Top

Published in:

Open Access 01-12-2023 | Research

Ratio of carbon dioxide veno-arterial difference to oxygen arterial-venous difference is not associated with lactate decrease after fluid bolus in critically ill patients with hyperlactatemia: results from a prospective observational study

Authors: Keitiane Kaefer, Charalampos Pierrakos, Thomas Nguyen, Dimitrios Velissaris, Rachid Attou, Jacques Devriendt, Sabino Scolletta, Fabio Silvio Taccone

Published in: BMC Anesthesiology | Issue 1/2023

Abstract

Background

High ratio of the carbon dioxide veno-arterial difference to the oxygen arterial-venous difference (P_vaCO₂/C_avO₂) is associated with fluid bolus (FB) induced increase in oxygen consumption (VO₂). This study investigated whether P_vaCO₂/C_avO₂ was associated with decreases in blood-lactate levels FB in critically ill patients with hyperlactatemia.

Methods

This prospective observational study examined adult patients in the intensive care unit (ICU) with lactate levels > 1.5 mmol/L who received FBs. Blood-lactate levels were measured before and after FB under unchanged metabolic, respiratory, and hemodynamic conditions. The primary outcome was blood-lactate levels after FB. Significant decreases in blood-lactate levels were considered as blood-lactate levels < 1.5 mmol/L or a decrease of more than 10% compared to baseline.

Results

The study enrolled 40 critically ill patients, and their median concentration of blood lactate was 2.6 [IQR:1.9 − 3.8] mmol/L. There were 27 (68%) patients with P_vaCO₂/C_avO₂ ≥ 1.4 mmHg/ml, and 10 of them had an increase in oxygen consumption (dVO₂) ≥ 15% after FB, while 13 (32%) patients had P_vaCO₂/C_avO₂ < 1.4 mmHg/ml before FB, and none of them had dVO₂ ≥ 15% after FB. FB increased the cardiac index in patients with high and low preinfusion P_vaCO₂/C_avO₂ (13.4% [IQR: 8.3 − 20.2] vs. 8.8% [IQR: 2.9 − 17.4], p = 0.34). Baseline P_vaCO₂/C_avO₂ was not found to be associated with a decrease in blood lactate after FB (OR: 0.88 [95% CI: 0.39 − 1.98], p = 0.76). A positive correlation was observed between changes in blood lactate and baseline P_vaCO₂/C_avO₂ (r = 0.35, p = 0.02).

Conclusions

In critically ill patients with hyperlactatemia, P_vaCO₂/C_avO₂ before FB cannot be used to predict decreases in blood-lactate levels after FB. Increased P_vaCO₂/C_avO₂ is associated with less decrease in blood-lactate levels.

Available only for authorised users

Vincent JL, De Backer D. Circulatory shock. N Engl J Med. 2013;369(18):1726–34. https://doi.org/10.1056/NEJMra1208943.CrossRef

Cecconi M, Hofer C, Teboul JL, et al. Fluid challenges in intensive care: the FENICE study: a global inception cohort study [published correction appears in intensive care med. Intensive Care Med. 2015;41(9):1737–8. https://doi.org/10.1007/s00134-015-3850-x. 2015;41(9):1529-1537.CrossRef

Levy B. Lactate and shock state: The metabolic view. Curr Opin Crit Care. 2006;12(4):315–21.CrossRef

Jansen TC, van Bommel J, Schoonderbeek FJ, et al. Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial. Am J Respir Crit Care Med. 2010;182(6):752–61. https://doi.org/10.1164/rccm.200912-1918OC.CrossRef

Hernández G, Ospina-Tascón GA, Damiani LP, et al. Effect of a resuscitation strategy targeting peripheral perfusion status vs serum lactate levels on 28-day mortality among patients with septic shock: the ANDROMEDA-SHOCK randomized clinical trial. JAMA. 2019;321(7):654–64. https://doi.org/10.1001/jama.2019.0071.CrossRef

Mekontso-Dessap A, Castelain V, Anguel N, et al. Combination of venoarterial PCO2 difference with arteriovenous O2 content difference to detect anaerobic metabolism in patients. Intensive Care Med. 2002;28(3):272–7. https://doi.org/10.1007/s00134-002-1215-8.CrossRef

