1
|
Lobo SM, Junior JMDS, Malbouisson LM. Improving perioperative care in low-resource settings with goal-directed therapy: a narrative review. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:744460. [PMID: 37648078 DOI: 10.1016/j.bjane.2023.08.004] [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: 04/17/2023] [Revised: 08/04/2023] [Accepted: 08/20/2023] [Indexed: 09/01/2023]
Abstract
Perioperative Goal-Directed Therapy (PGDT) has significantly showed to decrease complications and risk of death in high-risk patients according to numerous meta-analyses. The main goal of PGDT is to individualize the therapy with fluids, inotropes, and vasopressors, during and after surgery, according to patients' needs in order to prevent organic dysfunction development. In this opinion paper we aimed to focus a discussion on possible alternatives to invasive hemodynamic monitoring in low resource settings.
Collapse
Affiliation(s)
- Suzana Margareth Lobo
- Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP, Brazil.
| | - João Manoel da Silva Junior
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Luiz Marcelo Malbouisson
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| |
Collapse
|
2
|
Singh G, Pujara J, Trivedi V, Uday DD, Masaniya J, Babu MJ, Bhandari CD. Correlation of venous to arterial carbon dioxide partial pressure difference with other cardiac output indices in patients undergoing intracardiac repair for tetralogy of fallot. Ann Card Anaesth 2023; 26:171-176. [PMID: 37706382 PMCID: PMC10284487 DOI: 10.4103/aca.aca_53_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/15/2022] [Accepted: 06/25/2022] [Indexed: 09/15/2023] Open
Abstract
Background Clearance of tissue carbon dioxide by circulation is measured by venous to arterial carbon dioxide partial pressure difference (AVCO2) and is correlated with cardiac output (CO) in critically ill adult patients. This study aimed to correlate AVCO2 with other CO indices like arteriovenous oxygen saturation difference (AVO2), central venous oxygen saturation (ScVO2), and serum lactate in pediatric patients undergoing intracardiac repair (ICR) for tetralogy of Fallot (TOF). Methods We conducted a prospective observational study in 50 patients, of age 5 months to 5 years, undergoing ICR for TOF and analyzed AVO2, AVCO2, ScVO2, and lactate from arterial and venous blood gas pairs obtained at different time intervals from admission to pediatric intensive care unit (PICU) (T0), at 6 h (T1), 12 h (T2), 24 h (T3), and 48 h (T4) postoperatively. Bivariate correlations were analyzed using Pearson for parametric variables. Results Admission AVCO2 was not correlated with AVO2 (R2 = 0.166, P = 0.246), ScVO2 (R2 = -2.2, P = 0.124), and lactate (R2 = -0.07, P = 0.624). At T1, AVCO2 was correlated with AVO2 (R2 = 0.283, P = 0.0464) but not with ScVO2 (R2 = - 0.25, P = 0.079) and lactate (R2 = -0.07, P = 0.623). At T2, T3 and T4, AVCO2 was correlated with AVO2 (R2 = 0.338,0.440 & 0.318, P = 0.0162, 0.0013, and 0.024), ScVO2 (R2 = - 0.344, - 0.488, and -0.366; P = 0.0143, <0.0001, and 0.017), and lactate (R2 = 0.305, 0.467 and 0.607; P = 0.0314, 0.00062 and <0.0001). AVCO2 was negatively correlated with ScVO2. No correlation observed between admission AVCO2 and mechanical ventilation duration. Two nonsurvivors had higher value of admission AVCO2 compared to survivors. Conclusion AVCO2 is correlated with other CO surrogates like AVO2, ScVO2, and lactate in pediatric patients undergoing ICR for TOF.
Collapse
Affiliation(s)
- Guriqbal Singh
- Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmadabad, Gujarat, India
| | - Jigisha Pujara
- Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmadabad, Gujarat, India
| | - Visharad Trivedi
- Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmadabad, Gujarat, India
| | - Dhawalikar Deepti Uday
- Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmadabad, Gujarat, India
| | - Jyoti Masaniya
- Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmadabad, Gujarat, India
| | - Mittapalli Jeevan Babu
- Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmadabad, Gujarat, India
| | - Chanchal Daulal Bhandari
- Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmadabad, Gujarat, India
| |
Collapse
|
3
|
Mandel IA, Podoksenov YK, Mikheev SL, Suhodolo IV, Svirko YS, Shipulin VM, Ivanova AV, Yavorovskiy AG, Yaroshetskiy AI. Endothelial Function and Hypoxic–Hyperoxic Preconditioning in Coronary Surgery with a Cardiopulmonary Bypass: Randomized Clinical Trial. Biomedicines 2023; 11:biomedicines11041044. [PMID: 37189663 DOI: 10.3390/biomedicines11041044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/17/2023] [Accepted: 03/23/2023] [Indexed: 03/31/2023] Open
Abstract
A hypoxic–hyperoxic preconditioning (HHP) may be associated with cardioprotection by reducing endothelial damage and a beneficial effect on postoperative outcome in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Patients (n = 120) were randomly assigned to an HHP and a control group. A safe, inhaled oxygen fraction for the hypoxic preconditioning phase (10–14% oxygen for 10 min) was determined by measuring the anaerobic threshold. At the hyperoxic phase, a 75–80% oxygen fraction was used for 30 min. The cumulative frequency of postoperative complications was 14 (23.3%) in the HHP vs. 23 (41.1%), p = 0.041. The nitrate decreased after surgery by up to 20% in the HHP group and up to 38% in the control group. Endothelin-1 and nitric oxide metabolites were stable in HHP but remained low for more than 24 h in the control group. The endothelial damage markers appeared to be predictors of postoperative complications. The HHP with individual parameters based on the anaerobic threshold is a safe procedure, and it can reduce the frequency of postoperative complications. The endothelial damage markers appeared to be predictors of postoperative complications.
