1
|
Caballer A, Nogales S, Gruartmoner G, Mesquida J. Monitorización hemodinámica en la sepsis y el shock séptico. Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
|
2
|
Caballer A, Nogales S, Gruartmoner G, Mesquida J. [Haemodynamic monitoring in sepsis and septic shock]. Med Intensiva 2022; 46 Suppl 1:38-48. [PMID: 38341259 DOI: 10.1016/j.medine.2022.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/23/2022] [Accepted: 02/26/2022] [Indexed: 02/12/2024]
Abstract
Cardiovascular disturbances associated with sepsis cause hypoperfusion situations, which will negatively impact these patients' prognosis. The aim of haemodynamic monitoring is to guide the detection and correction of this hypoperfusion, and assist in decision making in optimising oxygen transport to tissues, primarily by manipulating cardiac output. This review seeks to summarise the different parameters of haemodynamic monitoring, the objectives of resuscitation, the physiological parameters, and the tools available to us for appropriate cardiac output manipulation.
Collapse
Affiliation(s)
- Alba Caballer
- Àrea de Crítics, Hospital Universitari Parc Taulí, Sabadell, Barcelona, España.
| | - Sara Nogales
- Àrea de Crítics, Hospital Universitari Parc Taulí, Sabadell, Barcelona, España
| | - Guillem Gruartmoner
- Àrea de Crítics, Hospital Universitari Parc Taulí, Sabadell, Barcelona, España
| | - Jaume Mesquida
- Àrea de Crítics, Hospital Universitari Parc Taulí, Sabadell, Barcelona, España
| |
Collapse
|
3
|
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.
Collapse
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.
| |
Collapse
|
4
|
Abstract
PURPOSE OF REVIEW The current article reviews recent findings on the monitoring and hemodynamic support of septic shock patients. RECENT FINDINGS The ultimate goal of hemodynamic resuscitation is to restore tissue oxygenation. A multimodal approach combining global and regional markers of tissue hypoxia seems appropriate to guide resuscitation. Several multicenter clinical trials have provided evidence against an aggressive fluid resuscitation strategy. Fluid administration should be personalized and based on the evidence of fluid responsiveness. Dynamic indices have proven to be highly predictive of responsiveness. Recent data suggest that balanced crystalloids may be associated with less renal failure. When fluid therapy is insufficient, a multimode approach with different types of vasopressors has been suggested as an initial approach. Dobutamine remains the firs inotropic option in patients with persistent hypotension and decrease ventricular systolic function. Calcium sensitizer and phosphodiesterase inhibitors may be considered, but evidence is still limited. Veno-arterial extracorporeal membrane oxygenation may be considered in selected unresponsive patients, particularly with myocardial depression, and in a highly experienced center. SUMMARY Resuscitation should be personalized and based on global and regional markers of tissue hypoxia as well as the fluid responsiveness indices. The beneficial effect of multimode approach with different types of vasopressors, remains to be determined.
Collapse
|
5
|
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.
Collapse
Affiliation(s)
- Jaume Mesquida
- Critical Care Department, Parc Taulí Hospital Universitari. Institut D'Investigació I Innovació Parc Taulí I3PT, 1, 08208, Sabadell, Spain.
| |
Collapse
|
6
|
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.
Collapse
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.
| |
Collapse
|
7
|
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]
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
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.
Collapse
|
10
|
Furuta S, Inouye DS, Hayashi MS, Takanishi DM, Yu M. Blood volume measured by ultrasound and radioisotope dilution in critically ill subjects. J Surg Res 2017; 207:77-84. [DOI: 10.1016/j.jss.2016.08.077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/26/2016] [Accepted: 08/24/2016] [Indexed: 02/08/2023]
|
11
|
|
12
|
Moore J, Dyson A, Singer M, Fraser J. Microcirculatory dysfunction and resuscitation: why, when, and how. Br J Anaesth 2015; 115:366-75. [DOI: 10.1093/bja/aev163] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
|
13
|
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.
Collapse
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
| |
Collapse
|
14
|
Hata RKL, Han L, Slade J, Miyahira A, Passion C, Ghows M, Izumi K, Yu M. Promoting sleep in the adult surgical intensive care unit patients to prevent delirium. Nurs Clin North Am 2014; 49:383-97. [PMID: 25155537 DOI: 10.1016/j.cnur.2014.05.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Ensuring adequate sleep for hospitalized patients is important for reducing stress, improving healing, and decreasing episodes of delirium. The purpose of this project was to implement a Sleep Program for stable patients in the surgical intensive care unit, thereby changing sleep management practices and ensuring quality of care using an evidence-based practice approach. Improving patient satisfaction with sleep by 28 percentage points may be attributed to a standardized process of providing a healing environment for patients to sleep.
Collapse
Affiliation(s)
- Rose K L Hata
- SICU, The Queen's Medical Center, 1301 Punchbowl Street, Honolulu, HI 96813, USA.
