Original article

Haemodynamic monitoring
with pulse-induced contour
cardiac output (PiCCO) in
critical care
Ros Cottis, Neil Magee and David J. Higgins

Haemodynamic monitoring is essential for the management of the critically ill. Effective
monitoring can give data that permit analysis of key circulatory functions and the
anticipation of deterioration so that pro-active treatments can be initiated.
Ros Cottis Senior
Sister Critical Care, There are many methods of monitoring the haemodynamic status of patients. The authors
BSc (Hons) have compared three of the most commonly used methods in the general Critical Care Unit.
Specialist Nursing
Practice ENB 100, These are the pulmonary artery catheter (PAC), oesophageal Doppler, and pulse-induced
Critical Care Unit, contour cardiac output (PiCCO) studies.
Southend Hospital,
Prittlewell Chase,
The focus is upon PiCCO, which is a comparatively less invasive method than the
Southend on Sea, traditionally used PAC. This has been chosen due to the authors’ particular interest in the
Essex SS0 ORY, UK.
Tel: +44 1702
additional parameters which can be monitored using PiCCO. With the PiCCO system it is
221351; E-mail: possible to measure intrathoracic blood volume (ITBV), extravascular lung water (EVLW) and
cottis@clara.co.uk cardiac function index (CFI). These parameters are of interest as they are considered to be
Neil Magee Staff
Nurse Critical Care,
the most specific measures of cardiac preload, pulmonary oedema and contractility and a
Southend Hospital, global indicator of cardiac performance.
ENB 100 Southend © 2003 Elsevier Ltd. All rights reserved.
Hospital,
Prittlewell Chase,
Southend on Sea,
Essex SS0 ORY, UK.
KEYWORDS: Haemodynamic monitoring; Pulse-induced contour cardiac output; Critical care.
Tel: +44 1702
221351; E-mail:
Neil.Magee@ Introduction nearest measurable parameters to tissue
southend.nhs.uk oxygenation are cardiac output, arterial blood
David J. Higgins Management of critically ill patients is based pressure, central venous pressure, arterial and
FRCA, Director of on knowledge of fundamental physiological central venous oxygenation and haemoglobin.
Critical Care,
Southend Hospital, variables. Monitoring techniques of the Therefore, the measurement of these
Prittlewell Chase, haemodynamic status of these patients have parameters is seen as essential in the
Southend on Sea, developed from the non-invasive monitoring management of these patients. Burchell et al.
Essex SS0 ORY, UK.
Tel: +44 1702 of single parameter to more invasive (1997) considered that the measurement of
221351; E-mail: monitoring of multiple parameters. This leads cardiac output is now accepted as a routine
Dave.Higgins@ to a far more comprehensive analysis allowing part of bedside monitoring. In the authors’
southend.nhs.uk
clinicians to anticipate events and provide unit, three main methods of monitoring the
(Requests for
offprints to RC) more effective treatment. patient’s haemodynamic status have evolved.
Manuscript Jacobsen (1995) states that in the critically ill The pulmonary artery catheter (PAC) was the
accepted: 30/06/03 and haemodynamically unstable patients the initial method, this was superseded by

© 2003 Elsevier Ltd. All rights reserved. Intensive and Critical Care Nursing (2 0 0 3) 1 9, 3 0 1–3 0 7 301
doi:10.1016/S0964-3397(03)00063-6
Intensive and Critical Care Nursing

Table 1 Comparison of pulse-induced continuous cardiac output, oesophageal Doppler and pulmonary artery
catheter for haemodynamic monitoring

PiCCO Oesophageal Doppler Pulmonary artery catheter

Method of Bolus of thermal indicator Ultrasound echography for Bolus injection of thermal
measurement and arterial waveform aortic diameter and Doppler indicator
analysis for flow determination
Parameters • CO • Descending aortic blood flow • CO
• GEDV • CO from aortic blood flow • CVP
• CFI • SV • PAP
• ITBV • HR • PAOP
• EVLW • SVR • PWP
• SV • Estimate left ventricular
• SVRI ejection time
• dP/dt
• HR
• AP
Advantages • Real time cardiac output • No vascular access required • Clinically accepted
• No added access required • Continuous monitoring variables
• Suitable for paediatrics • Minimal complications • Very accurate at time of
• Suitable for paediatrics measurement
• Measures lung water
Disadvantages • Bolus injection for • Highly dependant • Invasive
calibration on positioning • Affected by respiratory
• Inaccuracies in certain • Not applicable in cycle
medical conditions paediatrics • High risk of
• Risk of infection, • Data open to complications
thrombosis interpretation • Expensive in time and
• Expensive • Patients have to be equipment
sedated • Not applicable in
paediatrics

