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MCC 280303

REVIEW

CURRENT
OPINION Cardiac output monitoring – invasive
and noninvasive
Virendra K. Arya, Waiel Al-Moustadi, and Vikas Dutta

Purpose of review
The purpose of this article is to review various contemporary cardiac output (CO) measurement
technologies available and their utility in critically ill patients.
Recent findings
CO measurement devices can be invasive, minimally invasive, or noninvasive depending upon their
method of CO measurement. All devices have pros and cons, with pulmonary artery catheter (PAC)
being the gold standard. The invasive techniques are more accurate; however, their invasiveness can
cause more complications. The noninvasive devices predict CO via mathematical modeling with
several assumptions and are thus prone to errors in clinical situations. Recently, PAC has made a
comeback into clinical practice especially in cardiac intensive care units (ICUs). Critical care
echocardiography (CCE) is an upcoming tool that not only provides CO but also helps in differential
diagnosis. Lack of proper training and nonavailability of equipment are the main hindrances to the wide
adoption of CCE.
Summary
PAC thermodilution for CO measurement is still gold standard and most suitable in patients with cardiac
pathology and with experienced user. CCE offers an alternative to thermodilution and is suitable for all
ICUs; however, structural training is required.
Keywords
cardiac output, critical care echocardiography, invasive monitoring, noninvasive monitoring, pulmonary artery
catheter

INTRODUCTION INVASIVE MODALITIES

Cardiac output (CO) monitoring in critically ill
patients has become an essential diagnostic and
management tool, especially in the setting of mixed
shock. Various methods, invasive and noninvasive,
have been developed with their own merits and
limitations [1]. There are situations in intensive care
when clinical assessment like capillary refill may not
be a good sign for adequacy of systemic perfusion as
in patients on high dose vasopressors or with vascu-
lar compromise. Moreover, laboratory parameters
like lactic acid or mixed venous saturation may
not help to differentiate diverse types of circulatory
shock. In these situations, CO monitoring has been
& Canada
shown to be beneficial [2 ].
The present article will review the various con-
temporary technologies available for CO monitor-
ing and their clinical efficacy in various situations.
Overall, these modalities can be grouped into:
invasive, minimally invasive, and noninvasive
(Table 1).
Pulmonary artery catheter thermodilution
Pulmonary artery catheter (PAC) became popular
after its first introduction in the 1970s due to its
extensive and versatile hemodynamic data [3]. The
popularity of PAC subsequently declined over the
years due to some outcome studies from medical
intensive care units (ICUs) failing to show survival
benefits as well as reported complications [4–6].
Department of Anesthesiology, Perioperative and Pain Medicine, Max
Rady College of Medicine, University of Manitoba, Winnipeg, MB,
Correspondence to Virendra K. Arya, MD, FRCPC, Professor, Depart-
ment of Anesthesiology, Perioperative and Pain Medicine, Max Rady
College of Medicine, University of Manitoba, L2035, Saint Boniface
Hospital, L2035, 409 Tache Ave, Winnipeg R2H 2A6, Canada.
Tel: +1 204 891 5671; e-mail: aryavk_99@yahoo.com
Curr Opin Crit Care 2022, 28:000–000
DOI:10.1097/MCC.0000000000000937

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MCC 280303

Cardiopulmonary monitoring

Recently use of PAC in ICU has been revisited, and

KEY POINTS
 Invasive, minimally invasive, and noninvasive devices
are available for cardiac output (CO) measurements in
intensive care unit (ICU).
 Pulmonary artery catheter thermodilution is still the gold
standard to which other methods are compared for
accuracy and it is CO monitor of choice in
cardiac ICUs.
 Invasive methods are more accurate as compared to
noninvasive methods.
 Critical care echocardiography (CCE) in addition to
being a noninvasive technology is accurate but highly
dependent on the operator. In future CCE could be
modality of choice for all ICUs.
its significance has been realized in certain groups of
critically ill patients that include right ventricle (RV)
failure, pulmonary artery hypertension (PAH), left
ventricle (LV) failure and mixed shock [7]. More-
over, its utility was improved by adding a RV port,
continuous CO monitoring (CCOM), mixed venous
saturation (SvO2) sensor at the tip and temporary
pacing capability. The RV port allows simultaneous
display and overlap of the pulmonary artery (PA)
and RV waveforms. The overlap of RV end-diastolic
pressure wave over PA end-diastolic pressure wave
has been shown as the earliest indicator of RV
decompensation [8].
The significant advantage of fast CCOM algo-
rithm allows continuous monitoring of multiple
advanced hemodynamic parameters including

