Clinical trial NCT01880684: Validation of Capnography as a Predictor of Cardiac Output Change as Measured by FloTrac
Official title: Validation of Capnography as a Predictor of Cardiac Output Change as Measured by FloTrac
Study type: OBSERVATIONAL
Overall status: COMPLETED
Conditions: Hypovolemia
Cardiac Output, High
Cardiac Output, Low
Keywords: Thermodilution
Blood Volume
Cardiac Output
Leg
Capnography
Blood Pressure
Lead sponsor: Montreal Heart Institute
Sponsor class: OTHER
First posted: 2013-06-19
Enrollment: 50
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Observational model: COHORT
Time perspective: PROSPECTIVE
Sampling method: NON_PROBABILITY_SAMPLE
Study population: Patients of 18 years old or more presenting for cardiac or aortic surgery at the Montreal Heart Institute.

Brief summary: The aim of this study is to evaluate the correlation of capnography with non-invasive measurement of cardiac output with the FloTrac/EV1000 following a reversible fluid challenge, a passive leg raising maneuver, using thermodilution as the gold standard.

The main hypothesis is a correlation of 0.8 between the increasing of ETCO2 and the increasing of ejection volume measured by FloTrac/EV1000 following a passive leg raising maneuver.

Detailed description: Data are collected on past medical illnesses, medication, type of surgery, abnormalities on pre-operative transesophageal echocardiogram and localisation of arterial line.

Before induction of anesthesia, an arterial line is installed. The agents of induction of anesthesia and doses are left to the discretion of the attending anesthesiologist. The trachea is intubated, anesthesia circuit and sidestream CO2 sensor were connected to the endotracheal tube and positive pressure ventilation begins with standardized parameters: control assisted mode with no inspiratory effort, tidal volume of 6-8 mL/kg, respiratory rate of 8-10/minute and PEEP of 5 mmHg. Modification of the ventilation parameters is not permitted before and during the PLR maneuvers. Isoflurane and propofol are used for the maintenance of anesthesia. A PA catheter (Paceport, Edwards Lifesciences, Irvine, California, USA) is inserted in the right internal jugular vein. If a femoral line is installed, the FloTrac/EV1000 is connected to the femoral line, if not, the radial line is used for mini-invasive continuous cardiac output monitoring. The a and v wave aspect and ratio of CVP waveform is noted. The RV waveform is inspected for signs of abnormalities such as a non-horizontal slope restrictive pattern (Figure xx)18. The transducers are all placed at the midthoracic level and a "flush test" is performed prior to CO measurements with the FloTrac/EV1000 to ensure absence of resonance or damping of the system.

At baseline, in the operating room before the first PLR maneuver, the heart rate, systolic, diastolic and mean arterial pressure, CVP value, CI measured in triplicate with the thermodilution method and the FloTrac derived variables are recorded. These variables include the CO indexed CO and SVV measured by the FloTrac/EV1000. The same variables are recorded at 1, 3 and 5 minutes after the beginning of PLR except CI by thermodilution which is measured again only once, at 3 minutes and EtCO2 which is recorded every 12 seconds. The EtCO2 curve is inspected at baseline and during the PLR maneuver to ensure the changes in EtCO2 were not related to changes in inspired CO2, ventilator or circuit malfunction or increase in airway resistance.

After weaning from CPB, the same measures are taken twice: with chest opened, when hemodynamic stability is achieved, and CPB canulas taken out and with chest closed.

In the ICU, two additional PLR maneuvers were executed with a 30 minutes interval in between. The set of measurements previously described are recorded. The use of an epicardial temporary pacemaker, vasopressors (doses and type), vasodilators (doses and type) are also recorded.

