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although the optimal target temperature remains uncertain&#44; waiting for more large controlled trials on this matter&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The initial management of the so called &#8216;post-resuscitation syndrome&#8232;tm&#41; is challenging&#46; Hypovolemia&#44; excessive vasodilation and reversible myocardial stunning frequently results in early hypotension that can be life-threatening&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">4&#44;5</span></a> This hemodynamic instability is managed with the use of fluids&#44; inotropes and vasopressors if needed&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3&#44;4</span></a> Therefore&#44; it is important to have a correct monitoring of hemodynamic and pulmonary variables&#44; in order to optimize those therapies&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> sometimes using invasive devices&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The PiCCO<span class="elsevierStyleSup">&#168;r&#41;</span> &#40;pulse index continuous cardiac output&#41; system&#44; in use for over 10 years&#44; allows the measuring of a large number of variables throughout central venous and peripheral arterial catheterization alone&#46; Among other parameters&#44; it is used to measure cardiac output &#40;CO&#41; through a transpulmonary thermodilution method&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Despite the unquestionable utility of PiCCO<span class="elsevierStyleSup">&#168;r&#41;</span> in situations of hemodynamic instability&#44; as a thermodilution method&#44; it is assumed that the temperature within the artery stays stable during calibration and measurements&#46; That might not be the case during hypothermia and other variations of body temperature&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Transthoracic Doppler echocardiography &#40;ECHO&#41; has long proved its accuracy in CO estimation&#44; including in critically ill patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#8226;10</span></a> It can be performed in different scenarios&#44; 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patients received central venous catheter &#40;Kimal<span class="elsevierStyleSup">&#168;r&#41;</span>&#59; 5-lumened&#44; 8&#46;5<span class="elsevierStyleHsp" style=""></span>Fr<span class="elsevierStyleHsp" style=""></span>&#237;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>cm&#41; on the internal jugular or subclavian vein and a PiCCO<span class="elsevierStyleSup">&#168;r&#41;</span> catheter &#40;Pulsion Medical Systems&#44; 5<span class="elsevierStyleHsp" style=""></span>Fr<span class="elsevierStyleHsp" style=""></span>&#237;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>cm&#41; inserted in the femoral artery&#44; connected to a Siemens MP 50 monitor with the appropriate software&#46; Based on the modified Stewart-Hamilton equation&#44; cardiac output is inversely related to the concentration and total passage time of an indicator solution measured after its transit through the heart&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a><elsevierMultimedia ident="eq0005"></elsevierMultimedia>Equation 1&#58; Adapted Stewart-Hamilton equation&#44; where CO<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Cardiac output&#59; Tb<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Blood temperature&#59; Ti<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>injectate temperature&#59; Vi<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>injectate volume&#59; K<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>constant&#59; &#8738;¿Tb<span class="elsevierStyleHsp" style=""></span>&#237;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>area under the thermodilution curve&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">During the therapeutic hypothermia and rewarming period&#44; CO was calculated through the PiCCO system followed by ECHO estimation &#40;General Electric<span class="elsevierStyleSup">&#168;r&#41;</span> VIVID S5&#44; with 3&#46;5<span class="elsevierStyleHsp" style=""></span>MHz probe&#41;&#46; The two measurements were performed by different&#44; blinded investigators&#44; as close as possible &#40;maximum interval of time&#58; 10<span class="elsevierStyleHsp" style=""></span>minutes&#41;&#46; At the same time&#44; central temperature and hemodynamic data &#40;heart rate&#44; rhythm and mean arterial systemic pressure&#41; were registered&#46; It was assured the constancy of each interfering variable such as level of sedation&#44; ventilation parameters&#44; vasoactive drugs or any other IV infusion&#46; Therefore&#44; a pair of CO measurements &#40;one by PiCCO and one by ECHO&#41; for a determined temperature was obtained&#46; Additionally&#44; demographic data&#44; severity scores at admission&#44; cause and rhythm of arrest and final outcome were collected&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">We considered 0&#46;5<span class="elsevierStyleHsp" style=""></span>L&#47;min as the maximum clinically accepted difference between the values of CO<span class="elsevierStyleInf">ECHO</span> and CO<span class="elsevierStyleInf">PiCCO</span>&#46; In other words&#44; the two methods were considered to agree when the difference fell in the interval &#40;&#8743;0&#46;5&#44; 0&#46;5&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">PiCCO measurements</span><p id="par0060" class="elsevierStylePara elsevierViewall">For the CO calculation by thermodilution technique&#44; 20<span class="elsevierStyleHsp" style=""></span>ml of iced &#40;&#60;8<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; saline 0&#46;9&#37; was delivered in the proximal lumen of the central venous catheter and mixed with blood through the systemic and pulmonary circulation&#46; The injection was performed as rapidly as possible&#44; irrespective of the respiratory cycle&#46; The thermistor-tipped arterial line&#44; placed in the femoral artery&#44; quantified the change in temperature over time&#46; The thermodilution curve recorded by the arterial thermistor was automatically analyzed by the PiCCO<span class="elsevierStyleSup">&#168;r&#41;</span> software&#44; obtaining the value of CO&#46; Triplicate injections were performed for each set of measurements and considered the mean value of the three&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Echocardiographic measurements</span><p id="par0065" class="elsevierStylePara elsevierViewall">The Doppler estimated CO was obtained multiplying the heart rate &#40;HR&#41; by the Doppler estimated stroke volume &#40;SV&#41;&#46; The last one uses the velocity-time integral of flow through the left ventricular outflow tract &#40;VTI<span class="elsevierStyleInf">LVOT</span>&#41; and the area of the left ventricular outflow tract &#40;A<span class="elsevierStyleInf">LVOT</span>&#41; which&#44; in turn&#44; is calculated using the left ventricular outflow tract diameter &#40;D<span class="elsevierStyleInf">LVOT</span>&#41; by the following formula&#58;<elsevierMultimedia ident="eq0010"></elsevierMultimedia></p><p id="par0070" class="elsevierStylePara elsevierViewall">The VTI<span class="elsevierStyleInf">LVOT</span> was recorded by pulsed-wave Doppler from an apical fiver chamber view&#44; by placing the Doppler sample immediately below the aortic valve annulus&#44; aligned with the center of the valve where the flow is maximum&#46; The final value of VTI<span class="elsevierStyleInf">LVOT</span> was the mean of three consecutive determinations&#46; D<span class="elsevierStyleInf">LVOT</span> was measured in a parasternal long-axis view&#44; just before the aortic annulus&#44; from the inner edge to outer edge&#44; parallel to the valve apparatus&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Five complete and consecutive measurements were performed&#44; and considered the mean as the final value for CO<span class="elsevierStyleInf">ECHO</span>&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Echocardiography inter-observer and intra-observer variability analysis</span><p id="par0080" class="elsevierStylePara elsevierViewall">In order to assure the reliability of the CO<span class="elsevierStyleInf">ECHO</span> measurements&#44; as the operator dependent errors are the major pitfall of this technique&#44; a previous study was conducted to evaluate the echocardiographic skills of the five investigators involved in the major study&#46; Repeating the procedure as described above &#40;mean three determinations of VTI<span class="elsevierStyleInf">LVOT</span> and one of D<span class="elsevierStyleInf">LVOT</span>&#41;&#44; each investigator performed five CO<span class="elsevierStyleInf">ECHO</span> measurements in a patient under therapeutic hypothermia and was followed by other blinded investigator who obtained another five measurements&#46; This procedure was repeated in ten different patients so that every investigator was compared with each of the other four&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Statistical analysis</span><p id="par0085" class="elsevierStylePara elsevierViewall">Continuous variables were described with mean and standard deviation &#40;SD&#41; or median and inter-quantile range &#40;IQR&#58; 25th percentile&#8226;75th percentile&#41;&#44; as appropriate&#46; Categorical data were presented as frequencies and percentages&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">To assess the precision of the ECHO measurements&#44; the intra-observer