16 Jan 12

Mixed venous oxygen saturation cannot be estimated by central venous oxygen saturation in septic shock

Posted in ScvO2, Sepsis at 1:01 by Laci

By M Varpula, S Karlsson, E Ruokonen, V Pettilä

Intensive Care Med (2006) 32:1336–1343

Central venous oxygen saturation (ScvO2) in initial resuscitation is included in the Surviving Sepsis Campaign guidelines. ScvO2 monitoring has also been suggested to be comparable to mixed venous oxygen saturation (SvO2) for clinical purposes. The aim of our study was to assess the correlation and agreement of ScvO2 and SvO2 and compare ScvO2?SvO2 difference to lactate, oxygen-derived and hemodynamic parameters in early septic shock in ICU after initial resuscitation.

Design and setting
Prospective clinical study with 16 patients with septic shock at two university hospital ICUs. A dose of norepinephrine over 0.1ug/kg/min was required for inclusion.

Measurements and results
Five paired ScvO2 and SvO2 samples at 6-h intervals, altogether 72 samples, were collected during 24 h. The mean SvO2 was below the mean ScvO2 at all time points. Bias of difference was 4.2% and 95% limits of agreement ranged from 8.1% to 16.5%. The difference correlated significantly to CI and DO2.

Conclusion
The difference between paired ScvO2 and SvO2 varies highly. Therefore, SvO2 may not be estimated on the basis of ScvO2 in treatment of septic shock after resuscitation period in ICU.

23 Dec 08

Central venous-to-arterial carbon dioxide difference: an additional target for goal-directed therapy in septic shock?

Posted in Early goal directed therapy, ScvO2, Sepsis at 0:30 by Laci

By F Vallet, B Vallet, O Mathe, J Parraguette, A Mari et al

Intensive Care Med 2008:34;2218-2225

To test the hypothesis that, in resuscitated septic shock patients, central venous-to-arterial carbon dioxide difference [P(cv-a)CO2] may serve as a global index of tissue perfusion when the central venous oxygen saturation (ScvO2) goal value has already been reached.

Design
Prospective observational study.

Setting
A 22-bed intensive care unit (ICU).

Patients
After early resuscitation in the emergency unit, 50 consecutive septic shock patients with ScvO2 > 70% were included immediately after their admission into the ICU (T0). Patients were separated in Low P(cv-a)CO2 group (Low gap; n = 26) and High P(cv-a)CO2 group (High gap; n = 24) according to a threshold of 6 mmHg at T0.

Measurements
Measurements were performed every 6 h over 12 h (T0, T6, T12).

Results
At T0, there was a significant difference between Low gap patients and High gap patients for cardiac index (CI) (4.3 ± 1.6 vs. 2.7 ± 0.8 l/min/m≤, P < 0.0001) but not for ScvO2 values (78 ± 5 vs. 75 ± 5%, P = 0.07). From T0 to T12, the clearance of lactate was significantly larger for the Low gap group than for the High gap group (P < 0.05) as well as the decrease of SOFA score at T24 (P < 0.01). At T0, T6 and T12, CI and P(cv-a)CO2 values were inversely correlated (P < 0.0001).

Conclusion
In ICU-resuscitated patients, targeting only ScvO2 may not be sufficient to guide therapy. When the 70% ScvO2 goal-value is reached, the presence of a P(cv-a)CO2 larger than 6 mmHg might be a useful tool to identify patients who still remain inadequately resuscitated.

18 Dec 08

ACCM/PALS haemodynamic support guidelines for paediatric septic shock: an outcomes comparison with and without monitoring central venous oxygen saturation

Posted in Early goal directed therapy, ScvO2, Sepsis at 14:22 by Laci

By C F de Oliveira1, D S  de Oliveira1, A F C Gottschald, J D G Moura1, G A Costa1, A C Ventura et al

Intensive Care Med 2008:34;1065-1075

The ACCM/PALS guidelines address early correction of paediatric septic shock using conventional measures. In the evolution of these recommendations, indirect measures of the balance between systemic oxygen delivery and demands using central venous or superior vena cava oxygen saturation (ScvO2>=70%) in a goal-directed approach have been added. However, while these additional goal-directed endpoints are based on evidence-based adult studies, the extrapolation to the paediatric patient remains unvalidated.

Objective
The purpose of this study was to compare treatment according to ACCM/PALS guidelines, performed with and without ScvO2 goal-directed therapy, on the morbidity and mortality rate of children with severe sepsis and septic shock.

Design, participants and interventions
Children and adolescents with severe sepsis or fluid-refractory septic shock were randomly assigned to ACCM/PALS with or without ScvO2 goal-directed resuscitation.

Measurements
Twenty-eight-day mortality was the primary endpoint.
Results  Of the 102 enrolled patients, 51 received ACCM/PALS with ScvO2 goal-directed therapy and 51 received ACCM/PALS without ScvO2 goal-directed therapy. ScvO2 goal-directed therapy resulted in less mortality (28-day mortality 11.8% vs. 39.2%, p=0.002), and fewer new organ dysfunctions (p=0.03). ScvO2 goal-directed therapy resulted in more crystalloid (28 (20–40) vs. 5 (0–20)ml/kg, p<0.0001), blood transfusion (45.1% vs. 15.7%, p=0.002) and inotropic (29.4% vs. 7.8%, p=0.01) support in the first 6h.

Conclusions
This study supports the current ACCM/PALS guidelines. Goal-directed therapy using the endpoint of a ScvO2>=70% has a significant and additive impact on the outcome of children and adolescents with septic shock.

See the Editorial by M J Peters and J Brierley: Back to basics in septic shock

03 Nov 08

Year in review 2007: Critical Care – cardiology

Posted in Fluid management, Monitoring, Pre-operatie evaluation, ScvO2 at 0:00 by Laci

By L Camporota, M Terblanche and D Bennett

Critical Care 2008,12:232

This review summarises key research papers in the fields of cardiology and intensive care published during 2007 in Critical Care. To create a context and for comparison with the papers described in the review, we cite studies on the same subject published in other journals. The papers have been grouped into four categories: venous oximetry, cardiac surgery, perioperative fluid optimisation, and haemodynamic monitoring.

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