Collapse
|
4
|
Lundin A, Annborn M, Borgquist O, Düring J, Undén J, Rylander C. Veno-arterial CO 2 difference and lactate for prediction of early mortality after cardiac arrest. Acta Anaesthesiol Scand 2023; 67:655-662. [PMID: 36867177 DOI: 10.1111/aas.14224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 03/04/2023]
Abstract
Patients admitted to intensive care after cardiac arrest are at risk of circulatory shock and early mortality due to cardiovascular failure. The aim of this study was to evaluate the ability of the veno-arterial pCO2 difference (∆pCO2 ; central venous CO2 - arterial CO2 ) and lactate to predict early mortality in postcardiac arrest patients. This was a pre-planned prospective observational sub-study of the target temperature management 2 trial. The sub-study patients were included at five Swedish sites. Repeated measurements of ∆pCO2 and lactate were conducted at 4, 8, 12, 16, 24, 48, and 72 h after randomization. We assessed the association between each marker and 96-h mortality and their prognostic value for 96-h mortality. One hundred sixty-three patients were included in the analysis. Mortality at 96 h was 17%. During the initial 24 h, there was no difference in ∆pCO2 levels between 96-h survivors and non-survivors. ∆pCO2 measured at 4 h was associated with an increased risk of death within 96 h (adjusted odds ratio: 1.15; 95% confidence interval [CI]: 1.02-1.29; p = .018). Lactate levels were associated with poor outcome over multiple measurements. The area under the receiving operating curve to predict death within 96 h was 0.59 (95% CI: 0.48-0.74) and 0.82 (95% CI: 0.72-0.92) for ∆pCO2 and lactate, respectively. Our results do not support the use of ∆pCO2 to identify patients with early mortality in the postresuscitation phase. In contrast, non-survivors demonstrated higher lactate levels in the initial phase and lactate identified patients with early mortality with moderate accuracy.
Collapse
Affiliation(s)
- Andreas Lundin
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Martin Annborn
- Anesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University, Helsingborg Hospital, Helsingborg, Sweden
| | - Ola Borgquist
- Anaesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Department of Cardiothoracic Surgery, Anaesthesia and Intensive Care, Skane University Hospital, Lund, Sweden
| | - Joachim Düring
- Anaesthesia and Intensive Care, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Malmö, Sweden
| | - Johan Undén
- Operation and Intensive Care, Department of Clinical Sciences Lund, Lund University, Hallands Hospital, Halmstad, Sweden
| | - Christian Rylander
- Anaesthesia and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| |
Collapse
|
5
|
Wang J, Weng L, Xu J, Du B. Blood gas analysis as a surrogate for microhemodynamic monitoring in sepsis. World J Emerg Med 2023; 14:421-427. [PMID: 37969221 PMCID: PMC10632753 DOI: 10.5847/wjem.j.1920-8642.2023.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 05/14/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Emergency patients with sepsis or septic shock are at high risk of death. Despite increasing attention to microhemodynamics, the clinical use of advanced microcirculatory assessment is limited due to its shortcomings. Since blood gas analysis is a widely used technique reflecting global oxygen supply and consumption, it may serve as a surrogate for microcirculation monitoring in septic treatment. METHODS We performed a search using PubMed, Web of Science, and Google scholar. The studies and reviews that were most relevant to septic microcirculatory dysfunctions and blood gas parameters were identified and included. RESULTS Based on the pathophysiology of oxygen metabolism, the included articles provided a general overview of employing blood gas analysis and its derived set of indicators for microhemodynamic monitoring in septic care. Notwithstanding flaws, several parameters are linked to changes in the microcirculation. A comprehensive interpretation of blood gas parameters can be used in order to achieve hemodynamic optimization in septic patients. CONCLUSION Blood gas analysis in combination with clinical performance is a reliable alternative for microcirculatory assessments. A deep understanding of oxygen metabolism in septic settings may help emergency physicians to better use blood gas analysis in the evaluation and treatment of sepsis and septic shock.
Collapse
Affiliation(s)
- Jingyi Wang
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
- 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
| | - Jun Xu
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, 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
|
6
|
Akca HS, Akca H, Yapici N. Effect of delta carbon dioxide and lactate on prognosis in patients undergoing open-heart surgery. Niger J Clin Pract 2022; 25:1398-1404. [DOI: 10.4103/njcp.njcp_1328_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
7
|
Zhou XF, Yu RG, Chen Q, Xue YM, Chen H. Performance of Lactate and CO 2-Derived Parameters in Predicting Major Postoperative Complications After Cardiac Surgery With Cardiopulmonary Bypass: Protocol of a Diagnostic Accuracy Study. Front Cardiovasc Med 2021; 8:724713. [PMID: 34660725 PMCID: PMC8517114 DOI: 10.3389/fcvm.2021.724713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/08/2021] [Indexed: 12/12/2022] Open
Abstract
Background: CO2-derived parameters are increasingly used to identify either low-flow status or anaerobic metabolism in shock resuscitation. However, the performance of CO2-derived parameters in cardiac surgical patients is poorly understood. This study aims to compare the performance of lactate and CO2-derived parameters in predicting major postoperative complications after cardiac surgery with cardiopulmonary bypass. Methods: This is a prospective, single-center, diagnostic accuracy study. All patients who receive elective cardiac surgery involving cardiopulmonary bypass will be screened for study eligibility. Blood samples will be taken for the calculation of CO2-derived parameters, including the venous-arterial difference in CO2 partial pressure (PCO2 gap), venous-arterial difference in CO2 content to arterial-venous O2 content ratio (Cv-aCO2/Ca-vO2), and venous-arterial difference in CO2 partial pressure to arterial-venous O2 content ratio (Pv-aCO2/Ca-vO2) at ICU admission, and 3, 6, and 12 h later. Baseline, perioperative data will be collected daily for 7 days; patients will be followed up for 28 days to collect outcome data. The primary endpoint is the occurrence of major postoperative complications. Receiver-operating characteristics (ROC) curve analysis will be carried out to assess the predictive performance of lactate and CO2-derived parameters. The performance of the ROC curves will be compared. Discussion: The performance of lactate and CO2-derived parameters in predicting major postoperative complications will be investigated in the non-sepsis population, which has not been extensively investigated. Our study will compare the two surrogates of respiratory quotient directly, which is an important strength. Trial Registration: ChiCTR, ChiCTR2000029365. Registered January 26th, 2020, http://www.chictr.org.cn/showproj.aspx?proj=48744.