repeatability and inter-observer reproducibility were studied using intraclass correlation coefficients &#40;ICCs&#41;&#44; and corresponding 95&#37; confidence intervals&#46; These were estimated using a generalized linear mixed effects model with a random intercept and a random slope&#44; taking into account the correlation structure between CO measures of the same patient&#46; To evaluate the agreement between ECHO and PiCCO for measuring CO&#44; Bland&#8226;Altman graphical method was used&#46; Additionally&#44; a stratified analysis by temperature &#40;&#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; &#8805;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; was performed using generalized linear mixed effects models with a random intercept&#44; where the difference between the two methods was adjusted by temperature&#46; Both generalized linear mixed effects models considered a variance&#8226;covariance matrix defined as a multiple of the identity matrix&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The best cut-off value that identifies patients who have a difference between CO<span class="elsevierStyleInf">ECHO</span> and CO<span class="elsevierStyleInf">PiCCO</span> belonging to the interval &#40;&#8743;0&#46;5&#44; 0&#46;5&#41;&#44; was calculated by maximizing specificity&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> After discretizing CO measures by the obtained cut-off value&#44; diagnostic test performance measures &#40;sensitivity&#44; specificity&#44; positive and negative predictive values as well as false positive and false negative rates&#41; were calculated&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The level of significance <span class="elsevierStyleItalic">&#945;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05 was considered&#46; Data analysis was performed using Stata &#40;StataCorp&#46; 2011&#59; Stata Statistical Software&#58; Release 12&#44; College Station&#44; TX&#58; StataCorp LP&#46;&#41; and R software &#40;R&#58; A Language and Environment for Statistical Computing&#44; R Core Team&#44; R Foundation for Statistical Computing&#44; Vienna&#44; Austria&#44; year<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2014&#44; <a id="intr0005" class="elsevierStyleInterRef" href="http://www.r-project.org/">http&#58;&#47;&#47;www&#46;R-project&#46;org</a>&#46;&#41;&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Results</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Patients</span><p id="par0105" class="elsevierStylePara elsevierViewall">Fifteen patients met the inclusion criteria of the study&#46; The demographic characteristics&#44; severity scores at admission as well as the arrest rhythm and cause are displayed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Eleven patients &#40;73&#37;&#41; initiated hypothermia protocol in the ICU&#44; one started cooling in pre-hospital care and the remaining three began the protocol in the Emergency Department&#46; In-hospital mortality was 47&#37;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Echocardiography preliminary study</span><p id="par0110" class="elsevierStylePara elsevierViewall">Regarding the intra-observer repeatability and inter-observer reproducibility&#44; the intraclass correlation coefficients were both equal to 0&#46;998 &#40;95&#37; CI&#58; 0&#46;995&#8226;0&#46;999&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">CO measurements</span><p id="par0115" class="elsevierStylePara elsevierViewall">A total of 30 paired CO<span class="elsevierStyleInf">ECHO</span>&#47;CO<span class="elsevierStyleInf">PiCCO</span> measurements were analyzed&#46; The mean time interval between the measurements was 7 &#40;SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41;<span class="elsevierStyleHsp" style=""></span>minutes&#46; Mean temperature during the measurements was 35<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; with 18 paired measurements performed under 36<span class="elsevierStyleHsp" style=""></span>&#176;C and 12 at a temperature equal or superior to 36<span class="elsevierStyleHsp" style=""></span>&#176;C&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In overall pairs of CO measurements&#44; the mean difference between the two methods was &#8743;0&#46;24<span class="elsevierStyleHsp" style=""></span>L&#47;min&#44; with limits of agreement &#40;&#8743;1&#46;26&#44; 0&#46;77&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Considering the measurements at normothermia &#40;&#8805;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; the mean difference was 0&#46;030<span class="elsevierStyleHsp" style=""></span>L&#47;min&#44; with limits of agreement &#40;&#8743;0&#46;22&#44; 0&#46;28&#41;&#46; All of the 12 pairs of CO measurements registered at this temperature&#44; differed less than 0&#46;5<span class="elsevierStyleHsp" style=""></span>L&#47;min&#44; previously defined as an acceptable difference &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>a&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">In hypothermia &#40;&#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; the mean difference of CO measurements was &#8743;0&#46;426<span class="elsevierStyleHsp" style=""></span>L&#47;min with limits of agreement &#40;&#8743;1&#46;60&#44; 0&#46;75&#41; and only 44&#37; &#40;8&#47;18&#41; of the paired measurements fell in the interval &#40;&#8743;0&#46;5&#44; 0&#46;5&#41;&#46; For the remaining 10 measurements that differed more than 0&#46;5<span class="elsevierStyleHsp" style=""></span>L&#47;min&#44; the difference CO<span class="elsevierStyleInf">ECHO</span><span class="elsevierStyleHsp" style=""></span>&#8743;<span class="elsevierStyleHsp" style=""></span>CO<span class="elsevierStyleInf">PiCCO</span> was negative in most cases &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>b&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> reinforces that the concordance between CO<span class="elsevierStyleInf">PICCO</span> and CO<span class="elsevierStyleInf">ECHO</span> measurements was better when temperature was equal or above 36<span class="elsevierStyleHsp" style=""></span>&#176;C&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">The calculated temperature cut-off&#44; in order to maximize specificity&#44; was 35&#46;95<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; Above this temperature&#44; the specificity was 100&#37; and the false positive rate was 0&#37;&#44; traducing a complete agreement between the methods&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Results of the linear mixed effects models &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; are in accordance with those obtained previously&#46; In fact&#44; for temperatures &#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C the difference between the two methods&#44; after adjusting for temperature&#44; was statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; However&#44; for temperatures &#8805;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; no significant difference was found between the two methods &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;374&#41;&#46; Additionally&#44; the resulting ICC of the model for temperatures higher or equal 36<span class="elsevierStyleHsp" style=""></span>&#176;C was higher &#40;0&#46;998&#44; 95&#37; CI&#58; 0&#46;993&#8226;0&#46;999&#41; than that obtained for lower temperatures &#40;0&#46;843&#44; 95&#37; CI&#58; 0&#46;652&#8226;0&#46;939&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Discussion</span><p id="par0150" class="elsevierStylePara elsevierViewall">The results clearly show that the discordance between the cardiac output measured by PiCCO and transthoracic echocardiogram is bigger at lower temperatures&#46; Comparing the paired measurements during hypothermia &#40;&#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; and normothermia &#40;&#8805;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; it is clear that the later ones are far more coincident&#44; as shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> and confirmed by the results of the multivariable analysis&#46; The control of potential confounding variables was assured for every pair of measurements&#44; thus any difference between CO<span class="elsevierStyleInf">ECHO</span> and CO<span class="elsevierStyleInf">PiCCO</span> can be attributed exclusively to the methods&#46; Furthermore&#44; as echocardiography is not influenced by temperature changes&#44; we concluded that lower body temperature diminishes accuracy of PiCCO measurements&#46; This interference is called &#8220;thermal noise&#8221;&#44; and several authors proved its influence on the precision and accuracy of thermodilution measurements&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">13&#8226;16</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">To evaluate a certain measurement method&#44; one should consider both precision &#8226; closeness of agreement between replicate measurements &#8226; and accuracy &#8226; closeness of agreement between a measurement value and its true value&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> Tagami <span class="elsevierStyleItalic">et al&#46;</span> studied the precision of PiCCO in hypothermic patients following cardiac arrest by comparing measurements at different temperatures&#44; during hypothermia and the rewarming period and found no significant changes&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> However&#44; as Gasparetto <span class="elsevierStyleItalic">et