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Köhler D, Voshaar T, Stais P, Haidl P, Dellweg D. Hypoxische, anämische und kardial bedingte Hypoxämie: Wann beginnt die Hypoxie im Gewebe? Dtsch Med Wochenschr 2023; 148:475-482. [PMID: 36990120 DOI: 10.1055/a-2007-5450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
ZusammenfassungBei einer Hypoxämie ist oft der Sauerstoffgehalt noch im unteren Normbereich, sodass keine
Hypoxie im Gewebe vorliegt. Wird die Hypoxie-Schwelle im Gewebe bei einer hypoxisch, anämisch
und auch kardial bedingten Hypoxämie erreicht, kommt es im Zellstoffwechsel, unabhängig von
der Genese, zu identischen Gegenregulationen. Im klinischen Alltag wird diese
pathophysiologische Tatsache mitunter ignoriert, obwohl je nach Hypoxämie-Ursache die
Beurteilung und die Therapie stark unterschiedlich sind. Während für die anämische Hypoxämie
restriktive und allgemein akzeptierte Regeln in den Transfusionsrichtlinien festgelegt sind,
wird bei einer hypoxischen Hypoxie früh die Indikation zu einer meist invasiven Beatmung
gestellt. Die klinische Beurteilung und Indikationsstellung fokussiert dabei auf die Parameter
Sauerstoffsättigung, Sauerstoffpartialdruck und Oxygenierungsindex. Während der
Corona-Pandemie sind Fehlinterpretationen der Pathophysiologie sichtbar geworden und haben
vermutlich zu überflüssigen Intubationen geführt. Für die Behandlung einer hypoxischen Hypoxie
mittels invasiver Beatmung aber gibt es keine Evidenz. Im vorliegenden Review wird auf die
Pathophysiologie der verschiedenen Hypoxieursachen unter besonderer Berücksichtigung der
Intubation und Beatmung auf der Intensivstation eingegangen.
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Abdelwahab HW, Ghanem MS, Haddad AT, Ehab A. Effect of the Fraction of Inspired Oxygen on Intermittent Central Venous Oxygen Saturation Measurements. Open Respir Med J 2022. [DOI: 10.2174/18743064-v16-e2208150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background:
Central venous oxygen saturation (ScvO2) is an essential test readily performed both by medical and nursing personnel in a critical care setting. It gives information on the patient‘s oxygen supply, oxygen consumption, and cardiac output. It plays an important role in early goal-directed treatment.
Objectives:
This study was planned to assess the effect of different fractions of inspired oxygen (FiO2) levels on central venous oxygen saturation for consideration during the evaluation of central venous oxygen saturation.
Methods:
This interventional cross-over study enrolled 60 critically ill, nonmechanically ventilated patients. Blood samples were repeatedly drawn from the distal end of the central venous catheter for blood gas analysis after administration of 30%, 40%, and 50% FIO2 respectively.
Results:
The results showed that increasing FiO2 from 30% to 40% resulted in a mean increase in ScvO2 of 6.2%. While increasing FiO2 from 40% to 50% resulted in a mean increase in ScvO2 of 3.2%. A significant increase in ScvO2 with changes in FiO2 level was recorded among patients in shock or patients with pneumonia (from 30% to 50%, p=0.002 in shock patients and from 30% to 40%, p=0.02 in patients with pneumonia).
Conclusion:
Increasing FiO2 resulted in a substantial rise in ScvO2. ScvO2 changes in response to a therapeutic challenge should be interpreted at constant FiO2 level, especially in patients with pneumonia.
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Ramos M, Tau Anzoategui S. Preoxygenation: from hardcore physiology to the operating room. J Anesth 2022; 36:770-781. [PMID: 36136165 DOI: 10.1007/s00540-022-03105-z] [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: 02/01/2022] [Accepted: 09/08/2022] [Indexed: 10/14/2022]
Abstract
If we define the human body by the mass of the elements that compose it, we could say that we are oxygen and other elements. Oxygen, in addition to being fundamental in our composition, is an element that we constantly need to support cellular respiration and, therefore, life. Interestingly, despite its importance, humans have not developed mechanisms that allow us to store it and, therefore, we are unable to sustain life if we are deprived of ventilation, even for brief periods. Accordingly, the ability to induce the cessation of ventilation in a patient must be accompanied by different technical and non-technical skills that allow the patient's safety to be maintained in this highly vulnerable state. Through the use of basic mathematical tools and comparative physiology, we hereby propose to review the physiological foundations of preoxygenation to understand the reasons behind the clinical recommendations in this field.
