1
|
Motazedian P, Beauregard N, Letourneau I, Olaye I, Syed S, Lam E, Di Santo P, Mathew R, Clark EG, Sood MM, Lalu MM, Hibbert B, Bugeja A. Central Venous Oxygen Saturation for Estimating Mixed Venous Oxygen Saturation and Cardiac Index in the ICU: A Systematic Review and Meta-Analysis. Crit Care Med 2024:00003246-990000000-00369. [PMID: 39258966 DOI: 10.1097/ccm.0000000000006398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2024]
Abstract
OBJECTIVES The objectives of our systematic review and meta-analyses were to determine the diagnostic accuracy of central venous oxygen saturation (Scvo2) in estimating mixed venous oxygen saturation (Svo2) and cardiac index in critically ill patients. DATA SOURCES A systematic search using MEDLINE, Cochrane Central Register of Controlled Trials, and Embase was completed on May 6, 2024. STUDY SELECTION Studies of patients in the ICU for whom Scvo2 and at least one reference standard test was performed (thermodilution and/or Svo2) were included. DATA EXTRACTION Individual patient data were used to calculate the pooled intraclass correlation coefficient (ICC) for Svo2 and Spearman correlation for cardiac index. The Quality Assessment of Diagnostic Accuracy Studies-2 and Grading Recommendations Assessment, Development, and Evaluation tools were used for the risk of bias and certainty of evidence assessments. DATA SYNTHESIS Of 3427 studies, a total of 18 studies with 1971 patients were identified. We meta-analyzed 16 studies (1335 patients) that used Svo2 as a reference and three studies (166 patients) that used thermodilution as reference. The ICC for reference Svo2 was 0.83 (95% CI, 0.75-0.89) with a mean difference of 2.98% toward Scvo2. The Spearman rank correlation for reference cardiac index is 0.47 (95% CI, 0.46-0.48; p < 0.0001). CONCLUSIONS There is moderate reliability for Scvo2 in predicting Svo2 in critical care patients with variability based on sampling site and presence of sepsis. There is limited evidence on the independent use of Scvo2 in predicting cardiac index.
Collapse
Affiliation(s)
- Pouya Motazedian
- University of Ottawa School of Epidemiology and Public Health, Ottawa, ON, Canada
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Nickolas Beauregard
- University of Ottawa School of Epidemiology and Public Health, Ottawa, ON, Canada
| | - Isabelle Letourneau
- University of Ottawa School of Epidemiology and Public Health, Ottawa, ON, Canada
- Department of Obstetrics and Gynaecology, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Ida Olaye
- University of Ottawa School of Epidemiology and Public Health, Ottawa, ON, Canada
| | - Sarah Syed
- University of Ottawa School of Epidemiology and Public Health, Ottawa, ON, Canada
| | - Eric Lam
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Pietro Di Santo
- University of Ottawa School of Epidemiology and Public Health, Ottawa, ON, Canada
- University of Ottawa Heart Institute, Ottawa, ON, Canada
- University of Ottawa, Ottawa, ON, Canada
| | - Rebecca Mathew
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Edward G Clark
- Division of Nephrology, Department of Medicine, Kidney Research Centre, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Manish M Sood
- Division of Nephrology, Department of Medicine, Kidney Research Centre, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Manoj M Lalu
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON, Canada
- Clinical Epidemiology Program, Blueprint Translational Research Group, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Benjamin Hibbert
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Ann Bugeja
- University of Ottawa School of Epidemiology and Public Health, Ottawa, ON, Canada
- Division of Nephrology, Department of Medicine, Kidney Research Centre, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| |
Collapse
|
2
|
An R, Wan XX, Chen Y, Dong R, Wang CY, Jiang W, Weng L, Du B. Central venous oxygen saturation changes as a reliable predictor of the change of CI in septic shock: To explore potential influencing factors. Chin J Traumatol 2024:S1008-1275(24)00058-0. [PMID: 38789315 DOI: 10.1016/j.cjtee.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/09/2024] [Accepted: 05/12/2024] [Indexed: 05/26/2024] Open
Abstract
PURPOSE Assessing fluid responsiveness relying on central venous oxygen saturation (ScvO2) yields varied outcomes across several studies. This study aimed to determine the ability of the change in ScvO2 (ΔScvO2) to detect fluid responsiveness in ventilated septic shock patients and potential influencing factors. METHODS In this prospective, single-center study, all patients conducted from February 2023 to January 2024 received fluid challenge. Oxygen consumption was measured by indirect calorimetry, and fluid responsiveness was defined as an increase of cardiac index (CI) ≥ 10% measured by transthoracic echocardiography. Multivariate linear regression analysis was conducted to evaluate the impact of oxygen consumption, arterial oxygen saturation, CI, and hemoglobin on ScvO2 and its change before and after fluid challenge. RESULTS Among 49 patients (31 men, aged (59 ± 18) years), 27 were responders. The patients had an acute physiology and chronic health evaluation II score of 24 ± 8, a sequential organ failure assessment score of 11 ± 4, and a blood lactate level of (3.2 ± 3.1) mmol/L at enrollment. After the fluid challenge, the ΔScvO2 (mmHg) in the responders was greater than that in the non-responders (4 ± 6 vs. 1 ± 3, p = 0.019). Multivariate linear regression analysis suggested that CI was the only independent influencing factor of ScvO2, with R2 = 0.063, p = 0.008. After the fluid challenge, the change in CI became the only contributing factor to ΔScvO2 (R2 = 0.245, p < 0.001). ΔScvO2 had a good discriminatory ability for the responders and non-responders with a threshold of 4.4% (area under the curve = 0.732, p = 0.006). CONCLUSION ΔScvO2 served as a reliable surrogate marker for ΔCI and could be utilized to assess fluid responsiveness, given that the change of CI was the sole contributing factor to the ΔScvO2. In stable hemoglobin conditions, the absolute value of ScvO2 could serve as a monitoring indicator for adequate oxygen delivery independent of oxygen consumption.
