esCCO Case Report Vol.

3

Comparison oftrend performance of esCCOand APCO in
kidney transplantation
Submitted by:Takashi Terada, M.D., Ryoichi Ochiai, M.D.
First Department of Anesthesiology, Omori Medical Center, Toho University School of Medicine, Tokyo, Japan

Introduction

with the arterial pressure-based cardiac output (APCO)

Perioperative goal directed therapy (GDT) based

In this case report, we evaluated the performance ofon measurement of stroke volume (SV) is expected

non-invasively measured esCCO to trend changes inby referring to other papers3）.

to improve postoperative outcome . A device that

SV as compared to APCO (FloTrac/Vigileo, Edwards

can accurately measure stroke volume (SV) during

Lifesciences, Irvine, CA, USA).

1）

surgery and that is both minimally-invasive and low
cost is ideal. Many methods have been developed tomeasure SV less-invasively and continuously; pulse
contour and intrathoracic impedance methods have

Materials and methods
Adult patients scheduled for kidney transplantation

been widely used in clinical practice.

and able to provide informed consent were enrolled

Estimated continuous cardiac output (esCCO, Nihon

in the evaluation.

Kohden Corporation, Tokyo, Japan) is a technologythat continuously and non-invasively measures SVAnesthesia management

based on pulse wave transit time (PWTT), and uses

The surgery was performed under general andonly information derived from the electrocardiogram

epidural anesthesia. Anesthesia was induced with 2(ECG), pulse oximeter (SpO2) and blood pressure. Withμ/kg of fentanyl citrate, 2 mg/kg of propofol, andesCCO, continuous SV is available in surgeries where

0.8 mg/kg rocuronium bromide and maintained

ECG, SpO2 and blood pressure are measured.

with continuous infusion of sevoflurane (1.0-2.0%)

esCCO has been evaluated in a multi-center study

and remifentanil hydrochloride (0.05-0.5 mcg/kg/

involving 7 facilities in Japan. In the multi-centermin) and intermittent administration of rocuronium

study, Yamada, et. al. used intermittent cold bolus

bromide. In addition to measurements of ECG, SpO2

thermodilution (ICO) for initial calibration andby pulse oximetry, rectal temperature, and end-compared esCCO with ICO . They concluded thattidal carbon dioxide (etCO2), radial artery and central

the accuracy of esCCO is clinically comparable to ICO,

venous catheters were inserted after the induction of

but commented that esCCO could not be considered

anesthesia.

2）

self-contained and non-invasive because an invasive
method is used for initial calibration2）. Ishihara, et al.

Fluid management

reported on the performance of esCCO calibrated

The fluid management was guided by the kidneynon-invasively with patient’s demographic data.

transplantation protocol of our facility. After induction

The authors suggested that the ability of esCCO toof anesthesia, fluid of 5 mL/kg + amount of bleeding ×

measure trends in cardiac output (CO) is comparable

3 mL was given until a graft bed was prepared. APCO

was monitored during fluid challenge to maintain CVP

kidney, before artery clamping, and at the end of

at 15 mmHg without decreasing SV from the timesurgery. esCCO was calibrated non-invasively usingof initiation of suture of grafted kidney to the arterial

information of patient demographics.

declamping (artery reperfusion).

Case reports

Comparison of esCCO and APCO
esCCO and APCO were compared after induction

Case 1:of anesthesia, before the start of suture of grafted

55 years old female with height of 153 cm and weight

20025

esCCO

15100
1050

HR20150

5APCO
esCCO

0
10：00

11：00

12：00

13：00
Time

14：00

15：00

0
16：00

200

esCCO

ART-Sys

CO［L/min］

HR, SYS, DIA［bpm, mmHg］

APCO

25ART-Dia

APCO

Arterialanastomosis

HRART-Sys

Venousanastomosis

ART-Mean

Carperitide

Arterialanastomosis

Dopaminehydrochloride

Venousanastomosis

Ephedrine

Carperitide

Figure 1.