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Affiliation(s)
- Matias Ramos
- Department of Anesthesiology, Hospital de Clínicas "José de San Martín", Buenos Aires, Argentina.
| | - Santiago Tau Anzoategui
- Department of Anesthesiology, Hospital de Clínicas "José de San Martín", Buenos Aires, Argentina
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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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Russ M, Steiner E, Boemke W, Busch T, Melzer-Gartzke C, Taher M, Badulak J, Weber-Carstens S, Swenson ER, Francis RC, Pickerodt PA. Extracorporeal Membrane Oxygenation Blood Flow and Blood Recirculation Compromise Thermodilution-Based Measurements of Cardiac Output. ASAIO J 2022; 68:721-729. [PMID: 34860710 PMCID: PMC9067097 DOI: 10.1097/mat.0000000000001592] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The contribution of veno-venous (VV) extracorporeal membrane oxygenation (ECMO) to systemic oxygen delivery is determined by the ratio of total extracorporeal blood flow () to cardiac output (). Thermodilution-based measurements of may be compromised by blood recirculating through the ECMO (recirculation fraction; Rf). We measured the effects of and Rf on classic thermodilution-based measurements of in six anesthetized pigs. An ultrasound flow probe measured total aortic blood flow () at the aortic root. Rf was quantified with the ultrasound dilution technique. was set to 0-125% of and was measured using a pulmonary artery catheter (PAC) in healthy and lung injured animals. PAC overestimated () at all settings compared to . The mean bias between both methods was 2.1 L/min in healthy animals and 2.7 L/min after lung injury. The difference between and increased with an of 75-125%/ compared to QEC <50%/. Overestimation of was highest when resulted in a high Rf. Thus, thermodilution-based measurements can overestimate cardiac output during VV ECMO. The degree of overestimation of depends on the EC/ ratio and the recirculation fraction.
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Affiliation(s)
- Martin Russ
- From the Department of Anesthesiology and Intensive Care Medicine (CCM, CVK); Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Elvira Steiner
- From the Department of Anesthesiology and Intensive Care Medicine (CCM, CVK); Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Willehad Boemke
- From the Department of Anesthesiology and Intensive Care Medicine (CCM, CVK); Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Thilo Busch
- From the Department of Anesthesiology and Intensive Care Medicine (CCM, CVK); Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christoph Melzer-Gartzke
- From the Department of Anesthesiology and Intensive Care Medicine (CCM, CVK); Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Mahdi Taher
- From the Department of Anesthesiology and Intensive Care Medicine (CCM, CVK); Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jenelle Badulak
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington
| | - Steffen Weber-Carstens
- From the Department of Anesthesiology and Intensive Care Medicine (CCM, CVK); Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Erik R. Swenson
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington
- VA Puget Sound Health Care System, Seattle, Washington
| | - Roland C.E. Francis
- From the Department of Anesthesiology and Intensive Care Medicine (CCM, CVK); Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Philipp A. Pickerodt
- From the Department of Anesthesiology and Intensive Care Medicine (CCM, CVK); Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Kittleson MM, Prestinenzi P, Potena L. Right Heart Catheterization in Patients with Advanced Heart Failure: When to Perform? How to Interpret? Heart Fail Clin 2021; 17:647-660. [PMID: 34511212 DOI: 10.1016/j.hfc.2021.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Right heart catheterization is an established cornerstone of advanced heart failure management, as a clear understanding of the patient's hemodynamic status offers insight into diagnosis, prognosis, and management. In this review, the authors will describe the role of right heart catheterization in the diagnosis and management of shock, in the context of left ventricular assist devices, in the assessment of heart transplant candidacy, and also explore future directions of implantable monitoring devices for pulmonary artery and left atrial pressure monitoring.
