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176 Australasian Anaesthesia 201117727. Cowie B, Kluger R: Evaluation of systolic murmurs using transthoracic echocardiography by anaesthetictrainees. Anaesthesia 2011.28. Quinones MA, Douglas PS, Foster E, Gorcsan J, 3rd, Lewis JF, Pearlman AS, Rychik J, Salcedo EE, Seward JB,Stevenson JG, Thys DM, Weitz HH, Zoghbi WA, Creager MA, Winters WL, Jr., Elnicki M, Hirshfeld JW, Jr., LorellBH, Rodgers GP, Tracy CM: ACC/AHA clinical competence statement on echocardiography: a report of theAmerican College of Cardiology/American Heart Association/American College of Physicians-American Societyof Internal Medicine Task Force on clinical competence. Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 2003; 16: 379-402.29. Royse CF, Seah JL, Donelan L, Royse AG: Point of care ultrasound for basic haemodynamic assessment: novicecompared with an expert operator. Anaesthesia 2006; 61: 849-55.30. Vignon P, Dugrad A, Abraham J, Belcour D, Gondran G, Pepino F, Marin B, François B, Gastine Hervé Focusedtraining for goal-oriented hand-held echocardiography performed by noncardiologist residents in the intensivecare unit. Intensive Care Med (2007) 33:1795-1799.31. Hellmann DB, Whiting-O’Keefe Q, Shapiro EP, Martin LD, Martire C, Ziegelstein RC: The rate at which residentslearn to use hand-held echocardiography at the bedside. Am J Med 2005; 118: 1010-8.32. Recommendations for Training and Practice of Diagnostic Perioperative Transoesophageal Echocardiographyin Adult. ANZCA 2004.33. Dimensionless index is the ratio between the LVOT peak velocity or velocity time integral and the aortic valve peakvelocity or velocity time integral. A dimensionless index of 0.25 or less is consistent with severe aortic stenosis.
Cardiac output monitoring in non-cardiac surgery: how and why? 179Cardiac output monitoring in non-cardiac surgery: how and why?A/PROF. PHILIP PEYTON MD PHD FANZCADepartment of Anaesthesia, Austin Hospital, Melbourne, VICPhilip Peyton is a Staff Anaesthetist with an interest in research, with a focus on haemodynamic monitoring andlung gas exchange physiology. His MD was in the field of pulmonary blood flow measurement, and his PhD ininhalational agent pharmacokinetics.Conflict of Interest Statement: Philip Peyton and Austin Health are applicants in a US Patent Application. No.12/743224 “System and method for monitoring cardiac output”.BACKGROUNDThe number of technologies for monitoring of cardiac output in anaesthesia and critical care has grown substantiallyover the last 15-20 years. The aim has been to provide less invasive and hazardous alternatives to the pulmonaryartery catheter to optimise patient haemodynamics and fluid management. In recent years this has spurredinvestigation into improvements in patient outcomes. Research continues into the best combinations of fluidvolumes, use of crystalloid versus colloid solutions, and inotrope and vasopressor use to maintain physiologicalhomeostasis in the face of the blood and fluid losses, acid-base and thermoregulatory disturbance and cardiovascularinstability that can accompany anaesthesia for major surgery.The older techniques for measurement of cardiac output included methods that were not adapted to real-timeuse in the perioperative setting. Indicator dilution methods using injection of indicators such as indocyanine greenwere “single shot” techniques, as were methods based on uptake of inert gas, like nitrous oxide, by the lung.Thermodilution has been useful tool on the perioperative setting, but requires invasive cannulation with a right heartcatheter, as does the oxygen Fick method. The routine use of thermodilution and the pulmonary artery catheter isoften confined to cardiac surgery and high risk patients undergoing major surgery, such as liver transplantation.The newer less invasive techniques for cardiac output measurement fall broadly into the categories of pulsecontour based methods, Doppler devices, thoracic bioimpedance and partial CO 2 rebreathing. In combination witharterial and central venous blood pressure measurement, the data from these devices allow determination of cardiacoutput as well as systemic vascular resistance (SVR) or left ventricular afterload among other derived variables,which can then guide inotrope, vasopressor and volume therapy (Figure 1). In addition, many devices provideindices of ventricular preload to guide volume replacement therapy. However, while invasive measurement of bloodpressure is now common in clinical practice, use of minimally invasive techniques for stroke volume or cardiacoutput measurement remains far from routine. The limited use of these technologies is largely due to the cost ofthese devices and their disposable components, and concerns about their accuracy and precision.The principles behind these techniques, their reliability and their potential to influence patient management willbe reviewed.Figure 1. The components of haemodynamic assessment, and their modifiersPerfusion pressure(Preload)Fluids/VolumeCardiacoutput(Afterload)VascularResistanceInotropes &ChronotropyVasopressors
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