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Sáez de la Fuente I, Sáez de la Fuente J, Martín-Arriscado C, Sánchez-Izquierdo Riera JÁ, García de Lorenzo Y Mateos A, Montejo González JC. Utility of the central venous-to-arterial CO 2 difference to predict adverse outcomes after liver transplantation. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:526-535. [PMID: 36280569 DOI: 10.1016/j.redare.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 11/10/2021] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Test whether the development of abnormal venous-to arterial CO2 difference (ΔPCO2) during the early phases of postoperative care after a liver transplantation (LT) is related to multi-organ dysfunction and outcomes. MATERIALS AND METHODS Prospective cohort study accomplished in a mixed intensive care unit (ICU) at a university hospital. We included 150 eligible patients after a LT between 2015 and 2018. Patients were classified in four predefined groups according to the ΔPCO2 evolution during the first 6 h of resuscitation: (1) persistently normal ΔPCO2 (normal at T0 and T6); (2) decreasing ΔPCO2 (high at T0, normal at T6); (3) increasing ΔPCO2 (normal at T0, high at T6); and (4) persistently high ΔPCO2 (high at T0 and T6). Multiorgan dysfunction at day-3 was compared for predefined groups and a Kaplan Meier curve was constructed to show the survival probabilities using a log-rank test to evaluate differences between groups. A Spearman-Rho was used to test the agreement between cardiac output and ΔPCO2. RESULTS There were no significant differences between the study groups regarding higher SOFA scores at day-3 (P = .86), Δ-SOFA (P = .088), as well as global mortality rates (χ² = 5.72; P = .126) and mortality rates at day-30 (χ² = 2.23; P = .5252). A significantly poor inverse agreement between cardiac output and ΔPCO2 was observed (r2 -0,17; P = ,002) at different points of resuscitation. CONCLUSIONS After a LT, central venous-to-arterial CO2 difference was not associated with survival or postoperative adverse outcomes in a critical care patients population.
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Affiliation(s)
- I Sáez de la Fuente
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | - J Sáez de la Fuente
- Servicio de Farmacia Hospitalaria, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - C Martín-Arriscado
- Unidad de Investigación y Soporte Científico, Hospital Universitario 12, Madrid, Spain
| | | | | | - J C Montejo González
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain
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El-Nawawy AA, Hassaan SM, Hassouna HM. Evaluation of Venous-to-Arterial Carbon Dioxide Tension Difference as a Complementary Parameter During Pediatric Septic Shock Resuscitation: A Prospective Observational Study. Pediatr Emerg Care 2022; 38:201-206. [PMID: 35482493 DOI: 10.1097/pec.0000000000002560] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the venous-to-arterial carbon dioxide tension difference during early resuscitation in pediatric septic shock. METHODS A prospective observational study was conducted in the pediatric intensive care unit of a tertiary care teaching. Children having septic shock aged from 3 to 60 months were studied within the first 24 hours of admission. Central venous and peripheral arterial blood samples for blood gases analysis at time of central venous catheter insertion and after 6 hours were obtained. Central venous carbon dioxide pressure, arterial carbon dioxide pressure, and their difference (delta Pco2) were recorded. Patients were categorized, accordingly to delta Pco2 after 6 hours of resuscitation, into high delta Pco2 group (≥6 mm Hg) and low delta Pco2 group (<6 mm Hg). RESULTS Oxygen extraction ratio at 6 hours of resuscitation was significantly lower among the low delta Pco2 group. Arterial lactate showed marked improvement in the low delta Pco2 group to be less than 2 mmol/L at 12 hours of resuscitation. Low delta Pco2 group showed significant higher shock reversal with shorter shock reversal time. Mortality was significantly lower among low delta Pco2 group with shorter pediatric intensive care unit stay. CONCLUSIONS Delta Pco2 after 6 hours of resuscitation of <6 mm Hg indicates normalization of tissue perfusion during pediatric septic shock management. It could be used as a complementary tool to guide the resuscitation in the early phase of pediatric septic shock.
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Affiliation(s)
- Ahmed Ahmed El-Nawawy
- From the Department of Pediatrics, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Ltaief Z, Schneider AG, Liaudet L. Pathophysiology and clinical implications of the veno-arterial PCO 2 gap. Crit Care 2021; 25:318. [PMID: 34461974 PMCID: PMC8407023 DOI: 10.1186/s13054-021-03671-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Zied Ltaief
- Service of Adult Intensive Care Medicine, Lausanne University Hospital, 1011, Lausanne, Switzerland
| | | | - Lucas Liaudet
- Service of Adult Intensive Care Medicine, Lausanne University Hospital, 1011, Lausanne, Switzerland
- Unit of Pathophysiology, Faculty of Biology and Medicine, University of Lausanne, 1011, Lausanne, Switzerland
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Central venous-to-arterial PCO 2 difference as a marker to identify fluid responsiveness in septic shock. Sci Rep 2021; 11:17256. [PMID: 34446823 PMCID: PMC8390642 DOI: 10.1038/s41598-021-96806-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/06/2021] [Indexed: 11/24/2022] Open
Abstract
Defining the hemodynamic response to volume therapy is integral to managing critically ill patients with acute circulatory failure, especially in the absence of cardiac index (CI) measurement. This study aimed at investigating whether changes in central venous-to-arterial CO2 difference (Δ-ΔPCO2) and central venous oxygen saturation (ΔScvO2) induced by volume expansion (VE) are reliable parameters to define fluid responsiveness in sedated and mechanically ventilated septic patients. We prospectively studied 49 critically ill septic patients in whom VE was indicated because of circulatory failure and clinical indices. CI, ΔPCO2, ScvO2, and oxygen consumption (VO2) were measured before and after VE. Responders were defined as patients with a > 10% increase in CI (transpulmonary thermodilution) after VE. We calculated areas under the receiver operating characteristic curves (AUCs) for Δ-ΔPCO2, ΔScvO2, and changes in CI (ΔCI) after VE in the whole population and in the subgroup of patients with an increase in VO2 (ΔVO2) ≤ 10% after VE (oxygen-supply independency). Twenty-five patients were fluid responders. In the whole population, Δ-ΔPCO2 and ΔScvO2 were significantly correlated with ΔCI after VE (r = − 0.30, p = 0.03 and r = 0.42, p = 0.003, respectively). The AUCs for Δ-ΔPCO2 and ΔScvO2 to define fluid responsiveness (increase in CI > 10% after VE) were 0.76 (p < 0.001) and 0.68 (p = 0.02), respectively. In patients with ΔVO2 ≤ 10% (n = 36) after VE, the correlation between ΔScvO2 and ΔCI was 0.62 (p < 0.001), and between Δ-ΔPCO2 and ΔCI was − 0.47 (p = 0.004). The AUCs for Δ-ΔPCO2 and ΔScvO2 were 0.83 (p < 0.001) and 0.73 (p = 0.006), respectively. In these patients, Δ-ΔPCO2 ≤ -37.5% after VE allowed the categorization between responders and non-responders with a positive predictive value of 100% and a negative predictive value of 60%. In sedated and mechanically ventilated septic patients with no signs of tissue hypoxia (oxygen-supply independency), Δ-ΔPCO2 is a reliable parameter to define fluid responsiveness.
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Abstract
How to cite this article: Patil VP. Mystery of PCO2 Gap in Sepsis. Indian J Crit Care Med 2019;23(10):443-444.
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Affiliation(s)
- Vijaya P Patil
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Gavelli F, Teboul JL, Monnet X. How can CO 2-derived indices guide resuscitation in critically ill patients? J Thorac Dis 2019; 11:S1528-S1537. [PMID: 31388457 DOI: 10.21037/jtd.2019.07.10] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Assessing the adequacy of oxygen delivery with oxygen requirements is one of the key-goal of haemodynamic resuscitation. Clinical examination, lactate and central or mixed venous oxygen saturation (SvO2 and ScvO2, respectively) all have their limitations. Many of them may be overcome by the use of the carbon dioxide (CO2)-derived variables. The venoarterial difference in CO2 tension ("ΔPCO2" or "PCO2 gap") is not an indicator of anaerobic metabolism since it is influenced by the oxygen consumption. By contrast, it reliably indicates whether blood flow is sufficient to carry CO2 from the peripheral tissue to the lungs in view of its clearance: it, thus, reflects the adequacy of cardiac output with the metabolic condition. The ratio of the PCO2 gap with the arteriovenous difference of oxygen content (PCO2 gap/Ca-vO2) might be a marker of anaerobiosis. Conversely to SvO2 and ScvO2, it remains interpretable if the oxygen extraction is impaired as it is in case of sepsis. Compared to lactate, it has the main advantage to change without delay and to provide a real-time monitoring of tissue hypoxia.