al&#46;</span> pointed out&#44; not only the precision or reproducibility of PiCCO is important to validate but also its accuracy<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> under this condition&#46; This means responding to the question &#8220;how close the measurement is to the actual or real value&#8221; and implies a comparison with a gold standard technique&#44; in this context&#44; ideally non temperature-dependent&#44; such as echocardiography&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">On interpreting the results&#44; it must be remembered that echocardiography&#44; itself&#44; has its limitations and is not exempt of errors&#46; Concretely in the obtainment of cardiac output values&#44; it requires expertise on performing the five chamber view to measure VTI<span class="elsevierStyleInf">LVOT</span> and the long axis view&#44; sometimes difficult in the critically ill patients&#44; to measure the left ventricular outflow tract diameter &#40;D<span class="elsevierStyleInf">LVOT</span>&#41;&#46; Errors in this latest parameter are particularly serious&#44; as it is squared in the CO formula&#46; To overcome the potential errors on measuring the D<span class="elsevierStyleInf">LVOT</span>&#44; Vermeiren et al&#46; suggests its calculation according to the body surface area &#40;D<span class="elsevierStyleInf">LVOT</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#46;7<span class="elsevierStyleHsp" style=""></span>&#237;<span class="elsevierStyleHsp" style=""></span>BSA<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>12&#46;1&#41;&#46; The authors also admit the use of fixed values for D<span class="elsevierStyleInf">LVOT</span> like 1&#46;8 for female and 2&#46;0 for male patients&#44; or even the general value of 3<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> for A<span class="elsevierStyleInf">LVOT</span>&#44; which would greatly simplify the conclusions and decisions at the bedside&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">The measurements performed at &#8805;36&#176; had a very small mean difference &#40;0&#46;03<span class="elsevierStyleHsp" style=""></span>L&#47;min&#41; with narrow limits of agreement &#40;&#8743;0&#46;22&#44; 0&#46;28&#41;&#44; therefore considered completely concordant&#44; in terms of clinical practice&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">On the other hand&#44; the measurements of CO during hypothermia &#40;&#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; had a mean difference of 0&#46;426<span class="elsevierStyleHsp" style=""></span>L&#47;min&#44; still within the interval considered clinically accepted&#44; but with much wider limits of agreement &#40;&#8743;1&#46;60&#44; 0&#46;75&#41;&#44; traducing the elevated number of measurements that differed &#62;0&#46;5<span class="elsevierStyleHsp" style=""></span>L&#47;min&#46; In fact&#44; more than 50&#37; of the paired measurements performed at &#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C differed more than 0&#46;5<span class="elsevierStyleHsp" style=""></span>L&#47;min&#44; with a tendency to overestimate CO measured by PiCCO&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Accordingly&#44; the temperature cut-off value that assured specificity of 100&#37; was 35&#46;95<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; virtually the same as the 36<span class="elsevierStyleHsp" style=""></span>&#176;C used to distinguish normothermia and hypothermia&#46; This means that only above this temperature the difference CO<span class="elsevierStyleInf">ECHO</span><span class="elsevierStyleHsp" style=""></span>&#8743;<span class="elsevierStyleHsp" style=""></span>CO<span class="elsevierStyleInf">PiCCO</span> was &#60;0&#46;5<span class="elsevierStyleHsp" style=""></span>L&#47;min for all paired measurements&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">In clinical practice&#44; this can be extremely relevant&#44; as the difference between CO<span class="elsevierStyleInf">ECHO</span><span class="elsevierStyleHsp" style=""></span>&#8743;<span class="elsevierStyleHsp" style=""></span>CO<span class="elsevierStyleInf">PiCCO</span> that we considered as clinically accepted &#40;0&#46;5<span class="elsevierStyleHsp" style=""></span>L&#47;min&#41; is already rather high in the context of critically ill and often hemodynamically instable patients&#46; As so&#44; a method that misleads the CO calculation&#44; by more than 0&#46;5<span class="elsevierStyleHsp" style=""></span>L&#47;min&#44; seems to us too inaccurate to be useful in these situations&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The implications of these findings can overtake the strict context of hypothermia after cardiac arrest&#44; as the PiCCO system is used in other situations of low body temperature&#46; For example patients experiencing unintended perioperative hypothermia &#40;&#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> in surgeries where the PiCCO system is used to hemodynamic monitoring&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">The major limitation of this study is the sample size&#46; This fact also precluded the stratification for different CO values which could be useful for more detailed analysis&#46; Larger randomized studies are needed to confirm this inadequacy of PiCCO&#44; and possibly other thermodilution methods&#44; for patients under temperatures &#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Despite the very good results of the echocardiographic preliminary study&#44; as a technique observer-dependent&#44; it must always be considered as a potential source of bias&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Author contribution</span><p id="par0200" class="elsevierStylePara elsevierViewall">The Authors Teresa Souto Moura&#44; S&#237;lvia Aguiar Rosa&#44; Nuno Germano&#44; Raquel Cavaco&#44; Tania Sequeira and Luis Bento&#44; declare that they have made substantial contributions to the conception and design of the study&#44; the acquisition of data and the interpretation of the data&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Marta Alves&#44; Ana Luisa Papoila have performed the analysis and interpretation of the data&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">All the authors have commented on the draft of the article and critical revision of the intellectual content&#44; as well as the definitive approval of the version that is presented&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflicts of interest</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors declare that there is no conflict of interest&#46;</p></span></span>"
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              "titulo" => "Procedures"
            ]
            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "PiCCO measurements"
            ]
            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Echocardiographic measurements"
            ]
            4 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Echocardiography inter-observer and intra-observer variability analysis"
            ]
            5 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Statistical analysis"
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        ]
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          "identificador" => "sec0045"
          "titulo" => "Results"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Patients"
            ]
            1 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Echocardiography preliminary study"
            ]
            2 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "CO measurements"
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0065"
          "titulo" => "Discussion"
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        8 => array:2 [
          "identificador" => "sec0070"
          "titulo" => "Author contribution"
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        9 => array:2 [
          "identificador" => "sec0075"
          "titulo" => "Conflicts of interest"
        ]
        10 => array:2 [
          "identificador" => "xack338151"
          "titulo" => "Acknowledgment"
        ]
        11 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2016-12-19"
    "fechaAceptado" => "2017-03-17"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec963402"
          "palabras" => array:5 [
            0 => "PiCCO monitor"
            1 => "Cardiac output"
            2 => "Hypothermia"
            3 => "Doppler echocardiography"
            4 => "Hemodynamic monitoring"
          ]
        ]
      ]
      "es" => array:1 [
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          "identificador" => "xpalclavsec963401"
          "palabras" => array:5 [
            0 => "Monitor PiCCO"
            1 => "Gasto cardiaco"
            2 => "Hipotermia"
            3 => "Ecocardiograf&#237;a doppler"
            4 => "Monitorizaci&#243;n hemodin&#225;mica"
          ]
