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Kaefer K, Pierrakos C, Nguyen T, Velissaris D, Attou R, Devriendt J, Scolletta S, Taccone FS. Ratio of carbon dioxide veno-arterial difference to oxygen arterial-venous difference is not associated with lactate decrease after fluid bolus in critically ill patients with hyperlactatemia: results from a prospective observational study. BMC Anesthesiol 2023; 23:37. [PMID: 36721083 PMCID: PMC9887917 DOI: 10.1186/s12871-023-01993-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 01/23/2023] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND High ratio of the carbon dioxide veno-arterial difference to the oxygen arterial-venous difference (PvaCO2/CavO2) is associated with fluid bolus (FB) induced increase in oxygen consumption (VO2). This study investigated whether PvaCO2/CavO2 was associated with decreases in blood-lactate levels FB in critically ill patients with hyperlactatemia. METHODS This prospective observational study examined adult patients in the intensive care unit (ICU) with lactate levels > 1.5 mmol/L who received FBs. Blood-lactate levels were measured before and after FB under unchanged metabolic, respiratory, and hemodynamic conditions. The primary outcome was blood-lactate levels after FB. Significant decreases in blood-lactate levels were considered as blood-lactate levels < 1.5 mmol/L or a decrease of more than 10% compared to baseline. RESULTS The study enrolled 40 critically ill patients, and their median concentration of blood lactate was 2.6 [IQR:1.9 - 3.8] mmol/L. There were 27 (68%) patients with PvaCO2/CavO2 ≥ 1.4 mmHg/ml, and 10 of them had an increase in oxygen consumption (dVO2) ≥ 15% after FB, while 13 (32%) patients had PvaCO2/CavO2 < 1.4 mmHg/ml before FB, and none of them had dVO2 ≥ 15% after FB. FB increased the cardiac index in patients with high and low preinfusion PvaCO2/CavO2 (13.4% [IQR: 8.3 - 20.2] vs. 8.8% [IQR: 2.9 - 17.4], p = 0.34). Baseline PvaCO2/CavO2 was not found to be associated with a decrease in blood lactate after FB (OR: 0.88 [95% CI: 0.39 - 1.98], p = 0.76). A positive correlation was observed between changes in blood lactate and baseline PvaCO2/CavO2 (r = 0.35, p = 0.02). CONCLUSIONS In critically ill patients with hyperlactatemia, PvaCO2/CavO2 before FB cannot be used to predict decreases in blood-lactate levels after FB. Increased PvaCO2/CavO2 is associated with less decrease in blood-lactate levels.
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Affiliation(s)
- Keitiane Kaefer
- grid.4989.c0000 0001 2348 0746Intensive Care Department, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Charalampos Pierrakos
- grid.4989.c0000 0001 2348 0746Intensive Care Department, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Thomas Nguyen
- grid.4989.c0000 0001 2348 0746Intensive Care Department, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Dimitrios Velissaris
- grid.412458.eInternal Medicine Department, University Hospital of Patras, Patras, Greece
| | - Rachid Attou
- grid.4989.c0000 0001 2348 0746Intensive Care Department, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Devriendt
- grid.4989.c0000 0001 2348 0746Intensive Care Department, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Sabino Scolletta
- grid.411477.00000 0004 1759 0844Department of Emergency-Urgency and Organ Transplantation, Anesthesia and Intensive Care, University Hospital of Siena, Siena, Italy
| | - Fabio Silvio Taccone
- grid.412157.40000 0000 8571 829XIntensive Care Department, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Yuan S, He H, Long Y. Interpretation of venous-to-arterial carbon dioxide difference in the resuscitation of septic shock patients. J Thorac Dis 2019; 11:S1538-S1543. [PMID: 31388458 DOI: 10.21037/jtd.2019.02.79] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The venous-to-arterial carbon dioxide difference [P(v-a)CO2] was calculated from the difference of venous CO2 and arterial CO2, which has been used to reflect the global flow in the circulatory shock. Moreover, recent clinical studies found the P(v-a)CO2 was related to the sublingual microcirculation perfusion in the sepsis. However, it is still controversial that whether P(v-a)CO2 could be used to assess the microcirculatory flow in septic patients. Moreover, the related influent factors should be taken into account when interpreting P(v-a)CO2 in clinical practice. This paper reviews the relevant experimental and clinical scenarios of P(v-a)CO2 with the aim to help intensivists to use this parameter in the resuscitation of septic shock patients. Furthermore, we propose a conceptual framework to manage a high P(v-a)CO2 value in the resuscitation of septic shock. The triggers of correcting an elevated P(v-a)CO2 should take into consideration the other tissue perfusion parameters. Additionally, more evidence is required to validate that a decreasing in P(v-a)CO2 by increasing cardiac output would result in improvement of microcirculation. Further investigations are necessary to clarify the relationship between P(v-a)CO2 and microcirculation.
