esCCO Case Report Vol.

1

Hemodynamic Management
Using EstimatedContinuous Cardiac Output (esCCO)
during Kidney Transplantation in a Patientwith Hypertrophic Cardiomyopathy
Submitted by:

Takashi Terada, Ryoichi OchiaiFirst Department of Anesthesiology, Omori Medical Center, Toho University School of Medicine, Tokyo, Japan* This case was presented at the 29th Annual Meeting of Japan Society for Clinical Anesthesia, 2009,
and the 37th Congress of the Japanese Society of Intensive Care Medicine, 2010.

Introduction

Continuous information of the peripheral vascular
resistance provided by esSVRI was especially useful.

In pediatric kidney transplantation, it is important tosupply sufficient oxygen to prevent ischemic damage
to the grafted kidney. Consequently, adequate volumeof fluid infusion is required throughout and after

Preoperative Diagnosis

the transplant surgery. In patients with hypertrophic

A 14 year-old male child with a height of 145 cm

cardiomyopathy（HCM）,increased cardiac contractility

and a weight of 31 kg was scheduled to undergo

could lead to obstruction of left ventricular outflow,secondary transplantation from an ABO-incompatible

and eventually induce heart failure. In this study, wedonor（patient’s mother）. A chest X-ray revealed CTR

used estimated continuous cardiac output（esCCO）

50% and echocardiography confirmed anteroseptal

derived from pulse wave transit time（PWTT）tohypertrophy measuring up to 36.6 mm. Thus

adequately manage the circulation of a patient withthe patient was diagnosed with hypertrophic

HCM. Also, estimated systemic vascular resistancecardiomyopathy with left ventricular outflow tract

index（ esSVRI）was calculated by using esCCO.

obstruction（Fig.1）.

Figure 1.

Preoperative
echocardiogramAsymmetric septal hypertrophy.
Significant anteroseptal
hypertrophy measured up to36.6 mm is observed. ROVT
observed left ventricle septal
flattening. ASH is observed.

Anesthesia Course during
Transplantationechocardiography（TEE）, and estimated continuous

Due to the ABO-incompatibility, double filtration

guidance via right internal jugular vein. esCCO

plasmapheresis was performed and the antibody level

was calibrated by comparison with intermittent

was reduced to 8 before admission to the operating

thermodilution cardiac output（ICO）.

cardiac output（esCCO, Nihon Kohden Corporation,Japan）.The PAC was inserted with echocardiographic

room. Anesthesia was induced with fentanyl, propofol
and rocuronium, and maintained with air-oxygen-

After starting the surgery, TEE showed an increase

sevoflurane, rocuronium and remifentanil. In additionof left ventricular outflow gradient（increased bloodto standard monitoring, we used a pulmonary artery

velocity）, which required continuous administration

catheter（ PAC, 5 Fr Swan-Ganz® thermodilutionof noradrenaline at a rate of 0.05 μg/kg/min tocatheter, Edwards Lifesciences, USA）,transesophageal

prevent progression of stenosis（Fig.2, a）. The esSVRI

SPAP, DPAP, CVP［mmHg］

b c
Aneasthesia
start / stop

SEVO
N-Ad

200

Intubation
Surgery
start / complete

150

Extubation

100Figure 2.

HR

Anesthesia course

SBPa: TEE observed stenosis
b: TEE confirmed MRc: observation of first urine
HR: heart rate
SBP : systolic blood pressure
DBP : diastolic blood pressure
SEVO : sevoflurane
N-Ad : noradrenaline

DBP

50
09：00

esSVRI［dyn*sec/cm5/m2］

aArterial anastomosis

10：00

11：00

12：00a13：00
Time

14：00

15：00

16：00

b c

17：00

6SPAP50

5DPAP40

430

320

210

10
3000

060

CVP
esCCO
ICO

esSVRI

2000
1000
09：00

esCCO, ICO［L/min］

HR, SBP, DBP［bpm, mmHg］

250

10：00

11：00

12：00

13：00
Time

14：00

15：00

16：00

17：00

Figure 3.