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Affiliation(s)
- Francesco Gavelli
- Service de médecine intensive-réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Le Kremlin-Bicêtre, France.,Université Paris-Sud, Faculté de médecine Paris-Sud, Inserm UMR S_999, Le Kremlin-Bicêtre, France.,Emergency Medicine Unit, Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Novara, Italy
| | - Jean-Louis Teboul
- Service de médecine intensive-réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Le Kremlin-Bicêtre, France.,Université Paris-Sud, Faculté de médecine Paris-Sud, Inserm UMR S_999, Le Kremlin-Bicêtre, France
| | - Xavier Monnet
- Service de médecine intensive-réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Le Kremlin-Bicêtre, France.,Université Paris-Sud, Faculté de médecine Paris-Sud, Inserm UMR S_999, Le Kremlin-Bicêtre, France
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Araujo DT, Felice VB, Meregalli AF, Friedman G. Value of Central Venous to Arterial CO 2 Difference after Early Goal-directed Therapy in Septic Shock Patients. Indian J Crit Care Med 2019; 23:449-453. [PMID: 31749552 PMCID: PMC6842832 DOI: 10.5005/jp-journals-10071-23262] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background and aims Venous to arterial difference of carbon dioxide (Pv–aCO2) tracks tissue blood flow. We aimed to evaluate if Pv–aCO2 measured from a superior central vein sample is a prognostic index (ICU length of stay, SOFA score, 28th mortality rate) just after early goal-directed therapy (EGDT)comparing its ICU admission values between patients with normal and abnormal (>6 mm Hg) Pv–aCO2. As secondary objectives, we evaluated the relationship of Pv–aCO2 with other variables of perfusion during the 24 hours that followed EGDT. Materials and methods Prospective observational study conducted in an academic ICU adult septic shock patients after a 6-hour complete EGTD. Hemodynamic measurements, arterial/central venous blood gases, and arterial lactate were obtained on ICU admission and after 6, 18 and 24 hours. Results Sixty patients were included. Admission Pv–aCO2 values showed no prognostic value. Admission Pv–aCO2 (ROC curve 0.527 [CI 95% 0.394 to 0.658]) values showed low specificity and sensitivity as predictors of mortality. There was a difference observed in the mean Pv–aCO2 between nonsurvivors (NS) and survivors (S) after 6 hours. Central venous oxygen saturation (ScvO2) and Pv–aCO2 showed significant correlation (R2 = –0.41, P < 0.0001). Patients with normal ScvO2 (>70%) and abnormal Pv–aCO2 (>6 mm Hg) showed higher SOFA scores. Normal Pv–aCO2 group cleared their lactate levels in comparison to the abnormal Pv–aCO2 group. Conclusion In septic shock, admission Pv–aCO2 after EGDT is not related to worse outcomes. An abnormal Pv–aCO2 along with a normal ScvO2 is related to organ dysfunction. How to cite this article Araujo DT, Felice VB, Meregalli AF, Friedman G. Value of Central Venous to Arterial CO2 Difference after Early Goal-directed Therapy in Septic Shock Patients. Indian J Crit Care Med 2019;23(10):449–453.
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Affiliation(s)
- David Theophilo Araujo
- Central ICU, Santa Casa Hospital, Porto Alegre, Rio Grande do Su, Brazil; Programa de Pós-graduação em Ciências Pneumológicas, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Su, Brazil
| | - Vinicius Brenner Felice
- Central ICU, Santa Casa Hospital, Porto Alegre, Rio Grande do Su, Brazil; Programa de Pós-graduação em Ciências Pneumológicas, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Su, Brazil
| | - Andre Felipe Meregalli
- Central ICU, Santa Casa Hospital, Porto Alegre, Rio Grande do Su, Brazil; Programa de Pós-graduação em Ciências Pneumológicas, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Su, Brazil
| | - Gilberto Friedman
- Central ICU, Santa Casa Hospital, Porto Alegre, Rio Grande do Su, Brazil; Programa de Pós-graduação em Ciências Pneumológicas, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Su, Brazil
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Wittenberg-Voges L, Kästner SB, Raekallio M, Vainio OM, Rohn K, Hopster K. Effect of dexmedetomidine and xylazine followed by MK-467 on gastrointestinal microperfusion in anaesthetized horses. Vet Anaesth Analg 2017; 45:165-174. [PMID: 29439859 DOI: 10.1016/j.vaa.2017.08.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 06/15/2017] [Accepted: 08/21/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To compare the effects of MK-467 during isoflurane anaesthesia combined with xylazine or dexmedetomidine on global and gastrointestinal perfusion parameters. STUDY DESIGN Prospective, randomized experimental trial. ANIMALS A total of 15 warmblood horses. METHODS Horses were divided into two groups for administration of either dexmedetomidine (D) or xylazine (X) for premedication (D: 3.5 μg kg-1; X: 0.5 mg kg-1) and as constant rate infusion during isoflurane anaesthesia (D: 7 μg kg-1 hour-1; X: 1 mg kg-1 hour-1). During anaesthesia, heart rate, mean arterial blood pressure (MAP), systemic vascular resistance index (SVRI) and cardiac index (CI) were measured. Microperfusion of the colon, jejunum and stomach was measured using laser Doppler flowmetry. After 2 hours of stabilization, MK-467 (250 μg kg-1) was administered, and measurements were continued for another 90 minutes. For statistical analysis, the permutation test and Wilcoxon rank-sum test were used (p < 0.05). RESULTS There were no differences in baseline measurements between groups. The MK-467 bolus resulted in a significant decrease in MAP (D: -58%; X: -48%) and SVRI (D: -68%; X: -65%) lasting longer in group D (90 minutes) compared to group X (60 minutes). While CI increased (D: +31%; X: +35%), microperfusion was reduced in the colon (D: -44%; X: -34%), jejunum (D: -26%; X: -33%) and stomach (D: -37%; X: -35%). CONCLUSIONS AND CLINICAL RELEVANCE Alpha-2-agonist induced vasoconstriction was reversed by the MK-467 dose used, resulting in hypotension and rise in CI. Gastrointestinal microperfusion decreased, probably as a result of insufficient perfusion pressure. An infusion rate for MK-467 as well as an ideal agonist/antagonist ratio should be determined.
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Affiliation(s)
| | - Sabine Br Kästner
- Clinic for Horses, University of Veterinary Medicine Hannover, Hanover, Germany
| | - Marja Raekallio
- University of Helsinki, Faculty of Veterinary Medicine, Helsinki, Finland
| | - Outi M Vainio
- University of Helsinki, Faculty of Veterinary Medicine, Helsinki, Finland
| | - Karl Rohn
- Department of Biometry, University of Veterinary Medicine Hannover, Hanover, Germany
| | - Klaus Hopster
- Clinic for Horses, University of Veterinary Medicine Hannover, Hanover, Germany
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Viale JP. The venous-arterial partial pressure of carbon dioxide as a new monitoring of circulatory disorder: no so simple. J Clin Monit Comput 2017; 30:757-760. [PMID: 27038162 DOI: 10.1007/s10877-016-9872-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- J P Viale
- Université de Lyon, 69008, Lyon, France.
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Patel R, Solanki A, Patel H, Patel J, Pandya H, Sharma J. Monitoring Microcirculatory Blood Flow during Cardiopulmonary Bypass in Paediatric Cardiac Surgery Patients as a Predictor for Anaerobic Metabolism. J Clin Diagn Res 2017; 11:UC22-UC25. [PMID: 28571240 DOI: 10.7860/jcdr/2017/24360.9721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 02/05/2017] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Improving tissue oxygenation is one of most important tasks in management of low cardiac output. Central venous oxygen saturation (ScvO2) and lactate are established criteria for monitoring the adequacy of tissue oxygenation. The venous-to-arterial carbon dioxide difference [P(v-a)CO2] is inversely associated with cardiac output. AIM To study the use of P(v-a)CO2/C(a-v)O2 ratio as a marker of low cardiac output during Cardiopulmonary Bypass (CPB) in paediatric cardiac surgical patients. MATERIALS AND METHODS The present study was a prospective observational study conducted over a period of nine months from 1st August 2015 to 30th April 2016. A total of 110 children were enrolled, who underwent CPB during cardiac surgery. The CPB time, Mean Arterial Pressure (MAP), flow rate, cross clamp time, were recorded for all the patients as well as Arterial Blood Gas (ABG) and Venous Blood Gas (VBG) were checked at four different points of time: 1) Before CPB, 2) 10 minutes after initiation of CPB, 3) 30 minutes on CPB and 4) off CPB. RESULTS The results indicated that Receiver Operating Characteristic curve (ROC curve) at 30 minute of CPB time P(v-a)CO2/C(a-v)O2 was more specific and sensitive than lactate to detect anaerobic metabolism. Decrease platelet count was significant on second postoperative day. CONCLUSION The present study suggests the use of P(v-a)CO2/C(a-v)O2 ratio as a marker to detect low flow on CPB. Our study was single centric and with a small size, studies involving large population and multiple centers are required to support the recent findings.
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Affiliation(s)
- Ramesh Patel
- Professor and Head, Department of Cardiac Anaesthesia, U. N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Atul Solanki
- Chief Perfusionist, Department of Perfusion, U. N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Hasmukh Patel
- Resident, Department of Cardiac Anaesthesia, U. N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Jignesh Patel
- Perfusionist, Department of Perfusion, U. N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Himani Pandya
- Research Associate, Department of Research, U. N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Jainam Sharma
- Postgraduate Student, Department of Perfusion, U. N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
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Meddour M, Lemyze M, Tronchon L, Thévenin D, Mallat J. Utilité de la différence veinoartérielle en dioxyde de carbone dans la prise en charge du choc septique. MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-017-1258-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Robin E, Futier E, Pires O, Fleyfel M, Tavernier B, Lebuffe G, Vallet B. Central venous-to-arterial carbon dioxide difference as a prognostic tool in high-risk surgical patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:227. [PMID: 25967737 PMCID: PMC4486687 DOI: 10.1186/s13054-015-0917-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 04/13/2015] [Indexed: 12/30/2022]
Abstract
Introduction The purpose of this study was to evaluate the clinical relevance of high values of central venous-to-arterial carbon dioxide difference (PCO2 gap) in high-risk surgical patients admitted to a postoperative ICU. We hypothesized that PCO2 gap could serve as a useful tool to identify patients still requiring hemodynamic optimization at ICU admission. Methods One hundred and fifteen patients were included in this prospective single-center observational study during a 1-year period. High-risk surgical inclusion criteria were adapted from Schoemaker and colleagues. Demographic and biological data, PCO2 gap, central venous oxygen saturation, lactate level and postoperative complications were recorded for all patients at ICU admission, and 6 hours and 12 hours after admission. Results A total of 78 (68%) patients developed postoperative complications, of whom 54 (47%) developed organ failure. From admission to 12 hours after admission, there was a significant difference in mean PCO2 gap (8.7 ± 2.8 mmHg versus 5.1 ± 2.6 mmHg; P = 0.001) and median lactate values (1.54 (1.1-3.2) mmol/l versus 1.06 (0.8-1.8) mmol/l; P = 0.003) between patients who developed postoperative complications and those who did not. These differences were maximal at admission to the ICU. At ICU admission, the area under the receiver operating characteristic curve for occurrence of postoperative complications was 0.86 for the PCO2 gap compared to Sequential Organ Failure Assessment score (0.82), Simplified Acute Physiology Score II score (0.67), and lactate level (0.67). The threshold value for PCO2 gap was 5.8 mmHg. Multivariate analysis showed that only a high PCO2 gap and a high Sequential Organ Failure Assessment score were independently associated with the occurrence of postoperative complications. A high PCO2 gap (≥6 mmHg) was associated with more organ failure, an increase in duration of mechanical ventilation and length of hospital stay. Conclusion A high PCO2 gap at admission in the postoperative ICU was significantly associated with increased postoperative complications in high-risk surgical patients. If the increase in PCO2 gap is secondary to tissue hypoperfusion then the PCO2 gap might be a useful tool complementary to central venous oxygen saturation as a therapeutic target.