Dopaminehydrochlorid

Trend graph of case 1

Ephedrine

esCCO

15100
1050HR

20150

esCCO

5APCO

09：00

ART-Sys

CO［L/min］

HR, SYS, DIA［bpm, mmHg］

APCO

10：00

11：00

12：00

13：00
Time

14：00

15：00

16：00

200025esCCO

ART-Dia

APCO

Arterialanastomosis

HRART-Sys

Venousanastomosis

ART-Dia

Carperitide

Arterialanastomosis

Dopaminehydrochloride

Venousanastomosis

Phenylephrine

Carperitide

Figure 2.

Dopaminehydrochloride

Trend graph of case 2

Phenylephrine

esCCO

APCO

10esCCOART-Sys

CO［L/min］

15100

HR

20150

ART-Dia
Arterialanastomosis
Venousanastomosis
Carperitide

505Dopaminehydrochloride
Ephedrine

09：00

10：0011：00

12：00
Time

13：00

14：00

15：00

0Figure 3.

Trend graph of case 3

CO［L/min］

HR, SYS, DIA［bpm, mmHg］

APCO

esCCO Case Report Vol.

3of 42.7 kg. APCO and esCCO were 3.4 L/min and 2.9 L/

reperfusion injury after the grafted kidney is sutured.

min after the induction of anesthesia, 5.0 L/min andIn our facility, we use APCO to less-invasively measure

5.5 L/min before the initiation of suture of grafted

CO for fluid management. In Japan, APCO is widely

kidney, 6.3 L/min and 8.8 L/min before the arteryused to monitor SV during surgeries because: (1) theclamping (artery reperfusion) after the fluid challenge,

accuracy of APCO has been shown to be clinicallyand 2.9 L/min and 3.4 L/min at the end of the surgery,

acceptable4）, (2) it is less-invasive, and (3) it is easy torespectively.

use.

Case 2:during kidney transplantation in patients where

In these case reports, we compared APCO and esCCO
36 years old male with height of 182 cm and weight

hemodynamics changed significantly. These casesof 90.5 kg. APCO and esCCO were 3.9 L/min and 5.1 L/show the performance of esCCO to track changes in

min after the induction of anesthesia, 8.7 L/min andCO when compared to APCO (Fig.1-3).

10.1 L/min before the initiation of suture of grafted

esCCO non-invasively estimates CO based on PWTT,

kidney, 16.0 L/min and 20.0 L/min before the arterywhich is calculated as the time measured from a peak

clamping (artery reperfusion) after the fluid challenge,of ECG R-wave to a rise point of pulse wave measured

and 13.7 L/min and 13.5 L/min at the end of theby pulse oximetry2）. The principle of esCCO is based

surgery, respectively.

on combination of the Windkessel model5）and PWTT
to estimate CO non-invasively 6, 7）. For details, refer toCase 3:Appendix.

31 years old male with height of 180 cm and weight

Multiple regression analysis was used to formulateof 93.8 kg. APCO and esCCO were 6.5 L/min and 4.7 L/

the patient information CO calibration using patient

min after the induction of anesthesia, 7.3 L/min anddemographic data, including age, gender, height,

6.5 L/min before the initiation of suture of grafted

and body weight as well as blood pressure, heart ratekidney, 14.3 L/min and 12.0 L/min before the arteryand PWTT at the corresponding time-points3）. esCCO

clamping (artery reperfusion) after the fluid challenge,

calibrated with patient’s demographic data is totallyand 7.4 L/min and 7.4 L/min at the end of the surgery,

non-invasive, so it is expected that the application

respectively.

of esCCO may be expanded to a broader clinicalpopulation.

As shown in a trendgraph of each case, the measured

The pulse contour and impedance methods areesCCO shows strong agreement with APCO

well established as less-invasive measurements ofthroughout the surgery in all cases.