Collapse
Affiliation(s)
- Xiao-Fen Zhou
- Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Rong-Guo Yu
- Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Qian Chen
- Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Yi-Min Xue
- Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Han Chen
- Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| |
Collapse
|
8
|
Pierrakos C, De Bels D, Nguyen T, Velissaris D, Attou R, Devriendt J, Honore PM, Taccone FS, De Backer D. Changes in central venous-to-arterial carbon dioxide tension induced by fluid bolus in critically ill patients. PLoS One 2021; 16:e0257314. [PMID: 34506589 PMCID: PMC8432848 DOI: 10.1371/journal.pone.0257314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/28/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In this prospective observational study, we evaluated the effects of fluid bolus (FB) on venous-to-arterial carbon dioxide tension (PvaCO2) in 42 adult critically ill patients with pre-infusion PvaCO2 > 6 mmHg. RESULTS FB caused a decrease in PvaCO2, from 8.7 [7.6-10.9] mmHg to 6.9 [5.8-8.6] mmHg (p < 0.01). PvaCO2 decreased independently of pre-infusion cardiac index and PvaCO2 changes during FB were not correlated with changes in central venous oxygen saturation (ScvO2) whatever pre-infusion CI. Pre-infusion levels of PvaCO2 were inversely correlated with decreases in PvaCO2 during FB and a pre-infusion PvaCO2 value < 7.7 mmHg could exclude a decrease in PvaCO2 during FB (AUC: 0.79, 95%CI 0.64-0.93; Sensitivity, 91%; Specificity, 55%; p < 0.01). CONCLUSIONS Fluid bolus decreased abnormal PvaCO2 levels independently of pre-infusion CI. Low baseline PvaCO2 values suggest that a positive response to FB is unlikely.
Collapse
Affiliation(s)
- Charalampos Pierrakos
- Intensive Care Department, Brugmann University Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
- * E-mail:
| | - David De Bels
- Intensive Care Department, Brugmann University Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Thomas Nguyen
- Intensive Care Department, Brugmann University Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
| | | | - Rachid Attou
- Intensive Care Department, Brugmann University Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Jacques Devriendt
- Intensive Care Department, Brugmann University Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Patrick M. Honore
- Intensive Care Department, Brugmann University Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Fabio Silvio Taccone
- Intensive Care Department, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Bruxelles, Belgium
| |
Collapse
|
9
|
Central venous-to-arterial CO 2 difference is a poor tool to predict adverse outcomes after cardiac surgery: a retrospective study. Can J Anaesth 2021; 68:467-476. [PMID: 33403551 PMCID: PMC7785330 DOI: 10.1007/s12630-020-01881-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/26/2020] [Indexed: 12/29/2022] Open
Abstract
PURPOSE The venous-to-arterial carbon dioxide partial pressure difference (CO2 gap) has been reported to be a sensitive indicator of cardiac output adequacy. We aimed to assess whether the CO2 gap can predict postoperative adverse outcomes after cardiac surgery. METHODS A retrospective study was conducted of 5,151 patients from our departmental database who underwent cardiac surgery from 1 January 2008 to 31 December 2018. Lactate level (mmol·L-1), central venous oxygen saturation (ScVO2) (%), and the venous-to-arterial carbon dioxide difference (CO2 gap) were measured at intensive care unit (ICU) admission and on days 1 and 2 after cardiac surgery. The following postoperative adverse outcomes were collected: ICU mortality, hemopericardium or tamponade, resuscitated cardiac arrest, acute kidney injury, major bleeding, acute hepatic failure, mesenteric ischemia, and pneumonia. The primary outcome was the presence of at least one postoperative adverse outcome. Logistic regression was used to assess the association between ScVO2, lactate, and the CO2 gap with adverse outcomes. Their diagnostic performance was compared using a receiver operating characteristic (ROC) curve. RESULTS There were 1,933 patients (38%) with an adverse outcome. Cardiopulmonary bypass (CPB) parameters were similar between groups. The CO2 gap was slightly higher for the "adverse outcomes" group than for the "no adverse outcomes" group. Arterial lactate at admission, day 1, and day 2 was also slightly higher in patients with adverse outcomes. Central venous oxygen saturation was not significantly different between patients with and without adverse outcomes. The area under the ROC curve to predict outcomes after CPB for the CO2 gap at admission, day 1, and day 2 were 0.52, 0.55, and 0.53, respectively. CONCLUSION After cardiac surgery with CPB, the CO2 gap at ICU admission, day 1, and day 2 was associated with postoperative adverse outcomes but showed poor diagnostic performance.
Collapse
|
10
|
Lundin A, Dell'anna AM, Peluso L, Nobile L, Annoni F, Creteur J, Rylander C, Taccone FS. Veno-arterial CO 2 difference and respiratory quotient after cardiac arrest: An observational cohort study. J Crit Care 2020; 62:131-137. [PMID: 33360013 DOI: 10.1016/j.jcrc.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 11/15/2020] [Accepted: 12/02/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE To characterize venous-arterial CO2 difference (ΔpCO2) and the respiratory quotient (RQ) in post cardiac arrest patients and evaluate the association between these parameters and patient outcome. MATERIALS AND METHODS Data were obtained retrospectively from post cardiac arrest patients admitted between 2007 and 2016 to a medical intensive care unit. Comatose, adult patients in whom arterial and venous blood gas analyses were concomitantly performed in the first 24 h were included. Patients were grouped according to the time-point of sampling; 0-6, 6-12 and 12-24 h after admission. RESULTS 308 patients were included; 174 (56%) died before ICU discharge and 212 (69%) had an unfavorable neurologic outcome. RQ was associated with ICU mortality (OR:1.09 (95%CI: 1.04-1.14; p < 0.01)), although not with neurological outcome. ΔpCO2 was negatively associated with both ICU mortality (OR: 0.92 (95%CI: 0.86-0.99; p = 0.02)) and poor neurologic outcome (adjusted OR: 0.93 (95%CI: 0.87-0.99; p = 0.02)). ΔpCO2 predicted an elevated RQ; a ΔpCO2 above 8.5 mmHg identified a high RQ with reasonable sensitivity and specificity. CONCLUSIONS RQ was associated with ICU mortality and ΔpCO2 identified elevated RQ in the early phase after cardiac arrest. However, ΔpCO2 were negatively associated with both ICU mortality and neurologic outcome.