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Affiliation(s)
- Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai, Los Angeles, CA, USA
| | - Paola Prestinenzi
- Heart Failure and Heart Transplant Program, IRCCS Policlinico di Sant'Orsola, Building 25 via Massarenti, 9, 40138 Bologna, Italy
| | - Luciano Potena
- Heart Failure and Heart Transplant Program, IRCCS Policlinico di Sant'Orsola, Building 25 via Massarenti, 9, 40138 Bologna, Italy.
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Chen H, Xu J, Wang X, Wang Y, Tong F. Early Lactate-Guided Resuscitation of Elderly Septic Patients. J Intensive Care Med 2021; 37:686-692. [PMID: 34184576 DOI: 10.1177/08850666211023347] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Early lactate-guided resuscitation was endorsed in the guidelines of the Surviving Sepsis Campaign as a key strategy to decrease the mortality of patients admitted to the ICU department with septic shock. However, its effectiveness in elderly Asian patients is uncertain. METHOD We conducted a single-center trial to test the effectiveness of the early lactate-guided resuscitation of older Asian patients at the Second Hospital of Hebei Medical University. Eligible septic shock patients who consented to participation in the study were randomly assigned to receive early lactate-guided treatment or regular treatment as controls. RESULT A total of 82 patients met the hyperlactatemia criteria and participated in the trial. Forty-two patients received early lactate-guided treatment (lactate group) and 40 received regular treatment (control group). The lactate group received more fluids at initial 6 hours (3.3 ± 1.4 vs 2.4 ± 1.7 L, P = 0.01), but similar proportions of patients in both groups required the use of vasopressors and vasodilators. Patients in the lactate group showed significantly reduced ICU needs compared to the control group, which were weaned from mechanical ventilation more quickly (median 7, IQR 4 to 14 vs median 9, IQR 4.3 to 17.8, P = 0.02) and transferred out of the ICU earlier (median 4.5, IQR 2.8 to 7.3 vs median 6, IQR 3.2 to 8, P = 0.01). However, the hospital mortality (35.7% vs 42.5%, P = 0.35) and ICU mortality (31.0% vs 37.5%, P = 0.38) for both groups were not reduced. CONCLUSION For critically ill patients (elderly Asian patients) admitted to the ICU department with hyperlactatemia, early lactate-guided treatment reduced ICU needs but did not reduce mortality.
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Affiliation(s)
- Hui Chen
- Department of Intensive Care Unit, 71213The Second Hospital of Hebei Medical University, Hebei Province, China
| | - Jiangqing Xu
- Department of Intensive Care Unit, 71213The Second Hospital of Hebei Medical University, Hebei Province, China
| | - Xia Wang
- Department of Intensive Care Unit, 71213The Second Hospital of Hebei Medical University, Hebei Province, China
| | - Yaxuan Wang
- Department of Urology Surgery, 71213The Second Hospital of Hebei Medical University, Hebei Province, China
| | - Fei Tong
- Department of Intensive Care Unit, 71213The Second Hospital of Hebei Medical University, Hebei Province, China
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Araos J. The unappreciated role of dissolved arterial oxygen on venous oxygen saturation. J Vet Emerg Crit Care (San Antonio) 2019; 29:208-209. [PMID: 30697934 DOI: 10.1111/vec.12807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 01/19/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Joaquin Araos
- Section of Anesthesia, Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Montreal, Saint-Hyacinthe, Quebec, Canada
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Peripheral measurements of venous oxygen saturation and lactate as a less invasive alternative for hemodynamic monitoring. Scand J Trauma Resusc Emerg Med 2018; 26:75. [PMID: 30201000 PMCID: PMC6131814 DOI: 10.1186/s13049-018-0537-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 08/14/2018] [Indexed: 11/18/2022] Open