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Affiliation(s)
- Emmanuel Robin
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Lille, Lille, France.
| | - Emmanuel Futier
- Department of Anaesthesiology and Intensive Care Medicine, Hospital Estaing, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France.
| | - Oscar Pires
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Lille, Lille, France.
| | - Maher Fleyfel
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Lille, Lille, France.
| | - Benoit Tavernier
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Lille, Lille, France.
| | - Gilles Lebuffe
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Lille, Lille, France.
| | - Benoit Vallet
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Lille, Lille, France.
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Ospina-Tascón GA, Umaña M, Bermúdez W, Bautista-Rincón DF, Hernandez G, Bruhn A, Granados M, Salazar B, Arango-Dávila C, De Backer D. Combination of arterial lactate levels and venous-arterial CO2 to arterial-venous O 2 content difference ratio as markers of resuscitation in patients with septic shock. Intensive Care Med 2015; 41:796-805. [PMID: 25792204 PMCID: PMC4414929 DOI: 10.1007/s00134-015-3720-6] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 02/25/2015] [Indexed: 12/28/2022]
Abstract
PURPOSE To evaluate the prognostic value of the Cv-aCO2/Da-vO2 ratio combined with lactate levels during the early phases of resuscitation in septic shock. METHODS Prospective observational study in a 60-bed mixed ICU. One hundred and thirty-five patients with septic shock were included. The resuscitation protocol targeted mean arterial pressure, pulse pressure variations or central venous pressure, mixed venous oxygen saturation, and lactate levels. Patients were classified into four groups according to lactate levels and Cv-aCO2/Da-vO2 ratio at 6 h of resuscitation (T6): group 1, lactate ≥2.0 mmol/L and Cv-aCO2/Da-vO2 >1.0; group 2, lactate ≥2.0 mmol/L and Cv-aCO2/Da-vO2 ≤1.0; group 3, lactate <2.0 mmol/L and Cv-aCO2/Da-vO2 >1.0; and group 4, lactate <2.0 mmol/L and Cv-aCO2/Da-vO2 ≤1.0. RESULTS Combination of hyperlactatemia and high Cv-aCO2/Da-vO2 ratio was associated with the worst SOFA scores and lower survival rates at day 28 [log rank (Mantel-Cox) = 31.39, p < 0.0001]. Normalization of both variables was associated with the best outcomes. Patients with a high Cv-aCO2/Da-vO2 ratio and lactate <2.0 mmol/L had similar outcomes to hyperlactatemic patients with low Cv-aCO2/Da-vO2 ratio. The multivariate analysis revealed that Cv-aCO2/Da-vO2 ratio at both T0 (RR 3.85; 95 % CI 1.60-9.27) and T6 (RR 3.97; 95 % CI 1.54-10.24) was an independent predictor for mortality at day 28, as well as lactate levels at T6 (RR 1.58; 95 % CI 1.13-2.22). CONCLUSION Complementing lactate assessment with Cv-aCO2/Da-vO2 ratio during early stages of resuscitation of septic shock can better identify patients at high risk of adverse outcomes. The Cv-aCO2/Da-vO2 ratio may become a potential resuscitation goal in patients with septic shock.
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Affiliation(s)
- Gustavo A Ospina-Tascón
- Intensive Care Unit, Fundación Valle Del Lili - Universidad ICESI, Av. Simón Bolívar Cra. 98, Cali, Colombia,
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Central venous-to-arterial carbon dioxide partial pressure difference in early resuscitation from septic shock: a prospective observational study. Eur J Anaesthesiol 2015; 31:371-80. [PMID: 24625464 DOI: 10.1097/eja.0000000000000064] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Central venous-to-arterial carbon dioxide partial pressure difference (ΔPCO2) can be used as a marker for the efficacy of venous blood in removing the total CO2 produced by the tissues. To date, this role of ΔPCO2 has been assessed only in patients after resuscitation from septic shock with already normalised central venous oxygen saturation (ScvO2 ≥70%). There are no reports on the behaviour of ΔPCO2 and its relationship to cardiac index (CI) and clinical outcome before normal ScvO2 has been achieved. OBJECTIVES To investigate the behaviour of ΔPCO2 and its relationship to CI, blood lactate concentration and 28-day mortality during resuscitation in the very early phase of septic shock. To examine whether patients who normalise both ΔPCO2 and ScvO2 during the first 6 h of resuscitation will have a greater percentage decrease in blood lactate concentration than those who only achieve normal ScvO2. DESIGN Prospective observational study. SETTING Intensive Care Unit (ICU) in a university hospital. PATIENTS Eighty patients with septic shock were consecutively recruited. INTERVENTIONS Patients were resuscitated in accordance with the recommendations of the Surviving Sepsis Campaign. MAIN OUTCOME MEASURES Blood lactate concentrations, and haemodynamic and oxygen-derived variables were obtained at ICU admission (T0) and 6 h after admission (T6). Lactate decrease was defined as the percentage decrease in lactate concentration from T0 to T6. All cause 28-day mortality was also recorded. RESULTS Data are presented as median (interquartile range). At T0, there were significant differences (P < 0.0001) between normal (ΔPCO2 ≤0.8 kPa) and high ΔPCO2 groups for CI (3.9 [3.3 to 4.7] vs. 2.9 [2.3 to 3.1] l min m) and ScvO2 (73 [65 to 80] vs. 61 [53 to 63]%). The correlation between changes in CI and ΔPCO2 was r = -0.62, P < 0.0001. Patients who reached a normal ΔPCO2 at T6 had larger decreases in blood lactate concentration and Sequential Organ Failure Assessment scores on day 1. The lactate decrease was greatest in the subgroup achieving both normal ScvO2 and ΔPCO2 at T6. Lactate decrease, unlike ΔPCO2 and ScvO2, was an independent predictor of 28-day mortality. CONCLUSION Monitoring ΔPCO2 may be a useful tool to assess the adequacy of tissue perfusion during resuscitation. The normalisation of both ΔPCO2 and ScvO2 is associated with a greater decrease in blood lactate concentration than ScvO2 alone. The lactate decrease is an independent predictor of 28-day mortality. Further research is needed to confirm this hypothesis.
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Ospina-Tascón GA, Bautista-Rincón DF, Umaña M, Tafur JD, Gutiérrez A, García AF, Bermúdez W, Granados M, Arango-Dávila C, Hernández G. Persistently high venous-to-arterial carbon dioxide differences during early resuscitation are associated with poor outcomes in septic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R294. [PMID: 24330804 PMCID: PMC4056748 DOI: 10.1186/cc13160] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 10/21/2013] [Indexed: 01/11/2023]
Abstract
Introduction Venous-to-arterial carbon dioxide difference (Pv-aCO2) may reflect the adequacy of blood flow during shock states. We sought to test whether the development of Pv-aCO2 during the very early phases of resuscitation is related to multi-organ dysfunction and outcomes in a population of septic shock patients resuscitated targeting the usual oxygen-derived and hemodynamic parameters. Methods We conducted a prospective observational study in a 60-bed mixed ICU in a University affiliated Hospital. 85 patients with a new septic shock episode were included. A Pv-aCO2 value ≥ 6 mmHg was considered to be high. Patients were classified in four predefined groups according to the Pv-aCO2 evolution during the first 6 hours of resuscitation: (1) persistently high Pv-aCO2 (high at T0 and T6); (2) increasing Pv-aCO2 (normal at T0, high at T6); (3) decreasing Pv-aCO2 (high at T0, normal at T6); and (4) persistently normal Pv-aCO2 (normal at T0 and T6). Multiorgan dysfunction at day-3 was compared for predefined groups and a Kaplan Meier curve was constructed to show the survival probabilities at day-28 using a log-rank test to evaluate differences between groups. A Spearman-Rho was used to test the agreement between cardiac output and Pv-aCO2. Finally, we calculated the mortality risk ratios at day-28 among patients attaining normal oxygen parameters but with a concomitantly increased Pv-aCO2. Results Patients with persistently high and increasing Pv-aCO2 at T6 had significant higher SOFA scores at day-3 (p < 0.001) and higher mortality rates at day-28 (log rank test: 19.21, p < 0.001) compared with patients who evolved with normal Pv-aCO2 at T6. Interestingly, a poor agreement between cardiac output and Pv-aCO2 was observed (r2 = 0.025, p < 0.01) at different points of resuscitation. Patients who reached a central venous saturation (ScvO)2 ≥ 70% or mixed venous oxygen saturation (SvO2) ≥ 65% but with concomitantly high Pv-aCO2 at different developmental points (i.e., T0, T6 and T12) had a significant mortality risk ratio at day-28. Conclusion The persistence of high Pv-aCO2 during the early resuscitation of septic shock was associated with more severe multi-organ dysfunction and worse outcomes at day-28. Although mechanisms conducting to increase Pv-aCO2 during septic shock are insufficiently understood, Pv-aCO2 could identify a high risk of death in apparently resuscitated patients.
