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Liu S, Su L, Zhuge C, He H, Long Y. Initial 24-h perfusion index of ICU admission is associated with acute kidney injury in perioperative critically ill patients: A retrospective cohort analysis. JOURNAL OF INTENSIVE MEDICINE 2023; 3:261-267. [PMID: 37533811 PMCID: PMC10391560 DOI: 10.1016/j.jointm.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/31/2023] [Accepted: 02/25/2023] [Indexed: 08/04/2023]
Abstract
Background The relationship between perfusion index (PI) and organ dysfunction in patients in the intensive care unit (ICU) is not clear. This study aimed to explore the relationship between PI and renal function in the perioperative critical care setting and evaluate the predictive efficiency of PI on patients with acute kidney injury (AKI) in the ICU. Methods This retrospective analysis involved 12,979 patients who had undergone an operation and were admitted to the ICU in Peking Union Medical College Hospital from January 2014 to December 2019. The distribution of average PI in the first 24 h after ICU admission and its correlation with AKI was calculated by Cox regression. Receiver operating characteristic (ROC) curves were generated to compare the ability of PI, mean arterial pressure (MAP), creatinine, blood urea nitrogen (BUN), and central venous pressure (CVP) to discriminate AKI in the first 48 h in all perioperative critically ill patients. Results Average PI in the first 24 h served as an independent protective factor of AKI (Odds ratio [OR]=0.786, 95% confidence interval [CI]: 0.704-0.873, P <0.0001). With a decrease in PI by one unit, the incidence of AKI increased 1.74 times. Among the variables explored for the prediction of AKI (PI, MAP, creatine, BUN, and CVP), PI yielded the highest area under the ROC curve, with a sensitivity of 64.34% and specificity of 70.14%. A cut-off value of PI ≤2.12 could be used to predict AKI according to the Youden index. Moreover, patients in the low PI group (PI ≤2.12) exhibited a marked creatine elevation at 24-48 h with a slower decrease compared with those in the high PI group (PI >2.12). Conclusions As a local blood flow indicator, the initial 24-h average PI for perioperative critically ill patients can predict AKI during their first 120 h in the ICU.
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Affiliation(s)
- Shengjun Liu
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Longxiang Su
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Changjing Zhuge
- Beijing Institute for Scientific and Engineering Computing, Department of Mathematics, Faculty of Science, Beijing University of Technology, Beijing 100124, China
| | - Huaiwu He
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
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2
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Ju JW, Choe HW, Bae J, Lee S, Cho YJ, Nam K, Jeon Y. Intraoperative mild hyperoxia may be associated with improved survival after off-pump coronary artery bypass grafting: a retrospective observational study. Perioper Med (Lond) 2022; 11:27. [PMID: 35851431 PMCID: PMC9295444 DOI: 10.1186/s13741-022-00259-y] [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: 11/14/2021] [Accepted: 03/28/2022] [Indexed: 01/28/2023] Open
Abstract
Background The effect of hyperoxia due to supplemental oxygen administration on postoperative outcomes in patients undergoing cardiac surgery remains unclear. This retrospective study aimed to evaluate the relationship between intraoperative oxygen tension and mortality after off-pump coronary artery bypass grafting (OPCAB). Methods The study included adult patients who underwent isolated OPCAB between July 2010 and June 2020. Patients were categorised into three groups based on their intraoperative time-weighted average arterial oxygen partial pressure (PaO2): normoxia/near-normoxia (< 150 mmHg), mild hyperoxia (150–250 mmHg), and severe hyperoxia (> 250 mmHg). The risk of in-hospital mortality was compared using weighted logistic regression analysis. Restricted cubic spline analysis was performed to analyse intraoperative PaO2 as a continuous variable. The risk of cumulative all-cause mortality was compared using Cox regression analysis. Results The normoxia/near-normoxia, mild hyperoxia, and severe hyperoxia groups included 229, 991, and 173 patients (n = 1393), respectively. The mild hyperoxia group had a significantly lower risk of in-hospital mortality than the normoxia/near-normoxia (odds ratio [OR], 0.12; 95% confidence interval [CI], 0.06–0.22) and severe hyperoxia groups (OR, 0.06; 95% CI, 0.03–0.14). Intraoperative PaO2 exhibited a U-shaped relationship with in-hospital mortality in the non-hypoxic range. The risk of cumulative all-cause mortality was significantly lower in the mild hyperoxia group (hazard ratio, 0.72; 95% CI, 0.52–0.99) than in the normoxia/near-normoxia group. Conclusions Maintaining intraoperative PaO2 at 150–250 mmHg was associated with a lower risk of mortality after OPCAB than PaO2 at < 150 mmHg and at > 250 mmHg. Future randomised trials are required to confirm if mildly increasing arterial oxygen tension during OPCAB to 150–250 mmHg improves postoperative outcomes.
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Affiliation(s)
- Jae-Woo Ju
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, 03080, Republic of Korea
| | - Hyun Woo Choe
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, 03080, Republic of Korea
| | - Jinyoung Bae
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, 03080, Republic of Korea
| | - Seohee Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, 03080, Republic of Korea
| | - Youn Joung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, 03080, Republic of Korea
| | - Karam Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, 03080, Republic of Korea.
| | - Yunseok Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, 03080, Republic of Korea
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Endo Y, Hirokawa T, Miyasho T, Takegawa R, Shinozaki K, Rolston DM, Becker LB, Hayashida K. Monitoring the tissue perfusion during hemorrhagic shock and resuscitation: tissue-to-arterial carbon dioxide partial pressure gradient in a pig model. J Transl Med 2021; 19:390. [PMID: 34774068 PMCID: PMC8590759 DOI: 10.1186/s12967-021-03060-5] [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: 07/11/2021] [Accepted: 08/27/2021] [Indexed: 11/20/2022] Open
Abstract
Background Despite much evidence supporting the monitoring of the divergence of transcutaneous partial pressure of carbon dioxide (tcPCO2) from arterial partial pressure carbon dioxide (artPCO2) as an indicator of the shock status, data are limited on the relationships of the gradient between tcPCO2 and artPCO2 (tc-artPCO2) with the systemic oxygen metabolism and hemodynamic parameters. Our study aimed to test the hypothesis that tc-artPCO2 can detect inadequate tissue perfusion during hemorrhagic shock and resuscitation. Methods This prospective animal study was performed using female pigs at a university-based experimental laboratory. Progressive massive hemorrhagic shock was induced in mechanically ventilated pigs by stepwise blood withdrawal. All animals were then resuscitated by transfusing the stored blood in stages. A transcutaneous monitor was attached to their ears to measure tcPCO2. A pulmonary artery catheter (PAC) and pulse index continuous cardiac output (PiCCO) were used to monitor cardiac output (CO) and several hemodynamic parameters. The relationships of tc-artPCO2 with the study parameters and systemic oxygen delivery (DO2) were analyzed. Results Hemorrhage and blood transfusion precisely impacted hemodynamic and laboratory data as expected. The tc-artPCO2 level markedly increased as CO decreased. There were significant correlations of tc-artPCO2 with DO2 and COs (DO2: r = − 0.83, CO by PAC: r = − 0.79; CO by PiCCO: r = − 0.74; all P < 0.0001). The critical level of oxygen delivery (DO2crit) was 11.72 mL/kg/min according to transcutaneous partial pressure of oxygen (threshold of 30 mmHg). Receiver operating characteristic curve analyses revealed that the value of tc-artPCO2 for discrimination of DO2crit was highest with an area under the curve (AUC) of 0.94, followed by shock index (AUC = 0.78; P < 0.04 vs tc-artPCO2), and lactate (AUC = 0.65; P < 0.001 vs tc-artPCO2). Conclusions Our observations suggest the less-invasive tc-artPCO2 monitoring can sensitively detect inadequate systemic oxygen supply during hemorrhagic shock. Further evaluations are required in different forms of shock in other large animal models and in humans to assess its usefulness, safety, and ability to predict outcomes in critical illnesses.
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Affiliation(s)
- Yusuke Endo
- The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY, 11030, USA.,School of Veterinary Medicine, Rakuno Gakuen University, Hokkaido, Japan.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA
| | - Taku Hirokawa
- School of Veterinary Medicine, Rakuno Gakuen University, Hokkaido, Japan
| | - Taku Miyasho
- School of Veterinary Medicine, Rakuno Gakuen University, Hokkaido, Japan
| | - Ryosuke Takegawa
- The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY, 11030, USA.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA
| | - Koichiro Shinozaki
- The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY, 11030, USA.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA.,Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Daniel M Rolston
- Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA.,Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Lance B Becker
- The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY, 11030, USA.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA.,Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Kei Hayashida
- The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY, 11030, USA. .,Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA.
