1
|
Lee GR, Kim HS, Chung YJ, Kim EY. Venous-to-arterial carbon-dioxide tension difference as a useful predictor of patient prognosis after major surgery. Asian J Surg 2024; 47:2152-2160. [PMID: 38238140 DOI: 10.1016/j.asjsur.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/13/2023] [Accepted: 01/05/2024] [Indexed: 05/05/2024] Open
Abstract
PURPOSE Change in venous-to-arterial carbon dioxide partial pressure difference[P(v-a)CO2] could be a useful marker to assess tissue perfusion status. Herein, we assessed the predictive values of postoperative P(v-a)CO2 measurements for mortality in critically ill patients after major surgery. The correlation between P(v-a)CO2 values and other conventional parameters of patient prognosis was also evaluated. METHODS Patients admitted to the intensive care unit(ICU) after abdominal surgery were enrolled. Arterial and venous blood gas analyses were performed within 1 h(T0) and after 24 h(T1) of admission to the ICU, respectively. The relationship between P(v-a)CO2 levels at T1 and other conventional parameters were assessed using a Bland-Altman plot. Logistic regression analysis was performed to examine the predisposing factors of mortality after surgery. RESULTS A total of 231 patients were finally analyzed. We divided the participants into the high PvaCO2 group[P(v-a)CO2 ≥ 8.6] and the low PvaCO2 group[P(v-a)CO2 < 8.6]. Seven-day-, 28-day, and in-hospital mortality were significantly higher in the high PvaCO2 group than in the low PvaCO2 group. There was significant agreement between P(v-a)CO2 values at T1 and APACHE II scores, lactate levels at T1 and total SOFA scores at T1. In multivariate logistic analysis, an increased P(v-a)CO2 value at T1 was the only significant risk factor of 7-day mortality after surgery. [odds ratio:1.341, 95%confidence interval: 1.050-1.714, p=0.019]. CONCLUSION P(v-a)CO2 measurements could be not only a significant predictor of postoperative prognosis, but also a useful surveillance parameter to maintain tissue perfusion after abdominal surgery in patients with a potential risk of fatal complication-related tissue hypoperfusion.
Collapse
Affiliation(s)
- Gyeo Ra Lee
- Division of Trauma and Surgical Critical Care, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hye Sung Kim
- Division of Trauma and Surgical Critical Care, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yoon Ji Chung
- Division of Trauma and Surgical Critical Care, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Eun Young Kim
- Division of Trauma and Surgical Critical Care, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
| |
Collapse
|
2
|
Zhang Y, Zhou R. A review of using CO 2-derived variables to detect tissue hypoperfusion during cardiopulmonary bypass. Perfusion 2024; 39:445-451. [PMID: 36734648 DOI: 10.1177/02676591221151028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Complications after cardiac surgery with cardiopulmonary bypass (CPB) are associated with increased morbidity and mortality. Early detection and prompt reversion of tissue hypoperfusion during CPB are key factors to reduce organ dysfunction after cardiac surgery. CO2 (carbon dioxide)-derived variables which are easy to assess and routinely available to evaluate the adequacy of macro- and microcirculation may offer important information on the adequacy of the perfusion during CPB. However, since some practical issues remain unsolved in providing a reliable measurement of CO2 removal from the patient, CO2-derived variables are not widely monitoring during CPB. This review aims to demonstrate the basic principles of CO2-derived variables during CPB, the available techniques to assess CO2-derived variables on CPB and the clinically relevant applications.
Collapse
Affiliation(s)
- Yan Zhang
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Ronghua Zhou
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| |
Collapse
|
3
|
Ravisankar NP. Venoarterial Partial Pressure of Carbon Dioxide Difference: Let's Trend It! Indian J Crit Care Med 2024; 28:323-325. [PMID: 38585313 PMCID: PMC10998510 DOI: 10.5005/jp-journals-10071-24695] [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] [Indexed: 04/09/2024] Open
Abstract
How to cite this article: Ravisankar NR. Venoarterial Partial Pressure of Carbon Dioxide Difference: Let's Trend It! Indian J Crit Care Med 2024;28(4):323-325.
Collapse
Affiliation(s)
- Natesh Prabu Ravisankar
- Department of Critical Care Medicine, St John's Medical College Hospital, Bengaluru, Karnataka, India
| |
Collapse
|
4
|
Sánchez Díaz JS, Peniche Moguel KG, Reyes-Ruiz JM, Pérez Nieto OR, Escarramán Martínez D, Zamarrón López EI, Calyeca Sánchez MV. The ∆Pv-aCO2/∆Ca-vO2 ratio as a predictor of mortality in patients with severe acute respiratory distress syndrome related to COVID-19. PLoS One 2023; 18:e0290272. [PMID: 37672537 PMCID: PMC10482256 DOI: 10.1371/journal.pone.0290272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 08/05/2023] [Indexed: 09/08/2023] Open
Abstract
OBJECTIVE To evaluate the central venous-to-arterial carbon dioxide difference combined with arterial-to-venous oxygen content difference (∆Pv-aCO2/∆Ca-vO2 ratio) as a predictor of mortality in patients with COVID-19-related severe acute respiratory distress syndrome (ARDS). METHODS Patients admitted to the intensive care unit with severe ARDS secondary to SARS-CoV-2, and invasive mechanical ventilation were included in this single-center and retrospective cohort study performed between April 18, 2020, and January 18, 2022. The tissue perfusion indexes (lactate, central venous oxygen saturation [ScvO2], and venous-to-arterial carbon dioxide pressure difference [∆Pv-aCO2]), anaerobic metabolism index (∆Pv-aCO2/∆Ca-vO2 ratio), and severity index (Simplified Acute Physiology Score II [SAPSII]) were evaluated to determine its association with the mortality through Cox regression analysis, Kaplan-Meier curve and receiver operating characteristic (ROC) curve. RESULTS One hundred fifteen patients were included in the study and classified into two groups, the survivor group (n = 54) and the non-survivor group (n = 61). The lactate, ScvO2, ∆Pv-aCO2, and ∆Pv-aCO2/∆Ca-vO2 ratio medians were 1.6 mEq/L, 75%, 5 mmHg, and 1.56 mmHg/mL, respectively. The ∆Pv-aCO2/∆Ca-vO2 ratio (Hazard Ratio (HR) = 1.17, 95% confidence interval (CI) = 1.06-1.29, p = 0.001) was identified as a mortality biomarker for patients with COVID-19-related severe ARDS. The area under the curve for ∆Pv-aCO2/∆Ca-vO2 ratio was 0.691 (95% CI 0.598-0.774, p = 0.0001). The best cut-off point for ∆Pv-aCO2/∆Ca-vO2 ratio was >2.14 mmHg/mL, with a sensitivity of 49.18%, specificity of 85.19%, a positive likelihood of 3.32, and a negative likelihood of 0.6. The Kaplan-Meier curve showed that survival rates were significantly worse in patients with values greater than this cut-off point. CONCLUSIONS The ∆Pv-aCO2/∆Ca-vO2 ratio could be used as a predictor of mortality in patients with severe ARDS secondary to SARS-CoV-2.
Collapse
Affiliation(s)
- Jesús Salvador Sánchez Díaz
- Critical Care Department, Unidad Médica de Alta Especialidad, Hospital de Especialidades No. 14, Centro Médico Nacional “Adolfo Ruiz Cortines”, Instituto Mexicano del Seguro Social (IMSS), Veracruz, Mexico
| | - Karla Gabriela Peniche Moguel
- Critical Care Department, Unidad Médica de Alta Especialidad, Hospital de Especialidades No. 14, Centro Médico Nacional “Adolfo Ruiz Cortines”, Instituto Mexicano del Seguro Social (IMSS), Veracruz, Mexico
| | - José Manuel Reyes-Ruiz
- Department of Health Research, Unidad Médica de Alta Especialidad, Hospital de Especialidades No. 14, Centro Médico Nacional “Adolfo Ruiz Cortines”, Instituto Mexicano del Seguro Social (IMSS), Veracruz, Mexico
| | | | - Diego Escarramán Martínez
- Department of Anesthesiology, Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social (IMSS), Mexico City, Mexico
| | - Eder Iván Zamarrón López
- Critical Care Department, Hospital General Regional No. 6, Instituto Mexicano del Seguro Social (IMSS), Ciudad Madero, Tamaulipas, Mexico
| | - María Verónica Calyeca Sánchez
- Critical Care Department, Unidad Médica de Alta Especialidad, Hospital de Especialidades No. 14, Centro Médico Nacional “Adolfo Ruiz Cortines”, Instituto Mexicano del Seguro Social (IMSS), Veracruz, Mexico
| |
Collapse
|
5
|
Bouchacourt JP, Hurtado FJ, Kohn E, Illescas L, Dubin A, Riva JA. Role of Pv-aCO 2 gradient and Pv-aCO 2/Ca-vO 2 ratio during cardiac surgery: a retrospective observational study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2023; 73:611-619. [PMID: 34407454 PMCID: PMC10533982 DOI: 10.1016/j.bjane.2021.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 07/27/2021] [Accepted: 07/29/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Arterial lactate, mixed venous O2 saturation, venous minus arterial CO2 partial pressure (Pv-aCO2) and the ratio between this gradient and the arterial minus venous oxygen content (Pv-aCO2/Ca-vO2) were proposed as markers of tissue hypoperfusion and oxygenation. The main goals were to characterize the determinants of Pv-aCO2 and Pv-aCO2/Ca-vO2, and the interchangeability of the variables calculated from mixed and central venous samples. METHODS 35 cardiac surgery patients were included. Variables were measured or calculated: after anesthesia induction (T1), end of surgery (T2), and at 6...8.ßhours intervals after ICU admission (T3 and T4). RESULTS Macrohemodynamics was characterized by increased cardiac index and low systemic vascular resistances after surgery (p.ß<.ß0.05). Hemoglobin, arterial-pH, lactate, and systemic O2 metabolism showed significant changes during the study (p.ß<.ß0.05). Pv-aCO2 remained high and without changes, Pv-aCO2/Ca-vO2 was also high and decreased at T4 (p.ß<.ß0.05). A significant correlation was observed globally and at each time interval, between Pv-aCO2 or Pv-aCO2/Ca-vO2 with factors that may affect the CO2 hemoglobin dissociation. A multilevel linear regression model with Pv-aCO2 and Pv-aCO2/Ca-vO2 as outcome variables showed a significant association for Pv-aCO2 with SvO2, and BE (p.ß<.ß0.05), while Pv-aCO2/Ca-vO2 was significantly associated with Hb, SvO2, and BE (p.ß<.ß0.05) but not with cardiac output. Measurements and calculations from mixed and central venous blood were not interchangeable. CONCLUSIONS Pv-aCO2 and Pv-aCO2/Ca-vO2 could be influenced by different factors that affect the CO2 dissociation curve, these variables should be considered with caution in cardiac surgery patients. Finally, central venous and mixed values were not interchangeable.