Abstract
Background Peripheral measurement of venous oxygen saturation and lactate is a less invasive alternative to monitor tissue oxygenation as compared to measurements from a central venous catheter. However, there is a lack of evidence to support the use of peripheral measurements. In this study, we investigated the agreement between central and peripheral venous oxygen saturation and lactate. Methods We conducted a prospective observational study including 115 patients who underwent elective cardiac surgery between April and May 2015 at Rigshospitalet, Copenhagen, Denmark. Measurements were obtained simultaneously at induction of anaesthesia, upon arrival in the ICU and 3–4 h postoperatively. Bias and trending ability was identified using Bland-Altman analysis and a four-quadrant plot. Results Bias was 13.37% for venous oxygen saturation preoperatively (95% CI: 11.52–15.22, LoA: ±19.10, PE: 22.08%), 11.29% at arrival to the ICU (95% CI: 8.81–13.77, LoA: ±25.10, PE: 32.39%) and 16.49% at 3–4 h postoperatively (95% CI: 14.16–18.82, LoA: ±21.20, PE: 26.82%). A four-quadrant plot demonstrated an 89% concordance. Central and peripheral lactate showed a bias of 0.14 mmol/L preoperatively (95% CI: 0.11–0.17, LoA: ±0.30, PE: 32.08%), 0.16 mmol/L at arrival to ICU (95% CI: 0.09–0.23, LoA: ±0.70, PE: 38.88%) and 0.23 mmol/L at 3–4 h postoperatively (95% CI: 0.11–0.35, LoA: ±0.50, 25.18%). Discussion Measurements of peripheral oxygen saturation and lactate may be valuable in an emergency setting, avoiding unnecessary and time consuming application of a CVC. Conclusion We found a high bias but an acceptable trending ability between central and peripheral venous oxygenation. Central and peripheral lactate had excellent agreement. Further studies are necessary to validate the use of peripheral venous samples to identify patients at risk of impaired tissue oxygenation.
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Measurement of Oxygen Consumption Variations in Critically Ill Burns Patients: Are the Fick Method and Indirect Calorimetry Interchangeable? Shock 2018; 48:532-538. [PMID: 28452908 DOI: 10.1097/shk.0000000000000885] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES To evaluate the interchangeability of oxygen consumption variations measured with the Fick equation (ΔVO2Fick) and indirect calorimetry (ΔVO2Haldane) in critically ill burns patients. METHODS Prospective observational single-center study conducted in a university hospital. Twenty-two consecutive burns patients with circulatory insufficiency and hyperlactatemia (>2 mmol/L) who required a fluid challenge (FC) were included. All patients had cardiac output monitoring (transpulmonary thermodilution technique) and were ventilated and sedated. Simultaneous measurements of VO2Fick and VO2Haldane were performed before and immediately after the FC, at rest, and in hemodynamic conditions stabilized for at least 1 h. VO2Fick and VO2Haldane were measured, respectively, with the standard formulae (using arterial and central venous saturation measured with a blood gas analyzer) and with a metabolic monitor. RESULTS Forty-four paired measurements of VO2 were obtained. At each timepoint, the median (interquartile range, 25-75) VO2Haldane values were significantly higher than the median VO2Fick values (126 (103-192) vs. 90 (66-149) mL O2/min/m (P = 0.004) before FC and 129 (105-189) vs. 80 (54-119) mL O2/min/m (P = 0.001) after FC). Correlation between the ΔVO2Fick and the ΔVO2Haldane (%) measurements was poor, with an r = 0.06, (P = 0.77). The mean bias was 8.6% [limits of agreement (LOA): -75.7%, 92.9%]. CONCLUSIONS Analysis of agreement showed poor concordance for the ΔVO2Haldane and the ΔVO2Fick (%) with a low mean bias but large and clinically unacceptable LOA. ΔVO2Haldane and ΔVO2Fick (%) are not interchangeable in these conditions.