Eligibility criteria: Inclusion Criteria:

* 18 years old or more who have cardiac or aortic surgery

Exclusion Criteria:

* Pacemaker
* Lower limb amputation or absence of lower limb
* Moderate tricuspid insufficiency
* Preoperative arrythmia or prolonged arrythmia during data measurements
* Moderate aortic regurgitation
* Known deep vein thrombosis
* Intra-aortic balloon pump

Primary outcomes:
measure: Correlation between elevation in ETCO2 and cardiac output during a reversible fluid challenge, a passive leg raise
timeFrame: Participants will be followed from their arrival in the operating room until 2 hours post-operatively in the intensive care unit
Secondary outcomes:
measure: Correlation between changes in indexed cardiac output measured by Flotrac/EV1000 and by thermodilution during a reversible fluid challenge, a passive leg raise
timeFrame: Participants will be followed from their arrival in the operating room until 2 hours post-operatively in the intensive care unit
measure: Correlation between elevation in capnography and indexed cardiac output measured by thermodilution during a reversible fluid challenge, a passive leg raise
timeFrame: Participants will be followed from their arrival in the operating room until 2 hours post-operatively in the intensive care unit
measure: Correlation between changes in capnography and indexed cardiac output measured by Flotrac/EV1000 during a reversible fluid challenge, a passive leg raise
timeFrame: Participants will be followed from their arrival in the operating room until 2 hours post-operatively in the intensive care unit
Other outcomes:
Locations:
city: Montreal
country: Canada
facility: Montreal Heart Institute
state: Quebec
Study officials:
References:
citation: MARINO, Paul L. The ICU Book. Philadelphie, PA, Lippincott Williams & Wilkins, 2007, 1065 pages.
citation: Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, Moreno R, Carlet J, Le Gall JR, Payen D; Sepsis Occurrence in Acutely Ill Patients Investigators. Sepsis in European intensive care units: results of the SOAP study. Crit Care Med. 2006 Feb;34(2):344-53. doi: 10.1097/01.ccm.0000194725.48928.3a.
citation: Michard F, Teboul JL. Predicting fluid responsiveness in ICU patients: a critical analysis of the evidence. Chest. 2002 Jun;121(6):2000-8. doi: 10.1378/chest.121.6.2000.
citation: Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008 Jul;134(1):172-8. doi: 10.1378/chest.07-2331.
citation: Kumar A, Anel R, Bunnell E, Habet K, Zanotti S, Marshall S, Neumann A, Ali A, Cheang M, Kavinsky C, Parrillo JE. Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardiac performance, or the response to volume infusion in normal subjects. Crit Care Med. 2004 Mar;32(3):691-9. doi: 10.1097/01.ccm.0000114996.68110.c9.
citation: Osman D, Ridel C, Ray P, Monnet X, Anguel N, Richard C, Teboul JL. Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med. 2007 Jan;35(1):64-8. doi: 10.1097/01.CCM.0000249851.94101.4F.
citation: Tavernier B, Makhotine O, Lebuffe G, Dupont J, Scherpereel P. Systolic pressure variation as a guide to fluid therapy in patients with sepsis-induced hypotension. Anesthesiology. 1998 Dec;89(6):1313-21. doi: 10.1097/00000542-199812000-00007.
citation: Michard F, Boussat S, Chemla D, Anguel N, Mercat A, Lecarpentier Y, Richard C, Pinsky MR, Teboul JL. Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure. Am J Respir Crit Care Med. 2000 Jul;162(1):134-8. doi: 10.1164/ajrccm.162.1.9903035.