Collapse
Affiliation(s)
- Juan P Bouchacourt
- Universidad de la Rep..blica, School of Medicine, Hospital de Cl.ínicas, Department of Anesthesiology, Montevid..u, Uruguay
| | - F Javier Hurtado
- Universidad de la Rep..blica, School of Medicine, Department of Pathophysiology, Montevid..u, Uruguay
| | - Eduardo Kohn
- Universidad de la Rep..blica, School of Medicine, Hospital de Cl.ínicas, Department of Anesthesiology, Montevid..u, Uruguay
| | - Laura Illescas
- Universidad de la Rep..blica, School of Medicine, Hospital de Cl.ínicas, Department of Anesthesiology, Montevid..u, Uruguay
| | - Arnaldo Dubin
- Universidad Nacional de La Plata, Facultad de Ciencias M..dicas, C..tedra de Farmacolog.ía Aplicada, Buenos Aires, Argentina
| | - Juan A Riva
- Universidad de la Rep..blica, School of Medicine, Hospital de Cl.ínicas, Department of Anesthesiology, Montevid..u, Uruguay.
| |
Collapse
|
6
|
Wise R, Rodseth R, Párraga-Ros E, Latorre R, López Albors O, Correa-Martín L, M. Sánchez-Margallo F, Eugenia Candanosa-Aranda I, Poelaert J, Castellanos G, L. N. G. Malbrain M. The pathophysiological impact of intra-abdominal hypertension in pigs. PLoS One 2023; 18:e0290451. [PMID: 37639437 PMCID: PMC10461824 DOI: 10.1371/journal.pone.0290451] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 08/08/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Intra-abdominal hypertension and abdominal compartment syndrome are common with clinically significant consequences. We investigated the pathophysiological effects of raised IAP as part of a more extensive exploratory animal study. The study design included both pneumoperitoneum and mechanical intestinal obstruction models. METHODS Forty-nine female swine were divided into six groups: a control group (Cr; n = 5), three pneumoperitoneum groups with IAPs of 20mmHg (Pn20; n = 10), 30mmHg (Pn30; n = 10), 40mmHg (Pn40; n = 10), and two mechanical intestinal occlusion groups with IAPs of 20mmHg (MIO20; n = 9) and 30mmHg (MIO30; n = 5). RESULTS There were significant changes (p<0.05) noted in all organ systems, most notably systolic blood pressure (SBP) (p<0.001), cardiac index (CI) (p = 0.003), stroke volume index (SVI) (p<0.001), mean pulmonary airway pressure (MPP) (p<0.001), compliance (p<0.001), pO2 (p = 0.003), bicarbonate (p = 0.041), hemoglobin (p = 0.012), lipase (p = 0.041), total bilirubin (p = 0.041), gastric pH (p<0.001), calculated glomerular filtration rate (GFR) (p<0.001), and urine output (p<0.001). SVV increased progressively as the IAP increased with no obvious changes in intravascular volume status. There were no significant differences between the models regarding their impact on cardiovascular, respiratory, renal and gastrointestinal systems. However, significant differences were noted between the two models at 30mmHg, with MIO30 showing worse metabolic and hematological parameters, and Pn30 and Pn40 showing a more rapid rise in creatinine. CONCLUSIONS This study identified and quantified the impact of intra-abdominal hypertension at different pressures on several organ systems and highlighted the significance of even short-lived elevations. Two models of intra-abdominal pressure were used, with a mechanical obstruction model showing more rapid changes in metabolic and haematological changes. These may represent different underlying cellular and vascular pathophysiological processes, but this remains unclear.
Collapse
Affiliation(s)
- Robert Wise
- Faculty Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Discipline of Anaesthesiology, and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Adult Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, United Kingdom
| | - Reitze Rodseth
- Discipline of Anaesthesiology, and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Ester Párraga-Ros
- Department of Anatomy and Comparative Pathology, Veterinary Faculty, University of Murcia, Murcia, Spain
| | - Rafael Latorre
- Department of Anatomy and Comparative Pathology, Veterinary Faculty, University of Murcia, Murcia, Spain
| | - Octavio López Albors
- Department of Anatomy and Comparative Pathology, Veterinary Faculty, University of Murcia, Murcia, Spain
| | - Laura Correa-Martín
- Laparoscopy Department Jesus Uson Minimally Invasive Surgery Centre, Caceres, Spain
| | | | - Irma Eugenia Candanosa-Aranda
- Highlands Teaching and Research Farm, Faculty of Veterinary Medicine, National Autonomous University of Mexico, Queretaro. Mexico
| | - Jan Poelaert
- Faculty Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Gregorio Castellanos
- Department of General Surgery, Virgen de la Arrixaca General University Hospital, Murcia, Spain
| | - Manu L. N. G. Malbrain
- First Department of Anaesthesiology and Intensive Care Medicine, Medical University of Lublin, Lublin, Poland
- Medical Director (CMO), Medical Data Management, Medaman, Geel, Belgium
- International Fluid Academy, Lovenjoel, Belgium
| |
Collapse
|
7
|
Dubin A, Pozo MO. Venous Minus Arterial Carbon Dioxide Gradients in the Monitoring of Tissue Perfusion and Oxygenation: A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1262. [PMID: 37512072 PMCID: PMC10384777 DOI: 10.3390/medicina59071262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/18/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023]
Abstract
According to Fick's principle, the total uptake of (or release of) a substance by tissues is the product of blood flow and the difference between the arterial and the venous concentration of the substance. Therefore, the mixed or central venous minus arterial CO2 content difference depends on cardiac output (CO). Assuming a linear relationship between CO2 content and partial pressure, central or mixed venous minus arterial PCO2 differences (Pcv-aCO2 and Pmv-aCO2) are directly related to CO. Nevertheless, this relationship is affected by alterations in the CO2Hb dissociation curve induced by metabolic acidosis, hemodilution, the Haldane effect, and changes in CO2 production (VCO2). In addition, Pcv-aCO2 and Pmv-aCO2 are not interchangeable. Despite these confounders, CO is a main determinant of Pcv-aCO2. Since in a study performed in septic shock patients, Pmv-aCO2 was correlated with changes in sublingual microcirculation but not with those in CO, it has been proposed as a monitor for microcirculation. The respiratory quotient (RQ)-RQ = VCO2/O2 consumption-sharply increases in anaerobic situations induced by exercise or critical reductions in O2 transport. This results from anaerobic VCO2 secondary to bicarbonate buffering of anaerobically generated protons. The measurement of RQ requires expired gas analysis by a metabolic cart, which is not usually available. Thus, some studies have suggested that the ratio of Pcv-aCO2 to arterial minus central venous O2 content (Pcv-aCO2/Ca-cvO2) might be a surrogate for RQ and tissue oxygenation. In this review, we analyze the physiologic determinants of Pcv-aCO2 and Pcv-aCO2/Ca-cvO2 and their potential usefulness and limitations for the monitoring of critically ill patients. We discuss compelling evidence showing that they are misleading surrogates for tissue perfusion and oxygenation, mainly because they are systemic variables that fail to track regional changes. In addition, they are strongly dependent on changes in the CO2Hb dissociation curve, regardless of changes in systemic and microvascular perfusion and oxygenation.
Collapse
Affiliation(s)
- Arnaldo Dubin
- Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Cátedras de Terapia Intensiva y Farmacología Aplicada, 60 y 120, La Plata B1902AGW, Argentina
- Servicio de Terapia Intensiva, Sanatorio Otamendi, Azcuénaga 870, Ciudad Autónoma de Buenos Aires C1115AAB, Argentina
| | - Mario O Pozo
- Servicio de Terapia Intensiva, Hospital Británico, Perdriel 74, Ciudad Autónoma de Buenos Aires 1280AEB, Argentina
| |
Collapse
|
8
|
Werner M, Bergis B, Leblanc PE, Wildenberg L, Duranteau J, Vigué B, Harrois A. Femoral blood gas analysis, another tool to assess hemorrhage severity following trauma: an exploratory prospective study. Scand J Trauma Resusc Emerg Med 2023; 31:31. [PMID: 37340485 PMCID: PMC10280927 DOI: 10.1186/s13049-023-01095-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/07/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND Veno-arterial carbon dioxide tension difference (ΔPCO2) and mixed venous oxygen saturation (SvO2) have been shown to be markers of the adequacy between cardiac output and metabolic needs in critical care patients. However, they have hardly been assessed in trauma patients. We hypothesized that femoral ΔPCO2 (ΔPCO2 fem) and SvO2 (SvO2 fem) could predict the need for red blood cell (RBC) transfusion following severe trauma. METHODS We conducted a prospective and observational study in a French level I trauma center. Patients admitted to the trauma room following severe trauma with an Injury Severity Score (ISS) > 15, who had arterial and venous femoral catheters inserted were included. ΔPCO2 fem, SvO2 fem and arterial blood lactate were measured over the first 24 h of admission. Their abilities to predict the transfusion of at least one pack of RBC (pRBCH6) or hemostatic procedure during the first six hours of admission were assessed using receiver operating characteristics curve. RESULTS 59 trauma patients were included in the study. Median ISS was 26 (22-32). 28 patients (47%) received at least one pRBCH6 and 21 patients (35,6%) had a hemostatic procedure performed during the first six hours of admission. At admission, ΔPCO2 fem was 9.1 ± 6.0 mmHg, SvO2 fem 61.5 ± 21.6% and blood lactate was 2.7 ± 1.9 mmol/l. ΔPCO2 fem was significantly higher (11.6 ± 7.1 mmHg vs. 6.8 ± 3.7 mmHg, P = 0.003) and SvO2 fem was significantly lower (50 ± 23 mmHg vs. 71.8 ± 14.1 mmHg, P < 0.001) in patients who were transfused than in those who were not transfused. Best thresholds to predict pRBCH6 were 8.1 mmHg for ΔPCO2 fem and 63% for SvO2 fem. Best thresholds to predict the need for a hemostatic procedure were 5.9 mmHg for ΔPCO2 fem and 63% for SvO2 fem. Blood lactate was not predictive of pRBCH6 or the need for a hemostatic procedure. CONCLUSION In severe trauma patients, ΔPCO2 fem and SvO2 fem at admission were predictive for the need of RBC transfusion and hemostatic procedures during the first six hours of management while admission lactate was not. ΔPCO2 fem and SvO2 fem appear thus to be more sensitive to blood loss than blood lactate in trauma patients, which might be of importance to early assess the adequation of tissue blood flow with metabolic needs.
Collapse
Affiliation(s)
- Marie Werner
- Service d’Anesthésie Réanimation Chirurgicale, DMU 12 Anesthésie Réanimation Chirurgicale Médecine Péri-Opératoire et Douleur, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Équipe DYNAMIC, Inserm UMR_S999, Le Kremlin-Bicêtre, France
| | - Benjamin Bergis
- Service d’Anesthésie Réanimation Chirurgicale, DMU 12 Anesthésie Réanimation Chirurgicale Médecine Péri-Opératoire et Douleur, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Équipe DYNAMIC, Inserm UMR_S999, Le Kremlin-Bicêtre, France
| | - Pierre-Etienne Leblanc
- Service d’Anesthésie Réanimation Chirurgicale, DMU 12 Anesthésie Réanimation Chirurgicale Médecine Péri-Opératoire et Douleur, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
| | - Lucille Wildenberg
- Service d’Anesthésie Réanimation Chirurgicale, DMU 12 Anesthésie Réanimation Chirurgicale Médecine Péri-Opératoire et Douleur, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
| | - Jacques Duranteau
- Service d’Anesthésie Réanimation Chirurgicale, DMU 12 Anesthésie Réanimation Chirurgicale Médecine Péri-Opératoire et Douleur, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Équipe DYNAMIC, Inserm UMR_S999, Le Kremlin-Bicêtre, France
| | - Bernard Vigué
- Service d’Anesthésie Réanimation Chirurgicale, DMU 12 Anesthésie Réanimation Chirurgicale Médecine Péri-Opératoire et Douleur, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
| | - Anatole Harrois
- Service d’Anesthésie Réanimation Chirurgicale, DMU 12 Anesthésie Réanimation Chirurgicale Médecine Péri-Opératoire et Douleur, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Équipe DYNAMIC, Inserm UMR_S999, Le Kremlin-Bicêtre, France
| |
Collapse
|
9
|
Cousin VL, Joye R, Wacker J, Beghetti M, Polito A. Use of CO 2-Derived Variables in Cardiac Intensive Care Unit: Pathophysiology and Clinical Implications. J Cardiovasc Dev Dis 2023; 10:jcdd10050208. [PMID: 37233175 DOI: 10.3390/jcdd10050208] [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: 03/14/2023] [Revised: 04/28/2023] [Accepted: 05/09/2023] [Indexed: 05/27/2023] Open
Abstract
Shock is a life-threatening condition, and its timely recognition is essential for adequate management. Pediatric patients with congenital heart disease admitted to a cardiac intensive care unit (CICU) after surgical corrections are particularly at risk of low cardiac output syndrome (LCOS) and shock. Blood lactate levels and venous oxygen saturation (ScVO2) are usually used as shock biomarkers to monitor the efficacy of resuscitation efforts, but they are plagued by some limitations. Carbon dioxide (CO2)-derived parameters, namely veno-arterial CO2 difference (ΔCCO2) and the VCO2/VO2 ratio, may represent a potentially valuable addition as sensitive biomarkers to assess tissue perfusion and cellular oxygenation and may represent a valuable addition in shock monitoring. These variables have been mostly studied in the adult population, with a strong association between ΔCCO2 or VCO2/VO2 ratio and mortality. In children, particularly in CICU, few studies looked at these parameters, while they reported promising results on the use of CO2-derived indices for patients' management after cardiac surgeries. This review focuses on the physiological and pathophysiological determinants of ΔCCO2 and VCO2/VO2 ratio while summarizing the actual state of knowledge on the use of CO2-derived indices as hemodynamical markers in CICU.