Collapse
Affiliation(s)
- Ran An
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xi-Xi Wan
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China; Department of Critical Care Medicine, The Second Affiliated Hospital of Jiaxing University, Jiaxing, 314001, Zhejiang province, China
| | - Yan Chen
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Run Dong
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Chun-Yao Wang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Wei Jiang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Li Weng
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Bin Du
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China.
| |
Collapse
|
3
|
Wong C, Chung JK, Hu K, Chopra A. A 24-Year-Old Woman With Refractory Hypoxemia. Chest 2024; 165:e113-e117. [PMID: 38599755 DOI: 10.1016/j.chest.2023.04.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/16/2023] [Accepted: 04/25/2023] [Indexed: 04/12/2024] Open
Affiliation(s)
- Christian Wong
- Division of Pulmonary and Critical Care, Department of Medicine, Albany Medical Center, Albany, NY.
| | - Jae K Chung
- Division of Pulmonary and Critical Care, Department of Medicine, Albany Medical Center, Albany, NY
| | - Kurt Hu
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Amit Chopra
- Division of Pulmonary and Critical Care, Department of Medicine, Albany Medical Center, Albany, NY
| |
Collapse
|
4
|
Abstract
OBJECTIVES Superior vena cava oxygen saturation (SVC O 2 ) monitoring is well described for early detection of hemodynamic deterioration after neonatal cardiac surgery but inferior vena cava vein oxygen saturation (IVC O 2 ) monitoring data are limited. DESIGN Retrospective cohort study of 118 neonates with congenital heart disease (52 single ventricle) from February 2008 to January 2014. SETTING Pediatric cardiac ICU. PATIENTS Neonates (< 30 d) with concurrent admission IVC O 2 and SVC O 2 measurements after cardiac surgery with cardiopulmonary bypass. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary aim was to correlate admission IVC O 2 and SVC O 2 . Secondary aims included: correlate flank or cerebral near-infrared spectroscopy with IVC O 2 and SVC O 2 , respectively, and exploratory analysis to evaluate associations between oximetry data and a composite adverse outcome defined as any of the following: increasing serum lactate or vasoactive support at 2 hours post-admission, cardiac arrest, or mortality. Admission IVC O 2 and SVC O 2 correlated ( r = 0.54; p < 0.001). However, IVC O 2 measurements were significantly lower than paired SVC O 2 (mean difference, -6%; 95% CI, -8% to -4%; p < 0.001) with wide variability in sample agreement. Logistic regression showed that each 12% decrease in IVC O 2 was associated with a 12-fold greater odds of the composite adverse outcome (odds ratio [OR], 12; 95% CI, 3.9-34; p < 0.001). We failed to find an association between SVC O 2 and increased odds of the composite adverse outcome (OR, 1.8; 95% CI, 0.99-3.3; p = 0.053). In an exploratory analysis, the area under the receiver operating curve for IVC O 2 and SVC O 2 , and the composite adverse outcome, was 0.85 (95% CI, 0.77-0.92) and 0.63 (95% CI, 0.52-0.73), respectively. Admission IVC O 2 had strong correlation with concurrent flank near-infrared spectroscopy value ( r = 0.74; p < 0.001). SVC O 2 had a weak association with cerebral near-infrared spectroscopy ( r = 0.22; p = 0.02). CONCLUSIONS In postoperative neonates, admission IVC O 2 and SVC O 2 correlate. Lower admission IVC O 2 may identify a cohort of postsurgical neonates at risk for low cardiac output and associated morbidity.
Collapse
|
5
|
Mathew R, Fernando SM, Hu K, Parlow S, Di Santo P, Brodie D, Hibbert B. Optimal Perfusion Targets in Cardiogenic Shock. JACC. ADVANCES 2022; 1:100034. [PMID: 38939320 PMCID: PMC11198174 DOI: 10.1016/j.jacadv.2022.100034] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 06/29/2024]
Abstract
Cardiology shock is a syndrome of low cardiac output resulting in end-organ dysfunction. Few interventions have demonstrated meaningful clinical benefit, and cardiogenic shock continues to carry significant morbidity with mortality rates that have plateaued at upwards of 40% over the past decade. Clinicians must rely on clinical, biochemical, and hemodynamic parameters to guide resuscitation. Several features, including physical examination, renal function, serum lactate metabolism, venous oxygen saturation, and hemodynamic markers of right ventricular function, may be useful both as prognostic markers and to guide therapy. This article aims to review these targets, their utility in the care of patients with cardiology shock, and their association with outcomes.