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Valeanu L, Bubenek-Turconi SI, Ginghina C, Balan C. Hemodynamic Monitoring in Sepsis-A Conceptual Framework of Macro- and Microcirculatory Alterations. Diagnostics (Basel) 2021; 11:1559. [PMID: 34573901 PMCID: PMC8469937 DOI: 10.3390/diagnostics11091559] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/22/2021] [Accepted: 08/26/2021] [Indexed: 12/29/2022] Open
Abstract
Circulatory failure in sepsis is common and places a considerable burden on healthcare systems. It is associated with an increased likelihood of mortality, and timely recognition is a prerequisite to ensure optimum results. While there is consensus that aggressive source control, adequate antimicrobial therapy and hemodynamic management constitute crucial determinants of outcome, discussion remains about the best way to achieve each of these core principles. Sound cardiovascular support rests on tailored fluid resuscitation and vasopressor therapy. To this end, an overarching framework to improve cardiovascular dynamics has been a recurring theme in modern critical care. The object of this review is to examine the nature of one such framework that acknowledges the growing importance of adaptive hemodynamic support combining macro- and microhemodynamic variables to produce adequate tissue perfusion.
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Affiliation(s)
- Liana Valeanu
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (L.V.); (S.-I.B.-T.)
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Serban-Ion Bubenek-Turconi
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (L.V.); (S.-I.B.-T.)
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Carmen Ginghina
- 3rd Department of Cardiology, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania;
- Department of Cardiology, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Cosmin Balan
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (L.V.); (S.-I.B.-T.)
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5
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Martin DS. Lifting the lid on perioperative goal-directed therapy. Br J Anaesth 2021; 127:508-510. [PMID: 34389170 DOI: 10.1016/j.bja.2021.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 07/09/2021] [Accepted: 07/13/2021] [Indexed: 11/20/2022] Open
Abstract
The complex cellular interactions that underlie pathologies related to reduced oxygen delivery after surgery are poorly defined and difficult to measure. Heywood and colleagues explored the patterns of protein expression in skin biopsies taken from a subgroup of patients enrolled in a randomised trial designed to evaluate perioperative goal-directed therapy. One of their key findings was that a failure of participants to maintain preoperative systemic oxygen delivery was associated with an upregulation of intracellular proteins involved in counteracting oxidative stress. Their study highlights the importance of oxidative stress in the perioperative setting and suggests that maintenance of baseline oxygen delivery might be an important regulator of redox balance.
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Affiliation(s)
- Daniel S Martin
- Peninsula Medical School, University of Plymouth, Plymouth, UK.
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6
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Mesquida J. Non-invasive tools for guiding hemodynamic resuscitation in septic shock: the perfusion vs metabolic issue. J Clin Monit Comput 2020; 35:431-433. [PMID: 33258027 DOI: 10.1007/s10877-020-00622-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/20/2020] [Indexed: 11/28/2022]
Abstract
Transcutaneous oxygen pressure reflects the balance between cardiac output, arterial oxygenation, and the metabolic rate of the tissue. In septic shock, it allows a real time assessment of the adequacy of tissue perfusion, and therefore it has been proposed as a non-invasive tool to guide the hemodynamic resuscitation process. However, its value is limited in those situations where cardiac output has been optimized, but tissue dysoxia persists as results of an impairment in oxygen utilization.
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Affiliation(s)
- Jaume Mesquida
- Critical Care Department, Parc Taulí Hospital Universitari. Institut D'Investigació I Innovació Parc Taulí I3PT, 1, 08208, Sabadell, Spain.
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7
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Transcutaneous oxygen pressure-related variables as noninvasive indicators of low lactate clearance in sepsis patients after resuscitation. J Clin Monit Comput 2020; 35:435-442. [PMID: 32965558 DOI: 10.1007/s10877-020-00594-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 09/18/2020] [Indexed: 12/30/2022]
Abstract
The transcutaneous oxygen challenge test (OCT) is associated with central venous oxygen saturation and cardiac output index, and has predictive value for prognosis. Whether the change of transcutaneous oxygen pressure (PtcO2)-related variables can reflect lactate clearance in sepsis patients is worth studying. We conducted a prospective observational study of 79 patients with sepsis or septic shock in the ICU. Immediately after enrollment, PtcO2 monitoring was continuously performed for 6 h. The OCT was performed at enrollment (T0) and the sixth hour (T6). The correlation between lactate clearance and PtcO2-related variables such as PtcO2 at T6, ΔPtcO2 (PtcO2 at T6 - PtcO2 at T0), ΔPtcO2 index (PtcO2/PaO2 at T6 - PtcO2/PaO2 at T0), 10 OCT [(PtcO2 after 10 min on FiO2 of 1.0) - (PtcO2 at baseline)], Δ10 OCT (10 OCT at T6 - 10 OCT at T0) was analyzed. The difference of PtcO2-related variables was compared between the high and low lactate clearance groups. PtcO2 at T6 (r = 0.477, p < 0.001), ΔPtcO2 (r = 0.592, p < 0.001), ΔPtcO2 index (r = 0.553, p < 0.001) and Δ10 OCT (r = 0.379, p = 0.001) were significantly correlated with the lactate clearance. To discriminate low lactate clearance, the area under the ROC curve was largest for ΔPtcO2, which was 0.804. PtcO2 at T6, PtcO2 index, ΔPtcO2, ΔPtcO2 index and Δ10 OCT were significantly different between the two different lactate clearance groups. Low lactate clearance in the initial 6 h of resuscitation of septic shock was associated to lower improvements in PtcO2-related variables.
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8
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Harrington V, Gurung P. Reconciling protective and pathogenic roles of the NLRP3 inflammasome in leishmaniasis. Immunol Rev 2020; 297:53-66. [PMID: 32564424 DOI: 10.1111/imr.12886] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/12/2020] [Accepted: 05/20/2020] [Indexed: 12/29/2022]
Abstract
Leishmaniasis is a global health problem that affects more than 2 billion people worldwide. Recent advances in research have demonstrated critical roles for cytoplasmic sensors and inflammasomes during Leishmania spp. infection and pathogenesis. Specifically, several studies have focused on the role of nod-like receptor family, pyrin domain-containing protein 3 (NLRP3) inflammasome and inflammasome-associated cytokines IL-1β and IL-18 in leishmaniasis. Despite these studies, our understanding of the priming and activation events that lead to NLRP3 inflammasome activation during Leishmania spp. infection is limited. Furthermore, whether NLRP3 plays a protective or pathogenic role during Leishmania spp. infection is far from resolved, with some studies showing a protective role and others showing a pathogenic role. In this review, we performed a critical review of the literature to provide a current update on priming and activating signals required for NLRP3 inflammasome activation during Leishmania spp. infection. Finally, we provide a thorough review of the literature to reconcile differences in the observed protective vs pathogenic roles of the NLRP3 inflammasome during Leishmania spp. infection.
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Affiliation(s)
| | - Prajwal Gurung
- Inflammation Program, University of Iowa, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa, Iowa City, IA, USA.,Immunology Graduate Program, University of Iowa, Iowa City, IA, USA.,Interdisciplinary Graduate Program in Human Toxicology, University of Iowa, Iowa City, IA, USA
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9
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Parker T, Brealey D, Dyson A, Singer M. Optimising organ perfusion in the high-risk surgical and critical care patient: a narrative review. Br J Anaesth 2019; 123:170-176. [PMID: 31054772 DOI: 10.1016/j.bja.2019.03.027] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 02/18/2019] [Accepted: 03/12/2019] [Indexed: 12/18/2022] Open
Abstract
Maintenance or prompt restoration of an oxygen supply sufficient to facilitate adequate cellular metabolism is fundamental in maintaining organ function. This is particularly relevant when metabolic needs change markedly, for example in response to major surgery or critical illness. The consequences of inadequate tissue oxygenation include wound and anastomotic breakdown, organ dysfunction, and death. However, our ability to identify those at risk and to promptly recognise and correct tissue hypoperfusion is limited. Reliance is placed upon surrogate markers of tissue oxygenation such as arterial blood pressure and serum lactate that are insensitive to early organ compromise. Advances in oxygen sensing technology will facilitate monitoring in various organ beds and allow more precise titration of therapies to physiologically relevant endpoints. Clinical trials will be needed to evaluate any impact on outcomes, however accurate on-line monitoring of the adequacy of tissue oxygenation offers the promise of a paradigm shift in resuscitation and perioperative practice. This narrative review examines current evidence for goal-directed therapy in the optimisation of organ perfusion in high-risk surgical and critically ill patients, and offers arguments to support the potential utility of tissue oxygen monitoring.