SV, and APCO is especially popular, based partly
on reports demonstrating better accuracy of APCO

Discussion

compared to impedance method. APCO is based

Perioperative fluid optimization based on SV can lead

esCCO is based on PWTT. While APCO requires radial

to reduced hospital stay, reduced occurrence andartery catheterization, esCCO can be non-invasively

associated complications of postoperative nausea andmeasured only by measuring ECG, SpO2 and bloodon the pulse contour analysis, and the principle ofvomiting (PONV), and faster postoperative recovery ofpressures without additional sensors. Perioperative SV

gastrointestinal function1）. The only adequately tested

monitoring is believed to improve the quality of careand recommended CO monitor for goal directedin patients undergoing surgery; esCCO can provide

therapy is oesophageal Doppler, but there are otherflow-related parameters such as SV and CO as derived

CO monitors that may be useful and should beby routinely measured parameters and be useful toevaluated .

guide intraoperative goal directed fluid therapy.

In kidney transplantation, it is necessary to keep

To establish the clinical benefits of esCCO in GDT, we1）

blood pressure and CO at adequate levels to maintainwill continue to evaluate esCCO, focusing on the fluid

good kidney perfusion in order to prevent ischemic

responsiveness of esCCO.

esCCO Case Report Vol.

Appendix: Theoretical background3

following linear regression equation:

PWTT measures the time from the peak of the ECG
R-wave to the point where the pulse oximeter wave
reaches to the periphery, which is defined as the timeSV = αʼ× (PEP + PWTT1 + PWTT2) + βʼ
= αʼ× PWTT +βʼ
At least 2 pairs of SV and PWTT are needed to calculate

when the differentiated pulse wave reaches 30% of its

αʼ and βʼ, and both should be collected when SVpeak amplitude and described as PWTT by Ochiai etchanges. However, it is not practical to change SVal6) (Fig.4). PWTT is a sum of pre-ejection period (PEP),for calibration 8）. The following equation completes

pulse wave transit time from ascending aorta throughcalibration with a single SV measurement, as shown

radial artery (PWTT1) and pulse wave transit time fromto be the most accurate in an animal study8）:

PWTT1 through to the peripheral measurement site
(PWTT2).

SV = K × (α × PWTT +β)

Theoretically, each of the time components have an, where α is a fixed value and K and β are individualized

inverse correlation with SV , so a linear approximationfor each patient.

8）

can be considered. Thus, SV is expressed by theECG
Ascending aorta

PEPRadial artery

PWTT1
PWTT2

Pulse oximeter
waveFigure 4.
PWTTComponents of PWTT
PWTT = PEP + PWTT1 + PWTT2References1）Bundgaard-Nielsen M et al. Monitoring of peri-operative fluid
administration by individualized goal-directed therapy. Acta
Anaesthesiol Scand. 2007 Mar;51(3): 331-402）Yamada T et al. Multicenter study verifying a method of noninvasive continuous cardiac output measurement using pulse
wave transit time. A comparison with intermittent bolus
thermodilution cardiac output. Anesth Analg 2012; 115: 82-873）Ishihara H et al. The ability of a new continuous cardiac
output monitor to measure trends in cardiac output following
implementation of a patient information calibration and anautomated exclusion algorithm. J Clin Monit Comput. 2012
Dec; 26(6): 465-71
4）Terada T et al. Semi-invasive monitoring of cardiac output inrenal transplantation by a new device using arterial pressure
waveform analysis compare with intermittent pulmonary
thermodilution. Masui. 2010 Jul; 59 (7): 897-901  (Article in8758 SP63-020A ’16. 7. CLB. e

Japanese with English abstract)5）Manning TS, Shykoff BE, Izzo JL. Validity and Reliability ofDiastolic Pulse Contour Analysis (Windkessel Model) in
Humans. Hypertension 2002; 39: 963-86）Ochiai R, Takeda J, Hosaka H, et al. The relationship between
modified pulse wave transit time and cardiovascular changes
in isoflurane anesthetized dogs. J Clin Monit Comput 1999; 15:493-5017）Sugo Y. Ochiai R. Inclusion of the Pre-ejection Period in thePulse Wave Transit Time in a Cardiac Output Monitoring
Method. Therapeutic Research 2012; 33 1583-1591 (Article inJapanese with English abstract)8）Sugo Y, et al. A novel continuous cardiac output monitor basedon pulse wave transit time. Conf Proc IEEE Eng Med Biol Soc.
2010, pp.2853-2856