esCCO Case Report Vol.

2Anesthesia Management
Using EstimatedContinuous Cardiac Output (esCCO)
during Kidney Transplantation in a Pediatric Patient- Report of a Suspected Case of Severe Anaphylaxis
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 30th Annual Meeting of Japan Society for Clinical Anesthesia, 2010.

Introduction

Preoperative tests showed high levels of blood urea

There are several methods for continuously

12.05 mg/dl, and a low level of hemoglobin（Hgb）,

measuring cardiac outpu（t C O） i n p e d i a t r i c

8.4 g/dl. Chest X-ray and electrocardiograph（ECG）

nitrogen（BUN）, 33 mg/dl, and serum creatinine（Cr）

pa t ients , such as pulmonary artery catheter,

showed no sign of other abnormalities. Division of

intrathoracic impedance method, transesophageal

renal artery and vein, common iliac artery and veinechocardiogram, and PiCCO（PULSION Medical

was completed. An hour and 20 minutes later afterSystems, Germany）. However, all of these methods

the surgery started, while waiting for arrival of donor

require invasive procedures. Nihon Kohden

kidney, the patient experienced acute reduction ofCorporation（Tokyo, Japan）has developed a newblood pressure and esCCO（Fig.1, a）, and almost

method called Estimated Continuous Cardiac Output

at the same time, the CO 2 waveform（capnogram）（esCCO）for measuring cardiac output easily anddisappeared, resulting in a flat line. The patient also

non-invasively by using only ECG and pulse oximetry

had respiratory problems which eventually led tosignal. This report describes a suspected case oftracheal obstruction. Hemodynamic status remained

severe anaphylaxis in anesthesia management withunstable even after administration of ephedrine andesCCO during kidney transplantation surgery.

phenylephrine（Fig.1, b）. In the next 3 minutes, mild
flare reaction of chest and face was observed（Fig.1,c）so the patient was given 0.2 mg of intravenous

Case reportadrenaline and 250 mg of methylprednisolone（Fig.1,A 14 years and 11 months old male child with height

range and the normal capnogram appeared. Afterof 147 cm and weight of 30.3 kg was referred to us

that hemodynamics stayed stable and respiratory

for a kidney transplantation surgery. The patient wasstatus recovered. The donor kidney was successfullyd）.A minute later, blood pressure returned to normal

an extremely low birth weight infant with gestation

implanted and after the first urine was observed theperiod of 31 weeks and birth weight of 788 g. At

operation was completed. The patient was extubatedthe age of 2 years and 6 months, he was diagnosedin the operating room and then transferred to thewith focal glomerulosclerosis by renal biopsy, withICU.

indication of proteinuria. He has been maintainedon peritoneal since age 12. He was scheduled
to undergo kidney transplantation from a donor（patient’s mother）.

bcd

SBP
DBP

150

CVP-Mean
HR

100
50
0
12：00

12：10

12：20

12：30

12：40

12：50

13：00

100

Cdyn

50

0
12：00

12：10

12：20

12：30

12：40

12：50

13：00

500

10

250

5

0
12：00

12：10

12：20

12：30

12：40

12：50

esCCO［L/min］

Cdyn［mL/cmH2O］ HR, SBP, DBP, CVP［bpm, mmHg］

PWTT［ms］

a200

PWTT
esCCO

013：00

TimeFigure 1. Hemodynamic change during anaphylactic shocka : Acute reduction of blood pressure and esCCO
b : Administration of ephedrine and phenylephrinec : Flare reaction seen in chest and faced : Administration of adrenaline and methylprednisolone

SBP : systolic blood pressure
DBP : diastolic blood pressure
CVP : central venous pressure
HR : heart rate

Discussion

Cdyn : dynamic lung compliance
PWTT : pulse wave transit time
esCCO : estimated continuous cardiac output

Transesophageal echocardiography is less-invasive
and uses measurement of aortic valve surface area

Cardiac output measurement in severely ill pediatricand TVI（time velocity integral）of blood travel inpatients is considered to improve patient survival

the aorta. However, it requires highly advanced andrate, although it could involve risk of complications  

expert skills for precise measurement and it might

due to its invasiveness1）. With the improvement of

be too complicated for use during surgery. PiCCO istechnology, less-invasive cardiac output monitoring

another less-invasive method but requires catheter

is becoming available. For cardiac output monitoring,placement in the brachial or femoral artery. This

there are two prominent types of methods:

method is shown to be relatively precise in patients

continuous and intermittent. Intermittent monitoringwith stable hemodynamics3）4）, while its accuracy inmethods include thermodilution method using

patients with hemodynamic instabilities has not been

pulmonary artery catheter, and echocardiography2）,

established5）6）7）. The bioimpedance method requires

while continuous monitoring methods include

electrodes placed over the anterior thorax but this isDoppler method with transesophageal

likely to be affected by electrosurgical procedures soechocardiography, PiCCO based on the pulse

this method is restricted to certain surgeries.

contour method, and bioimpedance method using
ECG. Transesophageal echocardiography, PiCCOIn this reported case, we used esCCO（Nihonand bioimpedance methods are considered to be

Kohden, Japan）, which is designed to measure

relatively less-invasive.

cardiac output easily and non-invasively by using

esCCO Case Report Vol.

only ECG and pulse oximetry signal. Anaphylactic

PP = α × PWTT + β2（B）

shock usually accompanies decrease of peripheral
vascular resistance and increase of cardiac output.

where, α is a fixed value experimentally obtained

However in this case, the patient experienced shockfrom past studies8）10）. From the relationship between

with sudden decrease of blood pressure and esCCO.