Table 1. Summary of CO techniques

Modality Principal of measurement Advantages Disadvantages

Invasive
Pulmonary artery Indicator (heat content) dilution Gold standard reference
catheter (PAC) method method
Right heart filling pressures
and waveforms
Fast CCOM algorithm can
display CO, SvO2, SVR,
RVEF every 20 s
A-V pacing available
Very invasive
Misleading in intracardiac shunts (measures
right heart CO)
Potential for life threatening complications
during insertion and wedging if attention is
not paid to waveforms
No survival benefit in medical ICUs
Misinterpretation of data and waveforms by
inexperienced

Transpulmonary Indicator (heat content) dilution Less invasive than PAC
thermodilution (TPT) method Provides continuous CO of
left heart
Able to track low CO
changes
Can measure ITBV, GEDV,
EVLW, PVPI
Needs major distal arterial and central venous
line
Unreliable in hypothermia, ECMO, Low CO <2
l/min, pulmonary edema
Cross talk phenomenon
Requires regular calibration
Low time resolution due to intermittent
measurements

Minimally invasive
Pulse power analysis Uses invasive pulse power Less invasive Relies on many assumptions
and lithium dilution analysis and lithium dilution to Rapid response time, gives Effected by damping properties of measurement
technique calibrate CO continuous CO system
(LidCOplus) Uses pulse power analysis and a measurement beat to Trueness and precision poor in many clinical
LidCO rapid nomogram beat situations like arrhythmias, rapid changes in
Easy to calibrate vasomotor tone, use of vasopressors
Provides dynamic markers Nondepolarizing muscle relaxants interfere with
of preload calibration
Cannot be used in pregnancy, patients on
lithium therapy
Pulse wave analysis Uses invasive pulse wave analysis Similar to LidCO Similar to LidCO
PiCCO, volume view and TPT to calibrate CO Similar to LidCO and Pulse waveform analysis more prone to error
Flo Trac (Edwards Invasive pulse wave analysis and PiCCO than pulse power analysis in low CO states,
Lifesciences) a nomogram Similar to LidCO and high SVR, vasopressor use, peripheral edema
MostCare system Invasive pulse wave analysis and PiCCO Similar to LidCO and PiCCO
(Vygon, France) a nomogram Similar to LidCO and PiCCO

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Cardiac output monitoring -- invasive and noninvasive Arya et al.

Table 1 (Continued)

Modality Principal of measurement Advantages Disadvantages

Esophageal Doppler Doppler principle Estimates CO continuously Operator-dependent

in real time
Supportive data for use
perioperatively in high-
risk surgical patients to
reduce central lines and
hospital stay
Noninvasive
Pulse waveform Use finger-cuff or radial artery Noninvasive, rapid
analysis applanation tonometry to get response time and
arterial waveform for analysis continuous CO similar to
invasive arterial
waveform analysis
Pulse wave transit Use assumption that pulse wave Noninvasive, rapid
time transit time is inversely related response time and
to SV continuous CO similar to
invasive arterial
waveform analysis
Bioimpedance and Thoracic impedance and Noninvasive, easy to use
bioreactance reactance changes due to and interpret
blood volume changes Can be used in conscious
as well as unconscious
patients
Partial CO2 Indirect Fick’s principle Noninvasive, easy to use,
rebreathing gives real time CO
Can be used in conscious
patients
Thoracic Doppler Doppler principle Noninvasive
Critical Care Doppler principle and ultrasound TTE-Noninvasive, No
Echocardiography contraindications
(TTE, TEE) Additional diagnostic tool
for lung, volume status,
cardiac functions and
pathology
A-V, atrio-ventricular; CCOM, continuous cardiac output monitoring; ECMO, extra corporeal membrane oxygenation; EVLW, extravascular lung water; GEDV,
global end diastolic volume; ITBV, intrathoracic blood volume; PVPI, pulmonary vascular permeability index; RVEF, right ventricular ejection fraction; SvO2, mixed
venous saturation; SVR, systemic vascular resistance; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography.
Prone to motion artifacts
Not easily used in awake and alert patients
Slight errors in aortic diameter estimation can
result in big errors in CO estimations
Alignment angle <20 with blood flow is
required
Inaccurate in severe peripheral edema,
hypothermia, shock, severe vasoconstriction,
high doses of vasopressors
Limitations of invasive arterial waveform also
apply
Poor accuracy and precision
Cannot work when patients have cardiac
arrhythmias or rapid changes in vascular
tone
Not ready for clinical use
Poor accuracy and precision
Effected by electrode positioning, electrical
interference, fluid in the thorax, arrhythmias,
motion artefacts
Not ready for clinical use
Unsuitable in severe hypercapnia, increased
ICP and pulmonary artery hypertension and
agitated patients
Not ready for routine clinical use in ICU
Patient movement effects readings
Uses nomogram to predict valve area
Poor alignment underestimates CO
Training required and operator dependent
Difficult to get good TTE windows in
postoperative ventilated patients
TEE: cannot be used in conscious patients and
contraindicated in esophageal disease