Collapse
Affiliation(s)
- Rebecca Mathew
- Division of Cardiology, University of Ottawa, Ottawa, Ontario, Canada
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Shannon M. Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kira Hu
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Simon Parlow
- Division of Cardiology, University of Ottawa, Ottawa, Ontario, Canada
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Pietro Di Santo
- Division of Cardiology, University of Ottawa, Ottawa, Ontario, Canada
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York, USA
| | - Benjamin Hibbert
- Division of Cardiology, University of Ottawa, Ottawa, Ontario, Canada
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
6
|
|
7
|
Guo Z, Yin M, Kong J, Wang B, Dai K, Zuo T, Yu G, Bao Y. Relationship Analysis of Central Venous-to-arterial Carbon Dioxide Difference and Cardiac Index for Septic Shock. Sci Rep 2019; 9:8822. [PMID: 31217467 PMCID: PMC6584725 DOI: 10.1038/s41598-019-45252-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 05/29/2019] [Indexed: 01/08/2023] Open
Abstract
To analyze the relationship of the central venous-to-arterial carbon dioxide difference (p(cv-a)CO2) and cardiac index (CI) in patients with septic shock, an observational study was conducted in intensive care unit (ICU). 66 consecutive patients with septic shock and central venous oxygen saturation (ScvO2) ≥ 70% were included after early fluid resuscitation. Measurements were taken at a 6 h interval (T0, T6, T12, T18, T24) during first 24 h after their admission into ICU, including heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), p(cv-a)CO2, cardiac index(CI, L/(min•m2)) and ScvO2. Patients were divided into low p(cv-a)CO2 group (n = 35) and high p(cv-a)CO2 group (n = 31) according to a threshold of 6 mmHg for p(cv-a)CO2 at T0. As a result, at T0, T6, T12, T18 and T24, there were respectively significant differences between low and high p(cv-a)CO2 groups for CI (4.1 ± 1.4 vs 2.4 ± 0.6, 4.4 ± 0.9 vs 2.8 ± 0.7, 4.1 ± 1.3 vs 2.9 ± 0.6, 4.0 ± 1.3 vs 2.7 ± 0.8, 4.2 ± 1.4 vs 2.9 ± 0.8, p < 0.001 at each time point), 28-day mortality rate was 38.7%(12/31) for high p(cv-a)CO2 group and 22.8% (8/35) for low p(cv-a)CO2 group (p > 0.05), there were significant differences for p(cv-a)CO2 (p < 0.05) between low and high p(cv-a)CO2 groups, no differences for HR, MAP, CVP, ScvO2 (p > 0.05). CI was inversely correlated with p(cv-a)CO2 value (r = −0.804, p < 0.001), but not for ScvO2(r = 0.08, p > 0.05). Receiver operating characteristic curve analysis confirmed the correlation of p(cv-a)CO2 with CI (AUC: 0.782;p < 0.001; 95% confidence interval: 0.710–0.853). The cut-off value for the best predictive value of CI ≥ 2.2 L/(min·m2) was p(cv-a)CO2 of 5.55 mmHg or lower with a sensitivity of 85.7% and specificity of 66.8%. Hence CI measured with USCOM is inversely correlated with p(cv-a)CO2 values in guiding the resuscitation of patients with septic shock.
Collapse
Affiliation(s)
- Zhiqiang Guo
- Department of Critical Care Medicine of Beidaihe Hospital of Qinhuangdao, Qinhuangdao, China.