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      ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Invasive cardiac monitoring using thermodilution methods such as PiCCO&#168;r&#41; is widely used in critically ill patients and provides a wide range of hemodynamic variables&#44; including cardiac output &#40;CO&#41;&#46; However&#44; in post-cardiac arrest patients subjected to therapeutic hypothermia&#44; the low body temperature possibly could interfere with the technique&#46; Transthoracic Doppler echocardiography &#40;ECHO&#41; has long proved its accuracy in estimating CO&#44; and is not influenced by temperature changes&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To assess the accuracy of PiCCO&#168;r&#41; in measuring CO in patients under therapeutic hypothermia&#44; compared with ECHO&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Design and patients</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Thirty paired COECHO&#47;COPiCCO measurements were analyzed in 15 patients subjected to hypothermia after cardiac arrest&#46; Eighteen paired measurements were obtained at under 36<span class="elsevierStyleHsp" style=""></span>&#176;C and 12 at &#8805;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; A value of 0&#46;5<span class="elsevierStyleHsp" style=""></span>l&#47;min was considered the maximum accepted difference between the COECHO and COPiCCO values&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Under conditions of normothermia &#40;&#8805;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; the mean difference between COECHO and COPiCCO was 0&#46;030 l&#47;min&#44; with limits of agreement &#40;&#8743;0&#46;22&#44; 0&#46;28&#41; &#8226; all of the measurements differing by less than 0&#46;5 l&#47;min&#46; In situations of hypothermia &#40;&#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; the mean difference in CO measurements was &#8743;0&#46;426 l&#47;min&#44; with limits of agreement &#40;&#8743;1&#46;60&#44; 0&#46;75&#41;&#44; and only 44&#37; &#40;8&#47;18&#41; of the paired measurements fell within the interval &#40;&#8743;0&#46;5&#44; 0&#46;5&#41;&#46; The calculated temperature cut-off point maximizing specificity was 35&#46;95<span class="elsevierStyleHsp" style=""></span>&#176;C&#58; above this temperature&#44; specificity was 100&#37;&#44; with a false-positive rate of 0&#37;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The results clearly show clinically relevant discordance between COECHO and COPiCCO at temperatures of &#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; demonstrating the inaccuracy of PiCCO&#168;r&#41; for cardiac output measurements in hypothermic patients&#46;</p></span>"
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            "titulo" => "Objective"
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            "identificador" => "abst0015"
            "titulo" => "Design and patients"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La monitorizaci&#243;n invasiva cardiaca mediante m&#232;c&#41;todos de termodiluci&#243;n&#44; como PiCCO&#168;r&#41;&#44; es ampliamente utilizada en pacientes cr&#237;ticamente enfermos y proporciona una gran variedad de variables hemodin&#225;micas&#44; como el gasto cardiaco &#40;GC&#41;&#46; No obstante&#44; en los pacientes post-paro card&#237;aco bajo hipotermia terap&#232;c&#41;utica&#44; la baja temperatura corporal podr&#237;a interferir con la t&#232;c&#41;cnica&#46; La ecocardiograf&#237;a doppler transtor&#225;cica &#40;ECHO&#41; ha demostrado su exactitud en la estimaci&#243;n del GC y no est&#225; influenciada por los cambios de temperatura&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El objetivo del presente estudio fue evaluar la exactitud de PiCCO&#168;r&#41; para medir el GC en pacientes bajo hipotermia terap&#232;c&#41;utica&#44; en comparaci&#243;n con ECHO&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Dise&#241;o y pacientes</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Se analizaron 30 pares de mediciones GC&#95;ECHO&#47;GC&#95;PiCCO en 15 pacientes sometidos a hipotermia despu&#232;c&#41;s de un paro card&#237;aco&#46; La m&#225;xima diferencia aceptada entre los valores de GC&#95;ECHO y GC&#95;PiCCO se consider&#243; 18 mediciones pareadas se realizaron a menos de 36<span class="elsevierStyleHsp" style=""></span>&#176;C y 12 a &#8805;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; 0&#44;5<span class="elsevierStyleHsp" style=""></span>L&#47;min&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En la normotermia &#40;&#8805;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; la diferencia media entre GC&#95;ECHO y GC&#95;PiCCO fue de 0&#44;030<span class="elsevierStyleHsp" style=""></span>L&#47;min&#44; con l&#237;mites de concordancia &#40;&#8226;0&#44;22&#59; 0&#44;28&#41;&#44; todas las medidas difieren menos de 0&#44;5<span class="elsevierStyleHsp" style=""></span>L&#47;min&#46; En la hipotermia &#40;&#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; la diferencia media de las mediciones fue &#8226;0&#44;426<span class="elsevierStyleHsp" style=""></span>L&#47;min con l&#237;mites de concordancia &#40;&#8226;1&#44;60&#59; 0&#44;75&#41; y solo el 44&#37; de las mediciones cayeron en el intervalo &#40;&#8226;0&#44;5&#59; 0&#44;5&#41;&#46; El l&#237;mite de temperatura calculado que maximiza la especificidad fue 35&#44;95<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; por encima del cual la especificidad fue del 100&#37; y la tasa de falsos positivos del 0&#37;&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Los resultados muestran claramente una discordancia cl&#237;nicamente relevante entre GC&#95;ECHO y GC&#95;PiCCO en temperatura &#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; lo que revela la inexactitud de PiCCO&#168;r&#41; para las mediciones del gasto card&#237;aco en pacientes hipot&#232;c&#41;rmicos&#46;</p></span>"
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            "titulo" => "Resultados"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patients&#8232;tm&#41; characteristics &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age median &#40;IQR&#41; years</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">66 &#40;57&#8226;69&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Severity scores</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>APACHE II &#40;median&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>SAPS II &#40;median&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Arrest rhythm n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Asystole&nbsp;\t\t\t\t\t\t\n
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Original article
The accuracy of PiCCO¨r) in measuring cardiac output in patients under therapeutic hypothermia: Comparison with transthoracic echocardiography
La exactitud de PiCCO ¨r) para medir el gasto cardíaco en pacientes bajo hipotermia terapèc)utica: comparación con ecocardiografía transtorácica
T. Souto Mouraa,
Corresponding author
teresasoutomoura@gmail.com

Corresponding author.
, S. Aguiar Rosab, N. Germanoc, R. Cavacoc, T. Sequeirac, M. Alvesd, A.L. Papoilad,e, L. Bentoc
a Medicine Department 1, 4 São Josèc)
tm)s Hospital, Central Lisbon Hospitalar Centre, Portugal
b Cardiology Department, Santa Marta's Hospital, Central Lisbon Hospitalar Centre, Portugal
c Medical Urgency Unit, São Josèc)
tm)s Hospital, Central Lisbon Hospitalar Centre, Portugal
d Epidemiological and Statistical Analysis Department, Investigation Center of the Central Lisbon Hospitalar Centre, Portugal
e Statistical and Applications Center of NOVA Medical School, Portugal
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            "identificador" => "aff0005"
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          1 => array:3 [
            "entidad" => "Cardiology Department&#44; Santa Marta&#39;s Hospital&#44; Central Lisbon Hospitalar Centre&#44; Portugal"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
          2 => array:3 [
            "entidad" => "Medical Urgency Unit&#44; S&#227;o Jos&#232;c&#41;&#8232;tm&#41;s Hospital&#44; Central Lisbon Hospitalar Centre&#44; Portugal"
            "etiqueta" => "c"
            "identificador" => "aff0015"
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          3 => array:3 [
            "entidad" => "Epidemiological and Statistical Analysis Department&#44; Investigation Center of the Central Lisbon Hospitalar Centre&#44; Portugal"
            "etiqueta" => "d"
            "identificador" => "aff0020"
          ]
          4 => array:3 [
            "entidad" => "Statistical and Applications Center of NOVA Medical School&#44; Portugal"
            "etiqueta" => "e"
            "identificador" => "aff0025"
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          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
