REST 416- Lecture: Cardiopulmonary

calculations
2021

Dr Mohamed Kabbani
• Pediatric Cardiac ICU Consultant- King AbdulAziz Medical City
• Associate Professor/Joint Appointment - King Saud bin AbdulAziz University For
Health Sciences. Riyadh, Saudi Arabia.
 Objectives
• How to calculate cardiac output
• Calculate ejection fraction given stroke volume and end diastolic
volume
• Describe measurement of pulmonary artery pressure
• Described the measurement of pulmonary capillary wedge pressure
• Described the measurement of CVP
Cardiac Cycle
Cardiac Output

CO= HR × SV
SV = EDV – ESV
SV=Stroke volume
CO= Cardiac output
EDV- End diastolic volume
ESV=End systolic volume
HR=Heart rate
 Ejection fraction

Example: EDV=140 ml
ESV=50 ml

What is CO?
SV=EDV-ESV=140-50=90
90ml/140ml = 64% (EF 55-65% normal) EF= SV/EDV=90/140=64%
How can we assess adequate tissue oxygenation
and cardiac output?

• PaO, O22 Sat

• Specific organ perfusion ( kidney, brain stomach).
• Skin color and perfusion
• lactic acid
• SvO2: mixed venous oxygen saturation
• Cardiac output, oxygen consumption and
oxygen delivery.
 Fick’s principle
The tank is
100% full in A
(1 liter) B

A
 Fick’s principle
The tank is
100% full in A
(1 liter)
B
1 Liter

O.7
Lit 5
er

The tank is
75% full in B
(0.75 liter)

With each circle 25% of the gas tank is consumed and get refilled again.
 Fick’s principle
The tank is
100% full in A
(1 liter) 1 Liter

B O.7
Lit 5
er

A
The tank is
75% full in B
(0.75 liter)

With each circle 25% of the gas tank is consumed and get refilled again.
If you know that the car consumed 5 liters in one hour
The question is : how many circles does the car run per hour ?=

gas consumption in one hour / the amount of gas in the tank in A- the amount in B
5 / { 1 - 0.75 } = 5 / { 0.25 } = 20 circles / hour
 Fick principle: example on substance r

min
Q = 5 ml / 150/ml r
200/ml r
A
r

r rr
r
r
V
r r r
r

250 ml/min

( Flow) Q = ?
If the consumption of substance r is 250 ml/minutes
Then (Flow per minute) Q=
consumption of substance r per minute/ r content in A – r content in V
250/ (200-150)= 5 ml/minute
Fick principle {Adolf Fick used spirometry to measure O2 consumption in
order to calculate CO in late 1800}

flow ( Q) = Substance consumption / (substance Content in A - substance Content in V)

Arterial
flow

A : arterial
V: venous

Venous
return

cardiac output (Q) =

Oxygen consumption {V O2} / {arterial oxygen content - venous oxygen content }
Fick principle {Adolf Fick used spirometry to measure O2 consumption in
order to calculate CO in late 1800}

If flow(Q)
CaO2=20,= Substance
CvO2=15,consumption / (substanceisContent
Oxygen consumption in A
20 L /min - substance Content in V)
liter
20What
/ (20-15) = 4 liter
is the cardiac / min?
output

Arterial
flow

A : arterial
V: venous

Venous
return

cardiac output (Q) =

Oxygen consumption {V} / {arterial oxygen content - venous oxygen content }
VO2= oxygen consumption
 Methods to assess cardiac output
• ECHO • Oxygen delivery ~CO x CaO2.
• PA catheter. • FICK method =
( thermodilution )
O2 consumption
• SvO2 Q (flow)= -------------------
• ECHO CaO2 - CvO2
• Biomarker (lactic acid) O2 content (CAO2) = { 1.34 X Hb X Sao2 } + PAO2 X 0.003

O2 consumption
CO ~ --------------------------
( SaO2 - SvO2)
Mixed venous oxygen saturation Svo2

O2 consumption
CO ~ --------------------------
( SaO2 - SvO2)

If O2 consumption is If co is steady and O2

steady and O2 saturation saturation is unchanged,
is unchanged, Svo2 is Svo2 is inversely related to
directly related to CO O2 consumption {Vo2} .
 Assessing
pulmonary
and systemic
circulation
and shunt
 PVR, SVR and cardiac output