Change in PAP, CVP,
and esCCOabc
SPAP: TEE observed stenosis: TEE confirmed MR: observation of first urine: s ystolic pulmonary
arterial pressure
DPAP : d iastolic pulmonary
arterial pressure
CVP : c entral venous pressureesCCO : e stimated continuous
cardiac output
ICO: intermittent
thermodilution cardiacoutput
esSVRI : e stimated systemic
vascular resistance index

esCCO Case Report Vol.

12value at the time was 1500 dyn*sec/cm5/m（Fig.3,a）.

R-wave and fingertip pulse wave of a pulse oximeter,

Subsequently as fluid load increased, blood pressure

SV can be expressed by the following formula2）:increased. After the start of arterial anastomosis, TEE
showed tricuspid regurgitation（Fig.2, b）. The esSVRI
value at the time increased to 2300 dyn*sec/cm /m
5SV = K ×（α × PWTT + β）

2（Fig.3, b）. Tricuspid regurgitation was resolved uponwhere α is fixed to -0.3 which is optimally determineddecreasing the administration rate of noradrenaline

for an adult patient 3）. In contrast, K and β is

to 0.025 μg/kg/min. The esSVRI value at the time

determined by using several vital data obtained at the2c）. After
decreased to 1900 dyn*sec/cm5/m（Fig.3,time of calibration. After calibration, SV is continuously

that, the value was maintained at between 1500obtained by assigning PWTT sequentially to theto 1900 dyn*sec/cm5/m2. ICO was measured twice

above formula. Accordingly, esCCO is calculated byduring the surgery in addition to the calibration point

multiplying this SV by the patient’s heart rate. Since

and compared to esCCO. The first measurement

accuracy of esCCO in a pediatric patient has not beenof esCCO and ICO was 3.95 L and 4.3 L, and thefirmly established, we measured ICO intermittently

second was 3.66 L and 4.4 L. There was no significant

during the procedure to ensure consistency between

difference between esCCO and ICO. First urine output

ICO and esCCO.

was observed 8 minutes after reperfusion of thegraft（Fig.2, c）. The surgery was completed with anIn current clinical practice, not every catheter is madeanesthesia time of 7 hours 36 minutes, blood loss offor use in a pediatric patient, and the 5Fr Swan-Ganz

690 ml, total infusion volume of 3550 ml, and total

thermodilution catheter（ Edwards Lifesciences）

blood transfusion of 1280 ml.

used in this study is not capable of measuring CO
continuously. Furthermore, only limited methods
are available for measuring CO less or non-invasively

Discussionin pediatric patients. Bioimpedance method is

In a pediatric recipient undergoing kidneyin pediatric patients and shows superior accuracy totransplantation, the child heart has to supply oxygen

thermodilution in bias and precision4）. However, it isto the grafted adult kidney. Since oxygen supply

not recommended for intraoperative use, since thedepends on cardiac output（ CO）, it is essential

impedance cardiogram electrode should be placed

to maintain a relatively higher CO in a pediatricon the anterior chest and it is not suitable for long-recipient by postoperative fluid loading. In HCM,

term monitoring.

introduced as a means of measuring cardiac output

decrease in preload and afterload and enhanced
cardiac contractility may lead to the obstruction of

The monitoring of esCCO and esSVRI may be usefulleft ventricular outflow, reduction in blood pressure

as a continuous index for circulatory management.

and myocardial ischemia, and consequently result in

Although a good correlation was shown between

heart failure . In this study, it was critical to optimize

esCCO and ICO in adults5）, further study in pediatricafterload in terms of intraoperative circulatory

patients is still required to fully determine themanagement. As an index of afterload, we usedaccuracy of esCCO. When its accuracy is establishedesSVRI which was calculated by using esCCO andand precise calibration becomes available, esCCO andtargeted its range between 1500 dyn*sec/cm /m

2esSVRI will be useful in perioperative care monitoring

where increased left ventricular outflow gradient wasfor pediatric patients with heart disease undergoingobserved and 1900 dyn*sec/cm5/m2 where tricuspid

noncardiac surgery.

1）

5

regurgitation resolved.
Based on the fact that stroke volume（SV）is inversely
correlated with PWTT which is the time between ECG

esCCO Case Report Vol.

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