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01-12-2008 | Original

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

Authors: Fabrice Vallée, Benoit Vallet, Olivier Mathe, Jacqueline Parraguette, Arnaud Mari, Stein Silva, Kamran Samii, Olivier Fourcade, Michèle Genestal

Published in: Intensive Care Medicine | Issue 12/2008

Abstract

Objective

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/m², 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.

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Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM (2004) Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 32:858–873PubMedCrossRef

Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M (2001) Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345:1368–1377PubMedCrossRef

Varpula M, Karlsson S, Ruokonen E, Pettila V (2006) Mixed venous oxygen saturation cannot be estimated by central venous oxygen saturation in septic shock. Intensive Care Med 32:1336–1343PubMedCrossRef

van Beest P, Hofstra J, Schultz M, Boerma E, Spronk P, Kuiper M (2008) The incidence of low venous oxygen saturation on admission to the intensive care unit: a multi-center observational study in The Netherlands. Crit Care 12:R33

Ince C, Sinaasappel M (1999) Microcirculatory oxygenation and shunting in sepsis and shock. Crit Care Med 27:1369–1377PubMedCrossRef

Fink MP (2002) Cytopathic hypoxia. Is oxygen use impaired in sepsis as a result of an acquired intrinsic derangement in cellular respiration? Crit Care Clin 18:165–175PubMedCrossRef

Vallee F, Fourcade O, Marty P, Sanchez P, Samii K, Genestal M (2007) The hemodynamic “target”: a visual tool of goal-directed therapy for septic patients. Clinics 62:447–454PubMedCrossRef

Ladakis C, Myrianthefs P, Karabinis A, Karatzas G, Dosios T, Fildissis G, Gogas J, Baltopoulos G (2001) Central venous and mixed venous oxygen saturation in critically ill patients. Respiration 68:279–285PubMedCrossRef

Brandi LS, Giunta F, Pieri M, Sironi AM, Mazzanti T (1995) Venous-arterial PCO₂ and pH gradients in acutely ill postsurgical patients. Minerva Anestesiol 61:345–350PubMed

10.

Groeneveld AB, Vermeij CG, Thijs LG (1991) Arterial and mixed venous blood acid-base balance during hypoperfusion with incremental positive end-expiratory pressure in the pig. Anesth Analg 73:576–582PubMedCrossRef

11.

Durkin R, Gergits MA, Reed JF 3rd, Fitzgibbons J (1993) The relationship between the arteriovenous carbon dioxide gradient and cardiac index. J Crit Care 8:217–221PubMedCrossRef

12.

Mecher CE, Rackow EC, Astiz ME, Weil MH (1990) Venous hypercarbia associated with severe sepsis and systemic hypoperfusion. Crit Care Med 18:585–589PubMedCrossRef

13.

Bakker J, Vincent JL, Gris P, Leon M, Coffernils M, Kahn RJ (1992) Veno-arterial carbon dioxide gradient in human septic shock. Chest 101:509–515PubMedCrossRef

14.

Rackow EC, Astiz ME, Mecher CE, Weil MH (1994) Increased venous-arterial carbon dioxide tension difference during severe sepsis in rats. Crit Care Med 22:121–125PubMed

15.

Vallet B, Teboul JL, Cain S, Curtis S (2000) Venoarterial CO₂ difference during regional ischemic or hypoxic hypoxia. J Appl Physiol 89:1317–1321PubMed

16.

Neviere R, Chagnon JL, Teboul JL, Vallet B, Wattel F (2002) Small intestine intramucosal PCO₂ and microvascular blood flow during hypoxic and ischemic hypoxia. Crit Care Med 30:379–384PubMedCrossRef

17.

Lamia B, Monnet X, Teboul JL (2006) Meaning of arterio-venous PCO₂ difference in circulatory shock. Minerva Anestesiol 72:597–604PubMed

18.

Cuschieri J, Rivers EP, Donnino MW, Katilius M, Jacobsen G, Nguyen HB, Pamukov N, Horst HM (2005) Central venous-arterial carbon dioxide difference as an indicator of cardiac index. Intensive Care Med 31:818–822PubMedCrossRef

19.

Vallet B, Lebuffe G (2007) How to titrate vasopressors against fluid loading in septic shock. Adv Sepsis 6:34–40

20.