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Pischke SE, Tronstad C, Holhjem L, Line PD, Haugaa H, Tønnessen TI. Hepatic and abdominal carbon dioxide measurements detect and distinguish hepatic artery occlusion and portal vein occlusion in pigs. Liver Transpl 2012; 18:1485-94. [PMID: 22961940 DOI: 10.1002/lt.23544] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 08/29/2012] [Indexed: 12/28/2022]
Abstract
Hepatic artery (HA) occlusion and portal vein (PV) occlusion are the most common vascular complications after liver transplantation with an impact on mortality and retransplantation rates. The detection of severe hypoperfusion may be delayed with currently available diagnostic tools. Hypoperfusion and anaerobically produced lactic acid lead to increases in tissue carbon dioxide. We investigated whether the continuous assessment of the intrahepatic and intra-abdominal partial pressure of carbon dioxide (PCO(2) ) could be used to detect and distinguish HA and PV occlusions in real time. In 13 pigs, the HA and the PV were fully occluded (n = 7) or gradually occluded (n = 6). PCO(2) was monitored intrahepatically and between loops of small intestine. The hepatic and intestinal metabolism was assessed with microdialysis and PV as well as hepatic vein blood samples, and the results were compared to clinical parameters for the systemic circulation and blood gas analysis. Total HA occlusion led to significant increases in hepatic PCO(2) and lactate, and this was accompanied by significant decreases in the partial pressure of oxygen and glucose. PV occlusion induced a significant increase in intestinal PCO(2) (but not hepatic PCO(2) ) along with significant increases in intestinal lactate and glycerol. Gradual HA occlusion and PV occlusion caused steady hepatic and intestinal PCO(2) increases, respectively. Systemic clinical parameters such as the blood pressure, heart rate, and cardiac output were affected only by PV occlusion. In conclusion, even gradual HA occlusion affects liver metabolism and can be reliably identified with hepatic PCO(2) measurements. Intestinal PCO(2) increases only during PV occlusion. A combination of hepatic and intestinal PCO(2) measurements can reliably diagnose the affected vessel and depict the severity of the occlusion, and this may emerge as a potential real-time clinical monitoring tool for the postoperative course of liver transplantation and enable early interventions.
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Affiliation(s)
- Soeren Erik Pischke
- Division of Emergencies and Critical Care, Department of Anesthesiology, Oslo University Hospital, Oslo, Norway
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Hemodynamic management of cardiovascular failure by using PCO(2) venous-arterial difference. J Clin Monit Comput 2012; 26:367-74. [PMID: 22828858 DOI: 10.1007/s10877-012-9381-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2012] [Accepted: 07/10/2012] [Indexed: 12/20/2022]
Abstract
The difference between mixed venous blood carbon dioxide tension (PvCO(2)) and arterial carbon dioxide tension (PaCO(2)), called ∆PCO(2) has been proposed to better characterize the hemodynamic status. It depends on the global carbon dioxide (CO(2)) production, on cardiac output and on the complex relation between CO(2) tension and CO(2) content. The aim of this review is to detail the physiological background allowing adequate interpretation of ∆PCO(2) at the bedside. Clinical and experimental data support the use of ∆PCO(2) as a valuable help in the decision-making process in patients with hemodynamic instability. The difference between central venous CO(2) tension and arterial CO(2) tension, which is easy to obtain can substitute for ∆PCO(2) to assess the adequacy of cardiac output. Differences between local tissue CO(2) tension and arterial CO(2) tension can also be obtained and provide data on the adequacy of local blood flow to the local metabolic conditions.
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WAELGAARD L, DAHL BM, KVARSTEIN G, TØNNESSEN TI. Tissue gas tensions and tissue metabolites for detection of organ hypoperfusion and ischemia. Acta Anaesthesiol Scand 2012; 56:200-9. [PMID: 22103593 DOI: 10.1111/j.1399-6576.2011.02572.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2011] [Indexed: 12/30/2022]
Abstract
BACKGROUND The aim of this study was to evaluate how tissue gas tensions and tissue metabolites measured in situ can detect hypoperfusion and differentiate between aerobic and anaerobic conditions during hemorrhagic shock. We hypothesized that tissue PCO(2) (PtCO(2)) would detect hypoperfusion also under aerobic conditions and detect anaerobic metabolism concomitantly with or earlier than other markers. METHODS Prospective experimental animal study with eight anesthetized pigs subjected to a continuous blood loss ∼8% of total blood volume per hour until death. We measured cardiac index, organ blood flows, and tissue levels of PO(2), PCO(2), glucose, pyruvate, lactate, and glycerol in intestine, liver, kidney, and skeletal muscle. RESULTS With reduction in blood flow to the organs under aerobic conditions, PtCO(2) increased ∼1-4 kPa from baseline. With the onset of tissue hypoxia there was a pronounced increase of PtCO(2), lactate, lactate-pyruvate (LP) ratio, and glycerol. Tissue pH and bicarbonate decreased significantly, indicating that metabolic acid was buffered by bicarbonate to generate CO(2). CONCLUSION Moderate tissue hypoperfusion under aerobic conditions is associated with increased PtCO(2), in contrast to metabolic parameters of ischemia (lactate, LP ratio, and glycerol) which remain low. From the onset of ischemia there is a much more rapid and pronounced increase in PtCO(2), lactate, and LP ratio. PtCO(2) can be used as a marker of hypoperfusion under both aerobic and anaerobic conditions; it gives an earlier warning of hypoperfusion than metabolic markers and increases concomitantly with or earlier than other markers at the onset of tissue anaerobiosis.
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Affiliation(s)
- L. WAELGAARD
- The Acute Clinic; Department of Anesthesiology and Critical Care Medicine; Oslo University Hospital; Oslo; Norway
| | - B. M. DAHL
- The Intervention Centre; Oslo University Hospital; Oslo; Norway
| | - G. KVARSTEIN
- The Acute Clinic; Department of Anesthesiology and Critical Care Medicine; Oslo University Hospital; Oslo; Norway
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Futier E, Teboul J, Vallet B. Tissue carbon dioxide measurement as an index of perfusion: What have we missed? TRENDS IN ANAESTHESIA AND CRITICAL CARE 2011. [DOI: 10.1016/j.tacc.2011.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Vallée F, Mateo J, Vallet B, Payen D. Gradients de PCO2 : un reflet fiable de la perfusion macroet microcirculatoire. MEDECINE INTENSIVE REANIMATION 2011. [DOI: 10.1007/s13546-011-0222-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Barros JMP, do Nascimento P, Marinello JLP, Braz LG, Carvalho LR, Vane LA, Castiglia YMM, Braz JRC. The Effects of 6% Hydroxyethyl Starch–Hypertonic Saline in Resuscitation of Dogs with Hemorrhagic Shock. Anesth Analg 2011; 112:395-404. [DOI: 10.1213/ane.0b013e3181f2e9b2] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Futier E, Robin E, Jabaudon M, Guerin R, Petit A, Bazin JE, Constantin JM, Vallet B. Central venous O₂ saturation and venous-to-arterial CO₂ difference as complementary tools for goal-directed therapy during high-risk surgery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R193. [PMID: 21034476 PMCID: PMC3219300 DOI: 10.1186/cc9310] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2010] [Revised: 07/16/2010] [Accepted: 10/29/2010] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Central venous oxygen saturation (ScvO2) is a useful therapeutic target in septic shock and high-risk surgery. We tested the hypothesis that central venous-to-arterial carbon dioxide difference (P(cv-a)CO2), a global index of tissue perfusion, could be used as a complementary tool to ScvO2 for goal-directed fluid therapy (GDT) to identify persistent low flow after optimization of preload has been achieved by fluid loading during high-risk surgery. METHODS This is a secondary analysis of results obtained in a study involving 70 adult patients (ASA I to III), undergoing major abdominal surgery, and treated with an individualized goal-directed fluid replacement therapy. All patients were managed to maintain a respiratory variation in peak aortic flow velocity below 13%. Cardiac index (CI), oxygen delivery index (DO2i), ScvO2, P(cv-a)CO2 and postoperative complications were recorded blindly for all patients. RESULTS A total of 34% of patients developed postoperative complications. At baseline, there was no difference in demographic or haemodynamic variables between patients who developed complications and those who did not. In patients with complications, during surgery, both mean ScvO2 (78 ± 4 versus 81 ± 4%, P = 0.017) and minimal ScvO2 (minScvO2) (67 ± 6 versus 72 ± 6%, P = 0.0017) were lower than in patients without complications, despite perfusion of similar volumes of fluids and comparable CI and DO2i values. The optimal ScvO2 cut-off value was 70.6% and minScvO2 < 70% was independently associated with the development of postoperative complications (OR = 4.2 (95% CI: 1.1 to 14.4), P = 0.025). P(cv-a)CO2 was larger in patients with complications (7.8 ± 2 versus 5.6 ± 2 mmHg, P < 10-6). In patients with complications and ScvO2 ≥ 71%, P(cv-a)CO2 was also significantly larger (7.7 ± 2 versus 5.5 ± 2 mmHg, P < 10-6) than in patients without complications. The area under the receiver operating characteristic (ROC) curve was 0.785 (95% CI: 0.74 to 0.83) for discrimination of patients with ScvO2 ≥ 71% who did and did not develop complications, with 5 mmHg as the most predictive threshold value. CONCLUSIONS ScvO2 reflects important changes in O2 delivery in relation to O2 needs during the perioperative period. A P(cv-a)CO2 < 5 mmHg might serve as a complementary target to ScvO2 during GDT to identify persistent inadequacy of the circulatory response in face of metabolic requirements when an ScvO2 ≥ 71% is achieved. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT00852449.