CO, stroke volume (SV), SvO2, systemic vascular
resistance (SVR), and RV ejection fraction every
20 s while avoiding volume overload of cold saline
injection, as it uses a temperature filament to add
heat content to blood flow and measure blood tem-
perature change at PAC tip by a rapid response
&& &&
thermistor [9 ,10 ]. PAC has been the modality
of choice in cardiac surgical ICU for differentiating
mixed shock [11].
Misinterpretation of the obtained data is the
leading factor for PAC-related complications [12].
Critical care physicians need to be trained in the
interpretation of PAC-derived hemodynamic
parameters and waveform analysis [9 ,10 ]. Since
&&
PAC derived CO is measured in the RV, it cannot be
used as a surrogate for CO of LV in the presence of
intracardiac shunts and tricuspid valve
abnormalities. In the intermittent CO monitoring
by giving cold injectate, variabilities in the temper-
ature while injection, volume, and timing of the
injectate in relation to the breathing cycle are com-
mon sources of error [13]. In PAH and severe mitral
regurgitation (MR), the wedging of the catheter is
not recommended as there are reports of PA rupture
[14]. In severe MR, PAC wedged waveform looks like
PA waveform and if one ignores the timing of pres-
sure peak, he is likely to misinterpret wedged pres-
sure as PA pressures [15].
&&
Transpulmonary thermodilution
Transpulmonary thermodilution (TPT) was intro-
duced as an alternative to PAC thermodilution in
the early 2000s by two companies: PiCCOplus

