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Combination of arterial lactate levels and venous-arterial CO2 to arterial-venous O 2 content difference ratio as markers of resuscitation in patients with septic shock.

Ospina-Tascón GA, Umaña M, Bermúdez W, Bautista-Rincón DF, Hernandez G, Bruhn A, Granados M, Salazar B, Arango-Dávila C, De Backer D - Intensive Care Med (2015)

Bottom Line: Combination of hyperlactatemia and high Cv-aCO2/Da-vO2 ratio was associated with the worst SOFA scores and lower survival rates at day 28 [log rank (Mantel-Cox) = 31.39, p < 0.0001].Normalization of both variables was associated with the best outcomes.Patients with a high Cv-aCO2/Da-vO2 ratio and lactate <2.0 mmol/L had similar outcomes to hyperlactatemic patients with low Cv-aCO2/Da-vO2 ratio.

View Article: PubMed Central - PubMed

Affiliation: Intensive Care Unit, Fundación Valle Del Lili - Universidad ICESI, Av. Simón Bolívar Cra. 98, Cali, Colombia, gusospin@gmail.com.

ABSTRACT

Purpose: To evaluate the prognostic value of the Cv-aCO2/Da-vO2 ratio combined with lactate levels during the early phases of resuscitation in septic shock.

Methods: Prospective observational study in a 60-bed mixed ICU. One hundred and thirty-five patients with septic shock were included. The resuscitation protocol targeted mean arterial pressure, pulse pressure variations or central venous pressure, mixed venous oxygen saturation, and lactate levels. Patients were classified into four groups according to lactate levels and Cv-aCO2/Da-vO2 ratio at 6 h of resuscitation (T6): group 1, lactate ≥2.0 mmol/L and Cv-aCO2/Da-vO2 >1.0; group 2, lactate ≥2.0 mmol/L and Cv-aCO2/Da-vO2 ≤1.0; group 3, lactate <2.0 mmol/L and Cv-aCO2/Da-vO2 >1.0; and group 4, lactate <2.0 mmol/L and Cv-aCO2/Da-vO2 ≤1.0.

Results: Combination of hyperlactatemia and high Cv-aCO2/Da-vO2 ratio was associated with the worst SOFA scores and lower survival rates at day 28 [log rank (Mantel-Cox) = 31.39, p < 0.0001]. Normalization of both variables was associated with the best outcomes. Patients with a high Cv-aCO2/Da-vO2 ratio and lactate <2.0 mmol/L had similar outcomes to hyperlactatemic patients with low Cv-aCO2/Da-vO2 ratio. The multivariate analysis revealed that Cv-aCO2/Da-vO2 ratio at both T0 (RR 3.85; 95 % CI 1.60-9.27) and T6 (RR 3.97; 95 % CI 1.54-10.24) was an independent predictor for mortality at day 28, as well as lactate levels at T6 (RR 1.58; 95 % CI 1.13-2.22).

Conclusion: Complementing lactate assessment with Cv-aCO2/Da-vO2 ratio during early stages of resuscitation of septic shock can better identify patients at high risk of adverse outcomes. The Cv-aCO2/Da-vO2 ratio may become a potential resuscitation goal in patients with septic shock.

No MeSH data available.


Related in: MedlinePlus

Sequential Organ Failure Assessment (SOFA) scores at day 3 for predefined groups. Data presented as median (percentiles). Patients were separated into four groups according to lactate and Cv-aCO2/Da-vO2 ratio measured after the first 6 h of resuscitation: group 1, lactate ≥2.0 mmol/L and Cv-aCO2/Da-vO2 ratio >1.0; group 2, lactate ≥2.0 mmol/L and Cv-aCO2/Da-vO2 ratio ≤1.0; group 3, lactate <2.0 mmol/L and Cv-aCO2/Da-vO2 ratio >1.0; and group 4, lactate <2.0 mmol/L and Cv-aCO2/Da-vO2 ratio ≤1.0. Kruskal–Wallis one-way ANOVA, p < 0.001. **p < 0.01 by Tukey–Kramer showing differences between groups 1 vs. 3 and 1 vs. 4
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Fig1: Sequential Organ Failure Assessment (SOFA) scores at day 3 for predefined groups. Data presented as median (percentiles). Patients were separated into four groups according to lactate and Cv-aCO2/Da-vO2 ratio measured after the first 6 h of resuscitation: group 1, lactate ≥2.0 mmol/L and Cv-aCO2/Da-vO2 ratio >1.0; group 2, lactate ≥2.0 mmol/L and Cv-aCO2/Da-vO2 ratio ≤1.0; group 3, lactate <2.0 mmol/L and Cv-aCO2/Da-vO2 ratio >1.0; and group 4, lactate <2.0 mmol/L and Cv-aCO2/Da-vO2 ratio ≤1.0. Kruskal–Wallis one-way ANOVA, p < 0.001. **p < 0.01 by Tukey–Kramer showing differences between groups 1 vs. 3 and 1 vs. 4