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Affiliation(s)
- Emmanuel Futier
- Department of Anaesthesiology and Critical Care Medicine, Estaing Hospital, University Hospital of Clermont-Ferrand, 1 Place Lucie Aubrac, Clermont-Ferrand, 63000, France.
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Correlation of central venous–arterial and mixed venous–arterial carbon dioxide tension gradient with cardiac output during neurosurgical procedures in the sitting position. Eur J Anaesthesiol 2010; 27:882-9. [DOI: 10.1097/eja.0b013e32833d126f] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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VALLET BENOIT, FUTIER EMMANUEL, ROBIN EMMANUEL. Tissue oxygenation parameters to guide fluid therapy. ACTA ACUST UNITED AC 2010. [DOI: 10.1111/j.1778-428x.2010.01140.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Maddirala S, Khan A. Optimizing hemodynamic support in septic shock using central and mixed venous oxygen saturation. Crit Care Clin 2010; 26:323-33, table of contents. [PMID: 20381723 DOI: 10.1016/j.ccc.2009.12.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Global tissue hypoxia is one of the most important factors in the development of multisystem organ dysfunction. In hemodynamically unstable critically ill patients, central venous oxygen saturation (Scvo(2)) and mixed venous oxygen saturation (Svo(2)) monitoring has been shown to be a better indicator of global tissue hypoxia than vital signs and other clinical parameters alone. Svo(2) is probably more representative of global tissue oxygenation, whereas Scvo(2), is less invasive. Svo(2) and Scvo(2) monitoring can have diagnostic and therapeutic uses in understanding the efficacy of interventions in treating critically ill, hemodynamically unstable patients.
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Affiliation(s)
- Supriya Maddirala
- Division of Nephrology, Department of Internal Medicine, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
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Poli de Figueiredo LF, Cruz RJ, Silva E, Yada-Langui MM, Rocha e Silva M. Sustained Gastric Mucosal Acidosis After Hemorrhage in Spite of Rapid Hemodynamic Restoration With Blood or Hypertonic/Hyperoncotic Solution. J INVEST SURG 2009; 18:257-64. [PMID: 16299903 DOI: 10.1080/08941930500248904] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Splanchnic hypoperfusion has been implicated as the motor of multiple organ dysfunction. Hypertonic saline has shown to benefit microcirculatory blood flow. In hemorrhaged animals, we tested the hypothesis that small-volume 3% NaCl/10% dextran 40 (3%HSD) promotes global and regional improvements, including gastric mucosal acidosis reversal. Seventeen dogs (18.8 +/- 1.2 kg) were bled (20 mL/min) to a mean arterial pressure of 40-45 mm Hg, which was maintained at these levels for 15 min. They were randomly assigned to two groups: Blood (n = 9), total shed blood retransfused at 40 mL/min; or a 4-min bolus injection of 3%HSD (n = 8), in a volume equivalent to 25% of total shed blood. All animals were followed for 30 min thereafter. Gastric mucosal PCO2 (gas tonometry), portal vein PCO2, superior mesenteric artery blood flow (SMA, ultrasonic flowprobes), and systemic and regional O2-derived variables were evaluated throughout the protocol. Hemorrhage induced significant reductions of arterial pressure, cardiac output, and SMA blood flow, while portal-arterial and gastric-arterial PCO2 gradients increased. Total shed blood transfusion, as well as 3%HSD bolus injection, promptly restored all parameters, except for the increased gastric-arterial PCO2 gradient. We conclude that persistent gastric mucosal acidosis cannot be adequately predicted by global and splanchnic O2 derived variables in following hemorrhage and resuscitation with total shed blood transfusion or small-volume hypertonic-hyperoncotic solution.
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Silva AE, do Nascimento P, Beier SL, Roberto WM, Braz LG, Vane LA, Ganem EM, Braz JRC. Gastric Mucosal Perfusion in Dogs: Effects of Halogenated Anesthetics and of Hemorrhage. J INVEST SURG 2009; 21:15-23. [DOI: 10.1080/08941930701833892] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Dubin A, Edul VSK, Ince C. Determinants of Tissue PCO2 in Shock and Sepsis: Relationship to the Microcirculation. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Central venous-to-arterial carbon dioxide difference: an additional target for goal-directed therapy in septic shock? Intensive Care Med 2008; 34:2218-25. [PMID: 18607565 DOI: 10.1007/s00134-008-1199-0] [Citation(s) in RCA: 176] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2007] [Accepted: 06/06/2008] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To test the hypothesis that, in resuscitated septic shock patients, central venous-to-arterial carbon dioxide difference [P(cv-a)CO(2)] may serve as a global index of tissue perfusion when the central venous oxygen saturation (ScvO(2)) goal value has already been reached. DESIGN Prospective observational study. SETTING A 22-bed intensive care unit (ICU). PATIENTS After early resuscitation in the emergency unit, 50 consecutive septic shock patients with ScvO(2) > 70% were included immediately after their admission into the ICU (T0). Patients were separated in Low P(cv-a)CO(2) group (Low gap; n = 26) and High P(cv-a)CO(2) group (High gap; n = 24) according to a threshold of 6 mmHg at T0. MEASUREMENTS Measurements were performed every 6 h over 12 h (T0, T6, T12). RESULTS At T0, there was a significant difference between Low gap patients and High gap patients for cardiac index (CI) (4.3 +/- 1.6 vs. 2.7 +/- 0.8 l/min/m(2), P < 0.0001) but not for ScvO(2) values (78 +/- 5 vs. 75 +/- 5%, P = 0.07). From T0 to T12, the clearance of lactate was significantly larger for the Low gap group than for the High gap group (P < 0.05) as well as the decrease of SOFA score at T24 (P < 0.01). At T0, T6 and T12, CI and P(cv-a)CO(2) values were inversely correlated (P < 0.0001). CONCLUSION In ICU-resuscitated patients, targeting only ScvO(2) may not be sufficient to guide therapy. When the 70% ScvO(2) goal-value is reached, the presence of a P(cv-a)CO(2) larger than 6 mmHg might be a useful tool to identify patients who still remain inadequately resuscitated.
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van Haren FMP, Sleigh JW, Pickkers P, Van der Hoeven JG. Gastrointestinal perfusion in septic shock. Anaesth Intensive Care 2007; 35:679-94. [PMID: 17933153 DOI: 10.1177/0310057x0703500505] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Septic shock is characterised by vasodilation, myocardial depression and impaired microcirculatory blood flow, resulting in redistribution of regional blood flow. Animal and human studies have shown that gastrointestinal mucosal blood flow is impaired in septic shock. This is consistent with abnormalities found in many other microcirculatory vascular beds. Gastrointestinal mucosal microcirculatory perfusion deficits have been associated with gut injury and a decrease in gut barrier function, possibly causing augmentation of systemic inflammation and distant organ dysfunction. A range of techniques have been developed and used to quantify these gastrointestinal perfusion abnormalities. The following techniques have been used to study gastrointestinal perfusion in humans: tonometry, laser Doppler flowmetry, reflectance spectrophotometry, near-infrared spectroscopy, orthogonal polarisation spectral imaging, indocyanine green clearance, hepatic vein catheterisation and measurements of plasma D-lactate. Although these methods share the ability to predict outcome in septic shock patients, it is important to emphasise that the measurement results are not interchangeable. Different techniques measure different elements of gastrointestinal perfusion. Gastric tonometry is currently the most widely used technique because of its non-invasiveness and ease of use. Despite all the recent advances, the usefulness of gastrointestinal perfusion parameters in clinical decision-making is still limited. Treatment strategies specifically aimed at improving gastrointestinal perfuision have failed to actually correct mucosal perfusion abnormalities and hence not shown to improve important clinical endpoints. Current and future treatment strategies for septic shock should be tested for their effects on gastrointestinal perfusion; to further clarify its exact role in patient management, and to prevent therapies detrimental to gastrointestinal perfusion being implemented.