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Cardiopulmonary monitoring
(Pulsion Medical Systems, Germany) and EV1000/
VolumeView (Edwards Lifesciences, Irvine, CA,
USA). The primary purpose of TPT was to obtain
the precision of PAC in critically ill patients with
complex shock while being easier to set up with
higher margins of safety and less invasiveness [16]. A
computer software plots the thermodilution curve
from the distal sensor placed on an arterial cannula
in a major distal artery (femoral, axillary, or bra-
chial) after an injection of cold saline is given in the
superior venae cava (SVC) via central line. TPT can
measure CO, intrathoracic blood volume (ITBV),
global end-diastolic volume (GEDV), extravascular
lung water (EVLW), and a pulmonary vascular per-
meability index (PVPI) from transpulmonary ther-
modilution [1].
TPT and PAC derived CO in ICU patients has
been reported to correlate well [17]. TPT can track
changes in CO as low as 12% when at least three cold
boluses are used [18]. TPT measures left heart CO
while PAC measures right heart CO. However, TPT
measured CO becomes unreliable in severe valvular
regurgitation, therapeutic hypothermia, leak in cir-
cuit, extra corporeal membrane oxygenator, and
low CO state (<2 l/min) [19]. Patients with pulmo-
nary edema may be difficult to assess reliably as they
are exposed to indicator recirculation. Other tech-
nical limitations include crosstalk phenomena,
when the central line is placed on the femoral vein
on the same side of the arterial cannula [20]. Finally,
one of the significant limitations of TPT is its inter-
mittent measurement which means it will not allow
for the detection of short-term changes.
MINIMALLY INVASIVE
Arterial pulse analysis
Pulse power analysis (lithium dilution
technique)
The LidCOplus (LidCO Ltd., Cambridge, UK) deter-
mines continuous real-time CO changes based on
the pulse power analysis through the pulse CO
algorithm and uses lithium dilution for periodic
and initial calibration. For initial calibration lithium
is injected via a peripheral or central line and ana-
lyzed peripherally by a lithium analyzer sensor on
an arterial line to measure a washout curve over
time. Recalibration is necessary if an intervention
changes peripheral vascular resistance or notable
&
hemodynamic changes occur [21 ]. Lithium dilu-
tion measurements of CO correlate well with PAC
thermodilution and are considerably less invasive.
Lithium dilution technique cannot be used in
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bodyweight <40 kg, first trimester of pregnancy,
during coronary artery bypass grafting, when there
is clamping and unclamping of the aorta, patient on
lithium therapy, renal failure, and high doses of
nondepolarizing muscle relaxants may lead to over-
estimation of CO [22].
Pulse wave analysis
The commercial systems based on the pulse wave
analysis (PWA) method are of two types: auto/non-
calibrated and externally calibrated. The Volume-
View system (Edwards Lifesciences, USA), the PiCCO
system (Pulsion Medical Systems, Germany) and Flo
Trac sensor (Edwards Lifesciences, USA) measures
CO based on invasive arterial pulse waveform anal-
ysis. VolumeView system and PiCCO use thermistor
tipped femoral artery catheter and a central venous
catheter for TPT CO measurements for calibration.
The Flo Trac is externally calibrated using a CO value
measured by another method such as echocardiog-
raphy [1]. These devices can produce similar CO
values to PAC in patients with stable rhythm and
respiratory pattern but do not correlate well in a
dynamic situation when the patient requires signif-
icant inotropic or vasopressor support [16].
Esophageal Doppler monitoring
Esophageal Doppler monitoring (EDM) was intro-
duced in the 1970s for CO monitoring as minimally
invasive technology. The ultrasound waves emitted
by the probe inserted into esophagus measures the
velocity time integral (VTI) and the stroke distance
from red cell velocity in the aorta using Doppler’s
principle. Hence, any alignment error between the
ultrasound beam and blood flow is a potential
source of error. CO is measured by multiplying
VTI with the cross-sectional area (CSA) of aorta
and heart rate. CSA can be obtained directly using
ultrasound M-mode or from nomogram based on
age, height, and weight [23].
The National Institute for Health and Clinical
Excellence (NICE) guidelines supported the use of
EDM to assess CO in primary, complex or high-risk
surgical procedures based on the data suggesting a
reduction in postoperative complications, reduced
hospital stay and less use of central venous lines
[24]. EDM limitations include operator dependent
result variability of 10–12%, variability in aortic
CSA or nomogram may lead to incorrect calcula-
tions, in hemodynamically unstable patients the
assumption of fixed blood flow between the proxi-
mal and distal Aorta might be erroneous, and probe
misalignment of more than 208 leads to poor accu-
racy [25].
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Cardiac output monitoring -- invasive and noninvasive Arya et al.
NONINVASIVE MODALITIES