Collapse
Affiliation(s)
- Vladimir L Cousin
- Réanimation Pédiatrique, Women, Child and Adolescent Department, Geneva University Hospital, 1205 Geneva, Switzerland
| | - Raphael Joye
- Pediatric Cardiology Unit, Women, Child and Adolescent Department, Geneva University Hospital, 1205 Geneva, Switzerland
| | - Julie Wacker
- Pediatric Cardiology Unit, Women, Child and Adolescent Department, Geneva University Hospital, 1205 Geneva, Switzerland
| | - Maurice Beghetti
- Pediatric Cardiology Unit, Women, Child and Adolescent Department, Geneva University Hospital, 1205 Geneva, Switzerland
| | - Angelo Polito
- Réanimation Pédiatrique, Women, Child and Adolescent Department, Geneva University Hospital, 1205 Geneva, Switzerland
| |
Collapse
|
10
|
Teboul JL. How to integrate hemodynamic variables during resuscitation of septic shock? JOURNAL OF INTENSIVE MEDICINE 2023; 3:131-137. [PMID: 37188115 PMCID: PMC10175700 DOI: 10.1016/j.jointm.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/09/2022] [Accepted: 09/27/2022] [Indexed: 05/17/2023]
Abstract
Resuscitation of septic shock is a complex issue because the cardiovascular disturbances that characterize septic shock vary from one patient to another and can also change over time in the same patient. Therefore, different therapies (fluids, vasopressors, and inotropes) should be individually and carefully adapted to provide personalized and adequate treatment. Implementation of this scenario requires the collection and collation of all feasible information, including multiple hemodynamic variables. In this review article, we propose a logical stepwise approach to integrate relevant hemodynamic variables and provide the most appropriate treatment for septic shock.
Collapse
|
11
|
Singh G, Pujara J, Trivedi V, Uday DD, Masaniya J, Babu MJ, Bhandari CD. Correlation of venous to arterial carbon dioxide partial pressure difference with other cardiac output indices in patients undergoing intracardiac repair for tetralogy of fallot. Ann Card Anaesth 2023; 26:171-176. [PMID: 37706382 PMCID: PMC10284487 DOI: 10.4103/aca.aca_53_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/15/2022] [Accepted: 06/25/2022] [Indexed: 09/15/2023] Open
Abstract
Background Clearance of tissue carbon dioxide by circulation is measured by venous to arterial carbon dioxide partial pressure difference (AVCO2) and is correlated with cardiac output (CO) in critically ill adult patients. This study aimed to correlate AVCO2 with other CO indices like arteriovenous oxygen saturation difference (AVO2), central venous oxygen saturation (ScVO2), and serum lactate in pediatric patients undergoing intracardiac repair (ICR) for tetralogy of Fallot (TOF). Methods We conducted a prospective observational study in 50 patients, of age 5 months to 5 years, undergoing ICR for TOF and analyzed AVO2, AVCO2, ScVO2, and lactate from arterial and venous blood gas pairs obtained at different time intervals from admission to pediatric intensive care unit (PICU) (T0), at 6 h (T1), 12 h (T2), 24 h (T3), and 48 h (T4) postoperatively. Bivariate correlations were analyzed using Pearson for parametric variables. Results Admission AVCO2 was not correlated with AVO2 (R2 = 0.166, P = 0.246), ScVO2 (R2 = -2.2, P = 0.124), and lactate (R2 = -0.07, P = 0.624). At T1, AVCO2 was correlated with AVO2 (R2 = 0.283, P = 0.0464) but not with ScVO2 (R2 = - 0.25, P = 0.079) and lactate (R2 = -0.07, P = 0.623). At T2, T3 and T4, AVCO2 was correlated with AVO2 (R2 = 0.338,0.440 & 0.318, P = 0.0162, 0.0013, and 0.024), ScVO2 (R2 = - 0.344, - 0.488, and -0.366; P = 0.0143, <0.0001, and 0.017), and lactate (R2 = 0.305, 0.467 and 0.607; P = 0.0314, 0.00062 and <0.0001). AVCO2 was negatively correlated with ScVO2. No correlation observed between admission AVCO2 and mechanical ventilation duration. Two nonsurvivors had higher value of admission AVCO2 compared to survivors. Conclusion AVCO2 is correlated with other CO surrogates like AVO2, ScVO2, and lactate in pediatric patients undergoing ICR for TOF.
Collapse
Affiliation(s)
- Guriqbal Singh
- Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmadabad, Gujarat, India
| | - Jigisha Pujara
- Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmadabad, Gujarat, India
| | - Visharad Trivedi
- Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmadabad, Gujarat, India
| | - Dhawalikar Deepti Uday
- Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmadabad, Gujarat, India
| | - Jyoti Masaniya
- Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmadabad, Gujarat, India
| | - Mittapalli Jeevan Babu
- Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmadabad, Gujarat, India
| | - Chanchal Daulal Bhandari
- Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmadabad, Gujarat, India
| |
Collapse
|
12
|
Lundin A, Annborn M, Borgquist O, Düring J, Undén J, Rylander C. Veno-arterial CO 2 difference and lactate for prediction of early mortality after cardiac arrest. Acta Anaesthesiol Scand 2023; 67:655-662. [PMID: 36867177 DOI: 10.1111/aas.14224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 03/04/2023]
Abstract
Patients admitted to intensive care after cardiac arrest are at risk of circulatory shock and early mortality due to cardiovascular failure. The aim of this study was to evaluate the ability of the veno-arterial pCO2 difference (∆pCO2 ; central venous CO2 - arterial CO2 ) and lactate to predict early mortality in postcardiac arrest patients. This was a pre-planned prospective observational sub-study of the target temperature management 2 trial. The sub-study patients were included at five Swedish sites. Repeated measurements of ∆pCO2 and lactate were conducted at 4, 8, 12, 16, 24, 48, and 72 h after randomization. We assessed the association between each marker and 96-h mortality and their prognostic value for 96-h mortality. One hundred sixty-three patients were included in the analysis. Mortality at 96 h was 17%. During the initial 24 h, there was no difference in ∆pCO2 levels between 96-h survivors and non-survivors. ∆pCO2 measured at 4 h was associated with an increased risk of death within 96 h (adjusted odds ratio: 1.15; 95% confidence interval [CI]: 1.02-1.29; p = .018). Lactate levels were associated with poor outcome over multiple measurements. The area under the receiving operating curve to predict death within 96 h was 0.59 (95% CI: 0.48-0.74) and 0.82 (95% CI: 0.72-0.92) for ∆pCO2 and lactate, respectively. Our results do not support the use of ∆pCO2 to identify patients with early mortality in the postresuscitation phase. In contrast, non-survivors demonstrated higher lactate levels in the initial phase and lactate identified patients with early mortality with moderate accuracy.
Collapse
Affiliation(s)
- Andreas Lundin
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Martin Annborn
- Anesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University, Helsingborg Hospital, Helsingborg, Sweden
| | - Ola Borgquist
- Anaesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Department of Cardiothoracic Surgery, Anaesthesia and Intensive Care, Skane University Hospital, Lund, Sweden
| | - Joachim Düring
- Anaesthesia and Intensive Care, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Malmö, Sweden
| | - Johan Undén
- Operation and Intensive Care, Department of Clinical Sciences Lund, Lund University, Hallands Hospital, Halmstad, Sweden
| | - Christian Rylander
- Anaesthesia and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| |
Collapse
|
13
|
El-Nawawy AA, Hassaan SM, Hassouna HM. Evaluation of Venous-to-Arterial Carbon Dioxide Tension Difference as a Complementary Parameter During Pediatric Septic Shock Resuscitation: A Prospective Observational Study. Pediatr Emerg Care 2022; 38:201-206. [PMID: 35482493 DOI: 10.1097/pec.0000000000002560] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the venous-to-arterial carbon dioxide tension difference during early resuscitation in pediatric septic shock. METHODS A prospective observational study was conducted in the pediatric intensive care unit of a tertiary care teaching. Children having septic shock aged from 3 to 60 months were studied within the first 24 hours of admission. Central venous and peripheral arterial blood samples for blood gases analysis at time of central venous catheter insertion and after 6 hours were obtained. Central venous carbon dioxide pressure, arterial carbon dioxide pressure, and their difference (delta Pco2) were recorded. Patients were categorized, accordingly to delta Pco2 after 6 hours of resuscitation, into high delta Pco2 group (≥6 mm Hg) and low delta Pco2 group (<6 mm Hg). RESULTS Oxygen extraction ratio at 6 hours of resuscitation was significantly lower among the low delta Pco2 group. Arterial lactate showed marked improvement in the low delta Pco2 group to be less than 2 mmol/L at 12 hours of resuscitation. Low delta Pco2 group showed significant higher shock reversal with shorter shock reversal time. Mortality was significantly lower among low delta Pco2 group with shorter pediatric intensive care unit stay. CONCLUSIONS Delta Pco2 after 6 hours of resuscitation of <6 mm Hg indicates normalization of tissue perfusion during pediatric septic shock management. It could be used as a complementary tool to guide the resuscitation in the early phase of pediatric septic shock.
Collapse
Affiliation(s)
- Ahmed Ahmed El-Nawawy
- From the Department of Pediatrics, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | | |
Collapse
|
14
|
Guilherme E, Delignette MC, Pambet H, Lebreton T, Bonnet A, Pradat P, Boucheny C, Guichon C, Aubrun F, Gazon M. PCO 2 gap, its ratio to arteriovenous oxygen content, ScvO2 and lactate in high-risk abdominal surgery patients: An observational study. Anaesth Crit Care Pain Med 2022; 41:101033. [PMID: 35176527 DOI: 10.1016/j.accpm.2022.101033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/28/2021] [Accepted: 11/16/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The difference between arterial and central venous carbon dioxide partial pressure (PCO2 gap), a marker of oxygen delivery (DO2) and oxygen consumption (VO2) adequacy, has been evaluated as a promising prognostic tool in intensive care unit (ICU) patients. We therefore sought to study the association between intraoperative PCO2 gap and postoperative complications (POC) in the perioperative setting of elective major abdominal surgery. METHODS We conducted a single-centre prospective observational study. All adult patients who underwent major planned abdominal surgery were eligible. PCO2 gap was measured every 2 hours during surgery, at ICU admission and repeated 12 hours and 24 hours later. Severe POC within 28 days after surgery were defined as complications graded 3 or more according to Clavien-Dindo classification. Following a univariate analysis, a multivariable analysis using a logistic regression model was performed. RESULTS Ninety patients were included and divided into two groups according to the occurrence of POC. No significant difference was found between groups regarding baseline characteristics at inclusion. Thirty-nine (43%) patients developed postoperative complications. The median [IQR] intraoperative PCO2 gap was significantly higher in patients who had complications (6.5 [5.5-7.3] mmHg) compared to those who did not (5.0 [3.9-5.8] mmHg; p < 0.001). The area under the receiver operating characteristic curve for occurrence of POC was 0.78 for the PCO2 gap. After multivariable analysis, PCO2 gap was found independently associated with POC (OR: 14.9, 95% CI [4.68-60.1], p < 0.001) with a threshold value of 6.2 mmHg. The duration of surgery (OR: 1.01, 95% CI [1.00; 1.01], p = 0.04) and the need for vasoactive support during surgery (OR: 5.76, 95% CI [1.72; 24.1], p = 0.006) were also independently associated with POC. CONCLUSION Intraoperative PCO2 gap is a relevant predictive factor of severe postoperative complications in high-risk elective surgery patients. TRIAL REGISTRATION ClinicalTrials.gov, NCT03914976.