Wasserman K, Whipp BJ, Koyl SN, Beaver WL. Anaerobic threshold and respiratory gas exchange during exercise. J Appl Physiol. 1973;35(2):236–43. https://doi.org/10.1152/jappl.1973.35.2.236.CrossRef

Monnet X, Julien F, Ait-Hamou N, et al. Lactate and venoarterial carbon dioxide difference/arterial-venous oxygen difference ratio, but not central venous oxygen saturation, predict increase in oxygen consumption in fluid responders. Crit Care Med. 2013;41(6):1412–20. https://doi.org/10.1097/CCM.0b013e318275cece.CrossRef

Mallat J, Lemyze M, Meddour M, et al. Ratios of central venous-to-arterial carbon dioxide content or tension to arteriovenous oxygen content are better markers of global anaerobic metabolism than lactate in septic shock patients. Ann Intensive Care. 2016;6(1):10. https://doi.org/10.1186/s13613-016-0110-3.CrossRef

10.

Caruso V, Besch G, Nguyen M, et al. Treatment of hyperlactatemia in acute circulatory failure based on CO2-O2-derived indices: study protocol for a prospective, multicentric, single, blind, randomized superiority study (The LACTEL Study). Front Cardiovasc Med. 2022;9:898406. https://doi.org/10.3389/fcvm.2022.898406.CrossRef

11.

Vellinga NAR, Boerma EC, Koopmans M, et al. Mildly elevated lactate levels are associated with microcirculatory flow abnormalities and increased mortality: a microSOAP post hoc analysis. Crit Care. 2017;21(1):255. https://doi.org/10.1186/s13054-017-1842-7.CrossRef

12.

Scheeren TWL, Wicke JN, Teboul JL. Understanding the carbon dioxide gaps. Curr Opin Crit Care. 2018;24(3):181–9. https://doi.org/10.1097/MCC.0000000000000493.CrossRef

13.

Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801–10. https://doi.org/10.1001/jama.2016.0287.CrossRef

14.

Zhou X, Liu D, Su L, et al. Use of stepwise lactate kinetics-oriented hemodynamic therapy could improve the clinical outcomes of patients with sepsis-associated hyperlactatemia. Crit Care. 2017;21(1):33. https://doi.org/10.1186/s13054-017-1617-1.CrossRef

15.

Mesquida J, Saludes P, Gruartmoner G, et al. 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. Crit Care. 2015;19(1):126. https://doi.org/10.1186/s13054-015-0858-0.CrossRef

16.

He HW, Liu DW, Long Y, Wang XT. High central venous-to-arterial CO2 difference/arterial-central venous O2 difference ratio is associated with poor lactate clearance in septic patients after resuscitation. J Crit Care. 2016;31(1):76–81. https://doi.org/10.1016/j.jcrc.2015.10.017.CrossRef

17.

Ospina-Tascón GA, Umaña M, Bermúdez W, et al. 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. Intensive Care Med. 2015;41(5):796–805. https://doi.org/10.1007/s00134-015-3720-6.CrossRef

18.

Abou-Arab O, Braik R, Huette P, Bouhemad B, Lorne E, Guinot PG. The ratios of central venous to arterial carbon dioxide content and tension to arteriovenous oxygen content are not associated with overall anaerobic metabolism in postoperative cardiac surgery patients. PLoS One. 2018;13(10):e0205950. https://doi.org/10.1371/journal.pone.0205950.CrossRef

19.

Saludes P, Proença L, Gruartmoner G, et al. In response to: “understanding elevated Pv-aCO2 gap and Pv-aCO2/Ca-vO2 ratio in venous hyperoxia condition.” J Clin Monit Comput. 2017;31(6):1325–7. https://doi.org/10.1007/s10877-017-0006-2.CrossRef

20.

Du W, Long Y, Wang XT, Liu DW. The use of the ratio between the veno-arterial carbon dioxide difference and the arterial-venous oxygen difference to guide resuscitation in cardiac surgery patients with hyperlactatemia and normal central venous oxygen saturation. Chin Med J (Engl). 2015;128(10):1306–13. https://doi.org/10.4103/0366-6999.156770.CrossRef

21.

Older P. Anaerobic threshold, is it a magic number to determine fitness for surgery? Perioper Med (Lond). 2013;2(1):2. https://doi.org/10.1186/2047-0525-2-2. Published 21 Feb 2013.CrossRef

22.