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Affiliation(s)
- F M P van Haren
- Intensive Care Department, Waikato Hospital, Hamilton, New Zealand
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Siegemund M, Van Bommel J, Sinaasappel M, Schwarte LA, Studer W, Girard T, Vollebregt K, Ince C. The NO donor SIN-1 improves intestinal-arterial P(CO(2)) gap in experimental endotoxemia: an animal study. Acta Anaesthesiol Scand 2007; 51:693-700. [PMID: 17567269 DOI: 10.1111/j.1399-6576.2007.01334.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Dysfunction of the microcirculation is a prominent feature of sepsis and endotoxemia. Recently, it has been shown that microcirculatory alterations are completely reversed by local or systemic application of vasodilators in severely septic patients. Therefore, we investigated the influence of vasodilator therapy on microcirculatory dysfunction of the ileum during endotoxic shock in a prospective, controlled animal study. METHODS After baseline measurements, shock was induced in 12 domestic pigs by lipopolysaccharide via the mesenteric vein until the mean arterial pressure fell below 60 mmHg. After 30 min in shock, six animals were resuscitated with either fluid alone (control) or fluid and 2 microg/kg/min of the vasodilator 3-morpholino-sydnonimine (SIN-1). The systemic and regional hemodynamics and oxygenation parameters, tonometric ileal P(CO(2)) and microvascular oxygen pressures (muP(O(2))) (by oxygen-dependent Pd-porphyrin phosphorescence) were measured simultaneously. RESULTS The ileal-arterial P(CO(2)) gap increased during shock and the ileal mucosal and serosal muP(O(2)) decreased concurrently. SIN-1 in addition to fluid resuscitation significantly improved the ileal-arterial P(CO(2)), whereas fluid alone failed to decrease the P(CO(2)) gap. The SIN-1-induced improvement in the P(CO(2)) gap was accompanied by an increase in serosal muP(O(2)) above shock levels. Mucosal muP(O(2)) was resuscitated to baseline levels in both groups. CONCLUSION The application of the vasodilator SIN-1 in addition to fluid resuscitation improves the ileal-arterial P(CO(2)) gap and mucosal muP(O(2)), together with a moderate increase in serosal muP(O(2)), after endotoxic shock. This finding is consistent with the concept that vasodilators may correct pathologic flow distribution within the intestinal wall.
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Affiliation(s)
- M Siegemund
- Department of Physiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Morgan TJ, Venkatesh B, Beindorf A, Andrew I, Hall J. Acid-base and bio-energetics during balanced versus unbalanced normovolaemic haemodilution. Anaesth Intensive Care 2007; 35:173-9. [PMID: 17444304 DOI: 10.1177/0310057x0703500204] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Fluids balanced to avoid acid-base disturbances may be preferable to saline, which causes metabolic acidosis in high volume. We evaluated acid-base and bio-energetic effects of haemodilution with a crystalloid balanced on physical chemical principles, versus crystalloids causing metabolic acidosis or metabolic alkalosis. Anaesthetised, mechanically ventilated Sprague-Dawley rats (n=32, allocated to four groups) underwent six exchanges of 9 ml crystalloid for 3 ml blood. Exchange was with one of three crystalloids with strong ion difference (SID) values of 0, 24 (balanced) and 40 mEq/l. Controls did not undergo haemodilution. Mean haemoglobin concentration fell to approximately 50 g/l after haemodilution. With SID 24 mEq/l fluid, metabolic acid-base remained unchanged. Dilution with SID 0 mEq/l and 40 mEq/l fluids caused a progressive metabolic acidosis and alkalosis respectively. Standard base excess (SBE) and haemoglobin concentration were directly correlated in the SID 0 mEq/l group (R2 = 0.61), indirectly correlated in the SBE 40 mEq/l group (R2 = 0.48) and showed no correlation in the SID 24 mEq/l group (R2 = 0.003). There were no significant differences between final ileal values of CO2 gap, nucleotides concentration, energy charge, or luminal lactate concentration. SID 40 mEq/l crystalloid dilution caused a significant rise in subcutaneous lactate. In this group mean kidney ATP concentration was significantly less than controls and renal energy charge significantly lower than SID 0 mEq/l and control groups. We conclude that a crystalloid SID of 24 mEq/l provides balanced haemodilution. Bio-energetic perturbations with higher SID haemodilution may be more severe and need further investigation.
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Affiliation(s)
- T J Morgan
- University of Queensland Intensive Care Laboratories, Royal Brisbane Hospital, Brisbane, Queensland, Australia
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Solligård E, Wahba A, Skogvoll E, Stenseth R, Grønbech JE, Aadahl P. Rectal lactate levels in endoluminal microdialysate during routine coronary surgery. Anaesthesia 2007; 62:250-8. [PMID: 17300302 DOI: 10.1111/j.1365-2044.2006.04937.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The aim of this prospective study was to determine the feasibility of intestinal endoluminal microdialysis as a new method for clinical monitoring of the adequacy of splanchnic perfusion in the large bowel. A microdialysis catheter for continuous lactate, glycerol, glucose and pyruvate measurements attached to a tonometric catheter was placed into the lumen of the recto-sigmoid junction prior to surgery in 13 patients undergoing elective cardiac surgery with cardiopulmonary bypass (CPB). Lactate was also measured in blood and muscle. CPB was associated with a 10-fold increase in luminal lactate from 0.16 (0.01) to 1.67 (0.38) mmol x l(-1) (p < 0.001). Muscular lactate increased from baseline levels 1.20 (0.21) to 1.77 (0.36) mmol x l(-1) during CPB (p = 0.01), but the muscular lactate-pyruvate ratio remained unchanged. Arterial lactate increased only slightly from 0.9 (0.05) to 1.1 (0.06) mmol x l(-1) (p = 0.027) during CPB. Increased lactate concentrations in the large bowel during CPB are suggestive of local lactate production consistent with impaired oxygen delivery. Intestinal endoluminal microdialysis is a potential clinically applicable method for monitoring intestinal metabolism. Combined with tonometry, microdialysis provides the opportunity to monitor both circulation and metabolism in the rectal mucosa.
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Affiliation(s)
- E Solligård
- Department of Anaesthesiology and Intensive Care, St Olav University Hospital, Norwegian University of Science and Technology, N-7006 Trondheim, Norway.
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Steiner LA, Staender S, Sieber CC, Skarvan K. Effects of simulated hypovolaemia on haemodynamics, left ventricular function, mesenteric blood flow and gastric Pco2. Acta Anaesthesiol Scand 2007; 51:143-50. [PMID: 17261143 DOI: 10.1111/j.1399-6576.2006.01219.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Compensated clinically silent hypovolaemia may lead to low cardiac output, hypoperfusion and ischaemia. We investigated the cardiovascular effects of simulated hypovolaemia to determine whether it caused mesenteric ischaemia detectable by gastric tonometry. METHODS Thirteen healthy volunteers, aged 21-36 years, were investigated. Lower body negative pressure (LBNP) was used to simulate normotensive hypovolaemia. Cardiovascular parameters were measured using echocardiography. Mesenteric blood flow was investigated using Doppler sonography of the superior mesenteric artery (SMA). Gastric Pco(2) (P(g)co(2)) was measured using gas tonometry. Data were collected at baseline, LBNP and during a recovery period. RESULTS Normotensive hypovolaemia was induced successfully in 11 volunteers. There were no significant differences in mean arterial pressure between the three data points (91 +/- 6, 93 +/- 10 and 95 +/- 9 mmHg, respectively). With the induction of LBNP, the heart rate increased from 64 +/- 16 to 73 +/- 16 beats/min (P < 0.001), the cardiac index decreased from 2.7 +/- 1.0 to 1.8 +/- 0.6 l/min/m(2) (P= 0.002) and the systemic vascular resistance increased from 1535 +/- 445 to 2270 +/- 550 dyn s/cm(5) (P < 0.001). The SMA mean flow velocity decreased from 53 +/- 18 to 37 +/- 20 cm/s (69 +/- 20%) (P= 0.007), and increased to 56 +/- 34 cm/s (106 +/- 38%) (P= 0.001) during reperfusion. The SMA resistance increased from 92 +/- 30 to 174 +/- 110 mmHg/l/min (P= 0.004). These changes were reversible after termination of LBNP. By contrast, there were no significant differences in P(g)co(2) between the three data points. CONCLUSIONS In these volunteers, the mesenteric vascular bed contributed importantly to the maintenance of arterial pressure during normotensive hypovolaemia. However, this compensated hypovolaemia did not compromise the mesenteric perfusion sufficiently to increase P(g)co(2) and to allow detection by tonometry.
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Affiliation(s)
- L A Steiner
- Department of Anaesthesia, University Hospital Basel, Basel, Switzerland.
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Perin D, Cruz RJ, Silva E, Poli-de-Figueiredo LF. Low hematocrit impairs gastric mucosal CO2 removal during experimental severe normovolemic hemodilution. Clinics (Sao Paulo) 2006; 61:445-52. [PMID: 17072443 DOI: 10.1590/s1807-59322006000500012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2006] [Accepted: 06/20/2006] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE The net effects of acute normovolemic hemodilution with different hemoglobin levels on splanchnic perfusion have not been elucidated. The hypothesis that during moderate and severe normovolemic hemodilution, systemic and splanchnic hemodynamic parameters, oxygen-derived variables, and biochemical markers of anaerobic metabolism do not reflect the adequacy of gastric mucosa, was tested in this study. METHODS Twenty one anesthetized mongrel dogs (16 +/- 1 kg) were randomized to controls (CT, n = 7, no hemodilution), moderate hemodilution (hematocrit 2 5% +/- 3%, n = 7) or severe hemodilution (severe hemodilution, hematocrit 15% +/- 3%, n = 7), through an isovolemic exchange of whole blood and 6% hydroxyethyl starch, at a 20 mL/min rate, to the target hematocrit. The animals were followed for 120 min after hemodilution. Cardiac output (CO, L/min), portal vein blood flow (PVF, mL/min), portal vein-arterial and gastric mucosa-arterial CO2 gradients (PV-artCO2 and PCO2 gap, mm Hg, respectively) were measured throughout the experiment. RESULTS Exchange blood volumes were 33.9 +/- 3.3 and 61.5 +/- 5.8 mL/kg for moderate hemodilution and severe hemodilution, respectively. Arterial pressure and systemic and regional lactate levels remained stable in all groups. There were initial increases in cardiac output and portal vein blood flow in both moderate hemodilution and severe hemodilution; systemic and regional oxygen consumption remained stable largely due to increases in oxygen extraction rate. There was a significant increase in the PCO2-gap value only in severe hemodilution animals. CONCLUSION Global and regional hemodynamic stability were maintained after moderate and severe hemodilution. However, a very low hematocrit induced gastric mucosal acidosis, suggesting that gastric mucosal CO2 monitoring may be useful during major surgery or following trauma.
