6.14 23.56 ± 8.59 < 0.0001 0.90 –4.38 ± 4.11 34.19
(cm) (0.72-0.96)
P < 0.0001
CO¶ 3.75 ± 1.90 4.31 ± 2.88 0.02 0.85 –0.56 ± 1.62 73.67
(l/min) (0.61-0.95)
P < 0.0001
CI** 4.16 ± 1.23 4.73 ± 1.53 0.02 0.61 –0.56 ± 1.24 51.38
(l/min/m2) (0.17-0.85)
P < 0.01

Values are mean ± standard deviation.

*USCOM, ultrasonic cardiac output monitor; †percentage error, 100 × 1.96 × SD/mean; ‡OTD, outflow tract diameter; §VTI, velocity time integral; ¶CO, cardiac
output; **CI, cardiac index.

Fig. 2 Bland-Altman plots for cardiac output and cardiac index in
patients without septic shock (n = 18): Plot between the difference
of cardiac output calculated by echocardiography (COECHO) and by
ultrasonic cardiac output monitor (COUSCOM) versus the average
difference between these two methods with 95% limits of
agreement (2A). Plot between the difference of cardiac index
calculated by echocardiography (CIECHO) and by ultrasonic cardiac
output monitor (CIUSCOM) versus the average difference between
these two methods with 95% limits of agreement (2B).
measurement1,14,15. The limitations are its invasive nature,
it is time-consuming, and has more complications, espe-
cially in a paediatric population with shock. The size of
the PAC is large when compared to the calibre of the
central vein. USCOM is the newer method of measure-
ment. Recently, Chong et al.6 reported a meta-analysis of
the accuracy and precision of the USCOM and found
that it had a mean bias and precision of –0.39 l/min and
1.27 l/min and a percentage error against thermodilution
cardiac output of 42.7%. However, they concluded that
the USCOM may be useful in cardiac output monitoring
and that further studies are needed to investigate the
ability of the USCOM. Huang et al.16 commented on that
paper that from their results, rather than accepting the
reliability of the USCOM, it should be concluded that
the USCOM was unreliable to be used clinically. They
stated that the main reasons of errors regarding the
Non-invasive cardiac output measurement 171
B
Fig. 3 Bland-Altman plots for cardiac output and cardiac index in
patients with septic shock (n = 16): Plot between the difference of
cardiac output calculated by echocardiography (COECHO) and by
ultrasonic cardiac output monitor (COUSCOM) versus the average
difference between these two methods with 95% limits of
agreement (3A). Plot between the difference of cardiac index calcu-
lated by echocardiography (CIECHO) and by ultrasonic cardiac output
monitor (CIUSCOM) versus the average difference between these two
methods with 95% limits of agreement (3B).
precision of the USCOM were its extreme operator
dependency and parameters such as low cardiac output
and older age. Importantly, there was only one study in
a paediatric population in that meta-analysis. Knirsch et
al.17 reported cardiac output measurement in children
compared between the USCOM and thermodilution
cardiac output measurement. They concluded that using
the USCOM did not reliably represent absolute cardiac
output values as compared to PAC thermodilution17.
The ability of Doppler echocardiography to provide
non-invasive cardiac output measurement with minimal
172 T. Wongsirimetheekul et al.
discomfort or risk along with its portability, immediate
availability, and repeatability has been reported by many
studies5,18,19. Transoesophageal echocardiography (TEE)
with pulsed wave Doppler for cardiac output determina-
tion has been compared with PAC thermodilution in
various patient populations and demonstrated that this
technique had acceptable accuracy compared when per-
formed correctly1,20,21.
Nguyen HB et al.22 measured the cardiac index by the
USCOM and Doppler transthoracic echocardiography
in adult (n = 99) and paediatric (n = 44) patients in the
emergency room and found that the values obtained by
the USCOM appeared to be higher than Doppler echo-
cardiography and could not be a reliable method when
compared to Doppler. Our study confirmed that cardiac
output from the USCOM tended to be overestimated in
comparison with cardiac output from Doppler echocar-
diography, especially in paediatric septic shock patients.
Two variables calculated for cardiac output from the
USCOM were outflow tract diameter and velocity time
integral. Outflow tract diameter from the USCOM was
estimated according to the validated nomogram derived
from height and weight9 which was not significantly
different from the outflow tract diameter measured
directly by 2-dimensional echocardiography and had a
bias and precision of -0.07 ± 0.20 cm and a percentage
error less than 30%. However, the velocity time integral
derived from the USCOM was significantly greater than
that derived from echocardiography with a bias and
precision of -4.40 ± 3.84 cm and a percentage error more
than 30%. This could be explained by methods of obtain-
ing the velocity time integral from the USCOM using
continuous wave Doppler whereas Doppler echocardi-
ography uses pulsed wave Doppler. Chew et al.21 have
reviewed the accuracy and repeatability of Doppler
echocardiography to measure cardiac output in paedi-
atric populations. That review included 11 articles with
285 children and compared Doppler cardiac output
measurements to cardiac output from Fick, thermodilu-
tion, or dye dilution methods. They demonstrated the
precision of Doppler cardiac output in the order of 30%,
bias generally less than 10%, and repeatability varying
from 1-22% 21. The American Society of Echocardiog-
raphy8 recommended using pulsed wave Doppler tracing
average velocity of the blood cells passing through the
aortic valve orifice to derive a velocity time integral since
pulsed wave recorded velocities within the sample
volume properly matched the anatomical site of outflow
tract diameter at the aortic annulus measurement pref-
erably using left ventricular outflow tract to calculate
cross-sectional area4. Although the recording of flow
velocity used continuous wave Doppler as the technique
in the USCOM, the velocity time integral is related to
the cross-sectional area of the aortic valve opening rather
than the valve annulus8. Moreover, a non-imaging con-
tinuous wave transducer used in the USCOM will detect
the highest velocity along the path of the ultrasound
beam8. Although all compared parameters had good
correlations, this statistical method was not useful for
assessing agreement between two methods of measure-
ment. Instead, the Bland-Altman10,11 and percentage
error13 should be used to assess the correlation. Impor-
tantly, the percentage error was extremely high especially
in patients with septic shock when compared to the
percentage error in patients with non-septic shock. The
USCOM tended to overestimate cardiac output and
cardiac index in case of a relatively hyperdynamic heart
due to the highest velocity profile derived from con-
tinuous wave Doppler.
CONCLUSIONS
The USCOM could not be used as a reliable tool for
the absolute value measurement of cardiac output and
cardiac index in a paediatric population, especially in
patients with septic shock, when compared to Doppler
echocardiography. The main source of error was derived
time velocity integral from continuous wave Doppler. The
USCOM might be useful for monitoring the responses
after treatment in septic shock regarding improvement
or deterioration of cardiac output or cardiac index. How-
ever, further investigations should be performed to eval-
uate whether the USCOM could be used as a tool to
monitor paediatric patients with septic shock.
ACKNOWLEDGMENTS
The authors would like to acknowledge all participat-
ing children and their families for participation in this
study; all PICU nurses, paediatric residents and attend-
ing staffs for their medical care to the patients.
CONFLICT OF INTEREST: none declared.

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