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Central venous-to-arterial carbon dioxide difference combined with arterial-to-venous oxygen content difference is associated with lactate evolution in the hemodynamic resuscitation process in early septic shock.

Mesquida J, Saludes P, Gruartmoner G, Espinal C, Torrents E, Baigorri F, Artigas A - Crit Care (2015)

Bottom Line: Lactate improvement was defined as the decrease ≥ 10% of the previous lactate value.Those patients whose lactate values did not decrease had higher PcvaCO₂/CavO₂ ratio values at inclusion (1.8 ± 0.8vs. 1.4 ± 0.5, p 0.02).No-improvement in lactate values was associated to higher PcvaCO₂/CavO₂ ratio values in the previous control.

View Article: PubMed Central - PubMed

Affiliation: Critical Care Center, Hospital de Sabadell, Corporació Sanitària Universitària Parc Taulí, Universitat Autònoma de Barcelona, Parc Tauli, 1, Sabadell, 08208, Spain. jmesquida@tauli.cat.

ABSTRACT

Introduction: Since normal or high central venous oxygen saturation (ScvO₂) values cannot discriminate if tissue perfusion is adequate, integrating other markers of tissue hypoxia, such as central venous-to-arterial carbon dioxide difference (PcvaCO₂ gap) has been proposed. In the present study, we aimed to evaluate the ability of the PcvaCO₂ gap and the PcvaCO₂/arterial-venous oxygen content difference ratio (PcvaCO₂/CavO₂) to predict lactate evolution in septic shock.

Methods: Observational study. Septic shock patients within the first 24 hours of ICU admission. After restoration of mean arterial pressure, and central venous oxygen saturation, the PcvaCO₂ gap and the PcvaCO₂/CavO₂ ratio were calculated. Consecutive arterial and central venous blood samples were obtained for each patient within 24 hours. Lactate improvement was defined as the decrease ≥ 10% of the previous lactate value.

Results: Thirty-five septic shock patients were studied. At inclusion, the PcvaCO₂ gap was 5.6 ± 2.1 mmHg, and the PcvaCO₂/CavO₂ ratio was 1.6 ± 0.7 mmHg · dL/mL O₂. Those patients whose lactate values did not decrease had higher PcvaCO₂/CavO₂ ratio values at inclusion (1.8 ± 0.8vs. 1.4 ± 0.5, p 0.02). During the follow-up, 97 paired blood samples were obtained. No-improvement in lactate values was associated to higher PcvaCO₂/CavO₂ ratio values in the previous control. The ROC analysis showed an AUC 0.82 (p < 0.001), and a PcvaCO₂/CavO₂ ratio cut-off value of 1.4 mmHg · dL/mL O₂ showed sensitivity 0.80 and specificity 0.75 for lactate improvement prediction. The odds ratio of an adequate lactate clearance was 0.10 (p < 0.001) in those patients with an elevated PcvaCO₂/CavO₂ ratio (≥1.4).

Conclusion: In a population of septic shock patients with normalized MAP and ScvO₂, the presence of elevated PcvaCO₂/CavO₂ ratio significantly reduced the odds of adequate lactate clearance during the following hours.

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Number of paired samples for each studied patient under the 24-hour follow-up period. Each pair of measurements consists of two consecutive (3 ± 2 hours) simultaneous arterial and central venous blood samples, allowing for lactate clearance calculation.
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Fig1: Number of paired samples for each studied patient under the 24-hour follow-up period. Each pair of measurements consists of two consecutive (3 ± 2 hours) simultaneous arterial and central venous blood samples, allowing for lactate clearance calculation.

Mentions: During the follow-up period, 97 paired blood samples were obtained. The number of paired samples for each studied patient is shown in Figure 1. The elapsed time between consecutive measurements was 3 ± 2 hours. No improvement in lactate values was associated with higher PcvaCO2/CavO2 ratio values in the previous measurement (1.9 ± 0.9 vs. 1.2 ± 0.4 mmHg · dl/ml O2, P <0.001), while PcvaCO2 gap values did not statistically differ (6.0 ± 2.3 vs. 5.0 ± 2.1 mmHg, P = 0.08). Higher ScvO2 values were also observed in those patients whose lactate did not decrease within the following hours (73 ± 8% vs. 68 ± 9%, P = 0.01). When exploring the ability of these parameters in predicting adequate lactate clearance, for the whole 97 paired samples the PcvaCO2/CavO2 ratio ROC analysis showed an area under the curve of 0.82 (95% confidence interval = 0.73 to 0.92, P <0.001), and a cutoff value of 1.4 had the best relationship between sensitivity (0.8) and specificity (0.75). The PcvaCO2 gap ROC analysis showed an area under the curve of 0.62 (P = 0.07) for lactate improvement prediction. The odds ratio of an adequate lactate clearance was 0.10 (95% confidence interval = 0.03 to 0.3, P <0.001) in those patients with an elevated PcvaCO2/CavO2ratio (≥1.4), whereas it did not reach statistical significance (P = 0.1) for those patients with a PcvaCO2 gap ≥6 mmHg.Figure 1


Central venous-to-arterial carbon dioxide difference combined with arterial-to-venous oxygen content difference is associated with lactate evolution in the hemodynamic resuscitation process in early septic shock.