• Pressure= resistance x flow

• MPA-PCWP= PVR X QP
• PVR= MPA-PCWP / CO
• PVR=MPA-PCWP X (SaLA / PCWPO2 – SvPAO2/O2 consumption)
• SVR = MBP- CVP X { SaO2- SvO2 / O2 Consumption}
Pulmonary Artery Pressure Catheter
• Pulmonary arterial catheter
Clinical applications of PAC

PAC can generate large numbers of hemodynamic variables

• Central venous pressure (CVP)
• Pulmonary arterial occlusion pressure (PAOP)
• Cardiac output / cardiac index (CO / CI)
• Stroke volume (SV)
• R ventricle ejection fraction/ end diatolic volume (RVEF / RVEDV)
• Pulmonary vascular resistance index (PVRI)
• Oxygen delivery / uptake (DO2 / VO2)
Indications for PAP monitoring
• Shock of all types
• Assessment of cardiovascular function and response to therapy
• Assessment of pulmonary status
• Assessment of fluid requirement
• Perioperative monitoring
 Pulmonary artery Catheter (PAC)
• Advantages
• Provide lot of important hemodynamic parameters
• Sampling site for SvO2
• Disadvantages
• Costly
• Invasive
• Multiple complications (eg arrhythmia, catheter looping, balloon rupture, PA injury,
pulmonary infarction etc)
• Mortality not reduced and can be even higher
Crit Care Med 2003;31: 2734-2741
JAMA 1996;276 889-897
Use of PA catheter
• Measures pulmonary artery
pressure.
• Obtains blood sample to measure
mixed venous oxygen saturation.
• PA catheter has balloon when
inflated, it can measure PAWP.
Right heart catheterization and pulmonary capillary wedge
pressure measurement (PCWP)
Pulmonary artery wedge pressure (PAWP)
monitoring
PAP waveform
Area under curve is
inversely proportion to rate
of blood flow in PA ( = CO)
PAP measurements
Increased Normal Decreased
L heart failure Systolic: 20-30 Reduced
mmHG circulation blood
volume
Increased pulmonary blood Diastolic: 6-12
flow (left or right shunting, as mmHG
in atrial or ventricular septal
defects)
Any condition causing Mean: 10-15
increased pulmonary arteriolar mmHG
resistance, such as hypoxemia,
ARDS, PHTN.
ECHO estimation
of cardiac output

sto le
tole Sy
Dias
Aortic flow velocity time integral (VTI) multiplied by the cross-sectional
area (CSA) allows to compute stroke volume (SV) ejected by the left
ventricle (LV). Heart rate (HR) then allows to compute cardiac output (CO)
= VTI × CSA × HR. 
Central venous pressure
(CVP)
Central venous catheter placement
Central Venous Pressure (CVP)

Intravascular volume status

• Right ventricular function

• Patient response to drugs &/or fluids

34
Use of CVP catheter
• helps to assess cardiac function.
• evaluate venous return to the heart, and the volume status of the
body.
• The central venous (CV) line also provides access to a large vessel for
rapid, high-volume fluid administration.
• Enables frequent blood withdrawal for laboratory samples.
 CVP waveforms
a= atrial contraction
x= atrial relaxation
c= closure of tricuspid valve
v= start of atrium filling with
venous blood
y= open of tricuspid valve
and passive empty of RA to
RV
Central Venous Pressure Waves
 Central Venous Pressure (CVP)

• Central line or pulmonary artery catheter

• Normal values = 2 – 8 mm Hg

• Low CVP = hypovolemia or ↓ venous return

• High CVP = over hydration, ↑ venous return,

or right-sided heart failure

• Antibiotics, NS boluses, blood, & IV pushes

are allowed through the CVP line

38
Leveling and Zeroing
• Leveling
• Before/after insertion
• After patient, bed or transducer move
• Aligns transducer with catheter tip

• Zeroing
• Performed before insertion & readings

• Level and zero transducer at the phlebostatic

axis

39
Phlebostatic Axis

• 4th intercostal space, mid-

axillary line

• Level of the atria

40
What type of catheter?
Where is the catheter?
Mixed venous oxygen saturation Svo2

O2 consumption
CO ~ --------------------------
( SaO2 - SvO2)

If O2 consumption is If co is steady and O2

steady and O2 saturation saturation is unchanged,
is unchanged, Svo2 is Svo2 is inversely related to
directly related to CO O2 consumption {Vo2} .
CVP measurement
Increased Normal Decreased
R heart failure Reduced circulating
blood volume
Volume overload
Tricuspid valve 2-6 mmHG
stenosis 3-8 cmH2O
Constrictive
pericardititis
Pulmonary
hypertension
Cardiac temponade
Thanks