Academic Resource

Case Report

Experience with esCCO in Surgery in Elderly Patients
esCCO is a new parameter to estimate and continuously display
cardiac output (CO) and stroke volume (SV) by using pulse
waves obtained by pulse oximetry, electrocardiograms, andblood pressure* on a biological information monitor.

Chief, Department of Anesthesiology,
Ube Kosan Central Hospital,
Yamaguchi, Japan

Yasuhiro Morimoto, MD*Either invasive or non-invasive measurements of blood pressure may be used.

This report describes the hemodynamic management withmonitoring of esCCO during surgery in elderly patients.

Background

Elderly people are generally known to have an increased risk associated with anesthesia due to age-related multiple
underlying diseases or decreased defenses against invasion. Therefore, careful monitoring of patient status isimportant in the anesthetic management of the elderly patients.
Estimated Continuous Cardiac Output (esCCO) is a non-invasive continuous cardiac output monitor that uses thenegative correlation between stroke volume (SV) and Pulse Wave Transit Time (PWTT), which is determined on
the time from the ECG R-wave to the rise point of the pulse oximeter wave and provides a continuous display ofhemodynamic changes.
In addition, the cardiac index (CI) and stroke volume index (SVI) can be simultaneously measured as the EstimatedContinuous Cardiac Index (esCCI) and Estimated Stroke Volume Index (esSVI), respectively.
esCCO requires calibration at the start of measurement. Calibration can be performed in two modes: a mode using
values obtained by other CO measuring devices and a mode using patient information. Pulse pressure is involved inboth modes. This report describes cases of brain and colon resection surgeries in which hemodynamics was managedwith monitoring of the esCCO, which was calibrated using patient information and radial artery pulse pressure.

CaseCase 1
A 68-year-old man with a height of 170 cm
and a body weight of 64 kg was scheduled toundergo superficial temporal artery—middlecerebral artery anastomosis. Although thepatient had no other concurrent conditions
than hypertension, careful management wasnecessary for the hemodynamic changes
during general anesthesia because of a historyof repeated episodes of cerebral ischemicsymptoms. Anesthesia was introduced withpropofol and maintained with sevoflurane andremifentanil. During the surgery, the systolicblood pressure was maintained at ≥100 mmHg,
but the esCCI was decreased to 1.9 L/min.
Continuous infusion of dopamine was therefore
initiated at 5 μg/kg/min. Following the initiation
Figure 1 esCCO monitoring in Case 1of dopamine, the esCCI increased to ≥2.2 L/
min. The recovery after general anesthesia was rapid, and no neurological disorder was observed. During surgery, CO
measurement by arterial pressure waveform analysis (Arterial Pressure-based Cardiac Index: APCI) was also used.
Both measurements were correlated with an R-value of 0.55 (n = 24) (Figure 1).

Discussion

Case 1
During the neurosurgical surgery in patients with cerebral ischemia, maintaining cerebral blood flow is important.
Although arterial pressure is usually monitored during surgery to maintain hemodynamics, a decrease in esCCI wasalso used as a guide for administration of vasoactive drugs in this case. Administration of dopamine and ephedrine
led to increases in esCCI and blood pressure, resulting in appropriate maintenance of hemodynamics.
Hemodynamic management with monitoring of esCCO is useful during the neurosurgical surgery.

esCCO Case Report

Case

Case 2
A 95-year-old woman with a height of 149 cm
and a body weight of 27 kg was scheduled toundergo colon resection for transverse coloncancer. The patient had cognitive impairment
but no other medical history. Preoperative
echocardiography found mild mitral regurgitation
but cardiac function was preserved with anejection fraction of 71%.
Anesthesia was introduced with propofol andmaintained with desflurane and remifentanil
with tracheal intubation. Bilateral subcostal TAP
block was performed. The esCCI was 3.2 L/minat the start of measurement and ranged from 2.9
to 3.8 L/min with no significant change duringsurgery. Arterial Pulse Pressure Variation (PPV)
Figure 2 esCCO monitoring in Case 2
was monitored, and 200 mL of Voluven® wasadministered at the time when arterial PPV was ≥10%. The postoperative course was favorable (Figure 2).

Discussion

Case 2In laparotomy in elderly patients, appropriate management of intraoperative fluid volume is necessary and is
performed by monitoring of cardiac output as well as fluid volume with urine volume or PPV. The patient monitor
used in our institution can calculate PPV using arterial pressure measurements. Arterial pressure measurement andesCCI or PPV monitoring were used as a guide for administration of Voluven®. Use of esCCI and PPV as guides
allowed appropriate fluid management, and maintenance of hemodynamics led to a favorable postoperative course.

Summary

Anesthetic management in elderly patients requires management appropriate for the various risks, including
surgical procedures and medical histories. I had the opportunity to use the new technology esCCO in these cases. Incase 1, esCCO guided administration of the vasoactive drugs, whereas a combination of esCCO and PPV allowed
appropriate fluid management in case 2.
In surgery in elderly patients with high surgical risk, it is desired to monitor more biological information in a
non-invasive manner to ensure safe surgery. In particular, the esCCO technology, which provides cardiac output
monitoring by using routinely used parameters of ECG, SpO2 (pulse wave), and blood pressure without requiringadditional devices, is of great value in both clinical aspects and patient safety.
In the context of a growing number of elderly people, esCCO monitoring is also expected to lead to improvement in
the safety of brief surgeries in which blood pressure is managed with NIBP without using arterial pressure and which
will grow in number.
Routine use of esCCO allows us to be prepared for unforeseen situations of sudden hypotension and may therefore
lead to safe anesthetic management in elderly patients.

Points of use of esCCO

1. Guide for administration of vasoactive drugs and evaluation of hemodynamics
2. Realization of appropriate fluid management in combination with PPV
3. Improvement in safety of brief surgeries in combination with NIBP
4. Tool for preparedness for unforeseen emergencies

Future expectation

Further accumulation of cases is necessary to determine what cases are benefited and to evaluate the reliability ofthis technology in very elderly patients. Monitoring of estimated stroke volume variation (esSVV) by a non-invasive
method based on stroke volume is desired. In addition, it is likely that this technology can also be used in non-sedated
patients. As CO and SV can be measured using usual monitoring parameters, the technology can be probably used as
first touch in cardiac function assessment in postoperative care or emergency room settings.
This material is a summary of the presentation given at the 32nd Annual Meeting of the Japan Society for Geriatric Anesthesia with the permission of the Japan Geriatrics Society.

10208 SP70-0020 '21. 1. CLB. PDF