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Affiliation(s)
- Thomas Parker
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - David Brealey
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - Alex Dyson
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK.
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10
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Rafl J, Kulhanek F, Kudrna P, Ort V, Roubik K. Response time of indirectly accessed gas exchange depends on measurement method. BIOMED ENG-BIOMED TE 2018; 63:647-655. [PMID: 28802098 DOI: 10.1515/bmt-2017-0070] [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: 12/18/2016] [Accepted: 07/03/2017] [Indexed: 11/15/2022]
Abstract
Noninvasive techniques are routinely used for assessment of tissue effects of lung ventilation. However, comprehensive studies of the response time of the methods are scarce. The aim of this study was to compare the response time of noninvasive methods for monitoring of gas exchange to sudden changes in the composition of the inspired gas. A prospective experimental study with 16 healthy volunteers was conducted. A ventilation circuit was designed that enabled a fast change in the composition of the inspiratory gas mixture while allowing spontaneous breathing. The volunteers inhaled a hypoxic mixture, then a hypercapnic mixture, a hyperoxic mixture and finally a 0.3% CO mixture. The parameters with the fastest response to the sudden change of O2 in inhaled gas were peripheral capillary oxygen saturation (SpO2) and regional tissue oxygenation (rSO2). Transcutaneous oxygen partial pressure (tcpO2) had almost the same time of reaction, but its time of relaxation was 2-3 times longer. End-tidal carbon dioxide (EtCO2) response time to change of CO2 concentration in inhaled gas was less than half in comparison with transcutaneous carbon dioxide partial pressure (tcpCO2). All the examined parameters and devices reacted adequately to changes in gas concentration in the inspiratory gas mixture.
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Affiliation(s)
- Jakub Rafl
- Czech Technical University in Prague, Faculty of Biomedical Engineering, Department of Biomedical Technology, nam. Sitna 3105, 272 01 Kladno, Czech Republic, Phone: +420 728 229 991, Fax: +420 224 358 419
| | - Filip Kulhanek
- Czech Technical University in Prague, Faculty of Biomedical Engineering, Department of Biomedical Technology, 272 01 Kladno, Czech Republic
| | - Petr Kudrna
- Czech Technical University in Prague, Faculty of Biomedical Engineering, Department of Biomedical Technology, 272 01 Kladno, Czech Republic
| | - Vaclav Ort
- Czech Technical University in Prague, Faculty of Biomedical Engineering, Department of Biomedical Technology, 272 01 Kladno, Czech Republic
| | - Karel Roubik
- Czech Technical University in Prague, Faculty of Biomedical Engineering, Department of Biomedical Technology, 272 01 Kladno, Czech Republic
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11
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The Prognostic Value of Central Venous-to-Arterial CO2 Difference/Arterial-Central Venous O2 Difference Ratio in Septic Shock Patients with Central Venous O2 Saturation ≥80%. Shock 2017; 48:551-557. [DOI: 10.1097/shk.0000000000000893] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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12
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Influence of Fraction of Inspired Oxygen on Noninvasive Hemoglobin Measurement: Parallel Assessment of 2 Monitors. Anesth Analg 2017; 124:1820-1823. [PMID: 28221201 DOI: 10.1213/ane.0000000000001783] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Previous reports have brought specific attention to the relationship between oxygenation of the patient and the accuracy of noninvasive measurement of hemoglobin (Hb) using an optical sensor. This study aimed to assess prospectively the relationship between fraction of inspired oxygen (FIO2) and the bias of the measurement of Hb by the use of 2 different noninvasive monitors compared with the classic invasive technique. METHODS Forty-four patients were included prospectively. In each individual, Hb level was determined noninvasively by monitor Pronto-7™ (Masimo Corporation, Irvine, CA) and by monitor NBM-200MP™ (OrSense Ltd, Petah-Tikva, Israel), with the probe placed on 2 fingers on the same hand of the patient. Three measures were performed, first under breathing air and 2 others when fraction of expired oxygen rose to 50% ± 5% and to 90 ± 5%. Simultaneously, a nurse collected a venous blood sample, which was sent immediately to the hematology laboratory for Hb measurement. The main outcome measurement was the mean bias between noninvasive and invasive measurements. RESULTS Results show no change in median bias [interquartile range] with FIO2 for Pronto-7 (from 1.1 g/dL [0.0-2.0] in FIO2 21% to 1.0 g/dL [0.2-1.5] in FIO2 100%), but increasingly negative median bias with increasing FIO2 for NBM-200MP (from -0.3 g/dL [-1.3 to 0.3] in FIO2 21% to -0.8 g/dL [-1.5 to -0.1] in FIO2 100%, P = .04). DISCUSSION This study showed that noninvasive measurement of Hb could be influenced by inspired fraction of oxygen when the monitor NBM-200MP is used.
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13
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Xu J, Peng X, Pan C, Cai S, Zhang X, Xue M, Yang Y, Qiu H. Fluid responsiveness predicted by transcutaneous partial pressure of oxygen in patients with circulatory failure: a prospective study. Ann Intensive Care 2017; 7:56. [PMID: 28536944 PMCID: PMC5442033 DOI: 10.1186/s13613-017-0279-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 05/16/2017] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Significant effort has been devoted to defining parameters for predicting fluid responsiveness. Our goal was to study the feasibility of predicting fluid responsiveness by transcutaneous partial pressure of oxygen (PtcO2) in the critically ill patients. METHODS This was a single-center prospective study conducted in the intensive care unit of a tertiary care teaching hospital. Shock patients who presented with at least one clinical sign of inadequate tissue perfusion, defined as systolic blood pressure <90 mmHg or a decrease >40 mmHg in previously hypertensive patients or the need for vasopressive drugs; urine output <0.5 ml/kg/h for 2 h; tachycardia; lactate >4 mmol/l, for less than 24 h in the absence of a contraindication for fluids were eligible to participate in the study. PtcO2 was continuously recorded before and during a passive leg raising (PLR) test, and then before and after a 250 ml rapid saline infusion in 10 min. Fluid responsiveness is defined as a change in the stroke volume ≥10% after 250 ml of volume infusion. RESULTS Thirty-four patients were included, and 14 responded to volume expansion. In the responders, the mean arterial pressure, central venous pressure, cardiac output, stroke volume and PtcO2 increased significantly, while the heart rate decreased significantly by both PLR and volume expansion. Changes in the stroke volume induced either by PLR or volume expansion were significantly greater in responders than in non-responders. The correlation between the changes in PtcO2 and stroke volume induced by volume expansion was significant. Volume expansion induced an increase in the PtcO2 of 14% and PLR induced an increase in PtcO2 of 13% predicted fluid responsiveness. CONCLUSIONS This study suggested the changes in PtcO2 induced by volume expansion and a PLR test predicted fluid responsiveness in critically ill patients. Trial registration NCT02083757.
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Affiliation(s)
- Jingyuan Xu
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Rd., Nanjing, 210009, People's Republic of China
| | - Xiao Peng
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Rd., Nanjing, 210009, People's Republic of China
| | - Chun Pan
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Rd., Nanjing, 210009, People's Republic of China
| | - Shixia Cai
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Rd., Nanjing, 210009, People's Republic of China
| | - Xiwen Zhang
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Rd., Nanjing, 210009, People's Republic of China
| | - Ming Xue
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Rd., Nanjing, 210009, People's Republic of China
| | - Yi Yang
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Rd., Nanjing, 210009, People's Republic of China
| | - Haibo Qiu
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Rd., Nanjing, 210009, People's Republic of China.
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Hasanin A, Mukhtar A, Nassar H. Perfusion indices revisited. J Intensive Care 2017; 5:24. [PMID: 28331621 PMCID: PMC5351209 DOI: 10.1186/s40560-017-0220-5] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 03/07/2017] [Indexed: 12/18/2022] Open
Abstract
Monitoring of tissue perfusion is an essential step in the management of acute circulatory failure. The presence of cellular dysfunction has been a basic component of shock definition even in the absence of hypotension. Monitoring of tissue perfusion includes biomarkers of global tissue perfusion and measures for assessment of perfusion in non-vital organs. The presence of poor tissue perfusion in a shocked patient is usually associated with worse outcome. Persistently impaired perfusion despite adequate resuscitation is also associated with worse outcome. Thus, normalization of some perfusion indices has become one of the resuscitation targets in patients with septic shock. Although the collective evidence shows the clear relation between impaired peripheral perfusion and mortality, the use of different perfusion indices as a resuscitation target needs more research.