| | - Ming Yin
- Department of Interventional Endoscopy of General Hospital of North China Petroleum Administration, Renqiu, China
| | - Jichang Kong
- Deparment of Critical Care Medicine of General Hospital of North China Petroleum Administration, Renqiu, China
| | - Bin Wang
- Deparment of Critical Care Medicine of General Hospital of North China Petroleum Administration, Renqiu, China
| | - Kunpeng Dai
- Deparment of Critical Care Medicine of General Hospital of North China Petroleum Administration, Renqiu, China
| | - Tian Zuo
- Department of Critical Care Medicine of Beidaihe Hospital of Qinhuangdao, Qinhuangdao, China
| | - Guangyan Yu
- Deparment of Critical Care Medicine of General Hospital of North China Petroleum Administration, Renqiu, China
| | - Yong Bao
- Deparment of Critical Care Medicine of General Hospital of North China Petroleum Administration, Renqiu, China
| |
Collapse
|
8
|
Raghunathan K, Wang XS. In support of 'usual' perioperative care. Br J Anaesth 2016; 117:7-12. [PMID: 27165665 DOI: 10.1093/bja/aew067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- K Raghunathan
- Division of Veterans Affairs, Department of Anaesthesiology, Duke University Medical Centre/Durham VAMC, DUMC 3094, Durham, NC 27710, USA
| | - X S Wang
- Department of Anaesthesiology, Duke University Medical Centre, DUMC 3094, Durham, NC 27710, USA
| |
Collapse
|
9
|
Ho KM. Pitfalls in haemodynamic monitoring in the postoperative and critical care setting. Anaesth Intensive Care 2016; 44:14-9. [PMID: 26673584 DOI: 10.1177/0310057x1604400104] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Haemodynamic monitoring is a vital part of daily practice in anaesthesia and intensive care. Although there is evidence to suggest that goal-directed therapy may improve outcomes in the perioperative period, which haemodynamic targets we should aim at to optimise patient outcomes remain elusive and controversial. This review highlights the pitfalls in commonly used haemodynamic targets, including arterial blood pressure, central venous pressure, cardiac output, central venous oxygen saturation and dynamic haemodynamic indices. Evidence suggests that autoregulation in regional organ circulation may change either due to chronic hypertension or different disease processes such as traumatic brain injury, cerebrovascular ischaemia or haemorrhage; this will influence the preferred blood pressure target. Central venous pressure can be influenced by multiple pathophysiological factors and, unless central venous pressure is very low, it is rarely useful as a predictor for fluid responsiveness. Central venous oxygen saturation can be easily increased by a high arterial oxygen tension, making it useless as a surrogate marker of good cardiac output or systemic oxygen delivery in the presence of hyperoxaemia. Many dynamic haemodynamic indices have been reported to predict fluid responsiveness, but they all have their own limitations. There is also insufficient evidence to support that giving fluid until the patient is no longer fluid responsive can improve patient-centred outcomes. With the exception in the context of preventing contrast-induced nephropathy, large randomised controlled studies suggest that excessive fluid treatment may prolong duration of mechanical ventilation without preventing acute kidney injury in the critically ill.
Collapse
Affiliation(s)
- K M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia
| |
Collapse
|
10
|
Silbert BI, Litton E, Ho KM. Central Venous-to-Arterial Carbon Dioxide Gradient as a Marker of Occult Tissue Hypoperfusion after Major Surgery. Anaesth Intensive Care 2015; 43:628-634. [DOI: 10.1177/0310057x1504300512] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
The central venous-arterial carbon dioxide tension gradient (‘CO2 gap’) has been shown to correlate with cardiac output and tissue perfusion in septic shock. Compared to central venous oxygen saturation (SCVO2), the CO2 gap is less susceptible to the effect of hyperoxia and may be particularly useful as an adjunctive haemodynamic target in the perioperative period. This study investigated whether a high CO2 gap was associated with an increased systemic oxygen extraction (O2ER >0.3) or occult tissue hypoperfusion in 201 patients in the immediate postoperative period. The median CO2 gap of all patients was 8 mmHg (IQR 6 to 9), and a large CO2 gap was very common (>6 mmHg in 139 patients [69%], 95% CI 63 to 75; >5 mmHg in 170 patients [85%], 95% CI 79 to 89). A CO2 gap <5 mmHg had a higher sensitivity (93%) and negative predictive value (74%) than a CO2 gap <6 mmHg in excluding occult tissue hypoperfusion. Of the four variables that were predictive of an increased O2ER in the multivariate analysis—CO2 gap, arterial pH, haemoglobin and arterial lactate concentrations—the CO2 gap (odds ratio 4.41 per mmHg increment, 95% CI 1.7 to 11.2, P=0.002) was most important and explained about 34% of the variability in the risk of occult tissue hypoperfusion. In conclusion, a normal CO2 gap (<5 mmHg) had a high sensitivity and negative predictive value in excluding inadequate systemic oxygen delivery and may be useful as an adjunct to other haemodynamic targets in avoiding occult tissue hypoperfusion in the perioperative setting when high inspired oxygen concentrations are used.
Collapse
Affiliation(s)
- B. I. Silbert
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia
| | - E. Litton
- Department of Intensive Care Medicine, Royal Perth Hospital, School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia
| | - K. M. Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, School of Population Health, University of Western Australia, Perth, Western Australia
| |
Collapse
|
11
|
Vincent JL, Pelosi P, Pearse R, Payen D, Perel A, Hoeft A, Romagnoli S, Ranieri VM, Ichai C, Forget P, Della Rocca G, Rhodes A. Perioperative cardiovascular monitoring of high-risk patients: a consensus of 12. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:224. [PMID: 25953531 PMCID: PMC4424585 DOI: 10.1186/s13054-015-0932-7] [Citation(s) in RCA: 132] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A significant number of surgical patients are at risk of intra- or post-operative complications or both, which are associated with increased lengths of stay, costs, and mortality. Reducing these risks is important for the individual patient but also for health-care planners and managers. Insufficient tissue perfusion and cellular oxygenation due to hypovolemia, heart dysfunction or both is one of the leading causes of perioperative complications. Adequate perioperative management guided by effective and timely hemodynamic monitoring can help reduce the risk of complications and thus potentially improve outcomes. In this review, we describe the various available hemodynamic monitoring systems and how they can best be used to guide cardiovascular and fluid management in the perioperative period in high-risk surgical patients.