non-invasive oesophageal Doppler and most
recently the unstable patients have been
monitored using the pulse-induced continuous
cardiac output (PiCCO). These three
techniques are compared in Table 1.
Pulse-induced continuous
cardiac output
PiCCO is a device that quantifies several
parameters, including continuous (pulse
contour) cardiac output, cardiac preload,
systemic vascular resistance and extravascular
lung water (EVLW). The patient requires a
central venous line ideally sited in the internal
jugular or subclavian vein, and an arterial
catheter with a thermister is placed in one of
the larger systemic arteries, e.g. the femoral or
brachial artery. As Salukhe and Wyncoll (2002)
explain the PiCCO system works on the
principle that a known volume of thermal
indicator (ice-cold saline) is injected into a
central vein. The injectate rapidly disperses
volumetrically and thermally within the
pulmonary and cardiac volumes. This volume
of distribution is termed the intrathoracic
volume. When the thermal signal reaches the
arterial thermister, a temperature difference is
detected and a dissipation curve is generated.
The Stewart Hamilton equation is applied to
this and cardiac output is calculated. This
transpulmonary thermodilution also measures
cardiac preload volume and, of great benefit to
the bedside measurement of the critically ill
patient, provides an estimate of both
intrathoracic blood volume (ITBV) and EVLW.
Sakka et al. (2000) conducted a prospective
study in 37 patients with sepsis or septic
shock. All patients were sedated and
ventilated. A PAC and an arterial catheter with
integrated thermister were inserted and
connected to a computer system (COLD Z021,
Pulsion Medical Systems). 449 simultaneous
cardiac output measurements were analysed.
The cardiac output range for the PAC was
4.0–20.5 and 4.3–20.8 l/minute for the arterial
thermodilution method. It was concluded that
for the measurement of cardiac output the

302 Intensive and Critical Care Nursing (2 0 0 3) 1 9, 3 0 1–3 0 7 © 2003 Elsevier Ltd. All rights reserved.
 Haemodynamic monitoring with PiCCO in critical care

Table 2 Normal ranges (reproduced by kind therapy. Lichtwarck-Ascoff et al. (1992) were
permission of Pulsion Medical UK Ltd)
able to show that ITBV reflects the status of
Variable Normal ranges Unit
the circulating blood volume of Intensive Care
patients being artificially ventilated whereas
CI 3.0–5.0 l/minute/m2 the more frequently used standards, such as
ITBI 850–1000 ml/m2 central venous pressure and the pulmonary
ELWI 3.0–7.0 ml/kg artery occlusion pressure, do not reflect cardiac
CFI 4.5–6.5 1/minute
HR 60–90 1/minute preload. This has significant indications for
CVP 2–10 mmHg accurate and precise fluid management in
MAP 70–90 mmHg patients being monitored by the PiCCO. It
SVRI 1200–2000 dyne seconds/cm5 /m2
SVI 40–60 ml/m2
enables the nurse and the physician to monitor
SVV ≤10 % very accurately the volume challenges
required to optimise cardiac output.
The assessment and optimisation of cardiac
preload is fundamental in the management of
transpulmonary thermodilution method could the critically ill patient (Mitchell et al. 1992).
be regarded at least as accurate as pulmonary Inadequate preload leads to suboptimal tissue
artery thermodilution. perfusion and multi-organ failure, whereas
Following calibration by thermodilution, excessive fluid results in pulmonary oedema
the PiCCO continually quantifies several and worsening respiratory function, which
parameters: may contribute to both morbidity and
mortality.
1. Pulse-induced contour cardiac output
In patients presenting with septic shock it is
2. Arterial blood pressure
possible that due to increased capillary
3. Heart rate
permeability EVLW will be elevated but ITBV
4. Stroke volume
may be reduced. In the hyperdynamic phase
5. Systemic vascular resistance
of sepsis, a reduction in systemic vascular
6. Intrathoracic blood volume
resistance, accompanied by a pyrexia will also
7. Extravascular lung water
reduce ITBV. Cardiac output and cardiac index
8. Cardiac function index
(CI) will be elevated in this phase. Despite a
For normal values please refer to Table 2. high cardiac output it may be necessary to
The first five parameters are measured by administer fluid to maintain circulating
several other devices and are well known. The intravascular volume.
latter three, however, are relatively new and
are discussed further.
Extravascular lung water
EVLW correlates to extravascular thermal
Intrathoracic blood volume
volume in the lungs and is evaluated by the
The PiCCO offers the possibility to assess PiCCO through the mean transit time method.
ITBV derived from global end diastolic
volume (GEDV) determined by EVLW = Intrathoracic thermal volume
thermodilution measurement. GEDV correlates − Intrathoracic blood volume
well with ITBV in both experimental and
clinical studies. Bindels et al. (2000) found that The quantification of EVLW correlating to
ITBV is more reliable and therefore a superior pulmonary oedema is not possible with
indicator of cardiac preload in the clinical routine clinical studies and examinations. The
situation than pulmonary artery wedge early accumulation of interstitial oedema and
pressure (WP). Buhre et al. (2000) support this small changes in water content of the lungs are
by concluding that the measurement of ITBV not reliably detected or quantified with chest
by indicator dilution enables quantification of X-ray or arterial blood gases. The chest X-ray
blood volume shift from intra- to extrathoracic shows a density measurement of the entire
compartments and is helpful in guiding fluid chest. Therefore, the correlation is poor