| | - Lois Han
- SICU, The Queen's Medical Center, 1301 Punchbowl Street, Honolulu, HI 96813, USA
| | - Jill Slade
- SICU, The Queen's Medical Center, 1301 Punchbowl Street, Honolulu, HI 96813, USA
| | - Asa Miyahira
- SICU, The Queen's Medical Center, 1301 Punchbowl Street, Honolulu, HI 96813, USA
| | - ChristyAnne Passion
- SICU, The Queen's Medical Center, 1301 Punchbowl Street, Honolulu, HI 96813, USA
| | - Maimona Ghows
- SICU, The Queen's Medical Center, 1301 Punchbowl Street, Honolulu, HI 96813, USA
| | - Kara Izumi
- SICU, The Queen's Medical Center, 1301 Punchbowl Street, Honolulu, HI 96813, USA
| | - Mihae Yu
- Surgical Critical Care Fellowship, Department of Surgery, The Queen's Medical Center, University of Hawaii, 1356 Lusitana Street, 6th Floor, Honolulu, HI 96813, USA
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
Greenfield N, Balk RA. Evaluating the adequacy of fluid resuscitation in patients with septic shock: controversies and future directions. Hosp Pract (1995) 2014; 40:147-57. [PMID: 22615089 DOI: 10.3810/hp.2012.04.980] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Fluid resuscitation is a cornerstone in the treatment of severe sepsis and septic shock. However, there is little evidence to guide clinicians in its administration. Current guidelines recommend targeting fluid therapy based on measurements of cardiac filling pressures, such as central venous pressure. Static pressures are poor predictors of a patient's response to fluid. Such response can be better predicted by measuring changes in hemodynamic parameters caused by positive pressure ventilation or maneuvers designed to simulate increased preload. These changes can be measured by analysis of arterial waveforms, echocardiography or Doppler, or with emerging noninvasive technologies. This article reviews the current role of fluid replacement strategies and the use of monitoring systems in the overall resuscitation of patients with severe sepsis and septic shock.
Collapse
Affiliation(s)
- Neal Greenfield
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Rush Medical College, Chicago, IL
| | | |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
|
19
|
Dünser MW, Takala J, Brunauer A, Bakker J. Re-thinking resuscitation: leaving blood pressure cosmetics behind and moving forward to permissive hypotension and a tissue perfusion-based approach. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:326. [PMID: 24103466 PMCID: PMC4056569 DOI: 10.1186/cc12727] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Definitions of shock and resuscitation endpoints traditionally focus on blood pressures and cardiac output. This carries a high risk of overemphasizing systemic hemodynamics at the cost of tissue perfusion. In line with novel shock definitions and evidence of the lack of a correlation between macro- and microcirculation in shock, we recommend that macrocirculatory resuscitation endpoints, particularly arterial and central venous pressure as well as cardiac output, be reconsidered. In this viewpoint article, we propose a three-step approach of resuscitation endpoints in shock of all origins. This approach targets only a minimum individual and context-sensitive mean arterial blood pressure (for example, 45 to 50 mm Hg) to preserve heart and brain perfusion. Further resuscitation is exclusively guided by endpoints of tissue perfusion irrespectively of the presence of arterial hypotension ('permissive hypotension'). Finally, optimization of individual tissue (for example, renal) perfusion is targeted. Prospective clinical studies are necessary to confirm the postulated benefits of targeting these resuscitation endpoints.
Collapse
|
20
|
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.
Collapse
|
21
|
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.
Collapse
Affiliation(s)
- Alex Dyson
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, Cruciform Building, Gower St, London, WC1E 6BT, UK.
| | | | | | | | | | | | | | | |
Collapse
|
22
|
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.
Collapse
|
23
|
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.
Collapse
|
24
|
A prospective randomized trial using blood volume analysis in addition to pulmonary artery catheter, compared with pulmonary artery catheter alone, to guide shock resuscitation in critically ill surgical patients. Shock 2011; 35:220-8. [PMID: 20926981 DOI: 10.1097/shk.0b013e3181fc9178] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Measurement of blood volume (BV) may guide fluid and red blood cell management in critically ill patients when capillary leak from shock and fluid resuscitation makes assessment of intravascular volume difficult. This is a prospective randomized trial of critically ill surgical patients with septic shock, severe sepsis, severe respiratory failure, and/or cardiovascular collapse. The control group received fluid management based on pulmonary artery catheter parameters and red blood cell transfusions based on hematocrit values. The BV group received fluid and red blood cell transfusions based on BV analyses in addition to pulmonary artery catheter parameters. Blood volume was measured using the radioisotope tracer technique with iodine 131-labeled albumin. This allowed direct measurement of plasma volume and calculation of the red blood cell volume. The control group was blinded to the BV results. There were statistically significantly more times when the control group (compared with the BV group) demonstrated hypervolemia (48% vs. 37%) and red blood cell deficiency (33% vs. 16%). There was a delay in red blood cell transfusions administered to the control group by 1.5 +/- 2 days at which time the abnormality became clinically evident. Blood volume analyses provided additional information to the clinicians resulting in a change in treatment in 44% of the time to patients randomized to the BV group. The mortality rates were significantly different between the two groups (8% for the BV group and 24% in the control group; P = 0.03). Blood volume measurements allowed the physicians to promptly treat physiologic disturbances in both red blood cell volume and plasma volume, resulting in improved survival.
Collapse
|
25
|
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.
Collapse
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
| | | | | |
Collapse
|
26
|
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.
Collapse
Affiliation(s)
- Fabrice Vallée
- Département d'Anesthésie- Réanimation-SMUR, Hôpital Lariboisière, 75010, Paris, France.
| | | | | | | | | | | | | |
Collapse
|
27
|
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]
|
28
|
The availability of circulating blood volume values alters fluid management in critically ill surgical patients. Am J Surg 2009; 197:232-7. [DOI: 10.1016/j.amjsurg.2008.01.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2007] [Revised: 01/10/2008] [Accepted: 01/10/2008] [Indexed: 11/22/2022]
|
29
|
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
|
30
|
|
31
|
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.
Collapse
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
| | | | | | | | | | | |
Collapse
|
32
|
WHAT'S NEW IN SHOCK, JUNE 2007. Shock 2007. [DOI: 10.1097/shk.0b013e3180546b6b] [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]
|