Collapse
Affiliation(s)
- Enrique Guilherme
- Department of Anaesthesiology and Critical Care, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France.
| | - Marie-Charlotte Delignette
- Department of Anaesthesiology and Critical Care, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France
| | - Hadrien Pambet
- Department of Anaesthesiology and Critical Care, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France
| | - Thibault Lebreton
- Department of Anaesthesiology and Critical Care, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France
| | - Aurélie Bonnet
- Department of Anaesthesiology and Critical Care, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France
| | - Pierre Pradat
- Clinical Research Center, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France
| | - Camille Boucheny
- Clinical Research Center, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France
| | - Céline Guichon
- Department of Anaesthesiology and Critical Care, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France
| | - Fréderic Aubrun
- Department of Anaesthesiology and Critical Care, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France; Research on Healthcare Performance (RESHAPE), U1290 - INSERM & Claude Bernard University Lyon 1, France
| | - Mathieu Gazon
- Department of Anaesthesiology and Critical Care, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France
| |
Collapse
|
15
|
Akca HS, Akca H, Yapici N. Effect of delta carbon dioxide and lactate on prognosis in patients undergoing open-heart surgery. Niger J Clin Pract 2022; 25:1398-1404. [DOI: 10.4103/njcp.njcp_1328_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
16
|
Gomez H, Haugaa H, Escobar D, Botero AM, Pool R, Del Rio-Pertuz G, Manrique-Caballero CL, Gordon L, Frank A, Teboul JL, Zuckerbraun BS, Pinsky MR. The Microcirculatory Response to Endotoxemia and Resuscitation Is a Marker of Regional Renal Perfusion, Renal Metabolic Stress, and Tubular Injury. Antioxid Redox Signal 2021; 35:1407-1425. [PMID: 33587005 PMCID: PMC8905304 DOI: 10.1089/ars.2020.8149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Aims: We sought to investigate the relationship between macrohemodynamic resuscitation and microcirculatory parameters with the response of microcirculatory flow, tissue-specific parameters of metabolic stress and injury. We hypothesized that early resuscitation based on macrohemodynamic parameters does not prevent the development of organ dysfunction in a porcine model of endotoxemic shock, and that sublingual microcirculatory parameters are associated with markers of tissue metabolic stress and injury. Results: Both resuscitation groups had significant increases in creatinine and neutrophil gelatinase-associated lipocalin as compared with baseline. Neither the macrovascular response to endotoxemia or resuscitation, nor group allocation predicted the development of acute kidney injury (AKI). Only a microvascular flow index (MFI) <2.5 was associated with the development of renal tubular injury and AKI, and with increased renal, liver, peritoneal, and sublingual lactate/pyruvate (L/P) ratio and lactate. Among systemic parameters, only partial pressure of carbon dioxide (PCO2) gap >6 and P(a-v)CO2/C(v-a)O2 >1.8 were associated with increased organ L/P ratio and AKI. Innovation and Conclusion: Our findings demonstrate that targeting macrohemodynamics to guide resuscitation during endotoxemic shock failed to predict tissue metabolic stress and the response of the microvasculature to resuscitation, and was unsuccessful in preventing tubular injury and AKI. Mechanistically, our data suggest that loss of hemodynamic coherence and decoupling of microvascular flow from tissue metabolic demand during endotoxemia may explain the lack of association between macrohemodynamics and perfusion goals. Finally, we demonstrate that MFI, PCO2 gap, and P(v-a)CO2/C(a-v)O2 ratio outperformed macrohemodynamic parameters at predicting the development of renal metabolic stress and tubular injury, and therefore, that these indices merit further validation as promising resuscitation targets. Antioxid. Redox Signal. 35, 1407-1425.
Collapse
Affiliation(s)
- Hernando Gomez
- Department of Critical Care Medicine, Center for Critical Care Nephrology, The CRISMA Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Håkon Haugaa
- Department of Emergencies and Critical Care, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Nursing, Lovisenberg Diaconal University College, Oslo, Norway
| | - Daniel Escobar
- Department of Obstetrics and Gynecology, Bronx Care Hospital, Bronx, New York, USA
| | - Ana M Botero
- Department of Obstetrics and Gynecology, Staten Island University, Staten Island, New York, USA
| | - Rachel Pool
- Providence-Sacred Heart Medical Center, Spokane, Washington, USA
| | - Gaspar Del Rio-Pertuz
- Department of Critical Care Medicine, Center for Critical Care Nephrology, The CRISMA Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Carlos L Manrique-Caballero
- Department of Critical Care Medicine, Center for Critical Care Nephrology, The CRISMA Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lisa Gordon
- Department of Critical Care Medicine, Center for Critical Care Nephrology, The CRISMA Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alicia Frank
- Department of Critical Care Medicine, Center for Critical Care Nephrology, The CRISMA Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jean-Louis Teboul
- Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Brian S Zuckerbraun
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael R Pinsky
- Department of Critical Care Medicine, Center for Critical Care Nephrology, The CRISMA Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
17
|
Abraham S. PcvCO 2-PaCO 2/CaO 2-CcvO 2 Ratio: The Holy Grail in Resuscitation! Indian J Crit Care Med 2021; 25:1337-1338. [PMID: 35027789 PMCID: PMC8693104 DOI: 10.5005/jp-journals-10071-24062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: Abraham S. PcvCO2-PaCO2/CaO2-CcvO2 Ratio: The Holy Grail in Resuscitation! Indian J Crit Care Med 2021; 25(12):1337-1338.
Collapse
Affiliation(s)
- Shilpa Abraham
- Department of PICU, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
| |
Collapse
|
18
|
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
|
19
|
Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Alexandre Joosten
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Villejuif, France
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
20
|
Ltaief Z, Schneider AG, Liaudet L. Pathophysiology and clinical implications of the veno-arterial PCO 2 gap. Crit Care 2021; 25:318. [PMID: 34461974 PMCID: PMC8407023 DOI: 10.1186/s13054-021-03671-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
Collapse
Affiliation(s)
- Zied Ltaief
- Service of Adult Intensive Care Medicine, Lausanne University Hospital, 1011, Lausanne, Switzerland
| | | | - Lucas Liaudet
- Service of Adult Intensive Care Medicine, Lausanne University Hospital, 1011, Lausanne, Switzerland
- Unit of Pathophysiology, Faculty of Biology and Medicine, University of Lausanne, 1011, Lausanne, Switzerland
| |
Collapse
|
21
|
Central venous-to-arterial PCO 2 difference as a marker to identify fluid responsiveness in septic shock. Sci Rep 2021; 11:17256. [PMID: 34446823 PMCID: PMC8390642 DOI: 10.1038/s41598-021-96806-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/06/2021] [Indexed: 11/24/2022] Open
Abstract
Defining the hemodynamic response to volume therapy is integral to managing critically ill patients with acute circulatory failure, especially in the absence of cardiac index (CI) measurement. This study aimed at investigating whether changes in central venous-to-arterial CO2 difference (Δ-ΔPCO2) and central venous oxygen saturation (ΔScvO2) induced by volume expansion (VE) are reliable parameters to define fluid responsiveness in sedated and mechanically ventilated septic patients. We prospectively studied 49 critically ill septic patients in whom VE was indicated because of circulatory failure and clinical indices. CI, ΔPCO2, ScvO2, and oxygen consumption (VO2) were measured before and after VE. Responders were defined as patients with a > 10% increase in CI (transpulmonary thermodilution) after VE. We calculated areas under the receiver operating characteristic curves (AUCs) for Δ-ΔPCO2, ΔScvO2, and changes in CI (ΔCI) after VE in the whole population and in the subgroup of patients with an increase in VO2 (ΔVO2) ≤ 10% after VE (oxygen-supply independency). Twenty-five patients were fluid responders. In the whole population, Δ-ΔPCO2 and ΔScvO2 were significantly correlated with ΔCI after VE (r = − 0.30, p = 0.03 and r = 0.42, p = 0.003, respectively). The AUCs for Δ-ΔPCO2 and ΔScvO2 to define fluid responsiveness (increase in CI > 10% after VE) were 0.76 (p < 0.001) and 0.68 (p = 0.02), respectively. In patients with ΔVO2 ≤ 10% (n = 36) after VE, the correlation between ΔScvO2 and ΔCI was 0.62 (p < 0.001), and between Δ-ΔPCO2 and ΔCI was − 0.47 (p = 0.004). The AUCs for Δ-ΔPCO2 and ΔScvO2 were 0.83 (p < 0.001) and 0.73 (p = 0.006), respectively. In these patients, Δ-ΔPCO2 ≤ -37.5% after VE allowed the categorization between responders and non-responders with a positive predictive value of 100% and a negative predictive value of 60%. In sedated and mechanically ventilated septic patients with no signs of tissue hypoxia (oxygen-supply independency), Δ-ΔPCO2 is a reliable parameter to define fluid responsiveness.
Collapse
|
22
|
Venous-to-Arterial Carbon Dioxide Partial Pressure Difference: Predictor of Septic Patient Prognosis Depending on Central Venous Oxygen Saturation. Shock 2021; 53:710-716. [PMID: 31490355 DOI: 10.1097/shk.0000000000001442] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This study aimed to assess the viability of using the venous-to-arterial carbon dioxide partial pressure difference (P(v-a)CO2) to predict clinical worsening of septic shock, depending on central venous oxygen saturation (ScvO2). The prospective, observational, multicentric study conducted in three intensive care units (ICUs) included all patients with a septic shock episode during the first 6 h, with 122 patients assessed. Clinical worsening was defined as an increase of sequential organ failure assessment (SOFA) scores ≥1 (ΔSOFA ≥1) within 2 days. To assess the ability of P(v-a)CO2 to predict clinical worsening, univariate and multivariate analyses were performed according to ΔSOFA. A receiver-operating characteristic (ROC) analysis was used to confirm model predictions. Associations between P(v-a)CO2 and mortality were explored using correlations. Using multivariate analyses, two independent factors associated with ΔSOFA at least 1 were identified: an averaged 6-h value of lactate concentration (Lac [1-6]) (odds ratios [ORs], 2.43 [95% confidence interval, CI, 1.20-4.89]; P = 0.013) and an averaged 6-h value of P(v-a)CO2 (P(v-a)CO2 [1-6]) (OR, 1.49 [95% CI, 1.04-2.15]; P = 0.029). ROC analysis confirmed that Lac [1-6] and P(v-a)CO2 [1-6] were significantly associated with ΔSOFA at least 1, whereas ScvO2 [1-6] was not. Finally, ΔSOFA at least 1 was associated with higher 28-day (76% vs. 10%, P = 0.001) and ICU (83% vs. 12%, P = 0.001) mortality rates, which were higher in patients with P(v-a)CO2 [1-6] more than 5.8 mmHg (57% vs. 33%; P = 0.012). In conclusion, P(v-a)CO2 may help predict outcomes for septic shock patients regardless of ScvO2 values.
Collapse
|
23
|
Central Venous-to-Arterial PCO2 Difference and Central Venous Oxygen Saturation in the Detection of Extubation Failure in Critically Ill Patients. Crit Care Med 2021; 48:1454-1461. [PMID: 32520890 DOI: 10.1097/ccm.0000000000004446] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To evaluate the ability of central venous-to-arterial carbon dioxide pressure difference, central venous oxygen saturation, and the combination of these two parameters to detect extubation failure in critically ill patients. DESIGN Multicentric, prospective, observational study. SETTING Three ICUs. PATIENTS All patients who received mechanical ventilation for more than 48 hours and tolerated spontaneous breathing trials with a T-piece for 60 minutes. INTERVENTIONS Extubation after successful spontaneous breathing trials. Extubation failure was defined as the need for mechanical ventilation within 48 hours. MEASUREMENTS AND MAIN RESULTS The oxygen delivery index, oxygen consumption index, central venous oxygen saturation, central venous-to-arterial carbon dioxide pressure difference, and oxygen extraction were measured immediately before spontaneous breathing trials and at 60 minutes after spontaneous breathing trials initiation. Seventy-five patients were enrolled, and extubation failure was noted in 18 (24%) patients. Oxygen consumption index increased significantly during spontaneous breathing trials in the failure group. Oxygen delivery index increased in both success and failure groups. Oxygen extraction increased in the failure group (p = 0.005) and decreased in the success group (p = 0.001). Central venous oxygen saturation decreased in the failure group and increased in the success group (p = 0.014). ΔPCO2 value increased in the extubation failure group and decreased in the success group (p = 0.002). Changes in ΔPCO2 (Δ - ΔPCO2) and central venous oxygen saturation (ΔScvO2) during spontaneous breathing trials were independently associated with extubation failure (odds ratio, 1.02; 95% CI, 1.01-1.05; p = 0.006, and odds ratio, 0.84; 95% CI, 0.70-0.95; p = 0.02, respectively). Δ - ΔPCO2 and central venous oxygen saturation could predict extubation failure with areas under the curve of 0.865 and 0.856, respectively; however, their combined areas under the curve was better at 0.940. CONCLUSIONS We found that Δ - ΔPCO2 and central venous oxygen saturation, during spontaneous breathing trials, were independent predictors of weaning outcomes. Combination analysis of both parameters enhanced their diagnostic performance and provided excellent predictability in extubation failure detection in critically ill patients.
