Arterial pressure-based cardiac output monitoring:
A multicenter validation of the 3rd generation software
in septic patients
Daniel De Backer1 MD PhD, Gernot Marx2 MD, Andrew Tan3 MD,
Christopher Junker4, Marc Van Nuffelen1 MD, Lars Hüter5 MD,
Willy Ching3 RN, CCRN, Frédéric Michard6 MD PhD,
Jean-Louis Vincent1 MD PhD FCCM
ELECTRONIC SUPPLEMENTARY MATERIAL
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Electronic Table 1. Hemodynamic profile of the study population at inclusion with
only the first measurement analyzed.
Heart rate (bpm)
NA
Mean arterial pressure, mmHg
75 ± 10
iCO, L/min
7.2 ± 2.3
COG2, L/min
6.4 ± 1.8
COG3, L/min
7.2 ± 2.5
CCO, L/min
7.9 ± 2.5
TSVR, dynes/sec/cm5
929 ± 387
TSVR: total systemic vascular resistance; iCO: cardiac output measured by bolus
thermodilution; COG2: cardiac output measured by 2nd generation FloTrac; COG3:
cardiac output measured by 3rd generation FloTrac; CCO: cardiac output measured by
semi-continuous thermodilution.
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Electronic Table 2 . Mean bias and limits of agreement (95% Confidence interval)
according to total systemic vascular resistance (TSVR) values
Bias % (95%CI)
Percentage error % (95%CI)
Separation according to median TSVR value:
Patients below median TSVR value (n=201)
G3 – iCO
-5.1 (-9.5- -0.7)
29.2 (21.6 – 36.6)
G2 – iCO
-20.7 (-24.7 - -16.4)
27.4 (19.9 – 34.5)
CCO – iCO
8.8 (4.1 – 11.3)
26.8 (17.4 – 33.1)
Patients above TSVR median value (n=200)
G3 – iCO
0.3 (-4.4 – 4.0)
28.4 (20.7 – 35.4)
G2 – iCO
-4.2 (-8.4 – 0.1)
28.6 (20.9 – 35.8)
CCO – iCO
7.7 (4.2 – 12.7)
24.2 (19.5 – 33.3)
Extreme TSVR quartiles
Patients below 25th percentile value of TSVR (n=100)
G3 – iCO
-6.0 (-11.1 - -0.8)
27.4 (18.0 – 36.4)
G2 – iCO
-24.8 (-29.6 - -20.0)
25.4 (16.9 – 34.2)
CCO – iCO
4.6 (0.2 – 8.9)
23.4 (15.2 – 30.8)
Patients above 75th percentile value of TSVR (n=101)
G3 – iCO
3.0 (-1.8 – 8.3)
29.0 (18.3 – 36.4)
G2 – iCO
3.0 (-3.2 – 6.7)
27.2 (17.6 – 35.2)
CCO – iCO
8.1 (3.6 – 13.1)
26.2 (17.1 – 34.1)
Median TSVR = 822 (TSVR in patients below median 673 ± 98; TSVR in patients
above median 1074 ± 263). Percentile 25 TSVR = 685 (TSVR 595 ± 70; Percentile 75
TSVR = 997 (TSVR 1242 ± 282)
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iCO: cardiac output measured by bolus thermodilution; COG2: cardiac output
measured by 2nd generation FloTrac ; COG3: cardiac output measured by 3rd
generation FloTrac; CCO: cardiac output measured by semi-continuous
thermodilution
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Table 3: Magnitude of changes:
Direction of change of CO
CO measurement
Magnitude of change (%)
iCO
30.6 ± 15.3
COG3
18.7 ± 21.4
COG2
12.5 ± 14.5
CCO
21.9 ± 25.6
iCO
-1.3 ± 7.2
COG3
-0.8 ± 13.6
COG2
-0.2 ± 9.8
CCO
0.6 ± 13.3
iCO
-24.7 ± 8.8
COG3
-19.2 ± 15.6
COG2
-11.9 ± 15.7
CCO
-15.2 ± 18.3
reference (iCO)
iCO increased (36)
iCO stable (n=126)
iCO decreased (n=21)
No significant differences between methods in each class (ANOVA increased p=0.33,
stable p=0.19, and decreased p=0.17). Data are presented as mean ± SD.
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Legends of Electronic Figures:
Electronic Figure 1: Bland & Altman representations of COG2, COG3, and CCO vs
iCO at inclusion: Panel A shows relation between COG2 and iCO, panel B COG3 and
iCO, and panel C CCO and iCO
Electronic Figure 2. Logarithmic relationships between total systemic vascular
resistance (TSVR) and the differences between COG2 and iCO, COG3 and iCO, and
CCO and iCO using only one measurement per patient. Panel A shows relation
between COG2 and iCO, panel B CGO3 and iCO, and panel C CCO and iCO.
Electronic Figure 3. Receiver Operating Characteristic (ROC) curve for detection of
changes in iCO of at least 15% in the same direction:
Red line represents COG3, green line COG2, dark blue line CCO, purple line MAP, and
dotted light blue line chance (reference line at 0.5). The AUC were 0.79 (0.72-0.87)
for COG3, 0.78 (0.69-0.86) for COG2, and 0.75 (0.66-0.84) for CCO, and 0.51 (0.420.62) for MAP. COG3, COG2, and CCO were significantly higher than 0.5 and than
MAP (p<0.001) but there were no differences between the different techniques. Of
note, MAP was unable to detect changes in cardiac output in the same direction
(p=0.80). After adjustment for inclusion of multiple points per patient [1], the AUC
were 0.81 (0.74-0.88) for COG3, 0.80 (0.72-0.87) for COG2, and 0.78 (0.69-0.86) for
CCO.
Reference List
1. Liu H, Li G, Cumberland WG, Wu T (2005) Testing statistical significance of
the area under a Receiving Operating Characteristics curve for repeated
measures design with bootstrapping. Journal of Data Science 3: 257-278
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Electronic Figure 1 Panel A
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Electronic Figure 1 Panel B
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Electronic Figure 1 Panel C
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Electronic Figure 2 Panel A
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Electronic Figure 2 Panel B
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Electronic Figure 2 Panel C
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Electronic Figure 3
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