Collapse
Affiliation(s)
- Andreas Lundin
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 423 45 Gothenburg, Sweden.
| | - Antonio Maria Dell'anna
- Department of Intensive Care, Erasme Hospital, Université́ Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Erasme Hospital, Université́ Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Leda Nobile
- Department of Intensive Care, Erasme Hospital, Université́ Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Filippo Annoni
- Department of Intensive Care, Erasme Hospital, Université́ Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université́ Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Christian Rylander
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 423 45 Gothenburg, Sweden
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université́ Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| |
Collapse
|
11
|
Flick M, Duranteau J, Scheeren TW, Saugel B. Monitoring of the Sublingual Microcirculation During Cardiac Surgery: Current Knowledge and Future Directions. J Cardiothorac Vasc Anesth 2020; 34:2754-2765. [DOI: 10.1053/j.jvca.2019.10.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 09/29/2019] [Accepted: 10/21/2019] [Indexed: 11/11/2022]
|
12
|
The relationship between inotropic support therapy and central partial pressure of venous-arterial carbon dioxide after cardiopulmonary bypass. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 27:165-172. [PMID: 32082848 DOI: 10.5606/tgkdc.dergisi.2019.16851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 01/20/2019] [Indexed: 11/21/2022]
Abstract
Background This study aims to investigate the effects of partial pressure of venous-arterial carbon dioxide changes in the early period after cardiopulmonary bypass in patients who did or did not receive inotropic support therapy and the effect of these changes on tissue perfusion. Methods A total of 100 consecutive patients (70 males, 30 females; mean age 61.8±2.3 years; range, 20 to 75 years) who underwent open heart surgery were divided into two groups as those who did not receive any inotropic agent (group 1, n=50) and those who received at least one inotropic agent (group 2, n=50) during the early postoperative period. Heart rate, blood oxygen saturation level, mean arterial pressure, central venous pressure and urine volume, lactate and base excess levels were recorded during the postoperative first 24 hours. At the same timeframe, partial pressure of venous-arterial carbon dioxide level was calculated from central venous and peripheral blood samples. Results In both groups, partial pressure of venous-arterial carbon dioxide were significantly higher in the postoperative fourth hour compared with basal values. This significant difference continued for the postoperative first 24 hours. Partial pressure of venous-arterial carbon dioxide in group 2 was significantly higher at the 12th-hour measurement (p=0.002). Lactate levels at zeroth and eighth hours were significantly higher in group 2 (p=0.012 and p=0.017, respectively). Fourthhour urine excretion volumes were significantly lower in group 1 (p=0.010). Mean arterial pressure at zeroth, 12th and 20th hours was significantly higher in group 2 (p=0.001, p=0.016, and p=0.027, respectively). At the eighth-hour measurement, a positive weak relationship was detected between partial pressure of venousarterial carbon dioxide and lactate levels (r=0.253 and p=0.033). Conclusion This study demonstrated that partial pressure of venous-arterial carbon dioxide increased in the first few hours and remained to be high for 24 hours after cardiopulmonary bypass independently of the use of inotropic support. However, in the postoperative period, even after lactate and base excess levels return to baseline values, partial pressure of venous-arterial carbon dioxide may continue to remain at high values, which may indicate impaired perfusion in some tissues.
Collapse
|
13
|
Central Venous-Arterial CO2 Difference in Cardiac Surgery Patients-A Parameter in Relationship to Cardiac Output and Altered Microcirculatory Blood Flow. Shock 2020; 54:273-274. [PMID: 32080061 DOI: 10.1097/shk.0000000000001525] [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]
|
14
|
Mahendran S, Nguyen J, Butler E, Aneman A. Prospective, observational study of carbon dioxide gaps and free energy change and their association with fluid therapy following cardiac surgery. Acta Anaesthesiol Scand 2020; 64:202-210. [PMID: 31609473 DOI: 10.1111/aas.13480] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 08/15/2019] [Accepted: 09/12/2019] [Indexed: 12/30/2022]
Abstract
Background Venoarterial carbon dioxide pressure (pv-a CO2 ) and content (Cv-a CO2 ) differences, including the ratio to arteriovenous oxygen content difference (Ca-v O2 ), and free energy changes (-∆∆Ga-v ) may reflect tissue hypoperfusion. The associations with changes in cardiac output (CO) or oxygen consumption (VO2 ) following fluid bolus administration were investigated. Methods Single-centre, observational study of 89 adult post-operative cardiac surgical patients admitted to ICU. The pv-a CO2 , Cv-a CO2 and their ratios to Ca-v O2 as well as the -∆∆Ga-v were determined before and after a 250-500 mL fluid bolus using arterial, central venous and mixed venous blood gas analyses. Responses associated with changes ≥ or <15% in CO or oxygen consumption (VO2 ) were compared. Results In 234 boluses, the mixed venous to arterial pv-a CO2 and its ratio to Ca-v O2 were independently associated with an increase in CO; odds ratio 1.3 (95% CI 1.1-1.5) and 1.7 (95% CI 1.5-1.9) respectively, P < .001) and VO2 ; odds ratio 2.1 (95% CI 1.3-3.1), P < .001 for Ca-v O2 . No measures of pv-a CO2 , Cv-a CO2 or related ratios to the Ca-v O2 were associated with an increase in CO ≥15% following a single volume bolus. The mixed venous and central venous Cv-a CO2 to Ca-v O2 ratios were different for the first bolus episode only; mean differences 0.81 (95% CI 0.13-1.5), P = .02 and 0.44 (95% CI 0.06-0.82), P = .02, respectively, for increased VO2 ≥ 15%. The -∆∆Ga-v did not change. Conclusion The venoarterial carbon dioxide gradients and related calculations to assess the adequacy of tissue perfusion before a fluid bolus were not associated with subsequent increases in CO of oxygen consumption. Editorial Comment In some shock conditions, regional tissue hypoperfusion can be obvious and arterio-venous differences for CO2 or O2 may reflect this. This is not always the case; sometimes there are A-V differences or even a high lactate level without any obvious regional tissue hypoperfusion. Fluid therapy is a cornerstone in shock resuscitation treatment, but determining optimal fluid therapy is challenging, particularly as fluid overload may be detrimental. Fluid challenges are used as an "ex juvantebus" method to dose fluid therapy, but it is not clear if a positive response reflects a state of hypoperfusion or the existence of a cardiac reserve. Still, a better understanding on how to target and guide fluid therapy is welcome, and studies digging into the problem are needed. Here, invasively monitored post-operative cardiac surgery patients are assessed as a model to investigate if carbon dioxide gaps and free energy charge may be useful in detecting possible tissue hypoperfusion.