Collapse
|
24
|
Ratio of venous-to-arterial PCO 2 to arteriovenous oxygen content difference during regional ischemic or hypoxic hypoxia. Sci Rep 2021; 11:10172. [PMID: 33986417 PMCID: PMC8119496 DOI: 10.1038/s41598-021-89703-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 04/28/2021] [Indexed: 11/27/2022] Open
Abstract
The purpose of the study was to evaluate the behavior of the venous-to-arterial CO2 tension difference (ΔPCO2) over the arterial-to-venous oxygen content difference (ΔO2) ratio (ΔPCO2/ΔO2) and the difference between venous-to-arterial CO2 content calculated with the Douglas’ equation (ΔCCO2D) over ΔO2 ratio (ΔCCO2D/ΔO2) and their abilities to reflect the occurrence of anaerobic metabolism in two experimental models of tissue hypoxia: ischemic hypoxia (IH) and hypoxic hypoxia (HH). We also aimed to assess the influence of metabolic acidosis and Haldane effects on the PCO2/CO2 content relationship. In a vascularly isolated, innervated dog hindlimb perfused with a pump-membrane oxygenator system, the oxygen delivery (DO2) was lowered in a stepwise manner to decrease it beyond critical DO2 (DO2crit) by lowering either arterial PO2 (HH-model) or flow (IH-model). Twelve anesthetized and mechanically ventilated dogs were studied, 6 in each model. Limb DO2, oxygen consumption (\documentclass[12pt]{minimal}
\usepackage{amsmath}
\usepackage{wasysym}
\usepackage{amsfonts}
\usepackage{amssymb}
\usepackage{amsbsy}
\usepackage{mathrsfs}
\usepackage{upgreek}
\setlength{\oddsidemargin}{-69pt}
\begin{document}$${\dot{\text{V}}\text{O}}_{2}$$\end{document}V˙O2), ΔPCO2/ΔO2, and ΔCCO2D/ΔO2 were obtained every 15 min. Beyond DO2crit, \documentclass[12pt]{minimal}
\usepackage{amsmath}
\usepackage{wasysym}
\usepackage{amsfonts}
\usepackage{amssymb}
\usepackage{amsbsy}
\usepackage{mathrsfs}
\usepackage{upgreek}
\setlength{\oddsidemargin}{-69pt}
\begin{document}$${\dot{\text{V}}\text{O}}_{2}$$\end{document}V˙O2 decreased, indicating dysoxia. ΔPCO2/ΔO2, and ΔCCO2D/ΔO2 increased significantly only after reaching DO2crit in both models. At DO2crit, ΔPCO2/ΔO2 was significantly higher in the HH-model than in the IH-model (1.82 ± 0.09 vs. 1.39 ± 0.06, p = 0.002). At DO2crit, ΔCCO2D/ΔO2 was not significantly different between the two groups (0.87 ± 0.05 for IH vs. 1.01 ± 0.06 for HH, p = 0.09). Below DO2crit, we observed a discrepancy between the behavior of the two indices. In both models, ΔPCO2/ΔO2 continued to increase significantly (higher in the HH-model), whereas ΔCCO2D/ΔO2 tended to decrease to become not significantly different from its baseline in the IH-model. Metabolic acidosis significantly influenced the PCO2/CO2 content relationship, but not the Haldane effect. ΔPCO2/ΔO2 was able to depict the occurrence of anaerobic metabolism in both tissue hypoxia models. However, at very low DO2 values, ΔPCO2/ΔO2 did not only reflect the ongoing anaerobic metabolism; it was confounded by the effects of metabolic acidosis on the CO2–hemoglobin dissociation curve, and then it should be interpreted with caution.
Collapse
|
25
|
Abdalazeem ES, Abdelgawad B, El-Rahman AHA. Role of central venous-arterial PCO 2 difference in prediction of clinical outcome in ICU septic patients. EGYPTIAN JOURNAL OF ANAESTHESIA 2021. [DOI: 10.1080/11101849.2021.1910180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
| | - Basem Abdelgawad
- Cardiothoracic Surgery Departments, Faculty of Medicine, Benha University, Egypt
| | | |
Collapse
|
26
|
Mahrous RSS, Ismail TI. Evaluation of two different fluids regimens on central venous-to-arterial Carbon Dioxide difference (pCO 2 gap) - a randomized controlled trial. EGYPTIAN JOURNAL OF ANAESTHESIA 2021. [DOI: 10.1080/11101849.2021.1896428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Rabab S. S. Mahrous
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Tarek I. Ismail
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Helwan University, Helwan, Egypt
| |
Collapse
|
27
|
Biochemical markers for clinical monitoring of tissue perfusion. Mol Cell Biochem 2021; 476:1313-1326. [PMID: 33387216 PMCID: PMC7921020 DOI: 10.1007/s11010-020-04019-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 12/09/2020] [Indexed: 12/25/2022]
Abstract
The assessment and monitoring of the tissue perfusion is extremely important in critical conditions involving circulatory shock. There is a wide range of established methods for the assessment of cardiac output as a surrogate of oxygen delivery to the peripheral tissues. However, the evaluation of whether particular oxygen delivery is sufficient to ensure cellular metabolic demands is more challenging. In recent years, specific biochemical parameters have been described to indicate the status between tissue oxygen demands and supply. In this review, the authors summarize the application of some of these biochemical markers, including mixed venous oxygen saturation (SvO2), lactate, central venous–arterial carbon dioxide difference (PCO2 gap), and PCO2 gap/central arterial-to-venous oxygen difference (Ca–vO2) for hemodynamic assessment of tissue perfusion. The thorough monitoring of the adequacy of tissue perfusion and oxygen supply in critical conditions is essential for the selection of the most appropriate therapeutic strategy and it is associated with improved clinical outcomes.
Collapse
|
28
|
Wang Z, Wei X, Qin T, Chen S, Liao X, Guo W, Hu P, Wu Y, Li J, Liao Y, Wang S. Prognostic value of central venous-to-arterial carbon dioxide difference in patients with bloodstream infection. Int J Med Sci 2021; 18:929-935. [PMID: 33456350 PMCID: PMC7807196 DOI: 10.7150/ijms.51447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/17/2020] [Indexed: 11/18/2022] Open
Abstract
Background: Bloodstream infection (BSI) are prone to circulation disorders, which portend poor outcome. The central venous-to-arterial carbon dioxide difference (Pcv-aCO2) is a biomarker for circulation disorders, but the prognostic value of Pcv-aCO2 in BSI patients remains unclear. This study was to investigate the association of Pcv-aCO2 with adverse events in BSI patients. Methods: The patients with BSI between August 2014 and August 2017 were prospectively enrolled. Clinical characteristic and laboratory results were collected. We analyzed the association of the level of Pcv-aCO2 with clinical variables and 28-day mortality. Results: A total of 152 patients were enrolled. The Pcv-aCO2 was positively correlated with white blood cell count (r=0.241, p=0.003), procalcitonin (r=0.471, p<0.001), C-reactive protein (r=0.192, p=0.018), lactate (r=0.179, p=0.027), Sequential Organ Failure Assessment (r=0.318, p<0.001) and Acute Physiology And Chronic Health Evaluation II score (r=0.377, p<0.001), while that was negatively correlated with central venous oxygen saturation (r=-0.242, p<0.001) and platelet (r=-0.205, p=0.011). Kaplan-Meier curves demonstrated that patients with Pcv-aCO2 >6mmHg had a worse prognosis than those without (log rank=32.10, p<0.001). Multivariate analysis showed Level of Pcv-aCO2 was an independent risk factor for 28-day mortality (HR: 3.10, 95% CI: 1.43-6.74, p=0.004). The area under the receiver operating characteristic curve of Pcv-aCO2 for prediction of 28-day mortality in patients with BSI was 0.794. Pcv-aCO2>6 mmHg had 81.1% sensitivity and 78.8% specificity for predicting 28-day mortality. Conclusion: Pcv-aCO2 may be a simple and valuable biomarker to assessment of 28-day mortality in patients with BSI.
Collapse
Affiliation(s)
- Zhonghua Wang
- Department of Critical Care Medicine, Guangdong Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, China
| | - Xuebiao Wei
- Department of Critical Care Medicine, Guangdong Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, China
| | - Tiehe Qin
- Department of Critical Care Medicine, Guangdong Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, China
| | - Shenglong Chen
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, China
| | - Xiaolong Liao
- Department of Critical Care Medicine, Guangdong Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, China
| | - Weixin Guo
- Department of Critical Care Medicine, Guangdong Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, China
| | - Peihang Hu
- Department of Critical Care Medicine, Guangdong Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, China
| | - Yan Wu
- Department of Critical Care Medicine, Guangdong Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, China
| | - Jie Li
- Department of Critical Care Medicine, Guangdong Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, China
| | - Youwan Liao
- Department of Critical Care Medicine, Guangdong Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, China
| | - Shouhong Wang
- Department of Critical Care Medicine, Guangdong Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, China
| |
Collapse
|
29
|
Lundin A, Dell'anna AM, Peluso L, Nobile L, Annoni F, Creteur J, Rylander C, Taccone FS. Veno-arterial CO 2 difference and respiratory quotient after cardiac arrest: An observational cohort study. J Crit Care 2020; 62:131-137. [PMID: 33360013 DOI: 10.1016/j.jcrc.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 11/15/2020] [Accepted: 12/02/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE To characterize venous-arterial CO2 difference (ΔpCO2) and the respiratory quotient (RQ) in post cardiac arrest patients and evaluate the association between these parameters and patient outcome. MATERIALS AND METHODS Data were obtained retrospectively from post cardiac arrest patients admitted between 2007 and 2016 to a medical intensive care unit. Comatose, adult patients in whom arterial and venous blood gas analyses were concomitantly performed in the first 24 h were included. Patients were grouped according to the time-point of sampling; 0-6, 6-12 and 12-24 h after admission. RESULTS 308 patients were included; 174 (56%) died before ICU discharge and 212 (69%) had an unfavorable neurologic outcome. RQ was associated with ICU mortality (OR:1.09 (95%CI: 1.04-1.14; p < 0.01)), although not with neurological outcome. ΔpCO2 was negatively associated with both ICU mortality (OR: 0.92 (95%CI: 0.86-0.99; p = 0.02)) and poor neurologic outcome (adjusted OR: 0.93 (95%CI: 0.87-0.99; p = 0.02)). ΔpCO2 predicted an elevated RQ; a ΔpCO2 above 8.5 mmHg identified a high RQ with reasonable sensitivity and specificity. CONCLUSIONS RQ was associated with ICU mortality and ΔpCO2 identified elevated RQ in the early phase after cardiac arrest. However, ΔpCO2 were negatively associated with both ICU mortality and neurologic outcome.
Collapse
Affiliation(s)
- Andreas Lundin
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 423 45 Gothenburg, Sweden.
| | - Antonio Maria Dell'anna
- Department of Intensive Care, Erasme Hospital, Université́ Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Erasme Hospital, Université́ Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Leda Nobile
- Department of Intensive Care, Erasme Hospital, Université́ Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Filippo Annoni
- Department of Intensive Care, Erasme Hospital, Université́ Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université́ Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Christian Rylander
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 423 45 Gothenburg, Sweden
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université́ Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| |
Collapse
|
30
|
Increased ratio of P[v-a]CO 2 to C[a-v]O 2 without global hypoxia: the case of metformin-induced lactic acidosis. Respir Physiol Neurobiol 2020; 285:103586. [PMID: 33202296 DOI: 10.1016/j.resp.2020.103586] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/18/2020] [Accepted: 11/11/2020] [Indexed: 12/24/2022]
Abstract
The ratio of venoarterial CO2 tension to arteriovenous O2 content difference (P[v-a]CO2/C[a-v]O2) increases when lactic acidosis is due to inadequate oxygen supply (hypoxia); we aimed to verify whether it also increases when lactic acidosis develops because of mitochondrial dysfunction (dysoxia) with constant oxygen delivery. Twelve anaesthetised, mechanically ventilated pigs were intoxicated with IV metformin (4.0 to 6.4 g over 2.5 to 4.0 h). Saline and norepinephrine were used to preserve oxygen delivery. Lactate and P[v-a]CO2/C[a-v]O2 were measured every one or two hours (arterial and mixed venous blood). During metformin intoxication, lactate increased from 0.8 (0.6-0.9) to 8.5 (5.0-10.9) mmol/l (p < 0.001), even if oxygen delivery remained constant (from 352 ± 78 to 343 ± 97 ml/min, p = 0.098). P[v-a]CO2/C[a-v]O2 increased from 1.6 (1.2-1.8) to 2.3 (1.9-3.2) mmHg/ml/dl (p = 0.004). The intraclass correlation coefficient between lactate and P[v-a]CO2/C[a-v]O2 was 0.72 (p < 0.001). We conclude that P[v-a]CO2/C[a-v]O2 increases when lactic acidosis is due to dysoxia. Therefore, a high P[v-a]CO2/C[a-v]O2 may not discriminate hypoxia from dysoxia as the cause of lactic acidosis.