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An elevated respiratory quotient predicts complications after cardiac surgery under extracorporeal circulation: an observational pilot study. J Clin Monit Comput 2018; 33:145-153. [DOI: 10.1007/s10877-018-0137-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/31/2018] [Indexed: 01/15/2023]
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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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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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A comparative analysis of the effects of sevoflurane and propofol on cerebral oxygenation during steep Trendelenburg position and pneumoperitoneum for robotic-assisted laparoscopic prostatectomy. J Anesth 2016; 30:949-955. [PMID: 27565964 PMCID: PMC5097119 DOI: 10.1007/s00540-016-2241-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 08/13/2016] [Indexed: 11/17/2022]
Abstract
Purpose Steep Trendelenburg position and pneumoperitoneum during robotic-assisted laparoscopic prostatectomy (RALP) increase intracranial pressure (ICP) and may alter cerebral blood flow (CBF) and oxygenation. Volatile anesthetics and propofol have different effects on ICP, CBF, and cerebral metabolic rate and may have different impact on cerebral oxygenation during RALP. In this study, we measured jugular venous bulb oxygenation (SjO2) and regional oxygen saturation (SctO2) in patients undergoing RALP to evaluate cerebral oxygenation and compared the effects of sevoflurane and propofol. We also verified whether SctO2 may be an alternative to SjO2. Methods Fifty patients scheduled for RALP were randomly assigned to undergo sevoflurane (group S) or propofol (group P) anesthesia. SjO2, SctO2, mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), central venous pressure (CVP), partial pressures of arterial oxygen (PaO2) and carbon dioxide (PaCO2), hemoglobin concentration (Hb), Bispectral Index (BIS) and nasopharyngeal temperature (BT) were recorded 5 min before surgery commencement, 5 min after pneumoperitoneum, 5, 30, 60, 90, and 120 min after pneumoperitoneum in a Trendelenburg position, and after desufflation in a supine position. Results SjO2 was significantly higher in group S than in group P at all measurement points [group S vs. group P: 77 % (11) vs. 65 % (13), mean of all measurement points (1SD); p < 0.01]. Linear regression analysis (β = 0.106; r2 = 0.065; p = 0.004) shows a weak relationship between SjO2 and SctO2. Conclusions Sevoflurane maintains higher SjO2 levels than propofol during RALP. SctO2 does not accurately reflect SjO2.
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Nguyen HB, Jaehne AK, Jayaprakash N, Semler MW, Hegab S, Yataco AC, Tatem G, Salem D, Moore S, Boka K, Gill JK, Gardner-Gray J, Pflaum J, Domecq JP, Hurst G, Belsky JB, Fowkes R, Elkin RB, Simpson SQ, Falk JL, Singer DJ, Rivers EP. Early goal-directed therapy in severe sepsis and septic shock: insights and comparisons to ProCESS, ProMISe, and ARISE. Crit Care 2016; 20:160. [PMID: 27364620 PMCID: PMC4929762 DOI: 10.1186/s13054-016-1288-3] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Prior to 2001 there was no standard for early management of severe sepsis and septic shock in the emergency department. In the presence of standard or usual care, the prevailing mortality was over 40-50 %. In response, a systems-based approach, similar to that in acute myocardial infarction, stroke and trauma, called early goal-directed therapy was compared to standard care and this clinical trial resulted in a significant mortality reduction. Since the publication of that trial, similar outcome benefits have been reported in over 70 observational and randomized controlled studies comprising over 70,000 patients. As a result, early goal-directed therapy was largely incorporated into the first 6 hours of sepsis management (resuscitation bundle) adopted by the Surviving Sepsis Campaign and disseminated internationally as the standard of care for early sepsis management. Recently a trio of trials (ProCESS, ARISE, and ProMISe), while reporting an all-time low sepsis mortality, question the continued need for all of the elements of early goal-directed therapy or the need for protocolized care for patients with severe and septic shock. A review of the early hemodynamic pathogenesis, historical development, and definition of early goal-directed therapy, comparing trial conduction methodology and the changing landscape of sepsis mortality, are essential for an appropriate interpretation of these trials and their conclusions.