© 2003 Elsevier Ltd. All rights reserved. Intensive and Critical Care Nursing (2 0 0 3) 1 9, 3 0 1–3 0 7 303
Intensive and Critical Care Nursing
between EVLW and estimation of pulmonary
oedema using X-ray scores. It is a
two-dimensional representation of a
three-dimensional structure.
Breiburg et al. (2000) describe a noticeable
feature of all lungs damaged by Adult
Respiratory Distress Syndrome (ARDS). There
is an increase in the alveolar basement
membrane permeability, which decreases
plasma oncotic pressure resulting in
protein-rich fluid into the alveolar space. In
addition, the free flow of fluid into the
interstitial space results from a breakdown of
capillary epithelial and endothelial junctions
caused by proteolytic enzymes. As a result,
pulmonary lymphatic drainage capacity is
overwhelmed and accumulation of fluid
occurs in the interstitial and alveolar
spaces. In ARDS, EVLW will therefore be
increased. This is as a direct result of
modifications in hydrostatic pressures. The
ITBV would also be reduced, alongside the
loss of circulating volume due to the third
spacing of fluid.
The EVLW value is an indicator of the
severity of illness. Sturm (1990) showed the
relationship between the mortality of
Intensive Care patients with ARDS and EVLW.
The sample comprised 81 patients in a surgical
ITU. A proportion of the sample had suffered
multiple trauma and developed subsequent
sepsis with deteriorating respiratory failure,
the remainder had undergone abdominal
surgery and developed sepsis or peritonitis.
1382 lung water values were compared with
the corresponding parameters of lung
mechanics and gas exchange. It was found that
patients with an EVLW of up to 8–10 ml/kg
body weight had a mortality of 25%. This
significantly increased to 75% in EVLW of
greater than 10 ml/kg body weight (see Fig. 1).
Patients with increased EVLW need
mechanical ventilation and have a high
risk of nosocomial infection. Therefore, any
measures that reduce EVLW without
decreased perfusion are likely to increase the
chance of survival.
The fluid content of the lung increases in
such conditions as left heart failure,
pneumonia sepsis, intoxication and burns.
EVLW increases through increased fluid
transport to the interstitium as a result of
304 Intensive and Critical Care Nursing (2 0 0 3) 1 9, 3 0 1–3 0 7
Fig. 1 Close relationship between mortality and
extravascular lung water in patients with multiple
trauma (Sturm 1990). Reproduced by kind permission
of Pulsion Medical UK Ltd.
either left heart insufficiency, volume overload
or an increased pulmonary vascular
permeability for plasma proteins.
EVLW can be used as a haemodynamic
guide parameter. Mitchell et al. (1992)
conducted a randomised prospective trial to
determine whether fluid management that
emphasised diuresis and fluid restriction in
patients with pulmonary oedema, could effect
the development or resolution of EVLW.
Consequently, could the time on mechanical
ventilation and subsequent time in ITU be
reduced? 52 patients were randomised to an
EVLW management group. EVLW was
measured using the thermal-indocyanine green
dye double indicator method. 49 patients were
randomised to a WP management group in
whom fluid management was guided by WP
measurements. The two groups were managed
differently. The WP group had a median fluid
balance of 1600 ml. In the EVLW group, this
was reduced to a median of 754 ml. The EVLW
group had a mortality of 35% compared to
47% in the group guided by WP. Mitchell et al.
(1992) concluded that a lower positive fluid
balance especially in patients with pulmonary
oedema was associated with reduced ventilator
days and subsequent ITU days (see Fig. 2).
Bindels et al. (1999) advise that in unstable
haemodynamic situations patient with
cardiogenic pulmonary oedema may require
fluid challenges to improve cardiac output,
despite the presence of pulmonary oedema.
The pulmonary oedema, which is measured as
EVLW resolves rapidly when cardiac
performance improves despite positive fluid
balances in the first 24 hours.
© 2003 Elsevier Ltd. All rights reserved.
 Haemodynamic monitoring with PiCCO in critical care