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Affiliation(s)
- Ahmed Hasanin
- Anesthesia and Critical Care Medicine, Cairo University, Giza, Egypt.,Critical Care Department, El-Ameen Hospital, Taif, Kingdom of Saudi Arabia
| | - Ahmed Mukhtar
- Anesthesia and Critical Care Medicine, Cairo University, Giza, Egypt
| | - Heba Nassar
- Anesthesia and Critical Care Medicine, Cairo University, Giza, Egypt
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Microcirculatory monitoring in septic patients: Where do we stand? Med Intensiva 2017; 41:44-52. [PMID: 28104277 DOI: 10.1016/j.medin.2016.11.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 11/09/2016] [Accepted: 11/13/2016] [Indexed: 11/23/2022]
Abstract
Microcirculatory alterations play a pivotal role in sepsis-related morbidity and mortality. However, since the microcirculation has been a "black box", current hemodynamic management of septic patients is still guided by macrocirculatory parameters. In the last decades, the development of several technologies has shed some light on microcirculatory evaluation and monitoring, and the possibility of incorporating microcirculatory variables to clinical practice no longer seems to be beyond reach. The present review provides a brief summary of the current technologies for microcirculatory evaluation, and attempts to explore the potential role and benefits of their integration to the resuscitation process in critically ill septic patients.
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Saludes P, Proença L, Gruartmoner G, Enseñat L, Pérez-Madrigal A, Espinal C, Mesquida J. Central venous-to-arterial carbon dioxide difference and the effect of venous hyperoxia: A limiting factor, or an additional marker of severity in shock? J Clin Monit Comput 2016; 31:1203-1211. [PMID: 27832407 DOI: 10.1007/s10877-016-9954-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 11/06/2016] [Indexed: 12/18/2022]
Abstract
Central venous-to-arterial carbon dioxide difference (PcvaCO2) has demonstrated its prognostic value in critically ill patients suffering from shock, and current expert recommendations advocate for further resuscitation interventions when PcvaCO2 is elevated. PcvaCO2 combination with arterial-venous oxygen content difference (PcvaCO2/CavO2) seems to enhance its performance when assessing anaerobic metabolism. However, the fact that PCO2 values might be altered by changes in blood O2 content (the Haldane effect), has been presented as a limitation of PCO2-derived variables. The present study aimed at exploring the impact of hyperoxia on PcvaCO2 and PcvaCO2/CavO2 during the early phase of shock. Prospective interventional study. Ventilated patients suffering from shock within the first 24 h of ICU admission. Patients requiring FiO2 ≥ 0.5 were excluded. At inclusion, simultaneous arterial and central venous blood samples were collected. Patients underwent a hyperoxygenation test (5 min of FiO2 100%), and arterial and central venous blood samples were repeated. Oxygenation and CO2 variables were calculated at both time points. Twenty patients were studied. The main cause of shock was septic shock (70%). The hyperoxygenation trial increased oxygenation parameters in arterial and venous blood, whereas PCO2 only changed at the venous site. Resulting PcvaCO2 and PcvaCO2/CavO2 significantly increased [6.8 (4.9, 8.1) vs. 7.6 (6.7, 8.5) mmHg, p 0.001; and 1.9 (1.4, 2.2) vs. 2.3 (1.8, 3), p < 0.001, respectively]. Baseline PcvaCO2, PcvaCO2/CavO2 and ScvO2 correlated with the magnitude of PO2 augmentation at the venous site within the trial (ρ -0.46, p 0.04; ρ 0.6, p < 0.01; and ρ 0.7, p < 0.001, respectively). Increased PcvaCO2/CavO2 values were associated with higher mortality in our sample [1.46 (1.21, 1.89) survivors vs. 2.23 (1.86, 2.8) non-survivors, p < 0.01]. PcvaCO2 and PcvaCO2/CavO2 are influenced by oxygenation changes not related to flow. Elevated PcvaCO2 and PcvaCO2/CavO2 values might not only derive from cardiac output inadequacy, but also from venous hyperoxia. Elevated PcvaCO2/CavO2 values were associated with higher PO2 transmission to the venous compartment, suggesting higher shunting phenomena.
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Affiliation(s)
- P Saludes
- Critical Care Department, Hospital de Sabadell, Corporació Sanitària Universitària Parc Taulí, Universitat Autònoma de Barcelona, Parc Tauli, 1, 08208, Sabadell, Spain
| | - L Proença
- Critical Care Department, Hospital de Sabadell, Corporació Sanitària Universitària Parc Taulí, Universitat Autònoma de Barcelona, Parc Tauli, 1, 08208, Sabadell, Spain.,Serviço de Medicina Interna, Hospital Prof. Dr. Fernando Fonseca, Amadora, Portugal
| | - G Gruartmoner
- Critical Care Department, Hospital de Sabadell, Corporació Sanitària Universitària Parc Taulí, Universitat Autònoma de Barcelona, Parc Tauli, 1, 08208, Sabadell, Spain
| | - L Enseñat
- Critical Care Department, Hospital de Sabadell, Corporació Sanitària Universitària Parc Taulí, Universitat Autònoma de Barcelona, Parc Tauli, 1, 08208, Sabadell, Spain
| | - A Pérez-Madrigal
- Critical Care Department, Hospital de Sabadell, Corporació Sanitària Universitària Parc Taulí, Universitat Autònoma de Barcelona, Parc Tauli, 1, 08208, Sabadell, Spain
| | - C Espinal
- Critical Care Department, Hospital de Sabadell, Corporació Sanitària Universitària Parc Taulí, Universitat Autònoma de Barcelona, Parc Tauli, 1, 08208, Sabadell, Spain
| | - J Mesquida
- Critical Care Department, Hospital de Sabadell, Corporació Sanitària Universitària Parc Taulí, Universitat Autònoma de Barcelona, Parc Tauli, 1, 08208, Sabadell, Spain.
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He H, Long Y, Liu D, Wang X, Zhou X. Clinical classification of tissue perfusion based on the central venous oxygen saturation and the peripheral perfusion index. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:330. [PMID: 26369784 PMCID: PMC4568576 DOI: 10.1186/s13054-015-1057-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 08/30/2015] [Indexed: 01/09/2023]
Abstract
Introduction We investigated whether combining the peripheral perfusion index (PI) and central venous oxygen saturation(ScvO2) would identify subsets of patients for assessing the tissue perfusion and predicting outcome during the resuscitation in critically ill patients. Methods A total of 202 patients with central venous catheters for resuscitation were enrolled in this prospective observational study. The arterial, central venous blood gas and the PI were measured simultaneously at the enrollment (T0) and 8 h (T8) after early resuscitation. Based on the distribution of the PI in healthy population, a cutoff of PI ≥1.4 was defined as a normal PI. Moreover, the critical value of PI was defined as the best cutoff value related to the mortality in the study population. The PI impairment stratification is defined as follows: a normal PI(≥1.4), mild PI impairment (critical value < PI < 1.4) and critical PI impairment (PI ≤ critical value). Results The PI at T8 was with the greatest AUC for prediction the 30-day mortality and PI is an independent risk factor for 30-day mortality. Moreover, a cutoff of PI < 0.6 is related to poor outcomes following resuscitation. So, based on cutoffs of ScvO2 (70 %) and critical PI (0.6) at T8, we assigned the patients to four categories: group 1 (PI ≤ 0.6 on ScvO2 < 70 %), group 2 (PI ≤ 0.6 on ScvO2 ≥ 70 %), group 3 (PI > 0.6 on ScvO2 < 70 %), and group 4 (PI > 0.6 on ScvO2 ≥ 70 %). The combination of low ScvO2(<70 %) and PI(≤0.6) was associated with the lowest survival rates at 30 days [log rank (Mantel–Cox) = 87.518, p < 0.0001]. The sub-group patients who had high ScvO2(>80 %) at T8 were with low mortality and high PI. Moreover, the normal PI (≥1.4) did not show a better outcome than mild impaired PI (0.6-1.4) patients who had a normalized ScvO2(>70 %) after resuscitation. The PI was correlated with the lactate, P(v-a)CO2, and ScvO2 in all the measurements (n = 404). These relationships are strengthened with abnormal PI (PI < 1.4) but not with normal PI (PI ≥ 1.4). Conclusion Complementing ScvO2 assessment with PI can better identify endpoints of resuscitation and adverse outcomes. Pursuing a normalized PI (≥1.4) may not result in better outcomes for a mild impaired PI after ScvO2 is normalized. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-1057-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Huaiwu He
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, 1 shuaifuyuan, Dongcheng District, 100730, Beijing, China.