citation: Perel A. Assessing fluid responsiveness by the systolic pressure variation in mechanically ventilated patients. Systolic pressure variation as a guide to fluid therapy in patients with sepsis-induced hypotension. Anesthesiology. 1998 Dec;89(6):1309-10. doi: 10.1097/00000542-199812000-00005. No abstract available.
citation: Lattik R, Couture P, Denault AY, Carrier M, Harel F, Taillefer J, Tardif JC. Mitral Doppler indices are superior to two-dimensional echocardiographic and hemodynamic variables in predicting responsiveness of cardiac output to a rapid intravenous infusion of colloid. Anesth Analg. 2002 May;94(5):1092-9, table of contents. doi: 10.1097/00000539-200205000-00007.
citation: Tousignant CP, Walsh F, Mazer CD. The use of transesophageal echocardiography for preload assessment in critically ill patients. Anesth Analg. 2000 Feb;90(2):351-5. doi: 10.1097/00000539-200002000-00021.
citation: Shibutani K, Muraoka M, Shirasaki S, Kubal K, Sanchala VT, Gupte P. Do changes in end-tidal PCO2 quantitatively reflect changes in cardiac output? Anesth Analg. 1994 Nov;79(5):829-33. doi: 10.1213/00000539-199411000-00002.
citation: Isserles SA, Breen PH. Can changes in end-tidal PCO2 measure changes in cardiac output? Anesth Analg. 1991 Dec;73(6):808-14. doi: 10.1213/00000539-199112000-00023.
citation: Maslow A, Stearns G, Bert A, Feng W, Price D, Schwartz C, MacKinnon S, Rotenberg F, Hopkins R, Cooper G, Singh A, Loring S. Monitoring end-tidal carbon dioxide during weaning from cardiopulmonary bypass in patients without significant lung disease. Anesth Analg. 2001 Feb;92(2):306-13. doi: 10.1097/00000539-200102000-00004.
citation: Breukers RM, Sepehrkhouy S, Spiegelenberg SR, Groeneveld AB. Cardiac output measured by a new arterial pressure waveform analysis method without calibration compared with thermodilution after cardiac surgery. J Cardiothorac Vasc Anesth. 2007 Oct;21(5):632-5. doi: 10.1053/j.jvca.2007.01.001. Epub 2007 Apr 5.
citation: Cannesson M, Musard H, Desebbe O, Boucau C, Simon R, Henaine R, Lehot JJ. The ability of stroke volume variations obtained with Vigileo/FloTrac system to monitor fluid responsiveness in mechanically ventilated patients. Anesth Analg. 2009 Feb;108(2):513-7. doi: 10.1213/ane.0b013e318192a36b.
citation: Broch O, Renner J, Gruenewald M, Meybohm P, Schottler J, Steinfath M, Malbrain M, Bein B. A comparison of third-generation semi-invasive arterial waveform analysis with thermodilution in patients undergoing coronary surgery. ScientificWorldJournal. 2012;2012:451081. doi: 10.1100/2012/451081. Epub 2012 Jul 31.
citation: Kusaka Y, Yoshitani K, Irie T, Inatomi Y, Shinzawa M, Ohnishi Y. Clinical comparison of an echocardiograph-derived versus pulse counter-derived cardiac output measurement in abdominal aortic aneurysm surgery. J Cardiothorac Vasc Anesth. 2012 Apr;26(2):223-6. doi: 10.1053/j.jvca.2011.07.011. Epub 2011 Sep 15.
citation: Su BC, Tsai YF, Cheng CW, Yu HP, Yang MW, Lee WC, Lin CC. Stroke volume variation derived by arterial pulse contour analysis is a good indicator for preload estimation during liver transplantation. Transplant Proc. 2012 Mar;44(2):429-32. doi: 10.1016/j.transproceed.2011.12.037.
citation: Tsai YF, Su BC, Lin CC, Liu FC, Lee WC, Yu HP. Cardiac output derived from arterial pressure waveform analysis: validation of the third-generation software in patients undergoing orthotopic liver transplantation. Transplant Proc. 2012 Mar;44(2):433-7. doi: 10.1016/j.transproceed.2011.12.045.