Collapse
Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 808 route de Lennik, 1070, Brussels, Belgium.
| | - Paolo Pelosi
- AOU IRCCS San Martino-IST, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Largo Rosanna Benzi 8, 16132, Genoa, Italy.
| | - Rupert Pearse
- Adult Critical Care Unit, Royal London Hospital, Whitechapel Road, London, E1 1BB, UK.
| | - Didier Payen
- Department of Anesthesiology and Critical Care, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris 7 Denis Diderot, 75475, Paris, Cedex 10, France.
| | - Azriel Perel
- Department of Anesthesiology and Intensive Care, Sheba Medical Center, Tel Aviv University, Tel Aviv, 52621, Israel.
| | - Andreas Hoeft
- Department of Anesthesiology and Intensive Care Medicine, University of Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany.
| | - Stefano Romagnoli
- Department of Human Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Largo Giovanni Alessandro Brambilla 3, 50139, Florence, Italy.
| | - V Marco Ranieri
- Department of Anesthesia and Intensive Care Medicine, University of Turin, S.Giovanni Battista Molinette Hospital, 10126, Turin, Italy.
| | - Carole Ichai
- Medico-Surgical Intensive Care Unit, Saint-Roch University Hospital, University of Nice, 5 Rue Pierre Dévoluy, 06006, Nice, France.
| | - Patrice Forget
- Service d'Anesthésiologie, Cliniques Universitaires Saint-Luc, Institute of Neuroscience (IoNS), Université catholique de Louvain, Avenue Hippocrate 10, 1200, Brussels, Belgium.
| | - Giorgio Della Rocca
- Department of Anesthesia and Intensive Care Medicine, University Hospital, Medical School, University of Udine, P. le S. Maria della Misericordia 15, 33100, Udine, Italy.
| | - Andrew Rhodes
- Department of Intensive Care Medicine, St George's Healthcare NHS Trust, Blackshaw Road, London, SW17 0QT, UK.
| |
Collapse
|
12
|
Litton E, Silbert B, Ho KM. Clinical Predictors of a Low Central Venous Oxygen Saturation after Major Surgery: A Prospective Prevalence Study. Anaesth Intensive Care 2015; 43:59-65. [DOI: 10.1177/0310057x1504300109] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Optimising perioperative haemodynamic status may reduce postoperative complications. In this prospective prevalence study, we investigated the associations between standard haemodynamic parameters and a low central venous oxygen saturation (ScvO2) in patients after major surgery. A total of 201 patients requiring continuous arterial and central venous pressure monitoring after major surgery were recruited. Simultaneous arterial and central venous blood gases, haemodynamic and biochemical data and perfusion index were obtained from patients at a single time-point within 24 hours of surgery. A low ScvO2 (<70%) was observed in 109 patients (54%). Use of mechanical ventilation, mean arterial pressure, central venous pressure, haemoglobin concentrations, arterial pH and lactate concentrations, arterial oxygen (PaO2) and carbon dioxide tensions (PaCO2) were all associated with a low ScvO2 in the univariate analyses. In the multivariate analysis, only a higher perfusion index (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.78 to 0.98), PaO2 (OR 0.98 per mmHg increment, 95% CI 0.97 to 0.99) and PaCO2 (OR 0.88 per mmHg increment, 95% CI 0.82 to 0.95) and a lower central venous pressure (OR 1.14 per mmHg increment, 95% CI 1.04 to 1.25) were significantly associated with a reduced risk of a low ScvO2, all in a linear fashion. In conclusion, PaO2, PaCO2, perfusion index and central venous pressure were significant predictors of a low ScvO2 in patients after major surgery including cardiac surgery, suggesting that ScvO2 should always be interpreted with the arterial blood gases and that liberal perioperative fluid therapy aiming at a high central venous pressure may be detrimental in optimising ScvO2.
Collapse
Affiliation(s)
- E. Litton
- Department of Intensive Care Medicine, Royal Perth Hospital, School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia
| | - B. Silbert
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia
| | - K. M. Ho
- Department of Intensive Care Medicine, Royal Perth, School of Population Health, University of Western Australia, Perth, Western Australia
| |
Collapse
|
13
|
Squara P. Central venous oxygenation: when physiology explains apparent discrepancies. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:579. [PMID: 25407250 PMCID: PMC4282012 DOI: 10.1186/s13054-014-0579-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Central venous oxygen saturation (ScvO2) >70% or mixed venous oxygen saturation (SvO2) >65% is recommended for both septic and non-septic patients. Although it is the task of experts to suggest clear and simple guidelines, there is a risk of reducing critical care to these simple recommendations. This article reviews the basic physiological and pathological features as well as the metrological issues that provide clear evidence that SvO2 and ScvO2 are adaptative variables with large inter-patient variability. This variability is exemplified in a modeled population of 1,000 standard ICU patients and in a real population of 100 patients including 15,860 measurements. In these populations, it can be seen how optimizing one to three of the four S(c)vO2 components homogenized the patients and yields a clear dependency with the fourth one. This explains the discordant results observed in large studies where cardiac output was increased up to predetermined S(c)vO2 thresholds following arterial oxygen hemoglobin saturation, total body oxygen consumption needs and hemoglobin optimization. Although a systematic S(c)vO2 goal-oriented protocol can be statistically profitable before ICU admission, appropriate intensive care mandates determination of the best compromise between S(c)vO2 and its four components, taking into account the specific constraints of each individual patient.