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, 1 shuaifuyuan, Dongcheng District, 100730, Beijing, China.
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, 1 shuaifuyuan, Dongcheng District, 100730, Beijing, China.
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, 1 shuaifuyuan, Dongcheng District, 100730, Beijing, China.
| | - Xiang Zhou
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, 1 shuaifuyuan, Dongcheng District, 100730, Beijing, China.
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De Santis V, Singer M. Tissue oxygen tension monitoring of organ perfusion: rationale, methodologies, and literature review. Br J Anaesth 2015. [PMID: 26198717 DOI: 10.1093/bja/aev162] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Tissue oxygen tension is the partial pressure of oxygen within the interstitial space of an organ bed. As it represents the balance between local oxygen delivery and consumption at any given time, it offers a ready monitoring capability to assess the adequacy of tissue perfusion relative to local demands. This review covers the various methodologies used to measure tissue oxygen tension, describes the underlying physiological and pathophysiological principles, and summarizes human and laboratory data published to date.
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Affiliation(s)
- V De Santis
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, Cruciform Building, Gower Street, London WC1E 6BT, UK
| | - M Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, Cruciform Building, Gower Street, London WC1E 6BT, UK
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Abstract
Dissolved oxygen (i.e., unbound to hemoglobin) is often neglected as a determinant of central venous oxygen saturation (ScvO2) in review articles and textbooks. These statements may lead to potential misinterpretation of SCvO2 value across FiO2 changes. In this study, we aimed to explore the influence of PaO2 and FiO2 on ScvO2 in ventilated critically ill patients. This was a prospective observational study in two surgical intensive care units. Mechanically ventilated and sedated patients with cardiac output and ScvO2 monitoring and PaO2/FiO2 > 200 with inspiratory oxygen (FiO2) ≤ 0.5 were enrolled (cohort [ScvO2]). A second cohort of brain-injured patients with jugular venous oxygen saturation monitoring was studied to assess the application of the results to regional circulation (cohort [SjvO2]). Central venous oxygen saturation was measured at baseline FiO2 and at FiO2 = 1. We finally estimated the participation of the dissolved oxygen (PadissolvO2) to the ScvO2 variations. Twenty patients formed the cohort ScvO2 and eight formed the cohort SjvO2. Central venous oxygen saturation rose from 71% (69%-76%) to 84% (78%-88%) after increasing FiO2, whereas PaO2 rose from 100 (85-124) mmHg to 387 (360-449) mmHg. The rise of ScvO2 was mostly ascribable to the dissolved oxygen. The increase of ScvO2 was not explained by changes in cardiac output or hemoglobin levels. Jugular venous oxygen saturation rose from 71% (58%-78%) to 83% (78%-89%) after increasing FiO2. Arterial dissolved oxygen level can significantly influence the ScvO2 value. Therefore, PaO2 should not be overlooked while considering the ScvO2 value as a therapeutic goal. Interpretation of ScvO2 variations in response to a therapeutic challenge (i.e., fluid challenge, inotropic drug initiation) should be performed at constant FiO2.
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Lu YH, Liu L, Qiu XH, Yu Q, Yang Y, Qiu HB. Effect of early goal directed therapy on tissue perfusion in patients with septic shock. World J Emerg Med 2014; 4:117-22. [PMID: 25215104 PMCID: PMC4129837 DOI: 10.5847/wjem.j.issn.1920-8642.2013.02.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 04/16/2013] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND This study aimed to observe the effect of early goal directed therapy (EGDT) on tissue perfusion, microcirculation and tissue oxygenation in patients with septic shock. METHODS Patients with early septic shock (<24 hours) who had been admitted to the ICU of Zhongda Hospital Affiliated to Southeast University from September 2009 through May 2011 were enrolled (research time: 12 months), and they didn't meet the criteria of EGDT. Patients who had one of the following were excluded: stroke, brain injury, other types of shock, severe heart failure, acute myocardial infarction, age below 18 years, pregnancy, end-stage disease, cardiac arrest, extensive burns, oral bleeding, difficulty in opening the mouth, and the onset of septic shock beyond 24 hours. Patients treated with the standard protocol of EGDT were included. Transcutaneous pressure of oxygen and carbon dioxide (PtcO2, PtcCO2) were monitored and hemodynamic measurements were obtained. Side-stream dark field (SDF) imaging device was applied to obtain sublingual microcirculation. Hemodynamics, tissue oxygen, and sublingual microcirculation were compared before and after EGDT. If the variable meets the normal distribution, Student's t test was applied. Otherwise, Wilcoxon's rank-sum test was used. Correlation between variables was analyzed with Pearson's product-moment correlation coefficient method. RESULTS Twenty patients were involved, but one patient wasn't analyzed because he didn't meet the EGDT criteria. PtcO2 and PtcCO2 were monitored in 19 patients, of whom sublingual microcirculation was obtained. After EGDT, PtcO2 increased from 62.7±24.0 mmHg to 78.0±30.9 mmHg (P<0.05) and tissue oxygenation index (PtcO2/FiO2) was 110.7±60.4 mmHg before EGDT and 141.6±78.2 mmHg after EGDT (P<0.05). The difference between PtcCO2 and PCO2 decreased significantly after EGDT (P<0.05). The density of perfused small vessels (PPV) and microcirculatory flow index of small vessels (MFI) tended to increase, but there were no significant differences between them (P>0.05). PtcO2, PtcO2/FiO2, and PtcCO2 were not linearly related to central venous saturation, lactate, oxygen delivery, and oxygen consumption (P>0.05). CONCLUSION Peripheral perfusion was improved after EGDT in patients with septic shock, and it was not exactly reflected by the index of systemic perfusion.
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Affiliation(s)
- Yuan-Hua Lu
- ICU, Jiangxi Provincial People's Hospital, Nanchang 330006, China
| | - Ling Liu
- Critical Care Medicine, Zhong-da Hospital Affiliated to Southeast University, Nanjing 210009, China
| | - Xiao-Hua Qiu
- Critical Care Medicine, Zhong-da Hospital Affiliated to Southeast University, Nanjing 210009, China
| | - Qin Yu
- Critical Care Medicine, Zhong-da Hospital Affiliated to Southeast University, Nanjing 210009, China
| | - Yi Yang
- Critical Care Medicine, Zhong-da Hospital Affiliated to Southeast University, Nanjing 210009, China
| | - Hai-Bo Qiu
- Critical Care Medicine, Zhong-da Hospital Affiliated to Southeast University, Nanjing 210009, China
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Charton A, Péronnet F, Doutreleau S, Lonsdorfer E, Klein A, Jimenez L, Geny B, Diemunsch P, Richard R. Effect of administration of water enriched in O2 by injection or electrolysis on transcutaneous oxygen pressure in anesthetized pigs. Drug Des Devel Ther 2014; 8:1161-7. [PMID: 25210438 PMCID: PMC4154880 DOI: 10.2147/dddt.s66236] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Oral administration of oxygenated water has been shown to improve blood oxygenation and could be an alternate way for oxygen (O2) supply. In this experiment, tissue oxygenation was compared in anesthetized pigs receiving a placebo or water enriched in O2 by injection or a new electrolytic process. Methods Forty-two pigs randomized in three groups received either mineral water as placebo or water enriched in O2 by injection or the electrolytic process (10 mL/kg in the stomach). Hemodynamic parameters, partial pressure of oxygen in the arterial blood (PaO2), skin blood flow, and tissue oxygenation (transcutaneous oxygen pressure, or TcPO2) were monitored during 90 minutes of general anesthesia. Absorption and tissue distribution of the three waters administered were assessed using dilution of deuterium oxide. Results Mean arterial pressure, heart rate, PaO2, arteriovenous oxygen difference, and water absorption from the gut were not significantly different among the three groups. The deuterium to protium ratio was also similar in the plasma, skin, and muscle at the end of the protocol. Skin blood flow decreased in the three groups. TcPO2 slowly decreased over the last 60 minutes of the experiment in the three groups, but when compared to the control group, the values remained significantly higher in animals that received the water enriched in O2 by electrolysis. Conclusions In this protocol, water enriched in O2 by electrolysis lessened the decline of peripheral tissue oxygenation. This observation is compatible with the claim that the electrolytic process generates water clathrates which trap O2 and facilitate O2 diffusion along pressure gradients. Potential applications of O2-enriched water include an alternate method of oxygen supply.