Fig. 2 A prospective randomised study by Mitchell et al. including over 100 Intensive Care patients concluded
that haemodynamic management using EVLW, as opposed to the conventional pulmonary artery catheter (RHC)
management using PAOP, significantly reduced ventilation days (median: EVLW: 9 days, RHC: 22 days) as well as
the length of ICU stay (median: EVLW: 7 days, RHC: 15 days). The ICU mortality of the group guided by EVLW
was 35% compared to 47% in the group guided by pulmonary artery catheter (RHC) (Mitchell et al. 1992). KEY:
EVLW: extravascular lung water; RHC: pulmonary artery catheter; PAOP: pulmonary artery occlusion pressure.
Reproduced by kind permission of Pulsion Medical UK Ltd.

Cardiac function index unlike the measurements derived from using

Evaluation of the contractile state of the heart
is a crucial task in critical care. This can be
measured via a left ventricular catheter, and by
using the reference standard dP/dt max.
dP/dt is a direct measurement of contractility.
It calculates how fast the pressure is rising
during systole. If pressure close to the aortic
valve is measured, the rise in blood pressure
during ventricular systole is proportional to
the force of contraction.
It is not possible within the general Critical
Care Unit to do this, rendering the
measurement obsolete. When using a PAC, the
right ventricular ejection fraction (RVEF) and
the ratio between CI and a ‘filling pressure’,
e.g. CVP or PCWP (whilst giving a fluid
challenge), has been the method of choice to
interpret the condition of the heart. The PiCCO
offers a new method of determining cardiac
performance. This parameter is called the
cardiac function index (CFI) and this is derived
as the ratio of cardiac output divided by GEDV:
CI
CFI =
GEDV
The CFI is a preload independent variable,
which reflects the inotropic state of the heart.
In a study by Pfeiffer et al. (1994) conducted
on pigs, it was found that the CFI was closely
related to the previous indicator used (dP/dt
max). It had a high sensitivity to distinguish
between changes in volume and contractility,
the PAC. It was found that CFI is independent
of intrathoracic pressure, myocardial
compliance and vascular tone and it is
proposed that it therefore has the potential to
become a routine parameter of cardiac
performance.
Calibration of the PiCCO
As already stated, the PiCCO requires
calibration by thermodilution determination. If
the patient is stable, it is recommended this is
repeated every 8 hours. However, this is very
patient dependant and the manufacturers
suggest that it may be necessary to recalibrate
every hour in the initial stages of resuscitation.
Recalibration is also recommended if the
continuous cardiac output has changed
consistently in the same direction for
15 minutes or if there are large or sudden
changes in the patient’s clinical status. It must
be emphasised that the thermodilution curve
and arterial waveform must be considered
technically acceptable before the PiCCO can be
considered calibrated.
Advantages and disadvantages
of the PiCCO
The PiCCO is now the monitoring system
which is being used more frequently in the
authors’ unit, but its advantages and