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Affiliation(s)
- Daniel Perin
- Research Division, Heart Institute, São Paulo University Medical School, São Paulo, SP, Brazil
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Abstract
PURPOSE OF REVIEW Tissue hypoperfusion is a common pathophysiologic process leading to multiple organ dysfunction and death. Increases in tissue PCO2 can reflect an abnormal oxygen supply to the cells, so that monitoring tissue PCO2 by the use of gastric or sublingual capnometry may help identify circulatory abnormalities and guide their correction. This review provides an update on these technologies. RECENT FINDINGS Gastric tonometry aims at monitoring PCO2 in the stomach, an organ that becomes ischemic quite early when the circulatory status is jeopardized. Despite substantial initial enthusiasm, this technique has never been widely implemented due to methodological problems. The measurement of sublingual mucosal PCO2 (PslCO2) by sublingual capnometry is technically simple and noninvasive. Experimental studies have suggested that PslCO2 is a reliable marker of tissue perfusion. Clinical studies have demonstrated that high PslCO2 values are associated with impaired microcirculatory blood flow and a worse prognosis in critically ill patients. SUMMARY Gastric tonometry was proposed for regional PCO2 monitoring, but it is prone to a number of technical limitations. Sublingual capnometry could offer a valuable alternative for tissue PCO2 monitoring in clinical practice, representing a simple, noninvasive method to monitor tissue perfusion and titrate therapeutic interventions in critically ill patients.
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Affiliation(s)
- Jacques Creteur
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Belgium.
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Marik PE. Sublingual capnometry: a non-invasive measure of microcirculatory dysfunction and tissue hypoxia. Physiol Meas 2006; 27:R37-47. [PMID: 16705254 DOI: 10.1088/0967-3334/27/7/r01] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
With improvement in supportive care patients rarely die from their presenting illness but rather from its sequela, namely sequential multi-organ failure. Tissue hypoxia is believed to be the causation of multi-organ dysfunction syndrome (MODS). The expedient detection and correction of tissue hypoxia may therefore limit the development of MODS. The standard oxygenation and hemodynamic variables (blood pressure, arterial oxygenation, cardiac output) which are monitored in critically ill patients are 'upstream' markers and provide little information as to the adequacy of tissue oxygenation. Global 'downstream' markers such as mixed venous oxygen saturation and blood lactate are insensitive indicators of tissue hypoxia. Sublingual PCO(2) is a regional marker of microvascular perfusion and tissue hypoxia that holds great promise for the risk stratification and end-point of goal directed resuscitation in critically ill patients. This paper reviews the technology and application of sublingual PCO(2) monitoring.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA
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Marik PE. Monitoring therapeutic interventions in critically ill septic patients. Nutr Clin Pract 2005; 19:423-32. [PMID: 16215136 DOI: 10.1177/0115426504019005423] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Sepsis is the leading cause of admission to intensive care units in the United States. Although the treatment of sepsis is complex and multimodal, nutrition support plays an important role in the management of these patients. The diagnosis of sepsis, disease category, and severity of illness and the change in sepsis severity and organ function over time affect the delivery of nutrition support. This paper reviews the diagnostic criteria of sepsis, the use of "sepsis biomarkers," and regional and global markers of organ function in sepsis and quantitative measures of illness severity and organ dysfunction.
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Affiliation(s)
- Paul E Marik
- Department of Critical Care, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15261, USA.
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Abstract
PURPOSE OF REVIEW Tissue dysoxia is now widely regarded as the major factor leading to organ dysfunction in critically ill patients. Recent data suggests that early aggressive resuscitation of critically ill patients, which limits and/or reverses tissue dysoxia may prevent progression to organ dysfunction and improve outcome. The traditional clinical and laboratory markers used to assess tissue dysoxia are, however, insensitive and have numerous limitations. Regional carbon dioxide monitoring appears to be ideally suited to monitoring the adequacy of resuscitation. This review provides an update on this evolving technology. RECENT FINDINGS Gastric intramucosal carbon dioxide as measured by gastric tonometry has proven to be useful as a prognostic marker, in evaluating the response to specific therapeutic interventions and as an end point of resuscitation. Gastric tonometry is, however, cumbersome and has a number of limitations that may have prevented its widespread adoption. The measurement of carbon dioxide in the sublingual mucosa by sublingual capnometry is technically simple, noninvasive, and provides near instantaneous information. Clinical studies have demonstrated a good correlation between gastric intramucosal carbon dioxide and sublingual mucosa carbon dioxide. Sublingual mucosa carbon dioxide responds more rapidly to therapeutic interventions than does gastric intramucosal carbon dioxide and may be a better prognostic marker. SUMMARY Sublingual capnometry may be the ideal technology for guiding early goal directed therapy. This technology may be useful for monitoring tissue oxygenation, titrating therapeutic interventions, and as an end point for resuscitation in critically ill and injured patients.
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Affiliation(s)
- Paul E Marik
- Pulmonary and Critical Care Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA.
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Leister I, Sydow J, Stojanovic T, Füzesi L, Sattler B, Heuser M, Becker H, Markus PM. Impact of vasoactive intestinal polypeptide and gastrin-releasing peptide on small bowel microcirculation and mucosal injury after hepatic ischemia/reperfusion in rats. Int J Colorectal Dis 2005; 20:42-8. [PMID: 15602648 DOI: 10.1007/s00384-004-0610-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/06/2004] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Alterations in microvascular perfusion of the intestine after hepatic ischemia/reperfusion have been suggested as an important cause of postoperative septic complications. We therefore investigated small bowel microcirculation and mucosal injury after liver ischemia/reperfusion in a rat model. Furthermore, we analyzed the effects of the regulatory peptides vasoactive intestinal polypeptide and gastrin-releasing peptide for their splanchnic vasoactivity. METHODS Hepatic ischemia was induced by clamping of the left hepatic artery and vein for 40 min, followed by 60 min of reperfusion. The control group was treated similarly, but without clamping of the liver vessels. Ten minutes after clamping of the hepatic vessels, vasoactive intestinal polypeptide or gastrin-releasing peptide, respectively, were continuously infused intravenously in the experimental groups. Small bowel microcirculation and mucosal injury were assessed using intravital microscopy and the Chiu-score, respectively. RESULTS The functional capillary density of the small intestine following ischemia and reperfusion of the left hepatic lobe significantly decreased compared to normal controls in both the mucosa and the smooth intestinal muscle. Red blood cell velocity decreased, whereas leukocyte-endothelium adherence, stasis index and the mucosal injury score increased. Administration of vasoactive intestinal polypeptide resulted in an increase of functional capillary density in the mucosa and of the red blood cell velocity and a decrease in the stasis index. The mucosal injury score was significantly higher in reperfused animals without treatment. The application of gastrin-releasing peptide resulted in an isolated increase of the red blood cell velocity. Leukocyte adherences could not be altered by the regulatory peptides. CONCLUSION We conclude that hepatic ischemia/reperfusion injury leads to significant alterations of small bowel microcirculation and mucosal injury. Vasoactive intestinal polypeptide and gastrin-releasing peptide attenuate the damage in a different manner.
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Affiliation(s)
- Ingo Leister
- Department of General Surgery, Georg August University, Robert-Koch-Strasse 40, 37099 Göttingen, Germany.
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Dubin A, Estenssoro E, Murias G, Pozo MO, Sottile JP, Barán M, Piacentini E, Canales HS, Etcheverry G. Intramucosal-Arterial Pco2 Gradient Does Not Reflect Intestinal Dysoxia in Anemic Hypoxia. ACTA ACUST UNITED AC 2004; 57:1211-7. [PMID: 15625451 DOI: 10.1097/01.ta.0000107182.43213.4b] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND An increase in intramucosal-arterial Pco2 gradient (DeltaPco2) might be caused by tissue hypoxia or by diminished blood flow. Our hypothesis was that DeltaPco2 should not be altered in anemic hypoxia with preserved blood flow. METHODS In 18 anesthetized, mechanically ventilated sheep, oxygen transport was stepwise reduced by hemorrhage (hypovolemia, n = 9) or by hemorrhage and simultaneous dextran infusion (hemodilution, n = 9). RESULTS Hypovolemia and hemodilution produced comparable decreases in systemic and intestinal oxygen transport and uptake. However, mixed venoarterial and mesenteric venoarterial Pco2 gradients and DeltaPco2 were significantly higher in hypovolemia than in hemodilution (25 +/- 5 vs. 10 +/- 2 mm Hg; 21 +/- 6 vs. 10 +/- 5 mm Hg; and 41 +/- 18 vs. 14 +/- 9 mm Hg, respectively; p < 0.01). CONCLUSION DeltaPco2 did not reflect intestinal dysoxia during Vo2/Do2 dependency attributable to hemodilution. Blood flow seems to be the main determinant of DeltaPco2.
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Affiliation(s)
- Arnaldo Dubin
- Cátedra de Farmacología, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, La Plata, Argentina.