Collapse
|
14
|
|
15
|
Clinical utility of central venous saturation for the calculation of cardiac index in cardiac patients. J Card Fail 2014; 20:716-722. [PMID: 25038264 DOI: 10.1016/j.cardfail.2014.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 04/17/2014] [Accepted: 07/10/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND Mixed venous saturation (MVS) obtained from the distal pulmonary artery (PA) during Swan-Ganz catheterization is the criterion standard for calculating cardiac output (CO) and cardiac index (CI) with the use of the Fick method. We think that calculating CI with the use of central venous saturation (CVS) instead of PA-MVS is both feasible and accurate. Earlier studies were small, enrolled heterogeneous patient populations, and resulted in inconsistent findings. METHODS All patients undergoing right heart catheterization from January 2011 to January 2012 in our catheterization lab with simultaneous measurements of MVS obtained from the distal PA and CVS obtained from the superior vena cava (SVC) or right atrium (RA) were included. Out of the 902 patients enrolled, we excluded patients (n = 50) who had known cardiac shunt or dialysis fistula, had duplicate medical records, or were septic. We calculated the CI with the use of the assumed Fick method using both MVS (criterion standard) and CVS (SVC or RA saturations) in the remaining 852 patients. We measured the correlation and the agreement between the 2 methods with the use of the Pearson correlation coefficient and Bland-Altman analysis. RESULTS Totals of 112 patients with simultaneous PA and RA saturation measurements (group I) and 740 patients with simultaneous PA and SVC saturation measurements (group II) were included. We found an excellent linear correlation between SVC and PA saturation (r = 0.928) and between RA and PA saturation (r = 0.95). There was also an excellent correlation between CI calculated with the use of PA saturation and CI calculated with the use of SVC (r = 0.87) or RA (r = 0.93) saturation. The mean bias of CVS-derived CI compared with MVS-derived CI (criterion standard) was -0.1 (95% limits of agreement [LOA] -1 to +0.77) in the SVC group and -0.006 (LOA -0.68 to +0.69) in the RA group. Patients with low CI had stronger correlation and smaller bias between the 2 methods compared with those with normal or high CI. The presence of baseline hypoxemia, valvular heart disease, or acute coronary syndrome had no significant effect on the correlation or the bias between the 2 methods. CONCLUSIONS In cardiac patients, CVS can be used as a surrogate to true MVS in the calculation of CI. This method is readily available in patients who have central venous access, and may aid in early goal-directed treatment when cardiogenic shock is suspected.
Collapse
|
16
|
Suehiro K, Tanaka K, Matsuura T, Funao T, Yamada T, Mori T, Nishikawa K. Discrepancy Between Superior Vena Cava Oxygen Saturation and Mixed Venous Oxygen Saturation Can Predict Postoperative Complications in Cardiac Surgery Patients. J Cardiothorac Vasc Anesth 2014; 28:528-33. [DOI: 10.1053/j.jvca.2013.03.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Indexed: 01/22/2023]
|
17
|
Goal Directed Fluid Resuscitation: A Review of Hemodynamic, Metabolic, and Monitoring Based Goals. CURRENT ANESTHESIOLOGY REPORTS 2013. [DOI: 10.1007/s40140-013-0011-z] [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]
|
18
|
Bond CM, Djogovic D, Villa-Roel C, Bullard MJ, Meurer DP, Rowe BH. Pilot study comparing sepsis management with and without electronic clinical practice guidelines in an academic emergency department. J Emerg Med 2012; 44:698-708. [PMID: 23137959 DOI: 10.1016/j.jemermed.2012.08.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2012] [Revised: 04/16/2012] [Accepted: 08/24/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Sepsis is a potentially life-threatening condition that requires urgent management in an Emergency Department (ED). Evidence-based guidelines for managing sepsis have been developed; however, their integration into routine practice is often incomplete. Care maps may help clinicians meet guideline targets more often. OBJECTIVES To determine if electronic clinical practice guidelines (eCPGs) improve management of patients with severe sepsis and septic shock (SS/SS). METHODS The impact of an eCPG on the management of patients presenting with SS/SS over a 3-year period at a tertiary care ED was evaluated using retrospective case-control design and chart review methods. Cases and controls, matched by age and sex, were chosen from an electronic database using physician sepsis diagnoses. Data were compared using McNemar tests or paired t-tests, as appropriate. RESULTS Overall, 51 cases and controls were evaluated; the average age was 62 years, and 60% were male. eCPG patients were more likely to have a central venous pressure and central venous oxygen saturation measured; however, lactate measurement, blood cultures, and other investigations were similarly ordered (all p > 0.05). The administration of antibiotics within 3 h (63% vs. 41%; p = 0.03) and vasopressors (45% vs. 20%; p = 0.02) was more common in the eCPG group; however, use of corticosteroids and other interventions did not differ between the groups. Overall, survival was high and similar between groups. CONCLUSION A sepsis eCPG experienced variable use; however, physicians using the eCPG achieved more quality-of-care targets for SS/SS. Strategies to increase the utilization of eCPGs in Emergency Medicine seem warranted.