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        "titulo" => "La exactitud de PiCCO &#168;r&#41; para medir el gasto card&#237;aco en pacientes bajo hipotermia terap&#232;c&#41;utica&#58; comparaci&#243;n con ecocardiograf&#237;a transtor&#225;cica"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Scatterplot of PiCCO versus ECHO cardiac output measures&#44; considering the groups of temperature &#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C and &#8805;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; Dashed line represents the line where ECHO and PiCCO have equal values&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In post-cardiac arrest patients&#44; mild induced hypothermia has proven to be neuroprotective and to improve the global outcome after the initial period of cerebral hypoxia-ischemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1&#44;2</span></a> This probably occurs because hypothermia reduces cerebral oxygen demand&#44; decreases intracranial pressure and also limits the production of oxygen free radicals&#44; diminishing brain damage&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> The term targeted temperature management is now preferred&#44; and the most recent resuscitation guidelines recommend a constant temperature between 32&#8226;36<span class="elsevierStyleHsp" style=""></span>&#176;C for at least 24<span class="elsevierStyleHsp" style=""></span>h&#44; although the optimal target temperature remains uncertain&#44; waiting for more large controlled trials on this matter&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The initial management of the so called &#8216;post-resuscitation syndrome&#8232;tm&#41; is challenging&#46; Hypovolemia&#44; excessive vasodilation and reversible myocardial stunning frequently results in early hypotension that can be life-threatening&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">4&#44;5</span></a> This hemodynamic instability is managed with the use of fluids&#44; inotropes and vasopressors if needed&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3&#44;4</span></a> Therefore&#44; it is important to have a correct monitoring of hemodynamic and pulmonary variables&#44; in order to optimize those therapies&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> sometimes using invasive devices&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The PiCCO<span class="elsevierStyleSup">&#168;r&#41;</span> &#40;pulse index continuous cardiac output&#41; system&#44; in use for over 10 years&#44; allows the measuring of a large number of variables throughout central venous and peripheral arterial catheterization alone&#46; Among other parameters&#44; it is used to measure cardiac output &#40;CO&#41; through a transpulmonary thermodilution method&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Despite the unquestionable utility of PiCCO<span class="elsevierStyleSup">&#168;r&#41;</span> in situations of hemodynamic instability&#44; as a thermodilution method&#44; it is assumed that the temperature within the artery stays stable during calibration and measurements&#46; That might not be the case during hypothermia and other variations of body temperature&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Transthoracic Doppler echocardiography &#40;ECHO&#41; has long proved its accuracy in CO estimation&#44; including in critically ill patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#8226;10</span></a> It can be performed in different scenarios&#44; including therapeutic hypothermia&#44; and it is not influenced by temperature changes&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Therefore&#44; the aim of the present study was to assess the concordance between the CO values measured by PiCCO<span class="elsevierStyleSup">&#168;r&#41;</span> &#40;CO<span class="elsevierStyleInf">PiCCO</span>&#41; and by ECHO &#40;CO<span class="elsevierStyleInf">ECHO</span>&#41;&#44; in patients under therapeutic hypothermia following cardiac arrest&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Study design and patients</span><p id="par0035" class="elsevierStylePara elsevierViewall">This single-center&#44; prospective cohort study was conducted in the intensive care unit &#40;ICU&#41; of a tertiary hospital of Lisbon&#44; between August 2014 and July 2015&#46; Following approval of the ethic committee of Centro Hospitalar de Lisboa Central&#44; informed consent was obtained from each patient&#39;s next of kin or a posteriori from the patient himself&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The study included all patients admitted to the ICU for therapeutic hypothermia following cardiac arrest&#44; according to the unit protocol&#46; The exclusion criteria were any condition that contraindicated the insertion of PiCCO<span class="elsevierStyleSup">&#168;r&#41;</span> or impaired the transthoracic echocardiographic window&#44; as neck and thoracic severe trauma&#44; burning or skin infection&#46; Additionally&#44; patients were excluded if they had pathology that could diminish the accuracy of CO calculation using ECHO &#40;chronic atrial fibrillation&#44; cardiac valve disease&#44; pulmonary thromboembolism or intracardiac shunts&#41; or PiCCO &#40;severe peripheral arterial disease or arterial bypass&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Procedures</span><p id="par0045" class="elsevierStylePara elsevierViewall">At ICU admission&#44; patients received central venous catheter &#40;Kimal<span class="elsevierStyleSup">&#168;r&#41;</span>&#59; 5-lumened&#44; 8&#46;5<span class="elsevierStyleHsp" style=""></span>Fr<span class="elsevierStyleHsp" style=""></span>&#237;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>cm&#41; on the internal jugular or subclavian vein and a PiCCO<span class="elsevierStyleSup">&#168;r&#41;</span> catheter &#40;Pulsion Medical Systems&#44; 5<span class="elsevierStyleHsp" style=""></span>Fr<span class="elsevierStyleHsp" style=""></span>&#237;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>cm&#41; inserted in the femoral artery&#44; connected to a Siemens MP 50 monitor with the appropriate software&#46; Based on the modified Stewart-Hamilton equation&#44; cardiac output is inversely related to the concentration and total passage time of an indicator solution measured after its transit through the heart&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a><elsevierMultimedia ident="eq0005"></elsevierMultimedia>Equation 1&#58; Adapted Stewart-Hamilton equation&#44; where CO<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Cardiac output&#59; Tb<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Blood temperature&#59; Ti<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>injectate temperature&#59; Vi<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>injectate volume&#59; K<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>constant&#59; &#8738;¿Tb<span class="elsevierStyleHsp" style=""></span>&#237;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>area under the thermodilution curve&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">During the therapeutic hypothermia and rewarming period&#44; CO was calculated through the PiCCO system followed by ECHO estimation &#40;General Electric<span class="elsevierStyleSup">&#168;r&#41;</span> VIVID S5&#44; with 3&#46;5<span class="elsevierStyleHsp" style=""></span>MHz probe&#41;&#46; The two measurements were performed by different&#44; blinded investigators&#44; as close as possible &#40;maximum interval of time&#58; 10<span class="elsevierStyleHsp" style=""></span>minutes&#41;&#46; At the same time&#44; central temperature and hemodynamic data &#40;heart rate&#44; rhythm and mean arterial systemic pressure&#41; were registered&#46; It was assured the constancy of each interfering variable such as level of sedation&#44; ventilation parameters&#44; vasoactive drugs or any other IV infusion&#46; Therefore&#44; a pair of CO measurements &#40;one by PiCCO and one by ECHO&#41; for a determined temperature was obtained&#46; Additionally&#44; demographic data&#44; severity scores at admission&#44; cause and rhythm of arrest and final outcome were collected&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">We considered 0&#46;5<span class="elsevierStyleHsp" style=""></span>L&#47;min as the maximum clinically accepted difference between the values of CO<span class="elsevierStyleInf">ECHO</span> and CO<span class="elsevierStyleInf">PiCCO</span>&#46; In other words&#44; the two methods were considered to agree when the difference fell in the interval &#40;&#8743;0&#46;5&#44; 0&#46;5&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">PiCCO measurements</span><p id="par0060" class="elsevierStylePara elsevierViewall">For the CO calculation by thermodilution technique&#44; 20<span class="elsevierStyleHsp" style=""></span>ml of iced &#40;&#60;8<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; saline 0&#46;9&#37; was delivered in the proximal lumen of the central venous catheter and mixed with blood through the systemic and pulmonary circulation&#46; The injection was performed as rapidly as possible&#44; irrespective of the respiratory cycle&#46; The thermistor-tipped arterial line&#44; placed in the femoral artery&#44; quantified the change in temperature over time&#46; The thermodilution curve recorded by the arterial thermistor was automatically analyzed by the PiCCO<span class="elsevierStyleSup">&#168;r&#41;</span> software&#44; obtaining the value of CO&#46; Triplicate injections were performed for each set of measurements and considered the mean value of the three&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Echocardiographic measurements</span><p id="par0065" class="elsevierStylePara elsevierViewall">The Doppler estimated CO was obtained multiplying the heart rate &#40;HR&#41; by the Doppler estimated stroke volume &#40;SV&#41;&#46; The last one uses the velocity-time integral of flow through the left ventricular outflow tract &#40;VTI<span class="elsevierStyleInf">LVOT</span>&#41; and the area of the left ventricular outflow tract &#40;A<span class="elsevierStyleInf">LVOT</span>&#41; which&#44; in turn&#44; is calculated using the left ventricular outflow tract diameter &#40;D<span class="elsevierStyleInf">LVOT</span>&#41; by the following formula&#58;<elsevierMultimedia ident="eq0010"></elsevierMultimedia></p><p id="par0070" class="elsevierStylePara elsevierViewall">The VTI<span class="elsevierStyleInf">LVOT</span> was recorded by pulsed-wave Doppler from an apical fiver chamber view&#44; by placing the Doppler sample immediately below the aortic valve annulus&#44; aligned with the center of the valve where the flow is maximum&#46; The final value of VTI<span