citation: McLean AS, Huang SJ, Kot M, Rajamani A, Hoyling L. Comparison of cardiac output measurements in critically ill patients: FloTrac/Vigileo vs transthoracic Doppler echocardiography. Anaesth Intensive Care. 2011 Jul;39(4):590-8. doi: 10.1177/0310057X1103900409.
citation: Slagt C, de Leeuw MA, Beute J, Rijnsburger E, Hoeksema M, Mulder JW, Malagon I, Groeneveld AB. Cardiac output measured by uncalibrated arterial pressure waveform analysis by recently released software version 3.02 versus thermodilution in septic shock. J Clin Monit Comput. 2013 Apr;27(2):171-7. doi: 10.1007/s10877-012-9410-9. Epub 2012 Nov 15.
citation: Biais M, Vidil L, Sarrabay P, Cottenceau V, Revel P, Sztark F. Changes in stroke volume induced by passive leg raising in spontaneously breathing patients: comparison between echocardiography and Vigileo/FloTrac device. Crit Care. 2009;13(6):R195. doi: 10.1186/cc8195. Epub 2009 Dec 7.
citation: Mutoh T, Ishikawa T, Kobayashi S, Suzuki A, Yasui N. Performance of Third-generation FloTrac/Vigileo system during hyperdynamic therapy for delayed cerebral ischemia after subarachnoid hemorrhage. Surg Neurol Int. 2012;3:99. doi: 10.4103/2152-7806.100195. Epub 2012 Aug 27.
citation: Rutlen DL, Wackers FJ, Zaret BL. Radionuclide assessment of peripheral intravascular capacity: a technique to measure intravascular volume changes in the capacitance circulation in man. Circulation. 1981 Jul;64(1):146-52. doi: 10.1161/01.cir.64.1.146.
citation: Reich DL, Konstadt SN, Raissi S, Hubbard M, Thys DM. Trendelenburg position and passive leg raising do not significantly improve cardiopulmonary performance in the anesthetized patient with coronary artery disease. Crit Care Med. 1989 Apr;17(4):313-7. doi: 10.1097/00003246-198904000-00003.
citation: THOMAS M, SHILLINGFORD J. THE CIRCULATORY RESPONSE TO A STANDARD POSTURAL CHANGE IN ISCHAEMIC HEART DISEASE. Br Heart J. 1965 Jan;27(1):17-27. doi: 10.1136/hrt.27.1.17. No abstract available.
citation: Rocha P, Lemaigre D, Leroy M, Desfonds P, De Zuttere D, Liot F. Nitroglycerin-induced decrease of carbon monoxide diffusion capacity in acute myocardial infarction reversed by elevating legs. Crit Care Med. 1987 Feb;15(2):131-3. doi: 10.1097/00003246-198702000-00010.
citation: Takagi S, Yokota M, Iwase M, Yoshida J, Hayashi H, Sotobata I, Koide M, Saito H. The important role of left ventricular relaxation and left atrial pressure in the left ventricular filling velocity profile. Am Heart J. 1989 Nov;118(5 Pt 1):954-62. doi: 10.1016/0002-8703(89)90230-5.
citation: Gaffney FA, Bastian BC, Thal ER, Atkins JM, Blomqvist CG. Passive leg raising does not produce a significant or sustained autotransfusion effect. J Trauma. 1982 Mar;22(3):190-3. doi: 10.1097/00005373-198203000-00003.
citation: Monnet X, Rienzo M, Osman D, Anguel N, Richard C, Pinsky MR, Teboul JL. Passive leg raising predicts fluid responsiveness in the critically ill. Crit Care Med. 2006 May;34(5):1402-7. doi: 10.1097/01.CCM.0000215453.11735.06.
citation: Preau S, Saulnier F, Dewavrin F, Durocher A, Chagnon JL. Passive leg raising is predictive of fluid responsiveness in spontaneously breathing patients with severe sepsis or acute pancreatitis. Crit Care Med. 2010 Mar;38(3):819-25. doi: 10.1097/CCM.0b013e3181c8fe7a.
citation: Monnet X, Teboul JL. Passive leg raising. Intensive Care Med. 2008 Apr;34(4):659-63. doi: 10.1007/s00134-008-0994-y. Epub 2008 Jan 23.