Collapse
Affiliation(s)
- Christopher M Bond
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | | | | | | | | |
Collapse
|
19
|
Ho KM. Ten caveats of interpreting correlation coefficient in anaesthesia and intensive care research. Anaesth Intensive Care 2012; 40:595-7. [PMID: 22813485 DOI: 10.1177/0310057x1204000403] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
20
|
Kyle B, Litton E, Ho KM. Effect of hyperoxia and vascular occlusion on tissue oxygenation measured by near infra-red spectroscopy (InSpectra™): a volunteer study. Anaesthesia 2012; 67:1237-41. [DOI: 10.1111/j.1365-2044.2012.07265.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
21
|
Soussi MS, Jebali MA, Le Manach Y, Nasri M, Zouari B, Chenik S, Ferjani M. Central venous saturation is not an alternative to mixed venous saturation during cardiopulmonary bypass in coronary artery surgery patients. Perfusion 2012; 27:300-6. [PMID: 22499058 DOI: 10.1177/0267659112442902] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND To evaluate the correlation and agreement between central venous saturation (ScvO(2)) and mixed venous saturation (SvO(2)) during cardiopulmonary bypass. METHODS Twenty-two consecutive patients scheduled for coronary artery surgery were prospectively included. Paired measurements of ScvO(2) and SvO(2) were performed 5 minutes after aortic cross-clamping, after each cardioplegia dose and after de-clamping of the aortic cross-clamp. ScvO(2) and SvO(2) were measured, respectively, by a fibreoptic catheter in the superior vena cava and on blood samples from the venous return line of the extracorporeal circuit, using a blood gas analyser RESULTS Ninety-five paired measurements of venous saturation were obtained. Correlation between the measurements was associated with an r = 0.55. The mean bias was 2.2 [Limits of agreement: -13.6%, +18%]. Changes in oxygen saturation over time showed an r = 0.4 and a mean bias of 0.2 [Limits of agreement: -17.9%, +18.3%]. Multivariate analysis identified the oxygen consumption index as the only factor explaining this variability. CONCLUSIONS Although mean biases between the measurements were low, limits of agreement were too large to provide a clinically acceptable estimation of SvO(2) by ScvO(2) in these conditions. Variations in regional oxygen consumption seem to be the main factor worsening the relationship.
Collapse
Affiliation(s)
- M S Soussi
- Department of Anaesthesiology and Critical Care, Military Hospital, Tunis University, Tunis, Tunisia
| | | | | | | | | | | | | |
Collapse
|
22
|
Abstract
The use of pulmonary artery catheters has diminished, so that other technologies are emerging. Central venous oxygen saturation measurement (ScvO₂) as a surrogate for mixed venous oxygen saturation measurement (SvO₂) is simple and clinically accessible. To maximize the clinical utility of ScvO₂ (or SvO₂) measurement, it is useful to review what the measurement means in a physiologic context,how the measurement is made, important limitations, and how this measurement may be helpful in common clinical scenarios. Compared with cardiac output measurement, SvO₂ is more directly related to tissue oxygenation. Furthermore,when tissue oxygenation is a clinical concern, SvO₂ is less prone to error compared with cardiac output, where small measurement errors may lead to larger errors in interpreting adequacy of oxygen delivery. ScvO₂ should be measured from the tip of a central venous catheter placed close to, or within, the right atrium to reduce measurement error. Correct clinical interpretation of SvO₂, or its properly measured ScvO₂ surrogate, can be used to (1) estimate cardiac output using the Fick equation, (2) better understand whether a patient's oxygen delivery is adequate to meet their oxygen demands, (3) help guide clinical practice, particularly when resuscitating patients using validated early goal directed therapy treatment protocols, (4) understand and treat arterial hypoxemia, and (5) rapidly estimate shunt fraction (venous admixture).