Annane D, Aegerter P, Jars-Guincestre MC, Guidet B (2003) Current epidemiology of septic shock: the CUB-Rea Network. Am J Respir Crit Care Med 168:165–172PubMedCrossRef

21.

Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A, Steingrub JS, Garber GE, Helterbrand JD, Ely EW, Fisher CJ Jr (2001) Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 344:699–709PubMedCrossRef

22.

Adrogue HJ, Rashad MN, Gorin AB, Yacoub J, Madias NE (1989) Assessing acid-base status in circulatory failure. Differences between arterial and central venous blood. N Engl J Med 320:1312–1316PubMed

23.

Gutierrez G (2004) A mathematical model of tissue-blood carbon dioxide exchange during hypoxia. Am J Respir Crit Care Med 169:525–533PubMedCrossRef

24.

Wasserman K, Whipp BJ, Koyl SN, Beaver WL (1973) Anaerobic threshold and respiratory gas exchange during exercise. J Appl Physiol 35:236–243PubMed

25.

Raza O, Schlichtig R (2000) Metabolic component of intestinal PCO₂ during dysoxia. J Appl Physiol 89:2422–2429PubMed

26.

Cohen IL, Sheikh FM, Perkins RJ, Feustel PJ, Foster ED (1995) Effect of hemorrhagic shock and reperfusion on the respiratory quotient in swine. Crit Care Med 23:545–552PubMedCrossRef

27.

De Backer D, Creteur J, Preiser JC, Dubois MJ, Vincent JL (2002) Microvascular blood flow is altered in patients with sepsis. Am J Respir Crit Care Med 166:98–104PubMedCrossRef

28.

Bakker J, Coffernils M, Leon M, Gris P, Vincent JL (1991) Blood lactate levels are superior to oxygen-derived variables in predicting outcome in human septic shock. Chest 99:956–962PubMedCrossRef

29.

Teboul JL, Mercat A, Lenique F, Berton C, Richard C (1998) Value of the venous-arterial PCO₂ gradient to reflect the oxygen supply to demand in humans: effects of dobutamine. Crit Care Med 26:1007–1010PubMedCrossRef

30.

Groeneveld AB (1998) Interpreting the venous-arterial PCO₂ difference. Crit Care Med 26:979–980PubMedCrossRef

31.

Lind L (1995) Veno-arterial carbon dioxide and pH gradients and survival in critical illness. Eur J Clin Invest 25:201–205PubMedCrossRef

32.

Mekontso-Dessap A, Castelain V, Anguel N, Bahloul M, Schauvliege F, Richard C, Teboul JL (2002) Combination of venoarterial PCO₂ difference with arteriovenous O₂ content difference to detect anaerobic metabolism in patients. Intensive Care Med 28:272–277PubMedCrossRef

33.

Vincent JL, de Mendonca A, Cantraine F, Moreno R, Takala J, Suter PM, Sprung CL, Colardyn F, Blecher S (1998) Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on “sepsis-related problems” of the European Society of Intensive Care Medicine. Crit Care Med 26:1793–1800PubMed

34.

Abramson D, Scalea TM, Hitchcock R, Trooskin SZ, Henry SM, Greenspan J (1993) Lactate clearance and survival following injury. J Trauma 35:584–588; discussion 588–589PubMedCrossRef

35.

Nguyen HB, Rivers EP, Knoblich BP, Jacobsen G, Muzzin A, Ressler JA, Tomlanovich MC (2004) Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med 32:1637–1642PubMedCrossRef

36.

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 30:1572–1578PubMedCrossRef

37.

Varpula M, Tallgren M, Saukkonen K, Voipio-Pulkki LM, Pettila V (2005) Hemodynamic variables related to outcome in septic shock. Intensive Care Med 31:1066–1071PubMedCrossRef

Title: Central venous-to-arterial carbon dioxide difference: an additional target for goal-directed therapy in septic shock?
Authors: Fabrice Vallée
Benoit Vallet
Olivier Mathe
Jacqueline Parraguette
Arnaud Mari
Stein Silva
Kamran Samii
Olivier Fourcade
Michèle Genestal
Publication date: 01-12-2008
Publisher: Springer-Verlag
Published in: Intensive Care Medicine / Issue 12/2008
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-008-1199-0

Keynote webinar | Spotlight on medication adherence

Springer Medicine

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

Abstract

Objective

Design

Setting

Patients

Measurements

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Objective

Design

Setting

Patients

Measurements

Results

Conclusion

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