citation: Muller L, Toumi M, Bousquet PJ, Riu-Poulenc B, Louart G, Candela D, Zoric L, Suehs C, de La Coussaye JE, Molinari N, Lefrant JY; AzuRea Group. An increase in aortic blood flow after an infusion of 100 ml colloid over 1 minute can predict fluid responsiveness: the mini-fluid challenge study. Anesthesiology. 2011 Sep;115(3):541-7. doi: 10.1097/ALN.0b013e318229a500.
citation: Monnet X, Bataille A, Magalhaes E, Barrois J, Le Corre M, Gosset C, Guerin L, Richard C, Teboul JL. End-tidal carbon dioxide is better than arterial pressure for predicting volume responsiveness by the passive leg raising test. Intensive Care Med. 2013 Jan;39(1):93-100. doi: 10.1007/s00134-012-2693-y. Epub 2012 Sep 19.
citation: Denault AY, Haddad F, Jacobsohn E, Deschamps A. Perioperative right ventricular dysfunction. Curr Opin Anaesthesiol. 2013 Feb;26(1):71-81. doi: 10.1097/ACO.0b013e32835b8be2.
citation: Madsen PL, Nielsen HB, Christiansen P. Well-being and cerebral oxygen saturation during acute heart failure in humans. Clin Physiol. 2000 Mar;20(2):158-64. doi: 10.1046/j.1365-2281.2000.00241.x.
citation: Paquet C, Deschamps A, Denault AY, Couture P, Carrier M, Babin D, Levesque S, Piquette D, Lambert J, Tardif JC. Baseline regional cerebral oxygen saturation correlates with left ventricular systolic and diastolic function. J Cardiothorac Vasc Anesth. 2008 Dec;22(6):840-6. doi: 10.1053/j.jvca.2008.02.013. Epub 2008 May 12.
citation: Sokol DK, Markand ON, Daly EC, Luerssen TG, Malkoff MD. Near infrared spectroscopy (NIRS) distinguishes seizure types. Seizure. 2000 Jul;9(5):323-7. doi: 10.1053/seiz.2000.0406.
citation: Shojima M, Watanabe E, Mayanagi Y. Cerebral blood oxygenation after cerebrospinal fluid removal in hydrocephalus measured by near infrared spectroscopy. Surg Neurol. 2004 Oct;62(4):312-8; discussion 318. doi: 10.1016/j.surneu.2003.09.035.
citation: Gracias VH, Guillamondegui OD, Stiefel MF, Wilensky EM, Bloom S, Gupta R, Pryor JP, Reilly PM, Leroux PD, Schwab CW. Cerebral cortical oxygenation: a pilot study. J Trauma. 2004 Mar;56(3):469-72; discussion 472-4. doi: 10.1097/01.ta.0000114274.95423.c0.
citation: Vernieri F, Tibuzzi F, Pasqualetti P, Rosato N, Passarelli F, Rossini PM, Silvestrini M. Transcranial Doppler and near-infrared spectroscopy can evaluate the hemodynamic effect of carotid artery occlusion. Stroke. 2004 Jan;35(1):64-70. doi: 10.1161/01.STR.0000106486.26626.E2. Epub 2003 Dec 18.
citation: Taillefer MC, Denault AY. Cerebral near-infrared spectroscopy in adult heart surgery: systematic review of its clinical efficacy. Can J Anaesth. 2005 Jan;52(1):79-87. doi: 10.1007/BF03018586.
citation: Nagdyman N, Ewert P, Peters B, Miera O, Fleck T, Berger F. Comparison of different near-infrared spectroscopic cerebral oxygenation indices with central venous and jugular venous oxygenation saturation in children. Paediatr Anaesth. 2008 Feb;18(2):160-6. doi: 10.1111/j.1460-9592.2007.02365.x.
citation: Boulain T, Achard JM, Teboul JL, Richard C, Perrotin D, Ginies G. Changes in BP induced by passive leg raising predict response to fluid loading in critically ill patients. Chest. 2002 Apr;121(4):1245-52. doi: 10.1378/chest.121.4.1245.
citation: Society of Thoracic Surgeons Blood Conservation Guideline Task Force; Ferraris VA, Ferraris SP, Saha SP, Hessel EA 2nd, Haan CK, Royston BD, Bridges CR, Higgins RS, Despotis G, Brown JR; Society of Cardiovascular Anesthesiologists Special Task Force on Blood Transfusion; Spiess BD, Shore-Lesserson L, Stafford-Smith M, Mazer CD, Bennett-Guerrero E, Hill SE, Body S. Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg. 2007 May;83(5 Suppl):S27-86. doi: 10.1016/j.athoracsur.2007.02.099.