Collapse
Affiliation(s)
- Keith R Walley
- Critical Care Research Laboratories, Heart and Lung Institute at St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
| |
Collapse
|
23
|
van Beest P, Wietasch G, Scheeren T, Spronk P, Kuiper M. Clinical review: use of venous oxygen saturations as a goal - a yet unfinished puzzle. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:232. [PMID: 22047813 PMCID: PMC3334733 DOI: 10.1186/cc10351] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Shock is defined as global tissue hypoxia secondary to an imbalance between systemic oxygen delivery and oxygen demand. Venous oxygen saturations represent this relationship between oxygen delivery and oxygen demand and can therefore be used as an additional parameter to detect an impaired cardiorespiratory reserve. Before appropriate use of venous oxygen saturations, however, one should be aware of the physiology. Although venous oxygen saturation has been the subject of research for many years, increasing interest arose especially in the past decade for its use as a therapeutic goal in critically ill patients and during the perioperative period. Also, there has been debate on differences between mixed and central venous oxygen saturation and their interchangeability. Both mixed and central venous oxygen saturation are clinically useful but both variables should be used with insightful knowledge and caution. In general, low values warn the clinician about cardiocirculatory or metabolic impairment and should urge further diagnostics and appropriate action, whereas normal or high values do not rule out persistent tissue hypoxia. The use of venous oxygen saturations seems especially useful in the early phase of disease or injury. Whether venous oxygen saturations should be measured continuously remains unclear. Especially, continuous measurement of central venous oxygen saturation as part of the treatment protocol has been shown a valuable strategy in the emergency department and in cardiac surgery. In clinical practice, venous oxygen saturations should always be used in combination with vital signs and other relevant endpoints.
Collapse
Affiliation(s)
- Paul van Beest
- Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen 9700 RB, the Netherlands.
| | | | | | | | | |
Collapse
|
24
|
Should We Monitor ScVO(2) in Critically Ill Patients? Cardiol Res Pract 2011; 2012:370697. [PMID: 21941671 PMCID: PMC3177360 DOI: 10.1155/2012/370697] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Revised: 07/08/2011] [Accepted: 07/25/2011] [Indexed: 01/20/2023] Open
Abstract
Hemodynamic monitoring has become a real challenge in the intensive care unit. As an integrative parameter for oxygen supply/demand, venous oxygen saturation (SvO2) provided by pulmonary artery catheterization is one of the most popular parameters to assess the adequacy of cardiac output. However, technical limitations and potential iatrogenic complications constitute important limits for a widespread use. Regular central venous catheters coupled with a fiberoptic lumen for central venous oxygen saturation (ScvO2) monitoring have been proposed as a surrogate for SvO2 monitoring. The purpose of the present article is to review the physiological backgrounds of circulation, the pathophysiology of circulatory failure and subsequent venous oxygen saturation alterations, and finally the merits and the limits of the use of ScvO2 in different clinical situations.
Collapse
|
25
|
Current world literature. Curr Opin Support Palliat Care 2011; 5:174-83. [PMID: 21521986 DOI: 10.1097/spc.0b013e3283473351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
26
|
van Beest PA, van Ingen J, Boerma EC, Holman ND, Groen H, Koopmans M, Spronk PE, Kuiper MA. No agreement of mixed venous and central venous saturation in sepsis, independent of sepsis origin. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R219. [PMID: 21114844 PMCID: PMC3219992 DOI: 10.1186/cc9348] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Revised: 04/20/2010] [Accepted: 11/29/2010] [Indexed: 02/08/2023]
Abstract
Introduction Controversy remains regarding the relationship between central venous saturation (ScvO2) and mixed venous saturation (SvO2) and their use and interchangeability in patients with sepsis or septic shock. We tested the hypothesis that ScvO2 does not reliably predict SvO2 in sepsis. Additionally we looked at the influence of the source (splanchnic or non-splanchnic) of sepsis on this relationship. Methods In this prospective observational two-center study we concurrently determined ScvO2 and SvO2 in a group of 53 patients with severe sepsis during the first 24 hours after admission to the intensive care units in 2 Dutch hospitals. We assessed correlation and agreement of ScvO2 and SvO2, including the difference, i.e. the gradient, between ScvO2 and SvO2 (ScvO2 - SvO2). Additionally, we compared the mean differences between ScvO2 and SvO2 of both splanchnic and non-splanchnic group. Results A total of 265 paired blood samples were obtained. ScvO2 overestimated SvO2 by less than 5% with wide limits of agreement. For changes in ScvO2 and SvO2 results were similar. The distribution of the (ScvO2 - SvO2) (< 0 or ≥ 0) was similar in survivors and nonsurvivors. The mean (ScvO2 - SvO2) in the splanchnic group was similar to the mean (ScvO2 - SvO2) in the non-splanchnic group (0.8 ± 3.9% vs. 2.5 ± 6.2%; P = 0.30). O2ER (P = 0.23) and its predictive value for outcome (P = 0.20) were similar in both groups. Conclusions ScvO2 does not reliably predict SvO2 in patients with severe sepsis. The trend of ScvO2 is not superior to the absolute value in this context. A positive difference (ScvO2 - SvO2) is not associated with improved outcome.
Collapse
Affiliation(s)
- Paul A van Beest
- Department of Anesthesiology, University Medical Center Groningen, Hanzeplein 1, Groningen, 9700 RB, The Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|