PWTT and PP expressed by equation（B）,SV is derived

Almost at the same time, the patient experienced

from equation（C）, and β is determined by equation

acute reduction in lung compliance, such as（D）below.

disappearance of the capnogram and ventilatory
dysfunction. It appeared most likely that the patient

SV = K ×（α × PWTT ＋ β）

（C）

had severe bronchospasm. Air was trapped in theβ =（SV − K × α × PWTT）/ K（D）alveoli, intrathoracic pressure increased, blood flow
to left ventricular was blocked, and as a result blood

Not only the CO from the external device, CO derived

pressure and cardiac output suddenly decreased.

from patient information such as height and weight

After that, flare reaction was observed in thecan also be used for the calibration.

anterior chest and face. Blood pressure returnedto normal and the normal capnogram reappeared

It has been reported that there is a good correlation

after intravenous administration of adrenaline andbetween esCCO and intermittent thermodilution

methylprednisolone. This showed that the patient

cardiac output（ICO）in patients without arrhythmia

had severe bronchospasm followed by anaphylactic

who underwent cardiac surgery 8）. Calibration may

shock.

be the biggest challenge of esCCO. As mentioned
briefly above, esCCO has a patient information

This case indicates that esCCO would be especiallycalibration（Patient Info Cal）system which allows forhelpful to identify sudden changes in clinical status incompletely non-invasive CO measurement. The basis

patients with hemodynamic instabilities.

of the Patient Info Cal system is patient information
obtained from other clinical studies10）. Multivariate
analysis using patient’s age, gender, height, body

Brief Summary of esCCO Technology

weight as well as blood pressure, heart rate and

The esCCO algorithm calculates stroke volume（SV）

obtain CO value for Patient Info Cal. The accuracy ofcontinuously by using the negative correlation

esCCO calibrated with CO obtained by a pulmonary

between SV and pulse wave transit time（PWTT）

artery catheter has been shown to be clinicallywhich is determined based on the time from the ECG

applicable 8）. Also, the evaluation of the esCCO

R-wave peak to the rise point of the pulse oximeter

performance by Patient Info Cal and that of thePWTT at the initial calibration point was performed towave. According to the pulse contour method, SV

accuracy in pediatric patients are ongoing to expand

can be expressed as equation（A）9）:

its clinical application. In the near future, we expectthat esCCO will be established as a non-invasive andSV = K × pulse pressure（PP）（A）

convenient method for perioperative managementin pediatric surgeries through the further researches

At the calibration point, SV is determined by dividingthat confirm the performance of esCCO in pediatric

CO obtained from the external device by the heart

patients.

rate, and PP is determined based on blood pressure（invasive or non-invasive）. Then constant K isdetermined by assigning CO and PP at the calibration
point to the equation（A）. PP agrees with PWTT in ahemodynamically stable patient and is expressed asequation（B）:

esCCO Case Report Vol.

References
1） Hall JB. Searching for evidence to support pulmonary
artery catheter use in critically ill patients. JAMA. 2005 Oct
5; 294（13）:1693-4.
2） Skowno JJ, Broadhead M. Cardiac output measurementin pediatric anesthesia. Paediatr Anaesth. 2008 Nov; 18（11）:1019-28. Epub 2008 Aug 19.
3） de Wilde RB, Schreuder JJ, van den Berg PC, Jansen JR. An
evaluation of cardiac output by five arterial pulse contour
techniques during cardiac surgery. Anaesthesia. 2007Aug; 62（8）:760-8.
4） Calamandrei M, Mirabile L, Muschetta S, Gensini GF,De Simone L, Romano SM. Assessment of cardiac output inchildren: a comparison between the pressure recording
analytical method and Doppler echocardiography.
Pediatr Crit Care Med. 2008 May; 9（3）:310-2.
5） Bein B, Meybohm P, Cavus E, Renner J, Tonner PH,
Steinfath M, Scholz J, Doerges V. The reliability of pulse
contour-derived cardiac output during hemorrhage andafter vasopressor administration. Anesth Analg. 2007 Jul;
105（1）:107-13.

8752 SP61-007A ’16. 7. CLB. e26） Sujatha P, Mehta Y, Dhar A, Sarkar D, Meharwal ZS,Datt V. Comparison of cardiac output in OPCAB: bolus
thermodilution technique versus pulse contour analysis.
Ann Card Anaesth. 2006 Jan; 9（1）:44-8.
7） Johansson A, Chew M. Reliability of continuous
pulse contour cardiac output measurement during
hemodynamic instability. J Clin Monit Comput. 2007 Aug;21（4）:237-42. Epub 2007 Jun 1.
8） Ishihara H, Okawa H, Tanabe K, Tsubo T, Sugo Y, Akiyama T,Takeda S. A new non-invasive continuous cardiac output
trend solely utilizing routine cardiovascular monitors.
J Clin Monit Comput. 2004 Dec; 18（5-6）:313-20.
9） Sugo Y, Ukawa T, Takeda S, Ishihara H, Kazama T, Takeda J.
A Novel Continuous Cardiac Output Monitor Based on Pulse
Wave Transit Time. Conf Proc IEEE Eng Med Biol Soc.
2010; 2 010: 2853-6.
10）T. Yamada, Y. Sugo, J. Takeda, esCCO Research Team.
Verification of a non-invasive continuous cardiac output
measurement method based on the pulse-contour
analysis combined with pulse wave transit time. Eur J
Anaesthesiol 2010; 27（Suppl 47）:3AP5-9.