Mesquida J, Saludes P, Gruartmoner G, Espinal C, Torrents E, Baigorri F, Artigas A - Crit Care (2015)

Number of paired samples for each studied patient under the 24-hour follow-up period. Each pair of measurements consists of two consecutive (3 ± 2 hours) simultaneous arterial and central venous blood samples, allowing for lactate clearance calculation.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4384363&req=5

Fig1: Number of paired samples for each studied patient under the 24-hour follow-up period. Each pair of measurements consists of two consecutive (3 ± 2 hours) simultaneous arterial and central venous blood samples, allowing for lactate clearance calculation.
Mentions: During the follow-up period, 97 paired blood samples were obtained. The number of paired samples for each studied patient is shown in Figure 1. The elapsed time between consecutive measurements was 3 ± 2 hours. No improvement in lactate values was associated with higher PcvaCO2/CavO2 ratio values in the previous measurement (1.9 ± 0.9 vs. 1.2 ± 0.4 mmHg · dl/ml O2, P <0.001), while PcvaCO2 gap values did not statistically differ (6.0 ± 2.3 vs. 5.0 ± 2.1 mmHg, P = 0.08). Higher ScvO2 values were also observed in those patients whose lactate did not decrease within the following hours (73 ± 8% vs. 68 ± 9%, P = 0.01). When exploring the ability of these parameters in predicting adequate lactate clearance, for the whole 97 paired samples the PcvaCO2/CavO2 ratio ROC analysis showed an area under the curve of 0.82 (95% confidence interval = 0.73 to 0.92, P <0.001), and a cutoff value of 1.4 had the best relationship between sensitivity (0.8) and specificity (0.75). The PcvaCO2 gap ROC analysis showed an area under the curve of 0.62 (P = 0.07) for lactate improvement prediction. The odds ratio of an adequate lactate clearance was 0.10 (95% confidence interval = 0.03 to 0.3, P <0.001) in those patients with an elevated PcvaCO2/CavO2ratio (≥1.4), whereas it did not reach statistical significance (P = 0.1) for those patients with a PcvaCO2 gap ≥6 mmHg.Figure 1

Bottom Line: Lactate improvement was defined as the decrease ≥ 10% of the previous lactate value.Those patients whose lactate values did not decrease had higher PcvaCO₂/CavO₂ ratio values at inclusion (1.8 ± 0.8vs. 1.4 ± 0.5, p 0.02).No-improvement in lactate values was associated to higher PcvaCO₂/CavO₂ ratio values in the previous control.

View Article: PubMed Central - PubMed

Affiliation: Critical Care Center, Hospital de Sabadell, Corporació Sanitària Universitària Parc Taulí, Universitat Autònoma de Barcelona, Parc Tauli, 1, Sabadell, 08208, Spain. jmesquida@tauli.cat.

ABSTRACT

Introduction: Since normal or high central venous oxygen saturation (ScvO₂) values cannot discriminate if tissue perfusion is adequate, integrating other markers of tissue hypoxia, such as central venous-to-arterial carbon dioxide difference (PcvaCO₂ gap) has been proposed. In the present study, we aimed to evaluate the ability of the PcvaCO₂ gap and the PcvaCO₂/arterial-venous oxygen content difference ratio (PcvaCO₂/CavO₂) to predict lactate evolution in septic shock.

Methods: Observational study. Septic shock patients within the first 24 hours of ICU admission. After restoration of mean arterial pressure, and central venous oxygen saturation, the PcvaCO₂ gap and the PcvaCO₂/CavO₂ ratio were calculated. Consecutive arterial and central venous blood samples were obtained for each patient within 24 hours. Lactate improvement was defined as the decrease ≥ 10% of the previous lactate value.

Results: Thirty-five septic shock patients were studied. At inclusion, the PcvaCO₂ gap was 5.6 ± 2.1 mmHg, and the PcvaCO₂/CavO₂ ratio was 1.6 ± 0.7 mmHg · dL/mL O₂. Those patients whose lactate values did not decrease had higher PcvaCO₂/CavO₂ ratio values at inclusion (1.8 ± 0.8vs. 1.4 ± 0.5, p 0.02). During the follow-up, 97 paired blood samples were obtained. No-improvement in lactate values was associated to higher PcvaCO₂/CavO₂ ratio values in the previous control. The ROC analysis showed an AUC 0.82 (p < 0.001), and a PcvaCO₂/CavO₂ ratio cut-off value of 1.4 mmHg · dL/mL O₂ showed sensitivity 0.80 and specificity 0.75 for lactate improvement prediction. The odds ratio of an adequate lactate clearance was 0.10 (p < 0.001) in those patients with an elevated PcvaCO₂/CavO₂ ratio (≥1.4).

Conclusion: In a population of septic shock patients with normalized MAP and ScvO₂, the presence of elevated PcvaCO₂/CavO₂ ratio significantly reduced the odds of adequate lactate clearance during the following hours.

Show MeSH
Related in: MedlinePlus