Disagreement in cardiac output measurements between fourth-generation FloTrac and critical care ultrasonography in patients with circulatory shock: a prospective observational study

Thomas Kaufmann, Ramon P Clement, Bart Hiemstra, Jaap Jan Vos, Thomas W L Scheeren, Frederik Keus, Iwan C C van der Horst, SICS Study Group, Geert Koster, Frederik Keus, Iwan C C van der Horst, Willem Dieperink, Roos Bleijendaal, Yasmin F Cawale, Ramon P Clement, Devon Dijkhuizen, Ruben J Eck, Bart Hiemstra, Anja Haker, Casper D H Hilbink, Thomas Kaufmann, Martiene Klasen, Manon Klaver, Laura J Schokking, Victor W Sikkens, Madelon Vos, Justin Woerlee, Renske Wiersema, Thomas Kaufmann, Ramon P Clement, Bart Hiemstra, Jaap Jan Vos, Thomas W L Scheeren, Frederik Keus, Iwan C C van der Horst, SICS Study Group, Geert Koster, Frederik Keus, Iwan C C van der Horst, Willem Dieperink, Roos Bleijendaal, Yasmin F Cawale, Ramon P Clement, Devon Dijkhuizen, Ruben J Eck, Bart Hiemstra, Anja Haker, Casper D H Hilbink, Thomas Kaufmann, Martiene Klasen, Manon Klaver, Laura J Schokking, Victor W Sikkens, Madelon Vos, Justin Woerlee, Renske Wiersema

Abstract

Background: Cardiac output measurements may inform diagnosis and provide guidance of therapeutic interventions in patients with hemodynamic instability. The FloTrac™ algorithm uses uncalibrated arterial pressure waveform analysis to estimate cardiac output. Recently, a new version of the algorithm has been developed. The aim was to assess the agreement between FloTrac™ and routinely performed cardiac output measurements obtained by critical care ultrasonography in patients with circulatory shock.

Methods: A prospective observational study was performed in a tertiary hospital from June 2016 to January 2017. Adult critically ill patients with circulatory shock were eligible for inclusion. Cardiac output was measured simultaneously using FloTrac™ with a fourth-generation algorithm (COAP) and critical care ultrasonography (COCCUS). The strength of linear correlation of both methods was determined by the Pearson coefficient. Bland-Altman plot and four-quadrant plot were used to track agreement and trending ability.

Result: Eighty-nine paired cardiac output measurements were performed in 17 patients during their first 24 h of admittance. COAP and COCCUS had strong positive linear correlation (r 2 = 0.60, p < 0.001). Bias of COAP and COCCUS was 0.2 L min-1 (95% CI - 0.2 to 0.6) with limits of agreement of - 3.6 L min-1 (95% CI - 4.3 to - 2.9) to 4.0 L min-1 (95% CI 3.3 to 4.7). The percentage error was 65.6% (95% CI 53.2 to 77.3). Concordance rate was 64.4%.

Conclusions: In critically ill patients with circulatory shock, there was disagreement and clinically unacceptable trending ability between values of cardiac output obtained by uncalibrated arterial pressure waveform analysis and critical care ultrasonography.

Trial registration: Clinicaltrials.gov, NCT02912624, registered on September 23, 2016.

Keywords: Cardiac output; Critical care ultrasonography; Critically ill; Intensive care; Monitoring; Pulse contour analysis; Shock.

Conflict of interest statement

The local institutional review board (Medisch Ethische Toetsingscommissie, University Medical Center Groningen) approved the study (M15.168207 and M16.193856). Written informed consent was obtained from all patients.Not applicable.TWLS received honoraria from Edwards Lifesciences (Irvine, California, USA) for consulting and for giving lectures. The other authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Patient flowchart. Abbreviations: CCUS, critical care ultrasonography
Fig. 2
Fig. 2
Scatter plot of cardiac output measured by FloTrac™ and CCUS. Abbreviations: COAP, cardiac output measured using fourth-generation FloTrac™ algorithm; COCCUS, cardiac output measured by critical care ultrasonography
Fig. 3
Fig. 3
Bland-Altman plot for repeated measurements showing the comparison between COAP and COCCUS. The mean bias between COAP and COCCUS and the upper and lower limits of agreement (LOA) are presented. Abbreviations: COAP, cardiac output measured using fourth-generation FloTrac™ algorithm; COCCUS, cardiac output measured by critical care ultrasonography
Fig. 4
Fig. 4
Four-quadrant plot showing the trend of COAP versus COCCUS. Exclusion zone of 0.5 L min−1 (white area). Abbreviations: COAP, cardiac output measured using fourth-generation FloTrac™ algorithm; COCCUS, cardiac output measured by critical care ultrasonography

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