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Affiliation(s)
- Antoine Charton
- Department of Anesthesia and Critical Care, and EA 3072, Hôpital de Hautepierre; University of Strasbourg, Strasbourg, France
| | - François Péronnet
- Department of Kinesiology, Université de Montréal, Montreal, QC, Canada
| | - Stephane Doutreleau
- CHRU of Strasbourg, Physiology and Functional Explorations Department, New Civil Hospital, Strasbourg, France and University of Strasbourg, Faculty of Medicine, Physiology Department, Strasbourg, France
| | - Evelyne Lonsdorfer
- CHRU of Strasbourg, Physiology and Functional Explorations Department, New Civil Hospital, Strasbourg, France and University of Strasbourg, Faculty of Medicine, Physiology Department, Strasbourg, France
| | | | | | - Bernard Geny
- CHRU of Strasbourg, Physiology and Functional Explorations Department, New Civil Hospital, Strasbourg, France and University of Strasbourg, Faculty of Medicine, Physiology Department, Strasbourg, France
| | - Pierre Diemunsch
- Department of Anesthesia and Critical Care, and EA 3072, Hôpital de Hautepierre; University of Strasbourg, Strasbourg, France
| | - Ruddy Richard
- Department of Sport Medicine and Functional Explorations, CHU Clermont-Ferrand and INRA UMR 1019, CRNH-Auvergne, Clermont-Ferrand, France
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Schlager O, Gschwandtner ME, Willfort-Ehringer A, Kurz M, Mueller M, Koppensteiner R, Heinz G. Transcutaneous oxygen tension monitoring in critically ill patients receiving packed red blood cells. J Crit Care 2014; 29:1057-62. [PMID: 25012959 DOI: 10.1016/j.jcrc.2014.05.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 05/12/2014] [Accepted: 05/29/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Whether transfusions of packed red blood cells (PRBCs) affect tissue oxygenation in stable critically ill patients is still matter of discussion. The microvascular capacity for tissue oxygenation can be determined noninvasively by measuring transcutaneous oxygen tension (tcpO2). The aim of this study was to assess tissue oxygenation by measuring tcpO2 in stable critically ill patients receiving PRBC transfusions. METHODS Nineteen stable critically ill patients, who received 2 units of PRBC, were prospectively included into this pilot study. Transcutaneous oxygen tension was measured continuously during PRBC transfusions using Clark's electrodes. In addition, whole blood viscosity and global hemodynamics were determined. RESULTS Reliable measurement signals during continuous tcpO2 monitoring were observed in 17 of 19 included patients. Transcutaneous oxygen tension was related to the global oxygen consumption (r=-0.78; P=.003), the arterio-venous oxygen content difference (r=-0.65; P=.005), and the extraction rate (r=-0.71; P=.02). The transfusion-induced increase of the hemoglobin concentration was paralleled by an increase of the whole blood viscosity (P<.001). Microvascular tissue oxygenation by means of tcpO2 was not affected by PRBC transfusions (P=.46). Packed red blood cell transfusions resulted in an increase of global oxygen delivery (P=.02) and central venous oxygen saturation (P=.01), whereas oxygen consumption remained unchanged (P=.72). CONCLUSIONS In stable critically ill patients, microvascular tissue oxygenation can be continuously monitored by Clark's tcpO2 electrodes. According to continuous tcpO2 measurements, the microvascular tissue oxygenation is not affected by PRBC transfusions.
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Affiliation(s)
- Oliver Schlager
- Department of Medicine II, Division of Angiology, Medical University of Vienna, Vienna, Austria
| | - Michael E Gschwandtner
- Department of Medicine II, Division of Angiology, Medical University of Vienna, Vienna, Austria.
| | | | - Martin Kurz
- Department for Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Markus Mueller
- Department of Medicine II, Division of Angiology, Medical University of Vienna, Vienna, Austria
| | - Renate Koppensteiner
- Department of Medicine II, Division of Angiology, Medical University of Vienna, Vienna, Austria
| | - Gottfried Heinz
- Department of Medicine II, Division of Cardiology, Intensive Care Unit, Medical University of Vienna, Vienna, Austria
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The peripheral perfusion index and transcutaneous oxygen challenge test are predictive of mortality in septic patients after resuscitation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R116. [PMID: 23787173 PMCID: PMC4057372 DOI: 10.1186/cc12788] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 06/20/2013] [Indexed: 01/20/2023]
Abstract
Introduction The peripheral perfusion index (PI) is a noninvasive numerical value of peripheral perfusion, and the transcutaneous oxygen challenge test (OCT) is defined as the degree of transcutaneous partial pressure of oxygen (PtcO2) response to 1.0 FiO2. The value of noninvasive monitoring peripheral perfusion to predict outcome remains to be established in septic patients after resuscitation. Moreover, the prognostic value of PI has not been investigated in septic patients. Methods Forty-six septic patients, who were receiving PiCCO-Plus cardiac output monitoring, were included in the study group. Twenty stable postoperative patients were studied as a control group. All the patients inspired 1.0 of FiO2 for 10 minutes during the OCT. Global hemodynamic variables, traditional metabolic variables, PI and OCT related-variables were measured simultaneously at 24 hours after PiCCO catheter insertion. We obtained the 10min-OCT ((PtcO2 after 10 minutes on inspired 1.0 oxygen) - (baseline PtcO2)), and the oxygen challenge index ((10min-OCT)/(PaO2 on inspired 1.0 oxygen - baseline PaO2)) during the OCT. Results The PI was significantly correlated with baseline PtcO2, 10min-OCT and oxygen challenge index (OCI) in all the patients. The control group had a higher baseline PtcO2, 10min-OCT and PI than the septic shock group. In the sepsis group, the macro hemodynamic parameters and ScvO2 showed no differences between survivors and nonsurvivors. The nonsurvivors had a significantly lower PI, 10min-OCT and OCI, and higher arterial lactate level. The PI, 10min-OCT and OCI predicted the ICU mortality with an accuracy that was similar to arterial lactate level. A PI <0.2 and a 10min-OCT <66mmHg were related to poor outcome after resuscitation. Conclusions The PI and OCT are predictive of mortality for septic patients after resuscitation. Further investigations are required to determine whether the correction of an impaired level of peripheral perfusion may improve the outcome of septic shock patients.
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Dyson A, Simon F, Seifritz A, Zimmerling O, Matallo J, Calzia E, Radermacher P, Singer M. Bladder tissue oxygen tension monitoring in pigs subjected to a range of cardiorespiratory and pharmacological challenges. Intensive Care Med 2012; 38:1868-76. [PMID: 23052956 DOI: 10.1007/s00134-012-2712-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Accepted: 09/06/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE A fall in tissue oxygen tension (tPO(2)) is an early indicator of organ hypoxia in both patients and animal models. We previously demonstrated the utility of bladder tPO(2) in various rodent shock models. As a prelude to clinical testing, we aimed to provide further validation of bladder tPO(2) monitoring in a large animal model undergoing a range of cardiorespiratory insults and vasoactive drug interventions. METHODS Anaesthetized, mechanically ventilated, instrumented female pigs (n = 8) were subjected to a range of short-term cardiorespiratory (changes in inspired oxygen concentration (FiO(2)), haemorrhage, positive end-expiratory pressure) and pharmacologic (inotrope, pressor) challenges. Global haemodynamics, arterial and pulmonary blood gases and bladder tPO(2) were measured before and after each challenge. RESULTS Bladder tPO(2) values fell in line with increasing degrees of hypoxaemia and haemorrhage, and were restored during resuscitation. These changes often preceded those seen in global haemodynamics, arterial base excess and lactate. The rise in bladder tPO(2) with hyperoxia, performed as an oxygen challenge test, was incrementally blunted by progressive haemorrhage. Dobutamine and norepinephrine both increased cardiac output and global O(2) delivery, but had no effect on bladder tPO(2) or lactataemia in these healthy pigs. CONCLUSIONS In this pig model bladder tPO(2) provides a sensitive indicator of organ hypoxia compared to traditional biochemical markers during various cardiorespiratory challenges. This technique offers a potentially useful tool for clinical monitoring.
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Affiliation(s)
- Alex Dyson
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, Cruciform Building, Gower St, London, WC1E 6BT, UK.