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Maciel AT, Creteur J, Vincent JL. Tissue capnometry: does the answer lie under the tongue? Intensive Care Med 2004; 30:2157-65. [PMID: 15650865 DOI: 10.1007/s00134-004-2416-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2003] [Accepted: 07/26/2004] [Indexed: 10/26/2022]
Abstract
Increases in tissue partial pressure of carbon dioxide (PCO(2)) can reflect an abnormal oxygen supply to the cells, so that monitoring tissue PCO(2) may help identify circulatory abnormalities and guide their correction. Gastric tonometry aims at monitoring regional PCO(2) in the stomach, an easily accessible organ that becomes ischemic quite early when the circulatory status is jeopardized. Despite substantial initial enthusiasm, this technique has never been widely implemented due to various technical problems and artifacts during measurement. Experimental studies have suggested that sublingual PCO(2 )(P(sl)CO(2)) is a reliable marker of tissue perfusion. Clinical studies have demonstrated that high P(sl)CO(2) values and, especially, high gradients between P(sl)CO(2) and arterial PCO(2) (DeltaP(sl-a)CO(2)) are associated with impaired microcirculatory blood flow and a worse prognosis in critically ill patients. Although some questions remain to be answered about sublingual capnometry and its utility, this technique could offer new hope for tissue PCO(2) monitoring in clinical practice.
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Affiliation(s)
- Alexandre Toledo Maciel
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Route de Lennik 808, 1070 Brussels, Belgium
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Gutierrez G. A Mathematical Model of Tissue–Blood Carbon Dioxide Exchange during Hypoxia. Am J Respir Crit Care Med 2004; 169:525-33. [PMID: 14656752 DOI: 10.1164/rccm.200305-702oc] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A two-compartment mass transport model of tissue CO(2) exchange is developed to examine the relative contributions of blood flow and cellular hypoxia (dysoxia) to increases in tissue and venous blood CO(2) concentration. The model assumes perfectly mixed homogeneous conditions, steady-state equilibrium, and CO(2) production occurring exclusively at the tissues. The behavior of the model is compared with published data derived from an isolated dog hindlimb preparation subjected to either reductions in blood flow (ischemic hypoxia) or decreases in arterial PO(2) (hypoxic hypoxia). The results of the model corroborate the experimental finding of greater venous and tissue CO(2) concentrations with ischemic hypoxia than with hypoxic hypoxia. The model also predicts increases in tissue CO(2) concentration under conditions of adequate O(2) supply if CO(2) transfer from tissue to blood becomes impaired. Consequently, from a theoretical perspective, it appears that increases in the tissue or venous blood CO(2) concentration are neither sensitive nor specific markers of tissue dysoxia. The results of the model support the notion that changes in tissue and venous blood CO(2) concentration during dysoxia reflect primarily alterations in vascular perfusion and not scarcity in cellular energy supply.
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Affiliation(s)
- Guillermo Gutierrez
- Pulmonary and Critical Care Medicine Division, George Washington University, Washington, DC 20037, USA.
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De Backer D, Creteur J. Regional hypoxia and partial pressure of carbon dioxide gradients: what is the link? Intensive Care Med 2003; 29:2116-8. [PMID: 14708566 DOI: 10.1007/s00134-003-2020-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Knuesel R, Jakob SM, Brander L, Bracht H, Siegenthaler A, Takala J. Changes in regional blood flow and pCO2 gradients during isolated abdominal aortic blood flow reduction. Intensive Care Med 2003; 29:2255-2265. [PMID: 13680116 DOI: 10.1007/s00134-003-1954-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2002] [Accepted: 07/15/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVE pCO(2) gradients are used for the assessment of splanchnic regional and local mucosal blood flow changes in experimental and clinical research. pCO(2) gradients may not parallel blood flow changes because of concomitant changes in metabolism, hemoglobin, temperature, and the Haldane effect. DESIGN AND SETTING A randomized, controlled animal experiment in a university experimental research laboratory. INTERVENTIONS An extracorporeal shunt with reservoir and roller pump was inserted between the proximal and the distal abdominal aorta in 16 pigs. In animals randomized to the low-flow group ( n=8) splanchnic perfusion was reduced by running the roller pump. At baseline and after 45 min of stable shunt flow superior mesenteric artery, celiac trunk, spleen artery, and portal vein blood flows and regional venous-arterial and jejunal and gastric mucosal-arterial pCO(2) gradients were measured, and the respective regional O(2) consumption rates (VO(2)) calculated. MEASUREMENTS AND RESULTS In the low-flow group all regional blood flows and the associated VO(2) decreased to roughly 50% of baseline values, and hemoglobin decreased from 7.3 (4.4-9.6) g/dl to 5.7 (4.1-8.9) g/dl. Decreasing regional blood flows were consistently associated with increasing regional and mucosal pCO(2) gradients. CONCLUSIONS During isolated reduction in abdominal aortic blood flow there is no preferential distribution to any splanchnic vascular bed and changes in regional pCO(2) gradients reflect consistently the associated blood blow changes.
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Affiliation(s)
- Rafael Knuesel
- Department of Intensive Care Medicine, Inselspital, University Hospital Berne, 3010, Berne, Switzerland
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, University Hospital Berne, 3010, Berne, Switzerland.
| | - Lukas Brander
- Department of Intensive Care Medicine, Inselspital, University Hospital Berne, 3010, Berne, Switzerland
| | - Hendrik Bracht
- Department of Intensive Care Medicine, Inselspital, University Hospital Berne, 3010, Berne, Switzerland
| | - Andreas Siegenthaler
- Department of Intensive Care Medicine, Inselspital, University Hospital Berne, 3010, Berne, Switzerland
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, University Hospital Berne, 3010, Berne, Switzerland
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Abstract
BACKGROUND In a porcine hemorrhagic shock model we aimed to determine: (a) whether blood flow to the intestine and kidney was more reduced than cardiac output; (b) whether parameters of anaerobic metabolism correlated with regional blood flow; and (c) whether metabolic parameters in intestine, kidney and skeletal muscles detected a compromised metabolic state at an earlier stage than did systemic parameters. METHODS In an animal research laboratory at a university hospital six domestic pigs were subjected to volume-controlled hemorrhage. Every 30 min samples of blood were withdrawn. Systemic and regional hemodynamic parameters and tissue levels of PCO2 were monitored. Whole body and organ-specific oxygen consumption (VO2) and veno-arterial (VA) differences of lactate, glucose, potassium (K+), PCO2, H+ and base excess (BE) were calculated every 30 min. RESULTS With progressive hemorrhage, intestinal blood flow decreased to the same extent as cardiac output, whereas the reduction in renal blood flow was more pronounced. We found a concomitant reduction in VO2 (onset of supply dependent metabolism) in intestine, kidney and skeletal muscles. In muscular tissue PCO2 increased to levels three times higher than baseline, while renal and intestinal PCO2 increased eightfold. Supply dependency was associated with a concomitant increase in VA CO2 and VA H+. Also, VA lactate increased, mostly in intestine and least in skeletal muscle. Intestinal and renal VA K+ increased, while muscular VA K+ decreased. Arterial lactate and H+ increased considerably, whereas arterial BE decreased. CONCLUSION With progressive hemorrhage, renal blood flow, but not intestinal and skeletal muscle blood flow, was reduced more than cardiac output. Supply dependent oxygen metabolism (VO2) and organ acidosis occurred simultaneously in the three organs, despite differences in blood flow reductions. Organ ischemia coincided with a pronounced change in arterial lactate and systemic acid base parameters.
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Affiliation(s)
- G Kvarstein
- Department of Anesthesiology, Rikshospitalet, University of Oslo, Norway
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Morgan TJ, Venkatesh B. The Case for Tissue Base Excess. Intensive Care Med 2003. [DOI: 10.1007/978-1-4757-5548-0_53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Kirton O. Gastrointestinal tissue capnometry and critical oxygen delivery: flow versus hypoxia. Crit Care Med 2002; 30:484-5. [PMID: 11889336 DOI: 10.1097/00003246-200202000-00037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dubin A, Murias G, Estenssoro E, Canales H, Badie J, Pozo M, Sottile JP, Barán M, Pálizas F, Laporte M. Intramucosal-arterial PCO2 gap fails to reflect intestinal dysoxia in hypoxic hypoxia. Crit Care 2002; 6:514-20. [PMID: 12493073 PMCID: PMC153432 DOI: 10.1186/cc1813] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2002] [Revised: 08/05/2002] [Accepted: 08/06/2002] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION An elevation in intramucosal-arterial PCO2 gradient (DeltaPCO2) could be determined either by tissue hypoxia or by reduced blood flow. Our hypothesis was that in hypoxic hypoxia with preserved blood flow, DeltaPCO2 should not be altered. METHODS In 17 anesthetized and mechanically ventilated sheep, oxygen delivery was reduced by decreasing flow (ischemic hypoxia, IH) or arterial oxygen saturation (hypoxic hypoxia, HH), or no intervention was made (sham). In the IH group (n = 6), blood flow was lowered by stepwise hemorrhage; in the HH group (n = 6), hydrochloric acid was instilled intratracheally. We measured cardiac output, superior mesenteric blood flow, gases, hemoglobin, and oxygen saturations in arterial blood, mixed venous blood, and mesenteric venous blood, and ileal intramucosal PCO2 by tonometry. Systemic and intestinal oxygen transport and consumption were calculated, as was DeltaPCO2. After basal measurements, measurements were repeated at 30, 60, and 90 minutes. RESULTS Both progressive bleeding and hydrochloric acid aspiration provoked critical reductions in systemic and intestinal oxygen delivery and consumption. No changes occurred in the sham group. DeltaPCO2 increased in the IH group (12 +/- 10 [mean +/- SD] versus 40 +/- 13 mmHg; P < 0.001), but remained unchanged in HH and in the sham group (13 +/- 6 versus 10 +/- 13 mmHg and 8 +/- 5 versus 9 +/- 6 mmHg; not significant). DISCUSSION In this experimental model of hypoxic hypoxia with preserved blood flow, DeltaPCO2 was not modified during dependence of oxygen uptake on oxygen transport. These results suggest that DeltaPCO2 might be determined primarily by blood flow.
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Affiliation(s)
- Arnaldo Dubin
- Cátedra de Farmacologia, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Argentina.
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