Pulse wave analysis
Noninvasive PWA uses surface sensors to continu-
ously record the arterial pulse waveform and use
algorithm based internal calibration to estimate CO
continuously like invasive pulse waveform analysis.
Noninvasive PWA systems are either based on the
volume clamp method using a finger-cuff or on
automated radial artery applanation tonometry
using a sensor placed on the skin over the radial
artery [26].
Volume clamp method
Clear- Sight system (Edwards Lifesciences, Irvine,
CA, USA) and CNAP system (CNSystems Medizin-
technik, Graz, Austria) are finger cuff systems that
analyze the arterial pulse waveform coupled with an
algorithm that incorporates biometric and demo-
graphic data to assess CO. Using an inflatable finger
cuff and an infrared plethysmograph the blood
pressure waveform is indirectly constructed contin-
uously and analyzed using PWA to calculate the CO
[27].
Volume clamp method derived CO is inaccurate
in patients with severe peripheral edema, hypother-
mia, circulatory shock, severe vasoconstriction, or
high doses of vasopressors because the recording of
blood pressure waveform is not immaculate [28].
Automated radial artery applanation
tonometry
The T-Line system (Shanshi Medical, Shangqiu,
China) and the DMP-Life system (DAEYOMEDI
Co., Ansan, South Korea) use this principle to obtain
a blood pressure waveform from a superficial artery
running over a bony structure by using a sensor that
applanates (i.e., flattens) the artery. The arterial
pressure waveform thus obtained is analyzed using
PWA to extrapolate CO. T-Line system uses a sensor
included in a bracelet that electromechanically
adjusts sensor position and the DMP-Life system
uses an array of piezoresistive semiconductor trans-
ducer sensors [26]. The measurement of CO is
dependent upon proper positioning of the probe
on artery and even slight motion artifact results in
false readings.
A recent systemic review and meta-analysis on
the agreement of continuous noninvasive finger
cuff technology-derived CO with reference methods
of invasive CO measurements in adult surgical or
critically ill patients indicated that CO measure-
ments using noninvasive finger cuff technologies
and invasive reference methods are not interchange-
able [29]. In critically ill patients, absolute CO
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measurement by internally calibrated or uncali-
brated PWA systems may become unreliable because
of marked alterations in vasomotor tone. The non-
invasive PWA systems are not recommended in
critically ill patients with shock because these
patients will be equipped with an arterial catheter
&&
anyway [30 ].
Thoracic bioimpedence and bioreactance
Bioimpedance technology computes CO based on
the assumption that thoracic impedance changes
over time are proportional to the stroke volume [31].
The difference between the applied high frequency
voltage and the detected voltage are used to deter-
mine alteration in the transthoracic impedance.
Bioreactance is a modification of bioimpedance
which measures phase shifts of an oscillating cur-
rent that occur when it traverses the thorax. These
phase shifts only occur due to pulsatile flow and are
not altered by the amount of thoracic fluids, thus,
improving signal-to-noise ratio [31].
CO measurement in intubated cardiac surgical
patients by bioimpedance did not have acceptable
accuracy or trending ability when compared to
thermodilution-based continuous CO monitor
[32]. A recent meta-analysis found modest agree-
ment and inadequate percentage error for bioimpe-
dance, putting question marks on its accuracy. With
a wide percentage error, completely noninvasive CO
devices are not interchangeable with bolus thermo-
&
dilution [33 ]. Electrical interference of other devi-
ces and increased lung water renders these devices
ineffective in measuring CO in critically ill patients,
leading to lack of widespread use in ICU [34].
In surgical patients, SV values obtained by bio-
reactance showed neither clinically nor statistically
acceptable agreement with those obtained by esoph-
ageal Doppler [35]. The NICOM study specifically
evaluated the use of bioreactance for cardiogenic
shock patients and showed poor correlation com-
pared to both Fick and PAC thermodilution [36].
Potentially, the poor correlation of bioreactance
may be related to the thoracic fluid overload and
low flow state seen in cardiogenic shock patients
affecting such impedance-based measurements.
Pulse wave transit time
Pulse wave transit time is the time between the R-
wave in the electrocardiogram and the pulse wave
rise-point assessed by pulse oximetry. The esCCO
technology (Nihon Kohden, Tokyo, Japan) provides
noninvasive continuous CO readings assessed by
analysis of the electrocardiogram, pulse oximeter-
derived waveform, and arterial pressure.
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Cardiopulmonary monitoring
Despite reasonable trending ability, esCCO
demonstrated poor accuracy and precision as com-
pared to invasive TPT CO monitoring in patients
undergoing cardiac surgery and liver transplant sur-