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The transcutaneous oxygen challenge test: a noninvasive method for detecting low cardiac output in septic patients. Shock 2012; 37:152-5. [PMID: 22089202 DOI: 10.1097/shk.0b013e31823cc1c0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The transcutaneous partial pressure of oxygen (PtcO₂) index has been used to detect low-flow state in circulatory failure, but the value of the transcutaneous oxygen challenge test (OCT) to estimate low cardiac output has not been thoroughly evaluated. The prospective observational study examined 62 septic patients requiring PiCCO-Plus for cardiac output monitoring. Simultaneous basal blood gases from the arterial, central venous catheters were obtained. Cardiac indices were measured by the transpulmonary thermodilution technique at the same time, then the 10-min inspired 1.0 fractional inspired oxygen concentration (FIO₂) defined as the OCT was performed. Transcutaneous partial pressure of oxygen was measured continuously by using a noninvasive transcutaneous monitor throughout the test. The values for arterial pressure of oxygen (PaO₂) were examined on inspired of 1.0 FIO₂. We calculated the PtcO₂ index = (baseline PtcO₂/baseline PaO₂), 10-min OCT (10 OCT) = (PtcO₂ after 10 min on inspired 1.0 O₂) - (baseline PtcO₂), and the oxygen challenge index = (10 OCT) / (PaO₂ on inspired 1.0 O₂ - baseline PaO₂). Patients were divided into two groups: a normal cardiac index (CI) group with CI of greater than 3 L/min per m (n = 41) and a low CI group with CI of 3 L/min per m or less (n = 21). The 10 OCT and the oxygen challenge index predicted a low CI (≤ 3 L/min per m) with an accuracy that was similar to central venous oxygen saturation, which was significantly better than the PtcO₂ index. For a 10 OCT value of 53 mmHg, sensitivity was 0.83; specificity, 0.86; a positive predictive value, 0.92; and a negative predictive value, 0.72 for detecting CI of 3 L/min per m or less. We propose that the OCT substituted for the PtcO₂ index as an accurate alternative method of PtcO₂ for revealing low CI in septic patients.
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Jafari-Saraf L, Wilson SE, Gordon IL. Hyperspectral Image Measurements of Skin Hemoglobin Compared With Transcutaneous PO2 Measurements. Ann Vasc Surg 2012; 26:537-48. [DOI: 10.1016/j.avsg.2011.12.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2011] [Revised: 11/10/2011] [Accepted: 12/05/2011] [Indexed: 11/24/2022]
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Abstract
PURPOSE OF REVIEW The holy grail of circulatory monitoring is an accurate, continuous and relatively noninvasive means of assessing the adequacy of organ perfusion. This could be then advantageously used to direct therapeutic interventions to prevent both under-treatment and over-treatment and thus improve outcomes. However, in view of the heterogeneous response (adaptive or maladaptive) of different organs to various shock states, any monitor of perfusion adequacy cannot reflect every organ system, but should at least detect early deterioration in a 'canary' organ. Tissue oxygen tension reflects the balance between local oxygen supply and demand, and could thus be a potentially useful monitoring modality. This article examines the different technologies available and reviews the current literature regarding its utility as a monitor. RECENT FINDINGS Tissue oxygen tension, measured at a variety of sites in both human and laboratory studies, does appear to be a sensitive indicator of organ perfusion in different shock states. However, responses can vary not only between organs and between different shock states, but also over time. These changes reflect the particular oxygen supply-demand balance present in that tissue bed at that specific time point in the disease process. The response to a dynamic oxygen challenge test provides further information that allows severity to be more readily differentiated. SUMMARY Monitoring of tissue oxygen tension may offer a potentially useful tool for clinical management though significant validation needs to be first performed to confirm its promise.
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Dyson A, Rudiger A, Singer M. Temporal changes in tissue cardiorespiratory function during faecal peritonitis. Intensive Care Med 2011; 37:1192-200. [PMID: 21533572 DOI: 10.1007/s00134-011-2227-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2010] [Accepted: 03/21/2011] [Indexed: 12/23/2022]
Abstract
PURPOSE Sepsis affects both macro- and micro-circulatory transport of oxygen to tissues, causing regional hypoxia. However, this relationship is poorly characterized with respect to inter-organ variability, disease severity and the evolution to organ dysfunction. We hypothesized that an early circulatory insult precedes the development of organ dysfunction, and is more severe in predicted non-survivors. Consequently, we assessed temporal changes in myocardial function and regional tissue oxygenation in peripheral and deep organs in a rat model of faecal peritonitis. We also examined the utility of a dynamic oxygen challenge test to assess the microcirculation. METHODS Awake, tethered, fluid-resuscitated male Wistar rats were randomized to receive intraperitoneal injection of faecal slurry, or to act as controls. At either 6 or 24 h post insult, rats were anaesthetized and underwent echocardiography, arterial cannulation and placement of tissue oxygen probes in peripheral (muscle, bladder) and deep (liver and renal cortex) organ beds. Measurements were repeated during fluid loading and an oxygen challenge test (administration of high oxygen concentrations). RESULTS Early sepsis (6 h) was characterized by a fall in global oxygen delivery with concurrent decreases in muscle, renal cortical and, especially, liver tissue PO2. By contrast, during established sepsis (24 h), myocardial and circulatory function had largely recovered despite increasing clinical unwellness, hyperlactataemia and biochemical evidence of organ failure. O2 challenge revealed an early depression of response that, by 24 h, had improved in all organ beds bar the kidney. CONCLUSIONS This long-term septic model exhibited an early decline in tissue oxygenation, the degree of which related to predicted mortality. Clinical and biochemical deterioration, however, progressed despite cardiovascular recovery. Early circulatory dysfunction may thus be an important trigger for downstream processes that result in multi-organ failure. Furthermore, the utility of tissue PO2 monitoring to highlight the local oxygen supply-demand balance, and dynamic O2 challenge testing to assess microcirculatory function merit further investigation.
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Affiliation(s)
- Alex Dyson
- Bloomsbury Institute of Intensive Care Medicine, Department of Medicine and Wolfson Institute for Biomedical Research, University College London, Cruciform Building, Gower St., London, WC1E 6BT, UK
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Vallée F, Mateo J, Dubreuil G, Poussant T, Tachon G, Ouanounou I, Payen D. Cutaneous ear lobe Pco₂ at 37°C to evaluate microperfusion in patients with septic shock. Chest 2010; 138:1062-70. [PMID: 20472858 DOI: 10.1378/chest.09-2690] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Tissue hypercarbia is related to hypoperfusion and microcirculatory disturbances in patients with septic shock. Transcutaneous Pco₂ devices using a heated sensor to arterialize the tissue have been used as an alternative method for estimation of Paco₂. This study investigates whether a cutaneous sensor attached to an ear lobe and regulated to 37°C could be used to measure cutaneous Pco₂ (Pcco₂) and evaluate microperfusion in patients with septic shock. METHODS Fifteen stable patients in an ICU were studied as a control group. Forty-six patients with septic shock who were ventilated were enrolled as the study group. The difference of the gradients between Pcco₂ and Paco₂ (Pc-aco₂) and between Pcco₂ and end-tidal Pco₂(Pc-etco₂) were evaluated for 36 h. Variations of the Pc-aco₂ and Pc-etco₂ during fluid challenge were compared with microcirculatory skin blood flow (mBFskin) assessed by laser Doppler flowmetry. RESULTS The baseline levels for Pc-aco₂ and Pc-etco₂ were significantly higher in the patients with septic shock than in the control group (14.8 [12.6] vs 6 [2.7] mm Hg and 25 [16.3] vs 9 [3.8] mm Hg, P < .0001, respectively). During the following 36 h, the Pc-aco₂ and Pc-etco₂ for the surviving patients with septic shock decreased significantly compared with the nonsurvivors (P < .01). The evolution of macrohemodynamic parameters showed no differences between survivors and nonsurvivors. At hour 24, a Pc-aco₂ > 16 mm Hg and a Pc-etco₂ > 26 mm Hg were related to poor outcome. Pc-aco₂ and Pc-etco₂ variations during fluid challenge were inversely correlated with changes in mBFskin (r² = 0.7). CONCLUSIONS Ear lobe cutaneous Pco₂ at 37°C represents a noninvasive technique to assess tissue Pco₂ measurement. Pc-aco₂ and Pc-etco₂ were related to outcome and provide continuous information on microperfusion in patients with septic shock.
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Affiliation(s)
- Fabrice Vallée
- Département d'Anesthésie- Réanimation-SMUR, Hôpital Lariboisière, 75010, Paris, France.