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Affiliation(s)
- Siyi Yuan
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing 100730, China
| | - Huaiwu He
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing 100730, China
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing 100730, China
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Mesquida J, Saludes P, Pérez-Madrigal A, Proença L, Cortes E, Enseñat L, Espinal C, Gruartmoner G. Respiratory quotient estimations as additional prognostic tools in early septic shock. J Clin Monit Comput 2018; 32:1065-1072. [PMID: 29455321 DOI: 10.1007/s10877-018-0113-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 02/07/2018] [Indexed: 11/28/2022]
Abstract
Central venous-to-arterial carbon dioxide difference (PcvaCO2), and its correction by the arterial-to-venous oxygen content difference (PcvaCO2/CavO2) have been proposed as additional tools to evaluate tissue hypoxia. Since the relationship between pressure and content of CO2 (CCO2) might be affected by several factors, some authors advocate for the use of CcvaCO2/CavO2. The aim of the present study was to explore the factors that might intervene in the difference between PcvaCO2/CavO2 and CcvaCO2/CavO2, and to analyze their association with mortality. Observational study in a 30-bed mixed ICU. Fifty-two septic shock patients within the first 24 h of ICU admission were studied. After restoration of mean arterial pressure, hemodynamic and metabolic parameters were evaluated. A total of 110 sets of measurements were performed. Simultaneous PcvaCO2/CavO2 and CcvaCO2/CavO2 values were correlated, but agreement analysis showed a significant proportional bias. The difference between PcvaCO2/CavO2 and CcvaCO2/CavO2 was independently associated with pH, ScvO2, baseline CcvaCO2/CavO2 and hemoglobin. A stepwise regression analysis showed that pH was the single best predictor for the magnitude of such difference, with very limited effect of other variables. At inclusion, variables associated with ICU-mortality were lactate, pH, PcvaCO2/CavO2, and the difference between PcvaCO2/CavO2 and CcvaCO2/CavO2. Initial ScvO2, PcvaCO2, CcvaCO2/CavO2, and cardiac index were not different in survivors and non-survivors. In a population of early septic shock patients, simultaneous values of PcvaCO2/CavO2 and CcvaCO2/CavO2 were not equivalent, and the main determinant of the magnitude of the difference between these two parameters was pH. The PcvaCO2/CavO2 ratio was associated with ICU mortality, whereas CcvaCO2/CavO2 was not.
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Affiliation(s)
- J Mesquida
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Departament de Medicina, Universitat Autònoma de Barcelona, Sabadell, Spain.
| | - P Saludes
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Departament de Medicina, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - A Pérez-Madrigal
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Departament de Medicina, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - L Proença
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Departament de Medicina, Universitat Autònoma de Barcelona, Sabadell, Spain.,Serviço de Urgencia Geral, Hospital Prof. Dr. Fernando Fonseca, Amadora, Portugal
| | - E Cortes
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Departament de Medicina, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - L Enseñat
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Departament de Medicina, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - C Espinal
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Departament de Medicina, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - G Gruartmoner
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Departament de Medicina, Universitat Autònoma de Barcelona, Sabadell, Spain
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