Collapse
|
31
|
Corrêa TD, Pereira AJ, Takala J, Jakob SM. Regional venous-arterial CO 2 to arterial-venous O 2 content difference ratio in experimental circulatory shock and hypoxia. Intensive Care Med Exp 2020; 8:64. [PMID: 33119834 PMCID: PMC7596113 DOI: 10.1186/s40635-020-00353-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/22/2020] [Indexed: 01/28/2023] Open
Abstract
Background Venous–arterial carbon dioxide (CO2) to arterial–venous oxygen (O2) content difference ratio (Cv-aCO2/Ca-vO2) > 1 is supposed to be both sensitive and specific for anaerobic metabolism. What regional hemodynamic and metabolic parameters determine the ratio has not been clarified. Objectives To address determinants of systemic and renal, spleen, gut and liver Cv-aCO2/Ca-vO2. Methods Post hoc analysis of original data from published experimental studies aimed to address effects of different fluid resuscitation strategies on oxygen transport, lactate metabolism and organ dysfunction in fecal peritonitis and endotoxin infusion, and from animals in cardiac tamponade or hypoxic hypoxia. Systemic and regional hemodynamics, blood flow, lactate uptake, carbon dioxide and oxygen-derived variables were determined. Generalized estimating equations (GEE) were fit to assess contributors to systemic and regional Cv-aCO2/Ca-vO2. Results Median (range) of pooled systemic Cv-aCO2/Ca-vO2 in 64 pigs was 1.02 (0.02 to 3.84). While parameters reflecting regional lactate exchange were variably associated with the respective regional Cv-aCO2/Ca-vO2 ratios, only regional ratios were independently correlated with systemic ratio: renal Cv-aCO2 /Ca-vO2 (β = 0.148, 95% CI 0.062 to 0.234; p = 0.001), spleen Cv-aCO2/Ca-vO2 (β = 0.065, 95% CI 0.002 to 0.127; p = 0.042), gut Cv-aCO2/Ca-vO2 (β = 0.117, 95% CI 0.025 to 0.209; p = 0.013), liver Cv-aCO2/Ca-vO2 (β = − 0.159, 95% CI − 0.297 to − 0.022; p = 0.023), hepatosplanchnic Cv-aCO2/Ca-vO2 (β = 0.495, 95% CI 0.205 to 0.786; p = 0.001). Conclusion In a mixed set of animals in different shock forms or during hypoxic injury, hepatosplanchnic Cv-aCO2/Ca-vO2 ratio had the strongest independent association with systemic Cv-aCO2/Ca-vO2, while no independent association was demonstrated for lactate or hemodynamic variables.
Collapse
Affiliation(s)
- Thiago Domingos Corrêa
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland. .,Intensive Care Unit, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, 5th floor, São Paulo, 05651-901, Brazil.
| | - Adriano José Pereira
- Intensive Care Unit, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, 5th floor, São Paulo, 05651-901, Brazil.,Research Group, Hospital Municipal da Vila Santa Catarina, São Paulo, Brazil.,Postgraduate Program of Health Sciences, Federal University of Lavras, Lavras, Brazil
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan Mathias Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
32
|
Sánchez-Díaz JS, Peniche-Moguel KG, Rivera-Solís G, Martínez-Rodríguez EA, Del-Carpio-Orantes L, Pérez-Nieto OR, Zamarrón-López EI, Guerrero-Gutiérrez MA, Monares-Zepeda E. Hemodynamic monitoring with two blood gases: “a tool that does not go out of style”. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2020. [DOI: 10.5554/22562087.e928] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction. Hemodynamic monitoring of a critically ill patient is an indispensable tool both inside and outside intensive care; we currently have invasive, minimally invasive and non-invasive devices; however, no device has been shown to have a positive impact on the patient's evolution; arterial and venous blood gases provide information on the patient's actual microcirculatory and metabolic status and may be a hemodynamic monitoring tool.
Objective. To carry out a non-systematic review of the literature of hemodynamic monitoring carried out through the variables obtained in arterial and venous blood gases.
Material and methods. A non-systematic review of the literature was performed in the PubMed, OvidSP and ScienceDirect databases with selection of articles from 2000 to 2019.
Results. It was found that there are variables obtained in arterial and venous blood gases such as central venous oxygen saturation (SvcO2), venous-to-arterial carbon dioxide pressure (∆pv-aCO2), venous-to-arterial carbon dioxide pressure/arteriovenous oxygen content difference (∆pv-aCO2/∆Ca-vO2) that are related to cellular oxygenation, cardiac output (CO), microcirculatory veno-arterial flow and anaerobic metabolism and allow to assess tissue perfusion status.
Conclusion. The variables obtained by arterial and venous blood gases allow for non-invasive, accessible and affordable hemodynamic monitoring that can guide medical decision-making in critically ill patients.
Collapse
|
33
|
High Central Venous-to-Arterial CO2 Difference is Associated With Poor Outcomes in Patients After Cardiac Surgery: A Propensity Score Analysis. Shock 2020; 52:583-589. [PMID: 30724815 DOI: 10.1097/shk.0000000000001324] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE In contrast to arterial lactate, previous studies have proposed central venous-to-arterial CO2 difference (P (v-a)CO2) as a more useful guide for categorizing patients at risk of developing septic shock. It is worthwhile studying P (v-a)CO2 in determining whether it could serve as a useful predictor for poor postoperative outcomes in patients undergoing cardiac surgery. We investigated the ability of P(v-a)CO2 to predict poor outcomes of patients with postoperative cardiogenic shock. METHODS In total, 1,672 patients were enrolled in this study from January 1, 2014 to June 1, 2017. Of these patients, 143 exhibited complicated and poor outcomes. To address any bias, we derived a propensity score predicting the functions of P(v-a)CO2 on poor outcomes and matched 114 cases to 114 controls with a similar risk profile. In this cohort study, poor outcomes were defined as the occurrence of any adverse complications, including sudden death, cardiac arrest, extracorporeal membrane oxygenation, oliguria, and the administration of a large amount of vasoactive-inotropic drugs. RESULTS In propensity-matched patients, significant differences in P(v-a)CO2 (6.11 ± 2.94 mm Hg vs. 11.21 ± 5.22 mm Hg, P < 0.001) were noted between the control group and poor outcome group. The area under the receiver operating characteristic curve of P(v-a)CO2 (AUC: 0.837, 95% CI: 0.782-0.892) for the detection of poor outcomes was significantly better compared to that of the central venous oxygen saturation and arterial lactate. Additionally, there was a negative correlation between cardiac index and P(v-a)CO2 (R= -0.68, P < 0.001). CONCLUSION We have shown a correlation between P(v-a)CO2 to cardiac output which may be used as an alternative metric to predict the poor outcomes of patients with postoperative cardiogenic shock.
Collapse
|
34
|
Prognosis Value of Early Veno Arterial PCO2 Difference in Patients Under Peripheral Veno Arterial Extracorporeal Membrane Oxygenation. Shock 2020; 54:744-750. [DOI: 10.1097/shk.0000000000001554] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
35
|
Waldauf P, Jiroutkova K, Duska F. Using pCO 2 Gap in the Differential Diagnosis of Hyperlactatemia Outside the Context of Sepsis: A Physiological Review and Case Series. Crit Care Res Pract 2019; 2019:5364503. [PMID: 31885914 PMCID: PMC6914888 DOI: 10.1155/2019/5364503] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 10/17/2019] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION There is an inverse relationship between cardiac output and the central venous-arterial difference of partial pressures of carbon dioxide (pCO2 gap), and pCO2 gap has been used to guide early resuscitation of septic shock. It can be hypothesized that pCO2 gap can be used outside the context of sepsis to distinguish type A and type B lactic acidosis and thereby avoid unnecessary fluid resuscitation in patients with high lactate, but without organ hypoperfusion. METHODS We performed a structured review of the literature enlightening the physiological background. Next, we retrospectively selected a series of case reports of nonseptic critically ill patients with elevated lactate, in whom both arterial and central venous blood gases were simultaneously measured and the diagnosis of either type A or type B hyperlactataemia was conclusively known. In these cases, we calculated venous-arterial CO2 and O2 content differences and pCO2 gap. RESULTS Based on available physiological data, pCO2 can be considered as an acceptable surrogate of venous-arterial CO2 content difference, and it should better reflect cardiac output than central venous saturation or indices based on venous-arterial O2 content difference. In our case report of nonseptic patients, we observed that if global hypoperfusion was present (i.e., in type A lactic acidosis), pCO2 gap was elevated (>1 kPa), whilst in the absence of it (i.e., in type B lactic acidosis), pCO2 gap was low (<0.5 kPa). CONCLUSION Physiological rationale and a small case series are consistent with the hypothesis that low pCO2 gap in nonseptic critically ill is suggestive of the absence of tissue hypoperfusion, mandating the search for the cause of type B lactic acidosis rather than administration of fluids or other drugs aimed at increasing cardiac output.
Collapse
Affiliation(s)
- Petr Waldauf
- Department of Anaesthesia and Intensive Care Medicine, The Third Faculty of Medicine, Charles University and FNKV University Hospital, Prague, Czech Republic
| | - Katerina Jiroutkova
- Department of Anaesthesia and Intensive Care Medicine, The Third Faculty of Medicine, Charles University and FNKV University Hospital, Prague, Czech Republic
- Oxylab: Lab of Mitochondrial Physiology, The Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Frantisek Duska
- Department of Anaesthesia and Intensive Care Medicine, The Third Faculty of Medicine, Charles University and FNKV University Hospital, Prague, Czech Republic
- Oxylab: Lab of Mitochondrial Physiology, The Third Faculty of Medicine, Charles University, Prague, Czech Republic
| |
Collapse
|
36
|
Central venous-to-arterial PCO2 difference, arteriovenous oxygen content and outcome after adult cardiac surgery with cardiopulmonary bypass: A prospective observational study. Eur J Anaesthesiol 2019; 36:279-289. [PMID: 30664011 DOI: 10.1097/eja.0000000000000949] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Rapid identification and treatment of tissue hypoxia reaching anaerobiosis (dysoxia) may reduce organ failure and the occurrence of major postoperative complications (MPC) after cardiac surgery. The predictive ability of PCO2-based dysoxia biomarkers, central venous-to-arterial PCO2 difference (ΔPCO2) and ΔPCO2 to arteriovenous oxygen content difference ratio, is poorly studied in this setting. OBJECTIVES We evaluated the ability of PCO2-based tissue dysoxia biomarkers, blood lactate concentration and central venous oxygen saturation measured 2 h after admission to the ICU as predictors of MPC. DESIGN A prospective, observational cohort study. SETTING Single-centre, academic hospital cardiovascular ICU. PATIENTS We included adult patients undergoing cardiac surgery with cardiopulmonary bypass and measured dysoxia biomarkers at ICU admission, and after 2, 6 and 24 h. MAIN OUTCOME MEASURES The primary endpoint was MPC, a composite of cardiac and noncardiac MPC evaluated in the 48 h following surgery. After univariate analysis of MPC covariates including dysoxia biomarkers measured at 2 h, multivariate logistic regression analyses were performed to identify the association of these biomarkers with MPC for confounders. Areas under the receiver operating characteristic curves were determined for biomarkers which remained independently associated with MPC. RESULTS MPC occurred in 56.5% of the 308 patients analysed. ΔPCO2, blood lactate concentration and central venous oxygen saturation measured at 2 h, but not ΔPCO2 to arteriovenous oxygen content difference ratio, were significantly associated with MPC. However, only ΔPCO2 was independently associated with MPC after multivariate analysis. The areas under the receiver operating characteristic curves of ΔPCO2 measured at 2 h for MPC prediction was 0.64 (95% CI 0.57 to 0.70, P < 0.001). CONCLUSION After cardiac surgery with cardiopulmonary bypass, ΔPCO2 measured 2 h after ICU admission was the only dysoxia biomarker independently associated with MPC, but with limited performance. TRIAL REGISTRATION ClinicalTrials.gov, NCT03107572.