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Affiliation(s)
- H. Bryant Nguyen
- />Department of Medicine, Pulmonary and Critical Care Medicine, Loma Linda University, Loma Linda, CA USA
- />Department of Emergency Medicine, Loma Linda University, Loma Linda, CA USA
| | - Anja Kathrin Jaehne
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Quality Assurance, Aspirus Hospital, Iron River, MI USA
| | - Namita Jayaprakash
- />Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN USA
| | - Matthew W. Semler
- />Department of Medicine, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN USA
| | - Sara Hegab
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Angel Coz Yataco
- />Department of Medicine, Pulmonary and Critical Care Medicine, University of Kentucky, Lexington, KY USA
| | - Geneva Tatem
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Dhafer Salem
- />Department of Internal Medicine, Mercy Hospital Medical Center, Chicago, IL USA
| | - Steven Moore
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Kamran Boka
- />Department of Internal Medicine, Division of Critical Care Medicine, University of Texas Health Science Center at Houston, Houston, TX USA
| | - Jasreen Kaur Gill
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Jayna Gardner-Gray
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Jacqueline Pflaum
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Juan Pablo Domecq
- />Department of Internal Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />CONEVID, Conocimiento y Evidencia Research Unit, Universidad Peruana Cayetano Heredia, Lima, PERU
| | - Gina Hurst
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Justin B. Belsky
- />Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Raymond Fowkes
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Ronald B. Elkin
- />Pulmonary and Critical Care Medicine, California Pacific Medical Center, San Francisco, CA USA
| | - Steven Q. Simpson
- />Pulmonary and Critical Care Medicine, University of Kansas, Kansas City, Kansas USA
| | - Jay L. Falk
- />Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida USA
- />University of Central Florida College of Medicine, Orlando, Florida USA
- />University of Florida College of Medicine, Orlando, Florida USA
- />University of South Florida College of Medicine, Orlando, Florida USA
- />Florida State University College of Medicine, Orlando, Florida USA
| | - Daniel J. Singer
- />Department of Surgery, Division of Surgical Critical Care, Icahn School of Medicine, Mount Sinai Hospital,, New York, NY USA
| | - Emanuel P. Rivers
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Surgery, Henry Ford Hospital, Wayne State University, Detroit, MI USA
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16
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Ho KM. Pitfalls in haemodynamic monitoring in the postoperative and critical care setting. Anaesth Intensive Care 2016; 44:14-9. [PMID: 26673584 DOI: 10.1177/0310057x1604400104] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Haemodynamic monitoring is a vital part of daily practice in anaesthesia and intensive care. Although there is evidence to suggest that goal-directed therapy may improve outcomes in the perioperative period, which haemodynamic targets we should aim at to optimise patient outcomes remain elusive and controversial. This review highlights the pitfalls in commonly used haemodynamic targets, including arterial blood pressure, central venous pressure, cardiac output, central venous oxygen saturation and dynamic haemodynamic indices. Evidence suggests that autoregulation in regional organ circulation may change either due to chronic hypertension or different disease processes such as traumatic brain injury, cerebrovascular ischaemia or haemorrhage; this will influence the preferred blood pressure target. Central venous pressure can be influenced by multiple pathophysiological factors and, unless central venous pressure is very low, it is rarely useful as a predictor for fluid responsiveness. Central venous oxygen saturation can be easily increased by a high arterial oxygen tension, making it useless as a surrogate marker of good cardiac output or systemic oxygen delivery in the presence of hyperoxaemia. Many dynamic haemodynamic indices have been reported to predict fluid responsiveness, but they all have their own limitations. There is also insufficient evidence to support that giving fluid until the patient is no longer fluid responsive can improve patient-centred outcomes. With the exception in the context of preventing contrast-induced nephropathy, large randomised controlled studies suggest that excessive fluid treatment may prolong duration of mechanical ventilation without preventing acute kidney injury in the critically ill.
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Affiliation(s)
- K M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia
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17
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Reply to: On the reliability of central venous oxygen saturation as a target in fluid resuscitation. Eur J Anaesthesiol 2015; 32:67. [PMID: 25319503 DOI: 10.1097/eja.0000000000000164] [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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18
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Reply: To PMID 24667613. Shock 2015; 42:279-80. [PMID: 25122084 DOI: 10.1097/shk.0000000000000203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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He HW, Liu DW, Long Y, Wang XT. Mind the influence of arterial oxygen tension on central venous oxygen saturation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:569. [PMID: 25323159 PMCID: PMC4422222 DOI: 10.1186/s13054-014-0569-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Huai-wu He
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 shuaifuyuan, Dongcheng District, Beijing, 100730, China.
| | - Da-wei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 shuaifuyuan, Dongcheng District, Beijing, 100730, China.
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 shuaifuyuan, Dongcheng District, Beijing, 100730, China.
| | - Xiao-ting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 shuaifuyuan, Dongcheng District, Beijing, 100730, China.
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21
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What’s New in Shock? June 2014. Shock 2014. [DOI: 10.1097/shk.0000000000000185] [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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