class="elsevierStyleInf">LVOT</span> was the mean of three consecutive determinations&#46; D<span class="elsevierStyleInf">LVOT</span> was measured in a parasternal long-axis view&#44; just before the aortic annulus&#44; from the inner edge to outer edge&#44; parallel to the valve apparatus&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Five complete and consecutive measurements were performed&#44; and considered the mean as the final value for CO<span class="elsevierStyleInf">ECHO</span>&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Echocardiography inter-observer and intra-observer variability analysis</span><p id="par0080" class="elsevierStylePara elsevierViewall">In order to assure the reliability of the CO<span class="elsevierStyleInf">ECHO</span> measurements&#44; as the operator dependent errors are the major pitfall of this technique&#44; a previous study was conducted to evaluate the echocardiographic skills of the five investigators involved in the major study&#46; Repeating the procedure as described above &#40;mean three determinations of VTI<span class="elsevierStyleInf">LVOT</span> and one of D<span class="elsevierStyleInf">LVOT</span>&#41;&#44; each investigator performed five CO<span class="elsevierStyleInf">ECHO</span> measurements in a patient under therapeutic hypothermia and was followed by other blinded investigator who obtained another five measurements&#46; This procedure was repeated in ten different patients so that every investigator was compared with each of the other four&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Statistical analysis</span><p id="par0085" class="elsevierStylePara elsevierViewall">Continuous variables were described with mean and standard deviation &#40;SD&#41; or median and inter-quantile range &#40;IQR&#58; 25th percentile&#8226;75th percentile&#41;&#44; as appropriate&#46; Categorical data were presented as frequencies and percentages&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">To assess the precision of the ECHO measurements&#44; the intra-observer repeatability and inter-observer reproducibility were studied using intraclass correlation coefficients &#40;ICCs&#41;&#44; and corresponding 95&#37; confidence intervals&#46; These were estimated using a generalized linear mixed effects model with a random intercept and a random slope&#44; taking into account the correlation structure between CO measures of the same patient&#46; To evaluate the agreement between ECHO and PiCCO for measuring CO&#44; Bland&#8226;Altman graphical method was used&#46; Additionally&#44; a stratified analysis by temperature &#40;&#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; &#8805;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; was performed using generalized linear mixed effects models with a random intercept&#44; where the difference between the two methods was adjusted by temperature&#46; Both generalized linear mixed effects models considered a variance&#8226;covariance matrix defined as a multiple of the identity matrix&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The best cut-off value that identifies patients who have a difference between CO<span class="elsevierStyleInf">ECHO</span> and CO<span class="elsevierStyleInf">PiCCO</span> belonging to the interval &#40;&#8743;0&#46;5&#44; 0&#46;5&#41;&#44; was calculated by maximizing specificity&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> After discretizing CO measures by the obtained cut-off value&#44; diagnostic test performance measures &#40;sensitivity&#44; specificity&#44; positive and negative predictive values as well as false positive and false negative rates&#41; were calculated&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The level of significance <span class="elsevierStyleItalic">&#945;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05 was considered&#46; Data analysis was performed using Stata &#40;StataCorp&#46; 2011&#59; Stata Statistical Software&#58; Release 12&#44; College Station&#44; TX&#58; StataCorp LP&#46;&#41; and R software &#40;R&#58; A Language and Environment for Statistical Computing&#44; R Core Team&#44; R Foundation for Statistical Computing&#44; Vienna&#44; Austria&#44; year<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2014&#44; <a id="intr0005" class="elsevierStyleInterRef" href="http://www.r-project.org/">http&#58;&#47;&#47;www&#46;R-project&#46;org</a>&#46;&#41;&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Results</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Patients</span><p id="par0105" class="elsevierStylePara elsevierViewall">Fifteen patients met the inclusion criteria of the study&#46; The demographic characteristics&#44; severity scores at admission as well as the arrest rhythm and cause are displayed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Eleven patients &#40;73&#37;&#41; initiated hypothermia protocol in the ICU&#44; one started cooling in pre-hospital care and the remaining three began the protocol in the Emergency Department&#46; In-hospital mortality was 47&#37;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Echocardiography preliminary study</span><p id="par0110" class="elsevierStylePara elsevierViewall">Regarding the intra-observer repeatability and inter-observer reproducibility&#44; the intraclass correlation coefficients were both equal to 0&#46;998 &#40;95&#37; CI&#58; 0&#46;995&#8226;0&#46;999&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">CO measurements</span><p id="par0115" class="elsevierStylePara elsevierViewall">A total of 30 paired CO<span class="elsevierStyleInf">ECHO</span>&#47;CO<span class="elsevierStyleInf">PiCCO</span> measurements were analyzed&#46; The mean time interval between the measurements was 7 &#40;SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41;<span class="elsevierStyleHsp" style=""></span>minutes&#46; Mean temperature during the measurements was 35<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; with 18 paired measurements performed under 36<span class="elsevierStyleHsp" style=""></span>&#176;C and 12 at a temperature equal or superior to 36<span class="elsevierStyleHsp" style=""></span>&#176;C&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In overall pairs of CO measurements&#44; the mean difference between the two methods was &#8743;0&#46;24<span class="elsevierStyleHsp" style=""></span>L&#47;min&#44; with limits of agreement &#40;&#8743;1&#46;26&#44; 0&#46;77&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Considering the measurements at normothermia &#40;&#8805;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; the mean difference was 0&#46;030<span class="elsevierStyleHsp" style=""></span>L&#47;min&#44; with limits of agreement &#40;&#8743;0&#46;22&#44; 0&#46;28&#41;&#46; All of the 12 pairs of CO measurements registered at this temperature&#44; differed less than 0&#46;5<span class="elsevierStyleHsp" style=""></span>L&#47;min&#44; previously defined as an acceptable difference &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>a&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">In hypothermia &#40;&#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; the mean difference of CO measurements was &#8743;0&#46;426<span class="elsevierStyleHsp" style=""></span>L&#47;min with limits of agreement &#40;&#8743;1&#46;60&#44; 0&#46;75&#41; and only 44&#37; &#40;8&#47;18&#41; of the paired measurements fell in the interval &#40;&#8743;0&#46;5&#44; 0&#46;5&#41;&#46; For the remaining 10 measurements that differed more than 0&#46;5<span class="elsevierStyleHsp" style=""></span>L&#47;min&#44; the difference CO<span class="elsevierStyleInf">ECHO</span><span class="elsevierStyleHsp" style=""></span>&#8743;<span class="elsevierStyleHsp" style=""></span>CO<span class="elsevierStyleInf">PiCCO</span> was negative in most cases &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>b&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> reinforces that the concordance between CO<span class="elsevierStyleInf">PICCO</span> and CO<span class="elsevierStyleInf">ECHO</span> measurements was better when temperature was equal or above 36<span class="elsevierStyleHsp" style=""></span>&#176;C&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">The calculated temperature cut-off&#44; in order to maximize specificity&#44; was 35&#46;95<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; Above this temperature&#44; the specificity was 100&#37; and the false positive rate was 0&#37;&#44; traducing a complete agreement between the methods&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Results of the linear mixed effects models &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; are in accordance with those obtained previously&#46; In fact&#44; for temperatures &#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C the difference between the two methods&#44; after adjusting for temperature&#44; was statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; However&#44; for temperatures &#8805;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; no significant difference was found between the two methods &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;374&#41;&#46; Additionally&#44; the resulting ICC of the model for temperatures higher or equal 36<span class="elsevierStyleHsp" style=""></span>&#176;C was higher &#40;0&#46;998&#44; 95&#37; CI&#58; 0&#46;993&#8226;0&#46;999&#41; than that obtained for lower temperatures &#40;0&#46;843&#44; 95&#37; CI&#58; 0&#46;652&#8226;0&#46;939&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Discussion</span><p