gery, where monitoring CO is valuable in clinical
decision making [37,38]. Similarly, in ICU patients,
esCCO was not able to track changes in CO that were
induced by an increase in preload or by variations in
vasomotor tone [39].
Partial carbon dioxide rebreathing
This method calculates CO by modified Fick’s prin-
ciple and uses expired carbon dioxide (CO2) as an
indicator. NICO (Philips Respironics, Eindhoven,
The Netherlands) and INNOCOR (Innovision ApS,
Glamsbjerg, Denmark) use this technique. The per-
centage error of 40–49% reported by a validation
study and a meta-analysis makes them unsuitable
for the clinical use in intensive care [40,41]. Meas-
urements can be influenced by a nonsteady respira-
tory state (partial mechanical ventilation support),
an insufficiently sealed airway, intrapulmonary
shunting, atelectasis, and severe gas exchange
abnormalities, all of which are present in ICU
patients [42].
Transthoracic Doppler
USCOM (USCOM Ltd., Sydney, Australia) is a non-
invasive, continuous-wave Doppler monitor that
can be used to measure CO via a probe applied to
the suprasternal notch (trans-aortic flow, left heart
CO) or to the left sternal edge (trans-pulmonary
flow, Right heart CO). A flow profile VTI thus
obtained multiplied by the CSA of the target valve
is used to calculate the SV. The software accompa-
nying the device incorporates a nomogram that
estimates the valve CSA from height-indexed regres-
sion equations [43]. A meta-analysis of 10 studies
found that the pooled weighted percentage error
(relative to bolus thermodilution) attained by the
USCOM was 42.7%. It did not achieve a percentage
error of agreement with bolus thermodilution of
30%, which is criterion for acceptability of preci-
sion [44]. In an observational study, USCOM
showed a very strong correlation for the SV mea-
sured by it and by echocardiography in ICU patients
implying that CO derived could be operator depen-
dent [45].
Critical care echocardiography
Recently, echocardiography has become an essential
bedside tool for hemodynamic monitoring in real
&
time in ICU [46 ]. Critical care echocardiography
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(CCE) can be both a diagnostic tool as well as a CO
monitor. Transthoracic echocardiography (TTE) is
the most used method, but transesophageal echo-
cardiography (TEE) can be useful especially in intu-
&&
bated and ventilated patients [47 ]. CCE can be
used to measure CO and reliably tracking its changes
[48]. But reliable use of these tools needs compe-
tently trained clinicians.
In severely ill pregnant women TTE CO meas-
urements showed excellent agreement with those
obtained by PAC [49]. In critically ill mechanically
ventilated patients, TTE is an accurate and precise
method for estimating CO and significantly corre-
lates with PAC with a percentage error of 25% [50].
Given its noninvasive nature and availability, TTE
could be considered as a reference for the validation
of other CO techniques in future.
A specific training focused on Doppler and VTI
determination added to the standard basic TTE
training allows noncardiologist ICU physicians to
achieve a quick, reproducible, and accurate snap-
shot of CO assessment in most mechanically venti-
lated patients [51]. CCE has numerous advantages
over PAC but is operator dependent. Hence, CCE
can be complementary to PAC rather than being
exclusive in patients with septic shock who require
advanced hemodynamic monitoring [52]. CCE cer-
tification is offered by American society of echocar-
diography and despite widespread and increasing
use of ultrasound in ICUs, most countries lack a
formal training program and clearly defined com-
petencies in CCE [53]. Recently, European Society of
Intensive Care Medicine has published recommen-
dations for core critical care ultrasound competen-
cies as a part of specialist training in
&
multidisciplinary intensive care [54 ].
Comparison of various CO devices is compli-
cated due to CO being a highly dynamic variable
that changes quickly within a wide normal range.
Hence, it is important for clinicians to know the
basic principles of CO monitoring devices to under-
stand their clinical applicability and inherent limi-
tations. In addition, clinicians should recognize the
basis of how to assess a new monitoring technology
&
against a reference method [55 ].
CONCLUSION
PAC thermodilution is still the gold standard, and it
is making a comeback into clinical practice, espe-
cially in cardiac ICUs. CCE is a unique noninvasive
modality that offers an alternative to thermodilu-
tion by its accuracy, noninvasiveness and differen-
tial diagnostic value. Most noninvasive modalities
require further evidence of accuracy and reliability
to recommend in routine practice. Clinical
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MCC 280303
Cardiac output monitoring -- invasive and noninvasive Arya et al.
presentation, access to technology and practi-
tioner’s experience will be the main determining
factors in CO monitor selection.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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