Mentions: After the first 6 h of resuscitation, 110 (81 %) patients achieved a MAP >65 mmHg and 98 (73 %) a SvO2 >65 %. However, 84 (62 %) patients still had an arterial lactate ≥2.0 mmol/L and 65 (48 %) had a Cv-aCO2/Da-vO2 ratio >1.0. Accordingly, 42 patients were classified into group 1, 42 into group 2, 23 into group 3, and 28 into group 4. Patients in groups 1 and 2 had higher APACHE II scores and required higher vasopressor doses at T0 (Table 1). No significant differences were found in demographic data or other hemodynamic variables at T0 (Table 1 and ESM Table 1). All hemodynamic, blood gases, oxygen parameters, and ventilator settings at both T0 and T6 are presented in the ESM Table 1. Patients from groups 1 and 2 had more acidosis at T0 and T6. Regarding the clinical outcomes, patients from group 1 evolved with higher SOFA scores (Kruskal–Wallis, p < 0.001; post hoc test demonstrated significant differences among groups 1 vs. 3 and 1 vs. 4) (Fig. 1) and they also had the lowest survival rates at day 28 [log rank (Mantel–Cox) = 31.39, p < 0.0001] (Fig. 2). Intriguingly, patients in groups 2 and 3 had similar SOFA scores and outcomes at day 28 (Table 2). Furthermore, patients from group 1 had the lowest VO2 at T6 and T12 compared to all other groups, even though cardiac output, SvO2, and DO2 were not different (ESM Fig. 2).Table 1


Combination of arterial lactate levels and venous-arterial CO2 to arterial-venous O 2 content difference ratio as markers of resuscitation in patients with septic shock.

Ospina-Tascón GA, Umaña M, Bermúdez W, Bautista-Rincón DF, Hernandez G, Bruhn A, Granados M, Salazar B, Arango-Dávila C, De Backer D - Intensive Care Med (2015)

Sequential Organ Failure Assessment (SOFA) scores at day 3 for predefined groups. Data presented as median (percentiles). Patients were separated into four groups according to lactate and Cv-aCO2/Da-vO2 ratio measured after the first 6 h of resuscitation: group 1, lactate ≥2.0 mmol/L and Cv-aCO2/Da-vO2 ratio >1.0; group 2, lactate ≥2.0 mmol/L and Cv-aCO2/Da-vO2 ratio ≤1.0; group 3, lactate <2.0 mmol/L and Cv-aCO2/Da-vO2 ratio >1.0; and group 4, lactate <2.0 mmol/L and Cv-aCO2/Da-vO2 ratio ≤1.0. Kruskal–Wallis one-way ANOVA, p < 0.001. **p < 0.01 by Tukey–Kramer showing differences between groups 1 vs. 3 and 1 vs. 4
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Related In: Results  -  Collection

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getmorefigures.php?uid=PMC4414929&req=5