id="par0150" class="elsevierStylePara elsevierViewall">The results clearly show that the discordance between the cardiac output measured by PiCCO and transthoracic echocardiogram is bigger at lower temperatures&#46; Comparing the paired measurements during hypothermia &#40;&#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; and normothermia &#40;&#8805;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; it is clear that the later ones are far more coincident&#44; as shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> and confirmed by the results of the multivariable analysis&#46; The control of potential confounding variables was assured for every pair of measurements&#44; thus any difference between CO<span class="elsevierStyleInf">ECHO</span> and CO<span class="elsevierStyleInf">PiCCO</span> can be attributed exclusively to the methods&#46; Furthermore&#44; as echocardiography is not influenced by temperature changes&#44; we concluded that lower body temperature diminishes accuracy of PiCCO measurements&#46; This interference is called &#8220;thermal noise&#8221;&#44; and several authors proved its influence on the precision and accuracy of thermodilution measurements&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">13&#8226;16</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">To evaluate a certain measurement method&#44; one should consider both precision &#8226; closeness of agreement between replicate measurements &#8226; and accuracy &#8226; closeness of agreement between a measurement value and its true value&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> Tagami <span class="elsevierStyleItalic">et al&#46;</span> studied the precision of PiCCO in hypothermic patients following cardiac arrest by comparing measurements at different temperatures&#44; during hypothermia and the rewarming period and found no significant changes&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> However&#44; as Gasparetto <span class="elsevierStyleItalic">et al&#46;</span> pointed out&#44; not only the precision or reproducibility of PiCCO is important to validate but also its accuracy<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> under this condition&#46; This means responding to the question &#8220;how close the measurement is to the actual or real value&#8221; and implies a comparison with a gold standard technique&#44; in this context&#44; ideally non temperature-dependent&#44; such as echocardiography&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">On interpreting the results&#44; it must be remembered that echocardiography&#44; itself&#44; has its limitations and is not exempt of errors&#46; Concretely in the obtainment of cardiac output values&#44; it requires expertise on performing the five chamber view to measure VTI<span class="elsevierStyleInf">LVOT</span> and the long axis view&#44; sometimes difficult in the critically ill patients&#44; to measure the left ventricular outflow tract diameter &#40;D<span class="elsevierStyleInf">LVOT</span>&#41;&#46; Errors in this latest parameter are particularly serious&#44; as it is squared in the CO formula&#46; To overcome the potential errors on measuring the D<span class="elsevierStyleInf">LVOT</span>&#44; Vermeiren et al&#46; suggests its calculation according to the body surface area &#40;D<span class="elsevierStyleInf">LVOT</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#46;7<span class="elsevierStyleHsp" style=""></span>&#237;<span class="elsevierStyleHsp" style=""></span>BSA<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>12&#46;1&#41;&#46; The authors also admit the use of fixed values for D<span class="elsevierStyleInf">LVOT</span> like 1&#46;8 for female and 2&#46;0 for male patients&#44; or even the general value of 3<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> for A<span class="elsevierStyleInf">LVOT</span>&#44; which would greatly simplify the conclusions and decisions at the bedside&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">The measurements performed at &#8805;36&#176; had a very small mean difference &#40;0&#46;03<span class="elsevierStyleHsp" style=""></span>L&#47;min&#41; with narrow limits of agreement &#40;&#8743;0&#46;22&#44; 0&#46;28&#41;&#44; therefore considered completely concordant&#44; in terms of clinical practice&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">On the other hand&#44; the measurements of CO during hypothermia &#40;&#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; had a mean difference of 0&#46;426<span class="elsevierStyleHsp" style=""></span>L&#47;min&#44; still within the interval considered clinically accepted&#44; but with much wider limits of agreement &#40;&#8743;1&#46;60&#44; 0&#46;75&#41;&#44; traducing the elevated number of measurements that differed &#62;0&#46;5<span class="elsevierStyleHsp" style=""></span>L&#47;min&#46; In fact&#44; more than 50&#37; of the paired measurements performed at &#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C differed more than 0&#46;5<span class="elsevierStyleHsp" style=""></span>L&#47;min&#44; with a tendency to overestimate CO measured by PiCCO&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Accordingly&#44; the temperature cut-off value that assured specificity of 100&#37; was 35&#46;95<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; virtually the same as the 36<span class="elsevierStyleHsp" style=""></span>&#176;C used to distinguish normothermia and hypothermia&#46; This means that only above this temperature the difference CO<span class="elsevierStyleInf">ECHO</span><span class="elsevierStyleHsp" style=""></span>&#8743;<span class="elsevierStyleHsp" style=""></span>CO<span class="elsevierStyleInf">PiCCO</span> was &#60;0&#46;5<span class="elsevierStyleHsp" style=""></span>L&#47;min for all paired measurements&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">In clinical practice&#44; this can be extremely relevant&#44; as the difference between CO<span class="elsevierStyleInf">ECHO</span><span class="elsevierStyleHsp" style=""></span>&#8743;<span class="elsevierStyleHsp" style=""></span>CO<span class="elsevierStyleInf">PiCCO</span> that we considered as clinically accepted &#40;0&#46;5<span class="elsevierStyleHsp" style=""></span>L&#47;min&#41; is already rather high in the context of critically ill and often hemodynamically instable patients&#46; As so&#44; a method that misleads the CO calculation&#44; by more than 0&#46;5<span class="elsevierStyleHsp" style=""></span>L&#47;min&#44; seems to us too inaccurate to be useful in these situations&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The implications of these findings can overtake the strict context of hypothermia after cardiac arrest&#44; as the PiCCO system is used in other situations of low body temperature&#46; For example patients experiencing unintended perioperative hypothermia &#40;&#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> in surgeries where the PiCCO system is used to hemodynamic monitoring&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">The major limitation of this study is the sample size&#46; This fact also precluded the stratification for different CO values which could be useful for more detailed analysis&#46; Larger randomized studies are needed to confirm this inadequacy of PiCCO&#44; and possibly other thermodilution methods&#44; for patients under temperatures &#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Despite the very good results of the echocardiographic preliminary study&#44; as a technique observer-dependent&#44; it must always be considered as a potential source of bias&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Author contribution</span><p id="par0200" class="elsevierStylePara elsevierViewall">The Authors Teresa Souto Moura&#44; S&#237;lvia Aguiar Rosa&#44; Nuno Germano&#44; Raquel Cavaco&#44; Tania Sequeira and Luis Bento&#44; declare that they have made substantial contributions to the conception and design of the study&#44; the acquisition of data and the interpretation of the data&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Marta Alves&#44; Ana Luisa Papoila have performed the analysis and interpretation of the data&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">All the authors have commented on the draft of the article and critical revision of the intellectual content&#44; as well as the definitive approval of the version that is presented&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflicts of interest</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors declare that there is no conflict of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Invasive cardiac monitoring using thermodilution methods such as PiCCO&#168;r&#41; is widely used in critically ill patients and provides a wide range of hemodynamic variables&#44; including cardiac output &#40;CO&#41;&#46; However&#44; in post-cardiac arrest patients subjected to therapeutic hypothermia&#44; the low body temperature possibly could interfere with the technique&#46; Transthoracic Doppler echocardiography &#40;ECHO&#41; has long proved its accuracy in estimating CO&#44; and is not influenced by temperature changes&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To assess the accuracy of PiCCO&#168;r&#41; in measuring CO in patients under therapeutic hypothermia&#44; compared with ECHO&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Design and patients</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Thirty