Collapse
|
37
|
Buffering Capacity in Sepsis: A Prospective Cohort Study in Critically Ill Patients. J Clin Med 2019; 8:jcm8111759. [PMID: 31652676 PMCID: PMC6912238 DOI: 10.3390/jcm8111759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/18/2019] [Indexed: 11/19/2022] Open
Abstract
Background: The concept of buffering generally refers to the ability of a system/organism to withstand attempted changes. For acid-base balance in particular, it is the body’s ability to limit pH aberrations when factors that potentially affect it change. Buffering is vital for maintaining homeostasis of an organism. The present study was undertaken in order to investigate the probable buffering capacity changes in septic patients. Materials and methods: This prospective cohort study included 113 ICU patients (96 septic and 17 critically-ill non-septic/controls). The buffering capacity indices were assessed upon ICU admission and reassessed only in septic patients, either at improvement or upon severe deterioration. Applying Stewart’s approach, the buffering capacity was assessed with indices calculated from the observed central venous-arterial gradients: a) ΔPCO2/Δ[H+] or ΔpH, b) ΔSID/Δ[H+] or ΔpH. Results: In a generalized estimating equation linear regression model, septic patients displayed significant differences in ΔPCO2/ΔpH [beta coefficient = –47.63, 95% CI (–80.09) – (–15.17), p = 0.004], compared to non-septic patients on admission. Lower absolute value of ΔPCO2/ΔpH (%) on admission was associated with a significant reduction in ICU mortality (HR 0.98, 95% CI: 0.97–0.99, p = 0.02). At septic-group reassessment (remission or deterioration), one-unit increase of ΔPCO2/Δ[H+] reduced the ICU death hazard by 44% (HR 0.56, 95% CI: 0.33–0.96, p = 0.03). Conclusions: In the particular cohort of patients studied, a difference in the buffering capacity was recorded between septic and non-septic patients on admission. Moreover, buffering capacity was an independent predictor of fatal ICU outcome at both assessments, ICU-admission and sepsis remission or deterioration.
Collapse
|
38
|
Abstract
How to cite this article: Patil VP. Mystery of PCO2 Gap in Sepsis. Indian J Crit Care Med 2019;23(10):443-444.
Collapse
Affiliation(s)
- Vijaya P Patil
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| |
Collapse
|
39
|
Cardiogenic Shock Due to End-Stage Heart Failure and Acute Myocardial Infarction: Characteristics and Outcome of Temporary Mechanical Circulatory Support. Shock 2019; 50:167-172. [PMID: 29112104 DOI: 10.1097/shk.0000000000001052] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Mechanical circulatory support (MCS) is increasingly used in cardiogenic shock, but outcomes may differ between patients with acute myocardial infarction (AMI) or end-stage heart failure (ESHF). This study aimed to describe the characteristics of patients with cardiogenic shock due to AMI and ESHF. METHODS Single-center study of consecutive patients with cardiogenic shock due to AMI (n = 26) and ESHF (n = 42) who underwent MCS (extracorporeal life support, Impella or temporary ventricular assist devices). Arterial and venous O2 content and CO2 tension (PCO2), O2-hemoglobin affinity (P50) were measured. Veno-arterial difference in PCO2/arterio-venous difference in O2 content ratio was derived. Acid-base balance was characterized by the Gilfix method. MCS-related complications that required intervention or surgery were collected. RESULTS Patients with ESHF had lower ejection fraction, higher right and left-sided filling pressures, pulmonary artery pressure and vascular resistance, lower oxygen delivery (DO2) compared with AMI, which was not fully compensated by the increased hemoglobin P50. As a result, patients with ESHF had higher veno-arterial difference in PCO2 relative to arterio-venous difference in O2 content. Despite greater anerobic metabolism, patients with ESHF had less severe metabolic acidosis and base deficit compared with AMI, predominantly due to differences in strong ions. CONCLUSION The cardiogenic shock phenotype in ESHF was distinct from AMI, characterized by higher filling and pulmonary artery pressures, lower DO2, greater anaerobic metabolism but less severe metabolic acidosis.
Collapse
|
40
|
Abstract
BACKGROUND Noninvasive evaluation of muscle perfusion using near-infrared spectroscopy (NIRS) coupled with a vascular occlusion test (VOT) may provide an early and simple marker of altered perfusion and microcirculatory function in sepsis. OBJECTIVE The aim of the study was to compare the time-course of NIRS-derived variables with systemic measures of perfusion in an experimental model of peritonitis. METHODS Peritonitis was induced in eight anesthetized, mechanically ventilated, adult sheep (24-34 kg), by injecting autologous feces into the peritoneal cavity. Animals were followed until death or for a maximum of 30 h. Muscle tissue oxygen saturation (StO2) was determined using NIRS on the right posterior leg and arterial VOTs were performed by intermittent intra-aortic balloon inflation. Microdialysis was used to measure muscle lactate and pyruvate levels. RESULTS Muscle StO2 was significantly lower than baseline values from 8 h after sepsis induction, but with considerable intersubject variability. The NIRS VOT ascending (Asc) slope decreased to values <120%/min in most animals from 12 h after sepsis induction. Muscle lactate/pyruvate ratios were higher than baseline from 16 h after sepsis induction. Mixed venous oxygen saturation (SvO2) decreased to <70% and blood lactate levels increased to >2 mmol/L in most of the animals only 24 and 28 h after sepsis induction, respectively. Muscle NIRS StO2 correlated strongly with femoral venous oxygen saturation (r = 0.820) and moderately with SvO2 (r = 0.436). CONCLUSIONS The muscle NIRS Asc slope after a VOT is altered earlier than global markers of tissue hypoperfusion during sepsis. This simple noninvasive test can detect early changes in peripheral perfusion in sepsis.
Collapse
|
41
|
Improving the prognostic value of ∆PCO 2 following cardiac surgery: a prospective pilot study. J Clin Monit Comput 2019; 34:515-523. [PMID: 31292833 PMCID: PMC7223397 DOI: 10.1007/s10877-019-00352-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 07/01/2019] [Indexed: 11/21/2022]
Abstract
Conflicting results have been published on prognostic significance of central venous to arterial PCO2 difference (∆PCO2) after cardiac surgery. We compared the prognostic value of ∆PCO2 on intensive care unit (ICU) admission to an original algorithm combining ∆PCO2, ERO2 and lactate to identify different risk profiles. Additionally, we described the evolution of ∆PCO2 and its correlations with ERO2 and lactate during the first postoperative day (POD1). In this monocentre, prospective, and pilot study, 25 patients undergoing conventional cardiac surgery were included. Central venous and arterial blood gases were collected on ICU admission and at 6, 12 and 24 h postoperatively. High ∆PCO2 (≥ 6 mmHg) on ICU admission was found to be very frequent (64% of patients). Correlations between ∆PCO2 and ERO2 or lactate for POD1 values and variations were weak or non-existent. On ICU admission, a high ∆PCO2 did not predict a prolonged ICU length of stay (LOS). Conversely, a significant increase in both ICU and hospital LOS was observed in high-risk patients identified by the algorithm: 3.5 (3.0–6.3) days versus 7.0 (6.0–8.0) days (p = 0.01) and 12.0 (8.0–15.0) versus 8.0 (8.0–9.0) days (p < 0.01), respectively. An algorithm incorporating ICU admission values of ∆PCO2, ERO2 and lactate defined a high-risk profile that predicted prolonged ICU and hospital stays better than ∆PCO2 alone.
Collapse
|
42
|
Mari A, Nougue H, Mateo J, Vallet B, Vallée F. Transcutaneous PCO 2 monitoring in critically ill patients: update and perspectives. J Thorac Dis 2019; 11:S1558-S1567. [PMID: 31388461 DOI: 10.21037/jtd.2019.04.64] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The physiology of venous and tissue CO2 monitoring has a long and well-established physiological background, leading to the technological development of different tissue capnometric devices, such as transcutaneous capnometry monitoring (TCM). To outline briefly, measuring transcutaneous PCO2 (tcPCO2) depends on at least three main phenomena: (I) the production of CO2 by tissues (VCO2), (II) the removal of CO2 from the tissues by perfusion (wash-out phenomenon), and (III) the reference value of CO2 at tissue inlet represented by arterial CO2 content (approximated by arterial PCO2, or artPCO2). For this reason, there are, at present, roughly two clinical uses for tcPCO2 measurement: a respiratory approach where tcPCO2 is likely to estimate and non-invasively track artPCO2; and a hemodynamic under-estimate use where tcPCO2 can reflect tissue perfusion, summarized by a so-called "tc-art PCO2 gap". Recent research shows that these two uses are not incompatible and could be combined. The spectrum of indications and validation studies in ICUs is summarized in this review to give a survey of the potential applications of TCM in critically ill patients, focusing mainly on its potential (micro)circulatory monitoring contribution. We strongly believe that the greatest benefit of measuring tcPCO2 is not to only to estimate artPCO2, but also to quantify the gap between these two values, which can then help clinicians continuously and noninvasively assess both respiratory and hemodynamic failures in critically ill patients.
Collapse
Affiliation(s)
- Arnaud Mari
- Intensive Care Unit, Hôpital Yves Le Foll, Saint-Brieuc, France
| | - Hélène Nougue
- Department of Anesthesiology and Critical Care, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,UMR-S942, Hôpital Lariboisière, Paris, France.,University of Paris Diderot, Paris, France
| | - Joaquim Mateo
- Department of Anesthesiology and Critical Care, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,UMR-S942, Hôpital Lariboisière, Paris, France.,University of Paris Diderot, Paris, France
| | | | - Fabrice Vallée
- Department of Anesthesiology and Critical Care, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,UMR-S942, Hôpital Lariboisière, Paris, France.,University of Paris Diderot, Paris, France.,MEDISIM, Inria Paris-Saclay, Palaiseau, France
| |
Collapse
|
43
|
Abstract
Tissue hypoperfusion is a major cause of morbidity and mortality in critically ill patients but cannot always be detected by measuring standard whole-body hemodynamic and oxygen-related parameters (e.g., blood pressure, cardiac output, and central venous oxygen saturation). Preclinical and clinical studies have demonstrated that low-flow states are consistently associated with large increases in venous and tissue PCO2. Monitoring regional PCO2 with gastric tonometry (PgCO2) is known to have independent prognostic value for predicting postoperative complications and mortality. The PgCO2 gap might also be of value as a treatment target (endpoint) in critically ill patients. However, this tool has several limitations and has not yet been developed commercially, thus restricting its use. Regional capnography with sublingual and transcutaneous sensors might be an alternative noninvasive option for evaluating the adequacy of tissue perfusion in critically ill patients. However, further studies are needed to determine whether or not this monitoring technique is of value-particularly as an endpoint for guiding resuscitation. Bladder PCO2, has only been evaluated in animal studies, and so remains to be validated in patients.
Collapse
Affiliation(s)
- Stéphane Bar
- Anesthesiology and Critical Care Department, Amiens University Hospital, Amiens, France
| | - Marc-Olivier Fischer
- Normandie Univ, UNICAEN, CHU de Caen Normandie, Service d'Anesthésie Réanimation, Caen, France
| |
Collapse
|
44
|
Huette P, Ellouze O, Abou-Arab O, Guinot PG. Venous-to-arterial pCO 2 difference in high-risk surgical patients. J Thorac Dis 2019; 11:S1551-S1557. [PMID: 31388460 DOI: 10.21037/jtd.2019.01.109] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Alteration of tissue perfusion is a main contributor to organ dysfunction in high-risk surgical patients. The difference between venous carbon dioxide and arterial carbon dioxide pressure (pCO2 gap) has been described as a parameter reflecting tissue hypoperfusion in critically ill patients who are insufficiently resuscitated. The pCO2 gap/CavO2 ratio has also been described as an indicator of the respiratory quotient, thus the relationship between DO2 and VO2. Most of the knowledge about the pCO2 gap and the pCO2 gap/CavO2 ratio has come from studies in the literature on animal models or intensive care unit (ICU) patients. To date, publications pertaining to the operative setting are sparse. In the present review, we will first discuss the physiological background of the pCO2 gap and CO2-O2 derived parameters used in the operating room. Few studies have focused on the clinical relevance of the pCO2 gap in high-risk non-cardiac surgical patients. Prospective observational studies with a small sample size and retrospective studies have shown that the pCO2 gap may be a useful complementary tool to identify patients who remain insufficiently optimized hemodynamically. In a few studies, a high pCO2 gap was associated with postoperative complications following non-cardiac high-risk surgery. Results of observational studies conducted in patients undergoing cardiac surgery are contradictory. We focused on the divergence between non-cardiac surgery, cardiac surgery, and septic critically ill patients. When analyzing the literature, we can find some explanations for the discrepancies in the published results between cardiac and non-cardiac surgery. Finally, we will discuss the clinical utility of the pCO2 gap in high-risk surgical patients.