Cheong KF, Lee TL. Oxygen consumption–a comparison between calculation by Fick’s principle and measurement by indirect calorimetry. Med J Malaysia. 1997;52(1):70–5.

23.

Inadomi C, Terao Y, Yamashita K, Fukusaki M, Takada M, Sumikawa K. Comparison of oxygen consumption calculated by Fick’s principle (using a central venous catheter) and measured by indirect calorimetry. J Anesth. 2008;22(2):163–6. https://doi.org/10.1007/s00540-007-0588-9.CrossRef

24.

Vincent JL, Cecconi M, De Backer D. The fluid challenge. Crit Care. 2020;24(1):703. https://doi.org/10.1186/s13054-020-03443-y.CrossRef

25.

Leavy JA, Weil MH, Rackow EC. “Lactate washout” following circulatory arrest. JAMA. 1988;260(5):662–4.CrossRef

26.

Falk JL, Rackow EC, Leavy J, Astiz ME, Weil MH. Delayed lactate clearance in patients surviving circulatory shock. Acute Care. 1985;11(3–4):212–5.

27.

Yang M. Muscle lactate concentration during experimental hemorrhagic shock. J Anesth. 1998;12(2):76–80.CrossRef

28.

Scott S, Antonaglia V, Guiotto G, Paladino F, Schiraldi F. Two-hour lactate clearance predicts negative outcome in patients with cardiorespiratory insufficiency. Crit Care Res Pract. 2010;2010:1–6.CrossRef

29.

Wutrich Y, Barraud D, Conrad M, Cravoisy-Popovic A, Nace L, Bollaert PE, et al. Early increase in arterial lactate concentration under epinephrine infusion is associated with a better prognosis during shock. Shock. 2010;34(1):4–9.CrossRef

30.

Garcia-Alvarez M, Marik P, Bellomo R. Sepsis-associated hyperlactatemia. Crit Care. 2014;18(5):1–11.CrossRef

31.

Margaria R, Edwards HT, Dill DB. The possible mechanisms of contracting and paying the oxygen debt and the rôle of lactic acid in muscular contraction. Am J Physiol Content. 1933;106(3):689–715. https://doi.org/10.1152/ajplegacy.1933.106.3.689.CrossRef

32.

Ganushchak YM, Kurniawati ER, van der Horst ICC, et al. Patterns of oxygen debt repayment in cardiogenic shock patients sustained with extracorporeal life support: a retrospective study. J Crit Care. 2022;71:154044. https://doi.org/10.1016/j.jcrc.2022.154044.CrossRef

Title: Ratio of carbon dioxide veno-arterial difference to oxygen arterial-venous difference is not associated with lactate decrease after fluid bolus in critically ill patients with hyperlactatemia: results from a prospective observational study
Authors: Keitiane Kaefer
Charalampos Pierrakos
Thomas Nguyen
Dimitrios Velissaris
Rachid Attou
Jacques Devriendt
Sabino Scolletta
Fabio Silvio Taccone
Publication date: 01-12-2023
Publisher: BioMed Central
Published in: BMC Anesthesiology / Issue 1/2023
Electronic ISSN: 1471-2253
DOI: https://doi.org/10.1186/s12871-023-01993-6

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Ratio of carbon dioxide veno-arterial difference to oxygen arterial-venous difference is not associated with lactate decrease after fluid bolus in critically ill patients with hyperlactatemia: results from a prospective observational study

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2023

Antiemetic prophylaxis with droperidol in morphine-based intravenous patient-controlled analgesia: a propensity score matched cohort study

Effect of gabapentin on length of stay, opioid use, and pain scores in posterior spinal fusion for adolescent idiopathic scoliosis: a retrospective review across a multi-hospital system

Chronic pain in patients with gunshot wounds

Intrathecal dexmedetomidine as an adjuvant to plain ropivacaine for spinal anesthesia during cesarean section: a prospective, double-blinded, randomized trial for ED50 determination using an up-down sequential allocation method

Effect of continuous spinal anesthesia on the hemodynamics of labor analgesia in hypertensive pregnant women: a comparative, randomized clinical trial

Effect of surgical pleth index-guided remifentanil administration on perioperative outcomes in elderly patients: a prospective randomized controlled trial