paired COECHO&#47;COPiCCO measurements were analyzed in 15 patients subjected to hypothermia after cardiac arrest&#46; Eighteen paired measurements were obtained at under 36<span class="elsevierStyleHsp" style=""></span>&#176;C and 12 at &#8805;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; A value of 0&#46;5<span class="elsevierStyleHsp" style=""></span>l&#47;min was considered the maximum accepted difference between the COECHO and COPiCCO values&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Under conditions of normothermia &#40;&#8805;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; the mean difference between COECHO and COPiCCO was 0&#46;030 l&#47;min&#44; with limits of agreement &#40;&#8743;0&#46;22&#44; 0&#46;28&#41; &#8226; all of the measurements differing by less than 0&#46;5 l&#47;min&#46; In situations of hypothermia &#40;&#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; the mean difference in CO measurements was &#8743;0&#46;426 l&#47;min&#44; with limits of agreement &#40;&#8743;1&#46;60&#44; 0&#46;75&#41;&#44; and only 44&#37; &#40;8&#47;18&#41; of the paired measurements fell within the interval &#40;&#8743;0&#46;5&#44; 0&#46;5&#41;&#46; The calculated temperature cut-off point maximizing specificity was 35&#46;95<span class="elsevierStyleHsp" style=""></span>&#176;C&#58; above this temperature&#44; specificity was 100&#37;&#44; with a false-positive rate of 0&#37;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The results clearly show clinically relevant discordance between COECHO and COPiCCO at temperatures of &#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; demonstrating the inaccuracy of PiCCO&#168;r&#41; for cardiac output measurements in hypothermic patients&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La monitorizaci&#243;n invasiva cardiaca mediante m&#232;c&#41;todos de termodiluci&#243;n&#44; como PiCCO&#168;r&#41;&#44; es ampliamente utilizada en pacientes cr&#237;ticamente enfermos y proporciona una gran variedad de variables hemodin&#225;micas&#44; como el gasto cardiaco &#40;GC&#41;&#46; No obstante&#44; en los pacientes post-paro card&#237;aco bajo hipotermia terap&#232;c&#41;utica&#44; la baja temperatura corporal podr&#237;a interferir con la t&#232;c&#41;cnica&#46; La ecocardiograf&#237;a doppler transtor&#225;cica &#40;ECHO&#41; ha demostrado su exactitud en la estimaci&#243;n del GC y no est&#225; influenciada por los cambios de temperatura&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El objetivo del presente estudio fue evaluar la exactitud de PiCCO&#168;r&#41; para medir el GC en pacientes bajo hipotermia terap&#232;c&#41;utica&#44; en comparaci&#243;n con ECHO&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Dise&#241;o y pacientes</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Se analizaron 30 pares de mediciones GC&#95;ECHO&#47;GC&#95;PiCCO en 15 pacientes sometidos a hipotermia despu&#232;c&#41;s de un paro card&#237;aco&#46; La m&#225;xima diferencia aceptada entre los valores de GC&#95;ECHO y GC&#95;PiCCO se consider&#243; 18 mediciones pareadas se realizaron a menos de 36<span class="elsevierStyleHsp" style=""></span>&#176;C y 12 a &#8805;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; 0&#44;5<span class="elsevierStyleHsp" style=""></span>L&#47;min&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En la normotermia &#40;&#8805;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; la diferencia media entre GC&#95;ECHO y GC&#95;PiCCO fue de 0&#44;030<span class="elsevierStyleHsp" style=""></span>L&#47;min&#44; con l&#237;mites de concordancia &#40;&#8226;0&#44;22&#59; 0&#44;28&#41;&#44; todas las medidas difieren menos de 0&#44;5<span class="elsevierStyleHsp" style=""></span>L&#47;min&#46; En la hipotermia &#40;&#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; la diferencia media de las mediciones fue &#8226;0&#44;426<span class="elsevierStyleHsp" style=""></span>L&#47;min con l&#237;mites de concordancia &#40;&#8226;1&#44;60&#59; 0&#44;75&#41; y solo el 44&#37; de las mediciones cayeron en el intervalo &#40;&#8226;0&#44;5&#59; 0&#44;5&#41;&#46; El l&#237;mite de temperatura calculado que maximiza la especificidad fue 35&#44;95<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; por encima del cual la especificidad fue del 100&#37; y la tasa de falsos positivos del 0&#37;&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Los resultados muestran claramente una discordancia cl&#237;nicamente relevante entre GC&#95;ECHO y GC&#95;PiCCO en temperatura &#60;36<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; lo que revela la inexactitud de PiCCO&#168;r&#41; para las mediciones del gasto card&#237;aco en pacientes hipot&#232;c&#41;rmicos&#46;</p></span>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "S&#46;A&#46; Bernard"
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                            2 => "M&#46;D&#46; Buist"
                            3 => "B&#46;M&#46; Jones"
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                        "fecha" => "2002"
                        "volumen" => "346"
                        "paginaInicial" => "557"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11856794"
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                          "etal" => false
                          "autores" => array:1 [
                            0 => "T&#46;H&#46;A&#46;C&#46;A&#46;S&#46; Group"
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                      "doi" => "10.1056/NEJMoa012689"
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                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2002"
                        "volumen" => "346"
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                        "paginaFinal" => "556"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11856793"
                            "web" => "Medline"
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              "identificador" => "bib0115"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "European Resuscitation Council and European Society of Intensive Care Medicine Guidelines for Post-resuscitation Care 2015&#58; Section 5 of the European Resuscitation Council Guidelines for Resuscitation 2015"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;P&#46; Nolan"
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                            2 => "A&#46; Cariou"
                            3 => "T&#46; Cronberg"
                            4 => "V&#46;R&#46; Moulaert"
                            5 => "C&#46;D&#46; Deakin"
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                      "doi" => "10.1016/j.resuscitation.2015.07.018"
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                      "titulo" => "Post-cardiac arrest syndrome&#58; Epidemiology&#44; Pathophysiology&#44; Treatment&#44; and Prognostication A Consensus Statement From the International Liaison Committee on Resuscitation"
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                        0 => array:2 [
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                          "autores" => array:3 [
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                  ]
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                    0 => array:2 [
                      "doi" => "10.1161/CIRCULATIONAHA.108.190652"
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                        "tituloSerie" => "Circulation"
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                      "titulo" => "The precision of PiCCO measurements in hypothermic post-cardiac arrest patients"
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "T&#46; Tagami"
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                            2 => "R&#46; Tosa"
                            3 => "M&#46; Omura"
                            4 => "J&#46; Hagiwara"
                            5 => "H&#46; Hirama"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pulsed Doppler echocardiographic determination of stroke volume and cardiac output&#58; clinical validation of two new methods using the apical window"
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                          "etal" => false
                          "autores" => array:5 [
                            0 => "J&#46;F&#46; Lewis"
                            1 => "L&#46;C&#46; Kuo"
                            2 => "J&#46;G&#46; Nelson"
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                  ]
                  "host" => array:1 [
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                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation"
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                  "contribucion" => array:1 [
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                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46; McLean"
                            1 => "A&#46; Needham"
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                  "host" => array:1 [
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                      "Revista" => array:6 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Haemodynamic parameters obtained by transthoracic echocardiography and Swan-Ganz catheter&#58; a comparative study in liver transplant patients"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
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