Collapse
Affiliation(s)
- Pierre Huette
- Anaesthesiology and Critical Care Department, Cardiothoracic ICU, Amiens University Hospital, Amiens, France
| | - Omar Ellouze
- Anaesthesiology and Critical Care Department, Cardiovascular ICU, Dijon University Hospital, Dijon, France
| | - Osama Abou-Arab
- Anaesthesiology and Critical Care Department, Cardiothoracic ICU, Amiens University Hospital, Amiens, France
| | - Pierre-Grégoire Guinot
- Anaesthesiology and Critical Care Department, Cardiovascular ICU, Dijon University Hospital, Dijon, France
| |
Collapse
|
45
|
Yuan S, He H, Long Y. Interpretation of venous-to-arterial carbon dioxide difference in the resuscitation of septic shock patients. J Thorac Dis 2019; 11:S1538-S1543. [PMID: 31388458 DOI: 10.21037/jtd.2019.02.79] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The venous-to-arterial carbon dioxide difference [P(v-a)CO2] was calculated from the difference of venous CO2 and arterial CO2, which has been used to reflect the global flow in the circulatory shock. Moreover, recent clinical studies found the P(v-a)CO2 was related to the sublingual microcirculation perfusion in the sepsis. However, it is still controversial that whether P(v-a)CO2 could be used to assess the microcirculatory flow in septic patients. Moreover, the related influent factors should be taken into account when interpreting P(v-a)CO2 in clinical practice. This paper reviews the relevant experimental and clinical scenarios of P(v-a)CO2 with the aim to help intensivists to use this parameter in the resuscitation of septic shock patients. Furthermore, we propose a conceptual framework to manage a high P(v-a)CO2 value in the resuscitation of septic shock. The triggers of correcting an elevated P(v-a)CO2 should take into consideration the other tissue perfusion parameters. Additionally, more evidence is required to validate that a decreasing in P(v-a)CO2 by increasing cardiac output would result in improvement of microcirculation. Further investigations are necessary to clarify the relationship between P(v-a)CO2 and microcirculation.
Collapse
Affiliation(s)
- Siyi Yuan
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing 100730, China
| | - Huaiwu He
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing 100730, China
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing 100730, China
| |
Collapse
|
46
|
Gavelli F, Teboul JL, Monnet X. How can CO 2-derived indices guide resuscitation in critically ill patients? J Thorac Dis 2019; 11:S1528-S1537. [PMID: 31388457 DOI: 10.21037/jtd.2019.07.10] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Assessing the adequacy of oxygen delivery with oxygen requirements is one of the key-goal of haemodynamic resuscitation. Clinical examination, lactate and central or mixed venous oxygen saturation (SvO2 and ScvO2, respectively) all have their limitations. Many of them may be overcome by the use of the carbon dioxide (CO2)-derived variables. The venoarterial difference in CO2 tension ("ΔPCO2" or "PCO2 gap") is not an indicator of anaerobic metabolism since it is influenced by the oxygen consumption. By contrast, it reliably indicates whether blood flow is sufficient to carry CO2 from the peripheral tissue to the lungs in view of its clearance: it, thus, reflects the adequacy of cardiac output with the metabolic condition. The ratio of the PCO2 gap with the arteriovenous difference of oxygen content (PCO2 gap/Ca-vO2) might be a marker of anaerobiosis. Conversely to SvO2 and ScvO2, it remains interpretable if the oxygen extraction is impaired as it is in case of sepsis. Compared to lactate, it has the main advantage to change without delay and to provide a real-time monitoring of tissue hypoxia.
Collapse
Affiliation(s)
- Francesco Gavelli
- Service de médecine intensive-réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Le Kremlin-Bicêtre, France.,Université Paris-Sud, Faculté de médecine Paris-Sud, Inserm UMR S_999, Le Kremlin-Bicêtre, France.,Emergency Medicine Unit, Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Novara, Italy
| | - Jean-Louis Teboul
- Service de médecine intensive-réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Le Kremlin-Bicêtre, France.,Université Paris-Sud, Faculté de médecine Paris-Sud, Inserm UMR S_999, Le Kremlin-Bicêtre, France
| | - Xavier Monnet
- Service de médecine intensive-réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Le Kremlin-Bicêtre, France.,Université Paris-Sud, Faculté de médecine Paris-Sud, Inserm UMR S_999, Le Kremlin-Bicêtre, France
| |
Collapse
|
47
|
Nassar B, Mallat J. Usefulness of venous-to-arterial partial pressure of CO 2 difference to assess oxygen supply to demand adequacy: effects of dobutamine. J Thorac Dis 2019; 11:S1574-S1578. [PMID: 31388463 DOI: 10.21037/jtd.2019.04.85] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The central venous O2 saturation value and lactic acid levels are part of the diagnostic and therapeutic work up of patients in shock. These usual indicators of tissue hypoxia don't fully describe the adequacy of tissue perfusion. There is ample evidence that supplementing this data with the venous-to-arterial partial pressure of CO2 (PCO2) difference (ΔPCO2) complements the clinician's tools when treating patients with shock. Based on a modified Fick equation as it applies to CO2, in patients in a steady state, the ΔPCO2 reflects the cardiac output (CO). This observation has been shown to be of clinical value in resuscitating patients in shock. Moreover, the ΔPCO2 can be used to titrate inotropes, and differentiate the hemodynamic from the metabolic effect of dobutamine.
Collapse
Affiliation(s)
- Boulos Nassar
- Department of Critical Care Medicine, Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE.,Pulmonary and Critical Care Division, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Jihad Mallat
- Department of Critical Care Medicine, Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| |
Collapse
|
48
|
Zante B, Reichenspurner H, Kubik M, Schefold JC, Kluge S. Increased admission central venous-arterial CO 2 difference predicts ICU-mortality in adult cardiac surgery patients. Heart Lung 2019; 48:421-427. [PMID: 31200923 DOI: 10.1016/j.hrtlng.2019.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 05/26/2019] [Accepted: 05/29/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Invasive procedures such as cardiac surgery are associated with perioperative dysfunction of macrocirculation and/or microcirculation and organ failures. Maintenance or resuscitation of an adequate macrocirculation and/or microcirculation is thus crucial in patients after cardiac surgery. We investigated the prognostic power of early central venous-arterial carbon dioxide pressure difference (delta-pCO2) after cardiac surgery. METHODS Retrospective analysis of data from 1,019 cardiac surgery patients treated in the ICU of a tertiary medical care academic center. Clinical outcomes and laboratory measures including metabolic indices and calculated delta-pCO2 were assessed. Receiver operating characteristic (ROC) curves were generated and sensitivity / specificity analysis was performed. Univariate and multivariate regression models were analyzed. RESULTS The area under the ROC curve for delta-pCO2 to predict ICU mortality was 0.72 (sensitivity 65% / specificity 76%) with an optimal delta-pCO2 cut-off value of 8.6 mmHg. In multivariate regression, delta-pCO2 was associated with increased ICU mortality (HR 3.72, 95%-CI 1.3-10.66, p = 0.02). After adjustment for typical confounders, delta-pCO2 remained as independent predictor of ICU mortality after cardiac surgery. CONCLUSIONS In a retrospective data analysis in a large sample of adult post cardiac surgery patients treated in the ICU, we observed that admission central venous-arterial delta-pCO2 independently predicts ICU mortality. Delta-pCO2 might thus contribute risk stratification in ICU patients after cardiac surgery.
Collapse
Affiliation(s)
- Bjoern Zante
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany; Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany
| | - Mathias Kubik
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany; Department of Intensive Care Medicine, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Kluge
- Department of Intensive Care Medicine, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| |
Collapse
|
49
|
Gojda J, Waldauf P, Hrušková N, Blahutová B, Krajčová A, Urban T, Tůma P, Řasová K, Duška F. Lactate production without hypoxia in skeletal muscle during electrical cycling: Crossover study of femoral venous-arterial differences in healthy volunteers. PLoS One 2019; 14:e0200228. [PMID: 30822305 PMCID: PMC6396965 DOI: 10.1371/journal.pone.0200228] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 02/11/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Aim of the study was to compare metabolic response of leg skeletal muscle during functional electrical stimulation-driven unloaded cycling (FES) to that seen during volitional supine cycling. METHODS Fourteen healthy volunteers were exposed in random order to supine cycling, either volitional (10-25-50 W, 10 min) or FES assisted (unloaded, 10 min) in a crossover design. Whole body and leg muscle metabolism were assessed by indirect calorimetry with concomitant repeated measurements of femoral venous-arterial differences of blood gases, glucose, lactate and amino acids. RESULTS Unloaded FES cycling, but not volitional exercise, led to a significant increase in across-leg lactate production (from -1.1±2.1 to 5.5±7.4 mmol/min, p<0.001) and mild elevation of arterial lactate (from 1.8±0.7 to 2.5±0.8 mM). This occurred without widening of across-leg veno-arterial (VA) O2 and CO2 gaps. Femoral SvO2 difference was directly proportional to VA difference of lactate (R2 = 0.60, p = 0.002). Across-leg glucose uptake did not change with either type of exercise. Systemic oxygen consumption increased with FES cycling to similarly to 25W volitional exercise (138±29% resp. 124±23% of baseline). There was a net uptake of branched-chain amino acids and net release of Alanine from skeletal muscle, which were unaltered by either type of exercise. CONCLUSIONS Unloaded FES cycling, but not volitional exercise causes significant lactate production without hypoxia in skeletal muscle. This phenomenon can be significant in vulnerable patients' groups.
Collapse
Affiliation(s)
- Jan Gojda
- Department of Anaesthesia and Intensive Care Medicine, Kralovske Vinohrady University Hospital and The Third Faculty of Medicine, Charles University, Prague, Czech Republic
- 2 Department of Internal Medicine, Kralovske Vinohrady University Hospital and The Third Faculty of Medicine, Charles University, Prague, Czech Republic
- * E-mail:
| | - Petr Waldauf
- Department of Anaesthesia and Intensive Care Medicine, Kralovske Vinohrady University Hospital and The Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Natália Hrušková
- Department of Rehabilitation, Kralovske Vinohrady University Hospital and The Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Barbora Blahutová
- Department of Rehabilitation, Kralovske Vinohrady University Hospital and The Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Adéla Krajčová
- Department of Anaesthesia and Intensive Care Medicine, Kralovske Vinohrady University Hospital and The Third Faculty of Medicine, Charles University, Prague, Czech Republic
- 2 Department of Internal Medicine, Kralovske Vinohrady University Hospital and The Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Tomáš Urban
- Department of Anaesthesia and Intensive Care Medicine, Kralovske Vinohrady University Hospital and The Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Petr Tůma
- Department of Hygiene, The Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Kamila Řasová
- Department of Rehabilitation, Kralovske Vinohrady University Hospital and The Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - František Duška
- Department of Anaesthesia and Intensive Care Medicine, Kralovske Vinohrady University Hospital and The Third Faculty of Medicine, Charles University, Prague, Czech Republic
| |
Collapse
|
50
|
Ho KM, Harding R, Chamberlain J. A Comparison of Central Venous-Arterial and Mixed Venous-Arterial Carbon Dioxide Tension Gradient in Circulatory Failure. Anaesth Intensive Care 2019; 35:695-701. [DOI: 10.1177/0310057x0703500506] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- K. M. Ho
- Department of Intensive Care, Royal Perth Hospital, Perth, Western Australia, Australia
- , Intensive Care Unit
| | - R. Harding
- Department of Intensive Care, Royal Perth Hospital, Perth, Western Australia, Australia
- , Intensive Care Unit
| | - J. Chamberlain
- Department of Intensive Care, Royal Perth Hospital, Perth, Western Australia, Australia
- , Intensive Care Unit
| |
Collapse
|