Collapse
Affiliation(s)
- Sajeev Mahendran
- Faculty of Medicine University of New South Wales Sydney Australia
| | - John Nguyen
- Faculty of Medicine University of New South Wales Sydney Australia
| | - Ethan Butler
- Faculty of Medicine University of New South Wales Sydney Australia
| | - Anders Aneman
- Intensive Care Unit Liverpool Hospital South Western Sydney Local Health District Sydney Australia
- South Western Sydney Clinical School University of New South Wales Sydney Australia
- Faculty of Medicine and Health Sciences Macquarie University Sydney Australia
| |
Collapse
|
15
|
Central venous-to-arterial PCO2 difference, arteriovenous oxygen content and outcome after adult cardiac surgery with cardiopulmonary bypass: A prospective observational study. Eur J Anaesthesiol 2019; 36:279-289. [PMID: 30664011 DOI: 10.1097/eja.0000000000000949] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Rapid identification and treatment of tissue hypoxia reaching anaerobiosis (dysoxia) may reduce organ failure and the occurrence of major postoperative complications (MPC) after cardiac surgery. The predictive ability of PCO2-based dysoxia biomarkers, central venous-to-arterial PCO2 difference (ΔPCO2) and ΔPCO2 to arteriovenous oxygen content difference ratio, is poorly studied in this setting. OBJECTIVES We evaluated the ability of PCO2-based tissue dysoxia biomarkers, blood lactate concentration and central venous oxygen saturation measured 2 h after admission to the ICU as predictors of MPC. DESIGN A prospective, observational cohort study. SETTING Single-centre, academic hospital cardiovascular ICU. PATIENTS We included adult patients undergoing cardiac surgery with cardiopulmonary bypass and measured dysoxia biomarkers at ICU admission, and after 2, 6 and 24 h. MAIN OUTCOME MEASURES The primary endpoint was MPC, a composite of cardiac and noncardiac MPC evaluated in the 48 h following surgery. After univariate analysis of MPC covariates including dysoxia biomarkers measured at 2 h, multivariate logistic regression analyses were performed to identify the association of these biomarkers with MPC for confounders. Areas under the receiver operating characteristic curves were determined for biomarkers which remained independently associated with MPC. RESULTS MPC occurred in 56.5% of the 308 patients analysed. ΔPCO2, blood lactate concentration and central venous oxygen saturation measured at 2 h, but not ΔPCO2 to arteriovenous oxygen content difference ratio, were significantly associated with MPC. However, only ΔPCO2 was independently associated with MPC after multivariate analysis. The areas under the receiver operating characteristic curves of ΔPCO2 measured at 2 h for MPC prediction was 0.64 (95% CI 0.57 to 0.70, P < 0.001). CONCLUSION After cardiac surgery with cardiopulmonary bypass, ΔPCO2 measured 2 h after ICU admission was the only dysoxia biomarker independently associated with MPC, but with limited performance. TRIAL REGISTRATION ClinicalTrials.gov, NCT03107572.
Collapse
|
16
|
Improving the prognostic value of ∆PCO 2 following cardiac surgery: a prospective pilot study. J Clin Monit Comput 2019; 34:515-523. [PMID: 31292833 PMCID: PMC7223397 DOI: 10.1007/s10877-019-00352-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 07/01/2019] [Indexed: 11/21/2022]
Abstract
Conflicting results have been published on prognostic significance of central venous to arterial PCO2 difference (∆PCO2) after cardiac surgery. We compared the prognostic value of ∆PCO2 on intensive care unit (ICU) admission to an original algorithm combining ∆PCO2, ERO2 and lactate to identify different risk profiles. Additionally, we described the evolution of ∆PCO2 and its correlations with ERO2 and lactate during the first postoperative day (POD1). In this monocentre, prospective, and pilot study, 25 patients undergoing conventional cardiac surgery were included. Central venous and arterial blood gases were collected on ICU admission and at 6, 12 and 24 h postoperatively. High ∆PCO2 (≥ 6 mmHg) on ICU admission was found to be very frequent (64% of patients). Correlations between ∆PCO2 and ERO2 or lactate for POD1 values and variations were weak or non-existent. On ICU admission, a high ∆PCO2 did not predict a prolonged ICU length of stay (LOS). Conversely, a significant increase in both ICU and hospital LOS was observed in high-risk patients identified by the algorithm: 3.5 (3.0–6.3) days versus 7.0 (6.0–8.0) days (p = 0.01) and 12.0 (8.0–15.0) versus 8.0 (8.0–9.0) days (p < 0.01), respectively. An algorithm incorporating ICU admission values of ∆PCO2, ERO2 and lactate defined a high-risk profile that predicted prolonged ICU and hospital stays better than ∆PCO2 alone.
