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Four different methods of measuring cardiac index during cytoreductive surgery and hyperthermic intraperitoneal
Amon Heijne1, Piet Krijtenburg1, Andre Bremers2
1Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
Insights
Less invasive cardiac index (CI) monitoring methods like ClearSight, FloTrac, and ProAQT are unreliable during high-risk cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). These systems failed to accurately track CI compared to transpulmonary thermodilution (TPTD).
Area of Science:
- Anesthesiology and Critical Care Medicine
- Cardiovascular Hemodynamics
- Surgical Oncology
Background:
- Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) represent extensive, high-risk abdominal procedures.
- Accurate cardiac index (CI) monitoring is crucial during high-risk surgeries, with a growing trend towards less invasive methods.
- Existing less invasive CI monitoring techniques require validation in complex surgical settings like CRS-HIPEC.
Purpose of the Study:
- To evaluate the accuracy and reliability of various less invasive cardiac index (CI) monitoring systems.
- To compare CI measurements from ClearSight, FloTrac, ProAQT, and arterial pressure waveform analysis (APWA) against transpulmonary thermodilution (TPTD).
- To assess the performance of these devices during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in both the operating room and intensive care unit (ICU).
Main Methods:
- Twenty-five patients undergoing CRS-HIPEC were enrolled in the study.
- Simultaneous hemodynamic measurements, including cardiac index (CI), were collected at nine predefined time points.
- Data analysis involved Bland-Altman plots, four-quadrant plots, and interchangeability assessments to compare CI measurements from TPTD with ClearSight, FloTrac, ProAQT, and APWA.
Main Results:
- All tested devices (ClearSight, FloTrac, ProAQT, APWA) demonstrated significant bias and wide limits of agreement compared to transpulmonary thermodilution (TPTD).
- Percentage errors and interchangeability rates were high across all devices, indicating poor agreement.
- Trending capabilities, assessed by concordance and angular bias, were unsatisfactory for all less invasive methods, with low percentages of interchangeable data pairs.
Conclusions:
- ClearSight, FloTrac, and ProAQT systems are not reliable for accurate cardiac index (CI) measurement during CRS-HIPEC when compared to TPTD.
- The reproducibility of CI changes over time, evaluated through concordance, angular bias, and interchangeability, was insufficient for all tested devices.
- These findings suggest caution when using less invasive CI monitoring in this specific high-risk surgical population.
Background:
Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are high-risk extensive abdominal surgery. During high-risk surgery, less invasive methods for cardiac index (CI) measurement have been widely used in operating theater. We investigated the accuracy of CI derived from different methods (FroTrac, ProAQT, ClearSight, and arterial pressure waveform analysis [APWA], from PICCO) and compared them to transpulmonary thermodilution (TPTD) during CRS and HIPEC in the operative room and intensive care unit (ICU).
Methods:
Twenty-five patients scheduled for CRS-HIPEC were enrolled. During nine predefined time-points, simultaneous hemodynamic measurements were performed in the operating room and ICU. Absolute and relative changes of CI were analyzed using a Bland-Altman plot, four-quadrant plot, and interchangeability.
Results:
The mean bias was -0.1 L/min/m2 for ClearSight, ProAQT, and APWA and was -0.2 L/min/m2 for FloTrac compared with TPTD. All devices had large limits of agreement (LoA). The percentage of errors and interchangeabilities for ClearSight, FloTrac, ProAQT, and APWA were 50%, 50%, 54%, 36% and 36%, 47%, 40%, 72%, respectively. Trending capabilities expressed as concordance using clinically significant CI changes were -7º ± 39º, -19º ± 38º, -13º ± 41º, and -15º ± 39º. Interchangeability in trending showed low percentages of interchangeable and gray zone data pairs for all devices.
Conclusions:
During CRS-HIPEC, ClearSight, FloTrac and ProAQT systems were not able to reliably measure CI compared to TPTD. Reproducibility of changes over time using concordance, angular bias, radial LoA, and interchangeability in trending of all devices was unsatisfactory.