Fig1: Sequential Organ Failure Assessment (SOFA) scores at day 3 for predefined groups. Data presented as median (percentiles). Patients were separated into four groups according to lactate and Cv-aCO2/Da-vO2 ratio measured after the first 6 h of resuscitation: group 1, lactate ≥2.0 mmol/L and Cv-aCO2/Da-vO2 ratio >1.0; group 2, lactate ≥2.0 mmol/L and Cv-aCO2/Da-vO2 ratio ≤1.0; group 3, lactate <2.0 mmol/L and Cv-aCO2/Da-vO2 ratio >1.0; and group 4, lactate <2.0 mmol/L and Cv-aCO2/Da-vO2 ratio ≤1.0. Kruskal–Wallis one-way ANOVA, p < 0.001. **p < 0.01 by Tukey–Kramer showing differences between groups 1 vs. 3 and 1 vs. 4
Mentions: After the first 6 h of resuscitation, 110 (81 %) patients achieved a MAP >65 mmHg and 98 (73 %) a SvO2 >65 %. However, 84 (62 %) patients still had an arterial lactate ≥2.0 mmol/L and 65 (48 %) had a Cv-aCO2/Da-vO2 ratio >1.0. Accordingly, 42 patients were classified into group 1, 42 into group 2, 23 into group 3, and 28 into group 4. Patients in groups 1 and 2 had higher APACHE II scores and required higher vasopressor doses at T0 (Table 1). No significant differences were found in demographic data or other hemodynamic variables at T0 (Table 1 and ESM Table 1). All hemodynamic, blood gases, oxygen parameters, and ventilator settings at both T0 and T6 are presented in the ESM Table 1. Patients from groups 1 and 2 had more acidosis at T0 and T6. Regarding the clinical outcomes, patients from group 1 evolved with higher SOFA scores (Kruskal–Wallis, p < 0.001; post hoc test demonstrated significant differences among groups 1 vs. 3 and 1 vs. 4) (Fig. 1) and they also had the lowest survival rates at day 28 [log rank (Mantel–Cox) = 31.39, p < 0.0001] (Fig. 2). Intriguingly, patients in groups 2 and 3 had similar SOFA scores and outcomes at day 28 (Table 2). Furthermore, patients from group 1 had the lowest VO2 at T6 and T12 compared to all other groups, even though cardiac output, SvO2, and DO2 were not different (ESM Fig. 2).Table 1

Bottom Line: Combination of hyperlactatemia and high Cv-aCO2/Da-vO2 ratio was associated with the worst SOFA scores and lower survival rates at day 28 [log rank (Mantel-Cox) = 31.39, p < 0.0001].Normalization of both variables was associated with the best outcomes.Patients with a high Cv-aCO2/Da-vO2 ratio and lactate <2.0 mmol/L had similar outcomes to hyperlactatemic patients with low Cv-aCO2/Da-vO2 ratio.

View Article: PubMed Central - PubMed

Affiliation: Intensive Care Unit, Fundación Valle Del Lili - Universidad ICESI, Av. Simón Bolívar Cra. 98, Cali, Colombia, gusospin@gmail.com.

ABSTRACT

Purpose: To evaluate the prognostic value of the Cv-aCO2/Da-vO2 ratio combined with lactate levels during the early phases of resuscitation in septic shock.

Methods: Prospective observational study in a 60-bed mixed ICU. One hundred and thirty-five patients with septic shock were included. The resuscitation protocol targeted mean arterial pressure, pulse pressure variations or central venous pressure, mixed venous oxygen saturation, and lactate levels. Patients were classified into four groups according to lactate levels and Cv-aCO2/Da-vO2 ratio at 6 h of resuscitation (T6): group 1, lactate ≥2.0 mmol/L and Cv-aCO2/Da-vO2 >1.0; group 2, lactate ≥2.0 mmol/L and Cv-aCO2/Da-vO2 ≤1.0; group 3, lactate <2.0 mmol/L and Cv-aCO2/Da-vO2 >1.0; and group 4, lactate <2.0 mmol/L and Cv-aCO2/Da-vO2 ≤1.0.

Results: Combination of hyperlactatemia and high Cv-aCO2/Da-vO2 ratio was associated with the worst SOFA scores and lower survival rates at day 28 [log rank (Mantel-Cox) = 31.39, p < 0.0001]. Normalization of both variables was associated with the best outcomes. Patients with a high Cv-aCO2/Da-vO2 ratio and lactate <2.0 mmol/L had similar outcomes to hyperlactatemic patients with low Cv-aCO2/Da-vO2 ratio. The multivariate analysis revealed that Cv-aCO2/Da-vO2 ratio at both T0 (RR 3.85; 95 % CI 1.60-9.27) and T6 (RR 3.97; 95 % CI 1.54-10.24) was an independent predictor for mortality at day 28, as well as lactate levels at T6 (RR 1.58; 95 % CI 1.13-2.22).

Conclusion: Complementing lactate assessment with Cv-aCO2/Da-vO2 ratio during early stages of resuscitation of septic shock can better identify patients at high risk of adverse outcomes. The Cv-aCO2/Da-vO2 ratio may become a potential resuscitation goal in patients with septic shock.

No MeSH data available.


Related in: MedlinePlus