Collapse
|
17
|
Huette P, Ellouze O, Abou-Arab O, Guinot PG. Venous-to-arterial pCO 2 difference in high-risk surgical patients. J Thorac Dis 2019; 11:S1551-S1557. [PMID: 31388460 DOI: 10.21037/jtd.2019.01.109] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Alteration of tissue perfusion is a main contributor to organ dysfunction in high-risk surgical patients. The difference between venous carbon dioxide and arterial carbon dioxide pressure (pCO2 gap) has been described as a parameter reflecting tissue hypoperfusion in critically ill patients who are insufficiently resuscitated. The pCO2 gap/CavO2 ratio has also been described as an indicator of the respiratory quotient, thus the relationship between DO2 and VO2. Most of the knowledge about the pCO2 gap and the pCO2 gap/CavO2 ratio has come from studies in the literature on animal models or intensive care unit (ICU) patients. To date, publications pertaining to the operative setting are sparse. In the present review, we will first discuss the physiological background of the pCO2 gap and CO2-O2 derived parameters used in the operating room. Few studies have focused on the clinical relevance of the pCO2 gap in high-risk non-cardiac surgical patients. Prospective observational studies with a small sample size and retrospective studies have shown that the pCO2 gap may be a useful complementary tool to identify patients who remain insufficiently optimized hemodynamically. In a few studies, a high pCO2 gap was associated with postoperative complications following non-cardiac high-risk surgery. Results of observational studies conducted in patients undergoing cardiac surgery are contradictory. We focused on the divergence between non-cardiac surgery, cardiac surgery, and septic critically ill patients. When analyzing the literature, we can find some explanations for the discrepancies in the published results between cardiac and non-cardiac surgery. Finally, we will discuss the clinical utility of the pCO2 gap in high-risk surgical patients.
Collapse
Affiliation(s)
- Pierre Huette
- Anaesthesiology and Critical Care Department, Cardiothoracic ICU, Amiens University Hospital, Amiens, France
| | - Omar Ellouze
- Anaesthesiology and Critical Care Department, Cardiovascular ICU, Dijon University Hospital, Dijon, France
| | - Osama Abou-Arab
- Anaesthesiology and Critical Care Department, Cardiothoracic ICU, Amiens University Hospital, Amiens, France
| | - Pierre-Grégoire Guinot
- Anaesthesiology and Critical Care Department, Cardiovascular ICU, Dijon University Hospital, Dijon, France
| |
Collapse
|
18
|
Zante B, Reichenspurner H, Kubik M, Schefold JC, Kluge S. Increased admission central venous-arterial CO 2 difference predicts ICU-mortality in adult cardiac surgery patients. Heart Lung 2019; 48:421-427. [PMID: 31200923 DOI: 10.1016/j.hrtlng.2019.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 05/26/2019] [Accepted: 05/29/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Invasive procedures such as cardiac surgery are associated with perioperative dysfunction of macrocirculation and/or microcirculation and organ failures. Maintenance or resuscitation of an adequate macrocirculation and/or microcirculation is thus crucial in patients after cardiac surgery. We investigated the prognostic power of early central venous-arterial carbon dioxide pressure difference (delta-pCO2) after cardiac surgery. METHODS Retrospective analysis of data from 1,019 cardiac surgery patients treated in the ICU of a tertiary medical care academic center. Clinical outcomes and laboratory measures including metabolic indices and calculated delta-pCO2 were assessed. Receiver operating characteristic (ROC) curves were generated and sensitivity / specificity analysis was performed. Univariate and multivariate regression models were analyzed. RESULTS The area under the ROC curve for delta-pCO2 to predict ICU mortality was 0.72 (sensitivity 65% / specificity 76%) with an optimal delta-pCO2 cut-off value of 8.6 mmHg. In multivariate regression, delta-pCO2 was associated with increased ICU mortality (HR 3.72, 95%-CI 1.3-10.66, p = 0.02). After adjustment for typical confounders, delta-pCO2 remained as independent predictor of ICU mortality after cardiac surgery. CONCLUSIONS In a retrospective data analysis in a large sample of adult post cardiac surgery patients treated in the ICU, we observed that admission central venous-arterial delta-pCO2 independently predicts ICU mortality. Delta-pCO2 might thus contribute risk stratification in ICU patients after cardiac surgery.
Collapse
Affiliation(s)
- Bjoern Zante
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany; Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany
| | - Mathias Kubik
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany; Department of Intensive Care Medicine, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Kluge
- Department of Intensive Care Medicine, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| |
Collapse
|
19
|
Valizad Hassanloei M, Mahoori A, Karami N, Sina V. The Relationship between Arterial and Central Venous Blood Gases Values in Patients Undergoing Mechanical Ventilation after Cardiac Surgery. Anesth Pain Med 2018; 8:e74243. [PMID: 30214888 PMCID: PMC6119237 DOI: 10.5812/aapm.74243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/08/2018] [Accepted: 06/11/2018] [Indexed: 11/19/2022] Open
Abstract
Background The most straightforward method of ascertaining arterial PO2, PCO2, and other components of blood gas is to measure them directly from a blood sample. In situations in which arterial puncture cannot be achieved or may be technically difficult, the venous blood sample can be used. Methods In a prospective analytical study, 80 patients undergoing mechanical ventilation after open-heart surgery in the intensive care unit were evaluated. Simultaneous, matched arterial and central venous blood gas samples were taken from radial artery line and central vein, respectively, when the ABG (arterial blood gases) assessment was needed. Arterial and central venous blood samples were analyzed and data were expressed as mean and ± SD. Results The Pearson correlation coefficient for pH, PCO2, HCO3, and SatO2 was 0.898, 0.940, 0.840, and 0.567, respectively. There was a significant correlation between arterial and central venous values of pH, PCO2, and HCO3 (P < 0.0001). The mean difference between arterial and central venous PCO2 was -2.44 ± 2.6 mmHg, and the mean venous pH value was only 0.021 ± 0.037 units lower than the mean arterial value. In addition, the calculated mean bicarbonate concentration in venous blood was only about 0.06 ± 1.5 mEq.L higher than the mean arterial value. Conclusions The central venous PCO2, pH, and HCO3 measured during mechanical ventilation in the intensive care unit approximate arterial values closely enough to permit the estimation of the adequacy of ventilation and acid-base status. The central venous Sat O2 does not reliably parallel the arterial Sat O2. In conclusion, venous blood sampling can potentially reduce the requirement for ABG sampling in special situations.