© 2003 Elsevier Ltd. All rights reserved. Intensive and Critical Care Nursing (2 0 0 3) 1 9, 3 0 1–3 0 7 305
Intensive and Critical Care Nursing
disadvantages need to be examined. The main
advantages over the PAC is that it is
considered to be far less invasive, requiring
only a central line and arterial line which the
majority of critical care patients have as a
matter of course. This in turn leads to far less
risk of complications. Sakka et al. (2000) state
that in comparison to the PAC the PiCCO
system is considered to be less invasive and
the measurement of cardiac preload obtained
can be regarded as more reliable. In an earlier
study, Sakka et al. (1999) found that the
measurements obtained from transpulmonary
thermodilution are influenced less by the
respiratory cycle than the PAC, that they are
consistent and there is potentially less risk to
the patient. Goedje et al. (1999) also support
the use of the PiCCO by stating that it is a
reliable and useful method even during
cardiac instability. The PiCCO also has the
advantage of being suitable for use in
paediatrics. As Higgins and Singer (1993)
explain some concern exists over the use of the
PAC. Cost, complications and lack of necessary
expertise were cited as the major limiting
factors, although it was stated that many
clinicians felt that the benefit/risk ratio and
clinical indications for insertion also restricted
use. The PiCCO offers an alternative with
fewer limiting factors.
In comparison to the oesophageal Doppler,
which provides a safe, relatively non-invasive
and quick method of obtaining data, the PiCCO
is obviously far more invasive but the data
collected are far more extensive (see Table 1).
The problem, as explained by Matthews and
Nevin (1998) with the oesophageal Doppler is
that it requires frequent repositioning and at
times some of the data gathered are unreliable,
most markedly in patients making respiratory
effort. It is also suggested that the Doppler
does not provide information regarding both
chamber and pulmonary vascular pressures
unlike the PAC. However, Higgins and Singer
(1993) emphasise that the oesophageal Doppler
is a rapid means of establishing haemodynamic
monitoring. It is also invaluable in clinical
situations where catheter insertion may be
considered desirable but hazardous, such as in
the presence of severe coagulopathy.
There are some contraindications to the use
of PiCCO. It may be contraindicated if arterial
306 Intensive and Critical Care Nursing (2 0 0 3) 1 9, 3 0 1–3 0 7
access is restricted due to femoral artery
grafting or severe burns in areas where the
catheter would normally have been placed.
The PiCCO may give inaccurate
thermodilution measurements in patients with
intracardiac shunts, aortic aneurysm, aortic
stenosis, pneumonectomy, and during extra
corporeal circulation. The manufacturers also
warn that when the central venous catheter is
placed in the femoral vein there may be an
overestimation of cardiac output by
75 ml/minute.
The role of the nurse
As the scope of nursing evolves the profession
must be self-determining, influencing the
boundaries of practice, and the development
of new skills, roles and knowledge. Wright
et al. (1996) state that nurses play a pivotal role
in individualising patient care and Taylor
(1996) explains that doctors and nurses
working together in a non-hierarchical
manner can contribute to decision making
regarding patient treatment. The relationship
is characterised by trust and mutual respect.
As already discussed, the PiCCO requires
the use of a central venous line and arterial
line and the routine observations that the
nurse would make of these lines are essential
to patient care. However, it is important to
remember that pulse contour analysis is
potentially unreliable when heart rate, blood
pressure and total vascular resistance change
substantially (Purschke cited by Goedje et al.
1999). Therefore, as Goedje et al. (1999)
emphasise initial and frequent calibrations are
necessary to adjust to changes in aortic
impedance. These might be seen as powerful
and persuasive arguments that it should
become the role of the nurse at the bedside to
perform these calibrations in order to provide
and document record measurements. This
should in turn lead to more rapid and accurate
treatment of the patient.
Conclusion
Accurate monitoring of the haemodynamic
