Minimally Invasive Measurement of Cardiac Output during Surgery and Critical Care: A Meta-analysis of Accuracy and Precision

When assessing the accuracy and precision of a new technique for cardiac output measurement, the commonly quoted criterion for acceptability of agreement with a reference standard is that the percentage error (95% limits of agreement/mean cardiac output) should be 30% or less. We reviewed published data on four different minimally invasive methods adapted for use during surgery and critical care: pulse contour techniques, esophageal Doppler, partial carbon dioxide rebreathing, and transthoracic bioimpedance, to assess their bias, precision, and percentage error in agreement with thermodilution. An English language literature search identified published papers since 2000 which examined the agreement in adult patients between bolus thermodilution and each method. For each method a meta-analysis was done using studies in which the first measurement point for each patient could be identified, to obtain a pooled mean bias, precision, and percentage error weighted according to the number of measurements in each study. Forty-seven studies were identified as suitable for inclusion: N studies, n measurements: mean weighted bias [precision, percentage error] were: pulse contour N = 24, n = 714: –0.00 l/min [1.22 l/min, 41.3%]; esophageal Doppler N = 2, n = 57: –0.77 l/min [1.07 l/min, 42.1%]; partial carbon dioxide rebreathing N = 8, n = 167: –0.05 l/min [1.12 l/min, 44.5%]; transthoracic bioimpedance N = 13, n = 435: –0.10 l/min [1.14 l/min, 42.9%]. None of the four methods has achieved agreement with bolus thermodilution which meets the expected 30% limits. The relevance in clinical practice of these arbitrary limits should be reassessed.