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Ahmad R, Kuppusamy P. Theory, instrumentation, and applications of electron paramagnetic resonance oximetry. Chem Rev 2010; 110:3212-36. [PMID: 20218670 PMCID: PMC2868962 DOI: 10.1021/cr900396q] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Rizwan Ahmad
- Center for Biomedical EPR Spectroscopy and Imaging, Davis Heart and Lung Research Institute, Department of Internal Medicine, The Ohio State University, Columbus, Ohio 43210, USA
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Dyson A, Stidwill R, Taylor V, Singer M. The impact of inspired oxygen concentration on tissue oxygenation during progressive haemorrhage. Intensive Care Med 2009; 35:1783-91. [DOI: 10.1007/s00134-009-1577-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Accepted: 05/21/2009] [Indexed: 11/28/2022]
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ICS Medal Winners and Research Abstract Presentations. J Intensive Care Soc 2009. [DOI: 10.1177/175114370901000116] [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
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Using transcutaneous oxygen pressure measurements as selection criteria for activated protein C use. ACTA ACUST UNITED AC 2008; 65:30-3. [PMID: 18580526 DOI: 10.1097/ta.0b013e3180eeab28] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Limited resources and the expense of Activated Protein C (APC) (drotrecogin alfa) may contribute to the reluctance to utilize this drug in sepsis. Employing the PROWESS criteria resulted in absolute reduction in 28-day mortality of 6.1%, representing a relative risk reduction of 19.4%. Additional patient categorization and selection may lead to less frequent drug use with the same survival advantage. We used transcutaneous partial pressure of oxygen (PtcO2) as an indicator of microcirculatory perfusion to identify which septic patients may benefit from APC. METHODS Nineteen patients consecutively admitted with severe sepsis or septic shock that fulfilled the PROWESS criteria for APC treatment. APC was administered to patients with the PROWESS selection criteria, only if the PtcO2 information demonstrated tissue ischemia. RESULTS Nineteen patients met the PROWESS criteria. Ten patients demonstrated poor tissue perfusion using PtcO2 monitors and received APC. Nine patients had adequate tissue perfusion and did not receive APC. There were no differences in age, gender, APACHE II scores, lactate levels, or organ failure between the two groups. The 10 patients who received APC had a mortality of 3 of 10 (30%). The survivors of this group uniformly converted to PtcO2 values consistent with survival within 12 hours to 24 hours of drug administration. The nine patients who did not receive APC had a mortality of 2 of 9 (22%), not statistically significant from those who received the drug (p = 0.89). CONCLUSION Withholding APC did not result in an increase in mortality from severe sepsis in those patients who demonstrated adequate PtcO2 values. The transcutaneous oxygen measurement may be a useful adjuvant in addition to the other selection criteria for better identification of patients who may benefit from APC.
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Nishiguchi BK, Yu M, Suetsugu A, Jiang C, Takiguchi SA, Takanishi DM. Determination of reference ranges for transcutaneous oxygen and carbon dioxide tension and the oxygen challenge test in healthy and morbidly obese subjects. J Surg Res 2008; 150:204-11. [PMID: 18262560 DOI: 10.1016/j.jss.2007.12.775] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2007] [Revised: 10/16/2007] [Accepted: 12/06/2007] [Indexed: 11/30/2022]
Abstract
BACKGROUND Transcutaneous monitoring of oxygen and carbon dioxide tension emerged decades ago as reliable, indirect measurements of arterial pressure of oxygen and carbon dioxide in neonates. Investigators have since found other valuable roles for this modality, particularly in critically ill adults. This investigation was undertaken to further characterize these measurements in normal and in obese adults, who are contributing to a rising proportion of intensive care unit admissions. MATERIALS AND METHODS Transcutaneous sensors were adjusted for barometric pressure and calibrated to reference gases. The following were measured: equilibration time; oxygen saturation; transcutaneous oxygen tension; and transcutaneous carbon dioxide tension on room air and after administering fraction of inspired oxygen of 1.0 for 5 min (Oxygen Challenge Test). RESULTS One hundred three healthy and 47 obese subjects were enrolled. Oxygen Challenge Test values were 131.5 +/- 57.4 and 171.6 +/- 65.9 mm Hg for obese and healthy subjects, respectively (P value <0.001). Smoking status, respiratory rate, and transcutaneous oxygen tension on room air best predicted the Oxygen Challenge Test response. A negative correlation was found between transcutaneous oxygen on room air and the Oxygen Challenge Test versus body mass index (P < 0.001). CONCLUSIONS Reference ranges were determined for transcutaneous oxygen and carbon dioxide tension and the Oxygen Challenge Test in obese and in normal, healthy subjects. Increasing body mass index was associated with a lower baseline transcutaneous oxygen tension, but it was not an independent predictor of the Oxygen Challenge Test response in multivariate analysis.
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Affiliation(s)
- Brian K Nishiguchi
- Department of Surgery and Division of Surgical Critical Care, University of Hawaii, John A. Burns School of Medicine, Honolulu, Hawaii 96813, USA
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Kimberger O, Fleischmann E, Brandt S, Kugener A, Kabon B, Hiltebrand L, Krejci V, Kurz A. Supplemental oxygen, but not supplemental crystalloid fluid, increases tissue oxygen tension in healthy and anastomotic colon in pigs. Anesth Analg 2007; 105:773-9. [PMID: 17717239 DOI: 10.1213/01.ane.0000277490.90387.96] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Low tissue oxygen tension is an important factor leading to the development of wound dehiscence and anastomotic leakage after colon surgery. We tested whether supplemental fluid and supplemental oxygen can increase tissue oxygen tension in healthy and injured, perianastomotic, and anastomotic colon in an acutely instrumented pig model of anastomosis surgery. METHODS Sixteen Swiss Landrace pigs were anesthetized (isoflurane 0.8%-1%) and their lungs ventilated. The animals were randomly assigned to low fluid treatment ("low" group, 3 mL x kg(-1) x h(-1) lactated Ringer's solution) or high fluid treatment ("high" group, 10 mL/kg bolus, 18 mL x kg(-1) x h(-1) lactated Ringer's solution) during colon anastomosis surgery and a subsequent measurement period (4 h). Two-and-half hours after surgery, tissue oxygen tension was recorded for 30 min during ventilation with 30% oxygen. Three hours after surgery, the animals' lungs were ventilated with 100% oxygen for 60 min. Tissue oxygen tension was recorded in the last 30 min. Tissue oxygen tension was measured with polarographic Clark-type electrodes, positioned in healthy colonic wall, close (2 cm) to the anastomosis, and in the anastomosis. RESULTS In every group, tissue oxygen tension during ventilation with 100% oxygen was approximately twice as high as during ventilation with 30% oxygen, a statistically significant result. High or low volume crystalloid fluid treatment had no effect on colon tissue oxygen tension. CONCLUSIONS Supplemental oxygen, but not supplemental crystalloid fluid, increased tissue oxygen tension in healthy, perianastomotic, and anastomotic colon tissue.
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Yu M, Chapital A, Ho HC, Wang J, Takanishi D. A PROSPECTIVE RANDOMIZED TRIAL COMPARING OXYGEN DELIVERY VERSUS TRANSCUTANEOUS PRESSURE OF OXYGEN VALUES AS RESUSCITATIVE GOALS. Shock 2007; 27:615-22. [PMID: 17505300 DOI: 10.1097/shk.0b013e31802f0295] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Transcutaneous pressure of oxygen (PtcO2) correlates with arterial pressure of oxygen (PaO2) in nonshock states, but in shock states, PtcO2 approximates cardiac output with no response to increasing fraction of inspired oxygen (FiO2) and PaO2. An incremental change of more than 21 mmHg in PtcO2 in response to an FiO2 of 1.0 (identified as the oxygen challenge test [OCT]) implies adequate tissue perfusion, and lack of response has been associated with mortality. Patients with severe sepsis and septic shock requiring pulmonary artery catheters were randomized to two groups: the oxygen delivery (DO2) group was treated to a DO2 and mixed venous oxygen saturation goals, and the PtcO2 group was treated to achieve an OCT value of 40 mmHg or more. The DO2 (n = 30) and PtcO2 (n = 39) groups were similar in baseline characteristics. Mortality rate was 12 (40%) of 39 for the DO2 group and 5 (13%) of 39 for the PtcO2 group (P = 0.02). Logistic regression analysis of the statistically significant variables between survivors and nonsurvivors demonstrated that inability to reach the PtcO2 goal at 24 h after resuscitation (T24) and a positive cardiac history are associated with mortality (P < 0.001). The area under the receiver operating curve was 0.824 for the OCT at T24. The best OCT value was 25 mmHg at T24 with positive and negative predictive values of 87% and 90%, respectively. Treating patients with severe sepsis/septic shock to an OCT value of 25 mmHg or more may provide a specific end point of resuscitation that may be associated with better survival than resuscitating to the central hemodynamic parameters of DO2 and mixed venous oxygen saturation.
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Affiliation(s)
- Mihae Yu
- Department of Surgery and Division of Surgical Critical Care, University of Hawaii, Honolulu, Hawaii 96813, USA.
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WHAT'S NEW IN SHOCK, NOVEMBER 2006? Shock 2006. [DOI: 10.1097/01.shk.0000239776.41022.8f] [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]
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