Flow vs Pressure
Many different technologies have been used for Cardiac Output monitoring. However, the two most utilized are direct flow measurement using Doppler ultrasound and flow derived from mathematical algorithms using arterial blood pressure (ABP).
Direct flow measurement, by way of Doppler ultrasound, has the precision and responsiveness to guide Intraoperative Fluid Management (IOFM) using the clinically proven >10% change Stroke Volume Optimization (SVO) algorithm. Direct flow requires no additional calibration. Direct flow measurement by Doppler requires occasional focussing and in some scenarios, the signal is not always continuously available, making the technology less ideal for long term continuous monitoring. However, the EDM+, which utilises both flow and pressure measurements, ensures continuous access to calibrated waveforms.
Pressure based technologies, using pressure as a surrogate for flow, have their limitations, particularly in periods of hemodynamic instability. Pressured based methods using ABP lines have been shown to be prone to drift due to changes in vascular tone, arterial compliance and the consequent arterial blood pressure variation. These changes have been reported to be clinically significant and prevent such devices from successful use of the >10% SVO algorithm. As a result, such devices offer Pulse Pressure Variation and/or Stroke Volume Variation as their modality for guiding intervention.
These parameters have significant limitations in use as they require the patient to be:
- in sinus rythm;
- fully mechanically ventilated;
- tidal volume ≥7-8 mL/kg – higher tidal volumes elicit higher variations;
- heart rate:respiratory rate ratio ≥4;
- increasing PEEP results in higher variations;
- changes in lung or chest compliance, or patient position and right ventricular dysfunction or abdominal insufflation may affect readings.
In periods where the patient has stable hemodynamics, pressure based technologies can be used to make a continuous record of cardiac output.
The direct flow Doppler EDM, is preferred for guidance of intervention with fluid and drugs. EDM can do this effectively in the hemodynamically challenging environment of the Operating Theatre, where anesthesia and surgery result in rapid and frequent changes in compliance. Pressure based technologies are useful in stable postoperative patients but are limited in their ability to guide interventional treatment. A combination of both technologies, EDM+ is the best of both worlds.