Collapse
Affiliation(s)
| | - Alireza Mahoori
- Anesthesiology Department of Urmia University of Medical Sciences, Urmia, Iran
| | - Nazli Karami
- Anesthesiology Department of Urmia University of Medical Sciences, Urmia, Iran
- Corresponding author: Nazli Karami, Imam Khomeini Teaching Hospital, Ershad St. Urmia, Iran. Tel: +98-9122179344, Fax: +98-44 33468967, E-mail:
| | - Venus Sina
- Anesthesiology Department of Urmia University of Medical Sciences, Urmia, Iran
| |
Collapse
|
20
|
The Relationship between Arterial and Central Venous Blood Gases Values in Patients Undergoing Mechanical Ventilation after Cardiac Surgery. Anesth Pain Med 2018. [DOI: 10.5812/aapm.10.5812/aapm.74243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
21
|
Estimating Arterial Partial Pressure of Carbon Dioxide in Ventilated Patients: How Valid Are Surrogate Measures? Ann Am Thorac Soc 2018; 14:1005-1014. [PMID: 28570147 DOI: 10.1513/annalsats.201701-034fr] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The arterial partial pressure of carbon dioxide (PaCO2) is an important parameter in critically ill, mechanically ventilated patients. To limit invasive procedures or for more continuous monitoring of PaCO2, clinicians often rely on venous blood gases, capnography, or transcutaneous monitoring. Each of these has advantages and limitations. Central venous Pco2 allows accurate estimation of PaCO2, differing from it by an amount described by the Fick principle. As long as cardiac output is relatively normal, central venous Pco2 exceeds the arterial value by approximately 4 mm Hg. In contrast, peripheral venous Pco2 is a poor predictor of PaCO2, and we do not recommend using peripheral venous Pco2 in this manner. Capnography offers measurement of the end-tidal Pco2 (PetCO2), a value that is close to PaCO2 when the lung is healthy. It has the advantage of being noninvasive and continuously available. In mechanically ventilated patients with lung disease, however, PetCO2 often differs from PaCO2, sometimes by a large degree, often seriously underestimating the arterial value. Dependence of PetCO2 on alveolar dead space and ventilator expiratory time limits its value to predict PaCO2. When lung function or ventilator settings change, PetCO2 and PaCO2 can vary in different directions, producing further uncertainty. Transcutaneous Pco2 measurement has become practical and reliable. It is promising for judging steady state values for PaCO2 unless there is overt vasoconstriction of the skin. Moreover, it can be useful in conditions where capnography fails (high-frequency ventilation) or where arterial blood gas analysis is burdensome (clinic or home management of mechanical ventilation).
Collapse
|
22
|
Elevated Central Venous to Arterial CO2 Difference Is Not Associated With Poor Clinical Outcomes After Cardiac Surgery With Cardiopulmonary Bypass in Children. Pediatr Crit Care Med 2017. [PMID: 28622280 DOI: 10.1097/pcc.0000000000001229] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To investigate whether elevated central venous to arterial CO2 difference is associated with delayed extubation and prolonged ICU stay in children after cardiac surgery with cardiopulmonary bypass. DESIGN Retrospective review of medical records. SETTING PICU in a tertiary children's hospital. PATIENTS Pediatric patients younger than 18 years old who underwent cardiac surgery with cardiopulmonary bypass between January 2014 and December 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In total, 114 patients were included in this study. On ICU admission, blood samples were obtained simultaneously from an arterial line and a central venous line. There were no strong correlations between central venous to arterial CO2 difference (median, 11.1 [8.4-13] mm Hg) and other commonly used variables for the assessment of oxygen delivery including arteriovenous oxyhemoglobin saturation difference (R = 0.16) and blood lactate concentration (R = 0.02). When the patients were divided into two groups, based on the CO2 difference, the high group (difference ≥ 6 mm Hg; n = 103 [90%]) and the low group (difference < 6 mm Hg; n = 11 [10%]) showed no difference in the time to extubation (6 vs 5 hr, respectively; p = 0.80) or in the time to discharge from ICU (4 vs 5 d, respectively; p = 0.49). There was no mortality within 30 days of surgery. CONCLUSIONS Elevation of central venous to arterial CO2 difference on ICU admission in children after cardiac surgery with cardiopulmonary bypass does not appear to be associated with delayed extubation or prolonged ICU stay.