status of the critically ill patient is essential to
effective management. The PiCCO offers a
method of obtaining detailed information with
© 2003 Elsevier Ltd. All rights reserved.
 Haemodynamic monitoring with PiCCO in critical care
relatively few additional risks to the patients.
The PiCCO allows the clinician to measure
three parameters, which are relatively new,
ITBV, EVLW and CFI. These allow for a far
more holistic view of the haemodynamic
status of the patient and allows for the applied
treatment to be evaluated continuously. This
should result in more precise management of
the patient and help to achieve the ultimate
goal of maintaining tissue perfusion and
preventing tissue hypoxia optimising delivery
and use of oxygen.
References
Bindels AJGH, Van der Hoeven JG, Meinders AE 1999
Pulmonary artery wedge pressure and extravascular
lung water in patients with acute cardiogenic
pulmonary oedema requiring mechanical ventilation.
American Journal of Cardiology 84: 1158–1163
Bindels AJGH, Van der Hoeven JG, Graafland AD, de
Koning J, Meinders AE 2000 Relationship between
volume and pressure measurements and stroke
volume in critically ill patients. Critical Care 4: 193–199
Breiburg A, Aitken L, Reaby L, Clancy R, Pierce J 2000
Efficacy and safety of prone positioning for patients
with acute respiratory distress syndrome. Journal of
Advanced Nursing 32: 922–929
Buhre W, Weyland A, Buhre K, Kazmaier S, Mursch K,
Scmidt M, Sydow M, Sonntag H 2000 Effects of the
sitting position on the distribution of blood volume in
patients undergoing neurosurgical procedures. British
Journal of Anaesthesia 84: 354–357
Burchell SA, Yu M, Edwards JD 1997 Invasive techniques
for the estimation of cardiac output. International
Journal of Intensive Care Summer: 44–50
Goedje D, Hoeke K, Lichtwarck-Aschoff M, Lamm P,
Reichart B 1999 Continuous cardiac output by femoral
arterial thermodilution calibrated pulse contour
analysis: comparison with pulmonary arterial
thermodilution. Critical Care Medicine 27: 2407–2412
Higgins D, Singer M 1993 Transoesophageal Doppler for
continuous haemodynamic monitoring. British Journal
of Intensive Care 3: 376–378
© 2003 Elsevier Ltd. All rights reserved.
Jacobsen CJ 1995 Invasive cardiac output monitoring.
Costs, complications and benefits of new systems.
International Journal of Intensive Care Summer: 1995
Lichtwarck-Ascoff M, Zeravik J, Pfeiffer UJ 1992
Intrathoracic blood volume accurately reflects
circulatory volume status in critically ill patients with
mechanical ventilation. Intensive Care Medicine 18:
142–147
Matthews PC, Nevin M 1998 Cardiac output
measurement using the TECO1 oesophageal Doppler
monitor. A comparison with thermodilution.
International Journal of Intensive Care Autumn: 78–81
Mitchell JP, Schuller D, Calandrino FS, Schuster D 1992
Improved outcome based on fluid management in
critically ill patients requiring pulmonary artery
catheterisation. American Review of Respiratory
Diseases 145: 990–998
Pfeiffer UJ, Wisner-Euteneier AJ, Lichtwarck-Ascoff M,
Blumel G 1994 Less invasive monitoring of cardiac
performance using arterial thermodilution. Clinical
Intensive Care 5(Suppl.): 28
Salukhe TV, Wyncoll DLA 2002 Volumetric haemodynamic
monitoring and continuous pulse contour analysis—an
untapped resource for coronary and high dependency
care units? The British Journal of Cardiology (Acute
and Interventional Cardiology) 9: 20–25
Sakka SG, Ruhl CC, Pfeiffer UJ, Beale R, McLuckie A,
Reinhart K, Meier Hellmann A 1999 Assessment of
cardiac preload and extravascular lung water by
single transpulmonary thermodilution. Intensive Care
Medicine 26: 180–187
Sakka SG, Meier Hellmann A, Reinhart K 2000
Assessment of intrathoracic blood volume and
extravascular lung water by single transpulmonary
thermodilution. Intensive Care Medicine 26: 180–187
Sturm JA 1990 Development and significance of lung
water measurement in clinical and experimental
practice. In: Lewis FR, Pfeiffer UJ (eds) Practical
Applications of Fibreoptics in Critical Care
Monitoring. Springer-Verlag, Berlin-Heidelberg, New
York, pp 129–139
Taylor J 1996 Collaborative practice within the Intensive
Care Unit. A deconstruction. Intensive and Critical
Care Nursing 12: 64–71
Wright S, Bowkett J, Bray K 1996 The communication
gap in the ICU. A possible solution. Nursing in
Critical Care 1: 5
Intensive and Critical Care Nursing (2 0 0 3) 1 9, 3 0 1–3 0 7 307