Journal of Intensive Care Medicine

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Central venous to mixed venous blood oxygen and lactate gradients are associated with outcome in critically ill patients

Guillermo Gutierrez, Pablo Comignani, Luis Huespe, F. Javier Hurtado, Arnaldo Dubin, Vinayak Jha, Yanina Arzani, Silvio Lazzeri, Lombardo Sosa, Juan Riva, Wolf Kohn, Daniela Suarez, Gonzalo Lacuesta, Daniela Olmos, Carlos Mizdraji, Alejandra Ojeda
Original
Volume 34, Issue 9 / September , 2008

Pages 1662 - 1668

Abstract

Objective

Blood O2 saturation and lactate concentration gradients from superior vena cava (SVC) to pulmonary artery (PA) occur in critically ill patients. These gradients (ΔSO2 and Δ[Lac]) may be positive or negative. We tested the hypothesis that positive ΔSO2 and Δ[Lac] are associated with improved survival in critically ill patients.

Design and setting

Multinational, prospective observational study conducted in six medical and surgical ICUs.

Patients

Consecutive sample of 106 adults requiring insertion of a pulmonary artery catheter (PAC). Average age was 59.5 ± 15.5 years, APACHE II score was 15.5 ± 6.7 (mean ± SD). Main outcome measure was 28-day mortality.

Interventions

None.

Measurements and results

We drew blood samples from the proximal and distal ports of PACs every 6 h from the time of PAC insertion (Initial measurement) until its removal (Final measurement). Samples were analyzed for SO2, [Lac], glucose concentration and blood gases. Hemodynamic measurements were obtained after blood samples. We monitored patients for 30.9 ± 11.0 h. Overall mortality rate was 25.5%. More survivors had mean and final ΔSO2 ≥ 0 and Δ[Lac] ≥ 0 than decedents (p < 0.01; p < 0.05 respectively). On the average, ΔSO2 and Δ[Lac] were positive in survivors and negative in decedents. Survival odds ratios for final measurements of ΔSO2 ≥ 0 and Δ[Lac] ≥ 0 were 19.22 and 7.70, respectively (p < 0.05).

Conclusions

A strong association exists between positive ΔSO2 and Δ[Lac] and survival in critically ill patients. Whether therapy aimed at increasing ΔSO2 and Δ[Lac] results in improved ICU survival remains to be determined.

Keywords

References

  1. Edwards JD, Mayall RM (1998) Importance of the sampling site for measurement of mixed venous oxygen saturation in shock. Crit Care Med 26:1356–1360
    • View reference on PubMed
    • View reference on publisher's website
  2. Chawla LS, Zia H, Gutierrez G, Katz NM, Seneff MG, Shah M (2004) Lack of equivalence between central and mixed venous oxygen saturation. Chest 126:1891–1896
    • View reference on PubMed
    • View reference on publisher's website
  3. Dueck MH, Klimek M, Appenrodt S, Weigand C, Boerner U (2005) Trends but not individual values of central venous oxygen saturation agree with mixed venous oxygen saturation during varying hemodynamic conditions. Anesthesiology 103:249–257
    • View reference on PubMed
    • View reference on publisher's website
  4. Varpula M, Karlsson S, Ruokonen E, Pettilä V (2006) Mixed venous oxygen saturation cannot be estimated by central venous oxygen saturation in septic shock. Intensive Care Med 32:1336–1343
  5. Gutierrez G, Chawla LS, Seneff MG, Katz NM, Zia H (2005) Lactate concentration gradient from right atrium to pulmonary artery. Crit Care 2005:R425–R429
  6. Reinhart K, Kuhn HJ, Hartog C, Bredle DL (2004) Continuous central venous and pulmonary artery oxygen saturation monitoring in the critically ill. Intensive Care Med 30:1572–1578
  7. Rivers E (2006) Mixed vs. Central venous oxygen saturation may not be numerically equal, but both are still clinically useful. Chest 129:507–508
    • View reference on PubMed
    • View reference on publisher's website
  8. Lee J, Wright F, Barber R, Stanley L (1972) Central venous oxygen saturation in shock: a study in man. Anesthesiology 36:472–478
    • View reference on PubMed
    • View reference on publisher's website
  9. Gutierrez G, Venbrux A, Ignacio E, Reiner J, Chawla L, Desai A (2007) The concentration of oxygen, lactate and glucose in the central veins, right heart, and pulmonary artery: a study in patients with pulmonary hypertension. Crit Care 11:R44
    • View reference on PubMed
    • View reference on publisher's website
  10. Court O, Kumar A, Parrillo JE, Kumar A (2002) Clinical review: myocardial depression in sepsis and septic shock. Crit Care 6:500–508
    • View reference on PubMed
    • View reference on publisher's website
  11. Vánky FB, Håkanson E, Tamás E, Svedjeholm R (2006) Risk factors for postoperative heart failure in patients operated on for aortic stenosis. Ann Thorac Surg 8:1297–1304
    • View reference on publisher's website
  12. Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) APACHE II: a severity of disease classification system. Crit Care Med 13:818–829
    • View reference on PubMed
    • View reference on publisher's website
  13. Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, Schein RM, Sibbald WJ (1992) Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 101:1644–1655
    • View reference on PubMed
    • View reference on publisher's website
  14. Vittinghoff E (2004) Regression methods in biostatistics: linear, logistic, survival, and repeated measures models (Statistics for Biology & Health Series). Springer, New York, pp 180–268
  15. Zar JH (1999) Simple linear correlation. In: Biostatistical analysis, 4th edn. Prentice-Hall, Upper Saddle River, pp 377–383
  16. Holm SA (1979) A simple sequentially rejective multiple test procedure. Scand J Statistics 6:65–70
  17. Bewick V, Cheek L, Ball J (2004) Statistics review 13: receiver operating characteristic curves. Crit Care 8:508–512
    • View reference on PubMed
    • View reference on publisher's website
  18. Hanley JA, McNeil BJ (1983) A method of comparing the areas under receiver operating characteristic curves derived from the same cases. Radiology 148:839–843
    • View reference on PubMed
  19. Gutierrez G, Bismar H, Dantzker DR, Silva N (1992) Comparison of gastric intramucosal pH with measures of oxygen transport and consumption in critically ill patients. Crit Care Med 20:R451–R457
  20. Sander M, Spies CD, Foer A, Weymann L, Braun J, Volk T, Grubitzsch H, von Heymann C (2007) Agreement of central venous saturation and mixed venous saturation in cardiac surgery patients. Intensive Care Med 33:1719–1725
  21. Reinhart K, Bloos F (2005) The value of venous oximetry. Curr Opin Crit Care 11:259–263
    • View reference on PubMed
    • View reference on publisher's website
  22. Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL (2008) Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Med 34:17–60

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