Collapse
|
23
|
Rogers C, Stoica S, Ellis L, Stokes E, Wordsworth S, Dabner L, Clayton G, Downes R, Nicholson E, Bennett S, Angelini G, Reeves B, Murphy G. Randomized trial of near-infrared spectroscopy for personalized optimization of cerebral tissue oxygenation during cardiac surgery. Br J Anaesth 2017; 119:384-393. [DOI: 10.1093/bja/aex182] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
24
|
Murphy GJ, Mumford AD, Rogers CA, Wordsworth S, Stokes EA, Verheyden V, Kumar T, Harris J, Clayton G, Ellis L, Plummer Z, Dott W, Serraino F, Wozniak M, Morris T, Nath M, Sterne JA, Angelini GD, Reeves BC. Diagnostic and therapeutic medical devices for safer blood management in cardiac surgery: systematic reviews, observational studies and randomised controlled trials. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BackgroundAnaemia, coagulopathic bleeding and transfusion are strongly associated with organ failure, sepsis and death following cardiac surgery.ObjectiveTo evaluate the clinical effectiveness and cost-effectiveness of medical devices used as diagnostic and therapeutic tools for the management of anaemia and bleeding in cardiac surgery.Methods and resultsWorkstream 1 – in the COagulation and Platelet laboratory Testing in Cardiac surgery (COPTIC) study we demonstrated that risk assessment using baseline clinical factors predicted bleeding with a high degree of accuracy. The results from point-of-care (POC) platelet aggregometry or viscoelastometry tests or an expanded range of laboratory reference tests for coagulopathy did not improve predictive accuracy beyond that achieved with the clinical risk score alone. The routine use of POC tests was not cost-effective. A systematic review concluded that POC-based algorithms are not clinically effective. We developed two new clinical risk prediction scores for transfusion and bleeding that are available as e-calculators. Workstream 2 – in the PAtient-SPecific Oxygen monitoring to Reduce blood Transfusion during heart surgery (PASPORT) trial and a systematic review we demonstrated that personalised near-infrared spectroscopy-based algorithms for the optimisation of tissue oxygenation, or as indicators for red cell transfusion, were neither clinically effective nor cost-effective. Workstream 3 – in the REDWASH trial we failed to demonstrate a reduction in inflammation or organ injury in recipients of mechanically washed red cells compared with standard (unwashed) red cells.LimitationsExisting studies evaluating the predictive accuracy or effectiveness of POC tests of coagulopathy or near-infrared spectroscopy were at high risk of bias. Interventions that alter red cell transfusion exposure, a common surrogate outcome in most trials, were not found to be clinically effective.ConclusionsA systematic assessment of devices in clinical use as blood management adjuncts in cardiac surgery did not demonstrate clinical effectiveness or cost-effectiveness. The contribution of anaemia and coagulopathy to adverse clinical outcomes following cardiac surgery remains poorly understood. Further research to define the pathogenesis of these conditions may lead to more accurate diagnoses, more effective treatments and potentially improved clinical outcomes.Study registrationCurrent Controlled Trials ISRCTN20778544 (COPTIC study) and PROSPERO CRD42016033831 (systematic review) (workstream 1); Current Controlled Trials ISRCTN23557269 (PASPORT trial) and PROSPERO CRD4201502769 (systematic review) (workstream 2); and Current Controlled Trials ISRCTN27076315 (REDWASH trial) (workstream 3).FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 17. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Gavin J Murphy
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Andrew D Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Elizabeth A Stokes
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Veerle Verheyden
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Tracy Kumar
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Jessica Harris
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Gemma Clayton
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Lucy Ellis
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Zoe Plummer
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - William Dott
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Filiberto Serraino
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Marcin Wozniak
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Tom Morris
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Mintu Nath
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Jonathan A Sterne
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Gianni D Angelini
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| |
Collapse
|
25
|
Guinot PG, Badoux L, Bernard E, Abou-Arab O, Lorne E, Dupont H. Central Venous-to-Arterial Carbon Dioxide Partial Pressure Difference in Patients Undergoing Cardiac Surgery is Not Related to Postoperative Outcomes. J Cardiothorac Vasc Anesth 2017; 31:1190-1196. [DOI: 10.1053/j.jvca.2017.02.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Indexed: 01/08/2023]
|
26
|
|
27
|
Vincent JL, Taccone FS. Microvascular monitoring – Do ‘global’ markers help? Best Pract Res Clin Anaesthesiol 2016; 30:399-405. [DOI: 10.1016/j.bpa.2016.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 10/27/2016] [Indexed: 12/19/2022]
|
28
|
Mezger V, Balzer F, Habicher M, Sander M. [Venous saturation : Between oxygen delivery and consumption]. Med Klin Intensivmed Notfmed 2016; 112:492-498. [PMID: 26931134 DOI: 10.1007/s00063-016-0145-0] [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: 04/10/2015] [Revised: 12/14/2015] [Accepted: 01/10/2016] [Indexed: 02/08/2023]
Abstract
Venous saturation is an important parameter to assess the ratio between oxygen delivery and oxygen consumption for both intensive care medicine and during perioperative care. Mixed venous saturation (SvO2) is the most reliable parameter in this setting. Due to the high invasiveness of measuring mixed venous saturation, the less invasive central venous saturation (ScvO2) has been entrenched for determining the balance of oxygen delivery and consumption. However, central venous saturation is inferior compared to mixed venous saturation as it does not cover the lower part of the body, including splanchnic perfusion. Nevertheless, studies have shown that central venous saturation is a reliable marker for goal-directed therapy in intensive care medicine, especially in patients with septic or hemorrhagic shock. Furthermore, central venous saturation has deep impact as a prognostic factor concerning morbidity and mortality. It has to be mentioned that not only decreased venous saturations but also elevated venous saturations are associated with poor outcome. Besides mixed venous and central venous saturation, intensivists and anesthesiologists focus on the central venous-arterial pCO2 difference (dCO2). An elevated dCO2 is associated with poor outcome in patients after cardiac surgery or patients with sepsis. Yet, further investigations have to be performed to implement the dCO2 as a reliable marker in daily routine.
Collapse
Affiliation(s)
- V Mezger
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Charité Mitte und Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
| | - F Balzer
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Charité Mitte und Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - M Habicher
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Charité Mitte und Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - M Sander
- Klinik für Anaesthesiologie und Operative Intensivmedizin, Universitätsklinikum Gießen und Marburg GmbH, Gießen, Deutschland
| |
Collapse
|