Abstract
Systemic blood flow can be measured easily at the bedside in critically ill patients. However, measuring cardiac output cannot tell much about the adequacy of systemic blood flow for global metabolic conditions. For example, a cardiac output of 5 l/min, which is normal in a healthy human at rest, is abnormally low during exercise or under other conditions of marked increase in oxygen (O2) demand, such as sepsis. Therefore, the simple measurement of cardiac output cannot provide sufficient information about the need to increase systemic blood flow. The mixed venous blood O2 saturation (SvO2) and the difference between mixed venous and arterial blood carbon dioxide (CO2) pressures (PCO2 gap) have been proposed to assess the adequacy of cardiac output to metabolic conditions and thus to serve to evaluate the need to increase cardiac output. Since central venous catheters are now more often inserted than pulmonary artery catheters (PACs) in critically ill patients, O2 saturation measured in a central vein (ScvO2) and the difference between CO2 pressure in a central vein and arterial CO2 pressure have been proposed as substitutes for SvO2 and PCO2 gap, respectively.
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References
Weber KT, Andrews V, Janicki JS et al (1981) Amrinone and exercice performance in patients with chronic heart failure. Am J Cardiol 48:164–169
Kasnitz P, Druger GL, Yorra F, Simmons DH (1976) Mixed venous oxygen tension and hyperlactatemia. JAMA 236:570–574
Astiz ME, Rackow EC (1998) Septic shock. Lancet 351:1501–1505
Vincent JL, De Backer D (2013) Circulatory shock. N Engl J Med 369:1726–1734
Dubin A, Pozo MO, Casabella CA et al (2009) Increasing arterial blood pressure with norepinephrine does not improve microcirculatory blood flow: a prospective study. Crit Care 13:R92
Hamzaoui O, Georger JF, Monnet X et al (2010) Early administration of norepinephrine increases cardiac preload and cardiac output in septic patients with life-threatening hypotension. Crit Care 14:R142
Monnet X, Jabot J, Maizel J, Richard C, Teboul JL (2011) Norepinephrine increases cardiac preload and reduces preload dependency assessed by passive leg raising in septic shock patients. Crit Care Med 39:689–694
Teboul JL, Hamzaoui O, Monnet X (2011) SvO2 to monitor resuscitation of septic patients: let’s just understand the basic physiology. Crit Care 15:1005
Dellinger RP, Levy MM, Rhodes A et al (2013) Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 41:580–637
Yu M, Burchell S, Hasaniya NW, Takanishi DM, Myers SA, Takiguchi SA (1998) Relationship of mortality to increasing oxygen delivery in patients > 50 years of age: A prospective, randomized trial. Crit Care Med 26:1011–1019
Friedman G, De Backer D, Shahla M, Vincent JL (1998) Oxygen supply dependency can characterize septic shock. Intensive Care Med 24:118–123
Martin C, Viviand X, Vialet ASR, Rougnon T (1999) Effects of norepinephrine plus dobutamine or norepinephrine alone on left ventricular performance of septic shock patients. Crit Care Med 27:1708–1713
Teboul JL, Boujdaria R, Graini L, Berton C, Richard C (1993) Cardiac index vs oxygen-derived parameters for rational use of dobutamine in patients with congestive heart failure. Chest 103:81–85
De Backer D, Moraine JJ, Berré J, Kahn RJ, Vincent JL (1994) Effects of dobutamine on oxygen consumption in septic patients. Direct versus indirect determinations. Am J Respir Crit Care Med 150:95–100
Gattinoni L, Brazzi L, Pelosi P et al (1995) A trial of goal-oriented hemodynamic therapy in critically ill patients. SvO2 Collaborative Group. N Engl J Med 333:1025–1032
Krafft P, Steltzer H, Hiesmayr M, Klimscha W, Hammerle AF (1993) Mixed venous oxygen saturation in critically ill septic shock patients. The role of defined events. Chest 103:900–906
Jain A, Shroff SG, Janicki JS, Reddy HK, Weber KT (1991) Relation between mixed venous oxygen saturation and cardiac index. Nonlinearity and normalization for oxygen uptake and hemoglobin. Chest 99:1403–1409
Ronco JJ, Fenwick JC, Wiggs BR, Phang PT, Russell JA, Tweeddale MG (1993) Oxygen consumption is dependent of increases in oxygen delivery by dobutamine in septic patients who have normal or increased plasma lactate. Am Rev Respir Dis 147:25–31
Hayes MA, Timmins AC, Yau EH, Palazzo M, Watson D, Hinds CJ (1997) Oxygen transport patterns in patients with sepsis syndrome or septic shock: Influence of treatment and relationship to outcome. Crit Care Med 25:926–936
Scuderi PE, Bowton DL, Meredith JW, Harris LC, Evans JB, Anderson RL (1992) A comparison of three pulmonary artery oximetry catheters in Intensive Care Unit patients. Chest 102:896–905
Wiener RS, Welch HG (2007) Trends in the use of the pulmonary artery catheter in the United States, 1993–2004. JAMA 298:423–429
Rivers E, Nguyen B, Havstad S et al (2001) Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345:1368–1377
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
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
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
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
Gutierrez G, Comignani P, Huespe L et al (2008) Central venous to mixed venous blood oxygen and lactate gradients are associated with outcome in critically ill patients. Intensive Care Med 34:1662–1668
van Beest PA, van Ingen J, Boerma EC et al (2010) No agreement of mixed venous and central venous saturation in sepsis, independent of sepsis origin. Crit Care 14:R219
Monnet X, Julien F, Ait-Hamou N et al (2013) Lactate and veno-arterial 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 41:1412–1420
van Beest PA, Hofstra JJ, Schultz MJ, Boerma EC, Spronk PE, Kuiper MA (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
Pope JV, Jones AE, Gaieski DF, Arnold RC, Trzeciak S, Shapiro NI (2010) Multicenter study of central venous oxygen saturation (ScvO(2)) as a predictor of mortality in patients with sepsis. Ann Emerg Med 55:40–46
Velissaris D, Pierrakos C, Scolletta S, De Backer D, Vincent JL (2011) High mixed venous oxygen saturation levels do not exclude fluid responsiveness in critically ill septic patients. Crit Care 15:R177
Lamia B, Monnet X, Teboul JL (2006) Meaning of arterio-venous PCO2 difference in circulatory shock. Minerva Anestesiol 72:597–604
Groeneveld AB (1998) Interpreting the venous-arterial PCO2 difference. Crit Care Med 26:979–980
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 26:1007–1010
Zhang H, Vincent JL (1993) Arteriovenous differences in PCO2 and pH are good indicators of critical hypoperfusion. Am Rev Respir Dis 148:867–871
Vallet B, Teboul JL, Cain S, Curtis S (2000) Venoarterial CO(2) difference during regional ischemic or hypoxic hypoxia. J Appl Physiol 89:1317–1321
Nevière R, Chagnon JL, Teboul JL, Vallet B, Wattel F (2002) Small intestine intramucosal PCO(2) and microvascular blood flow during hypoxic and ischemic hypoxia. Crit Care Med 30:379–384
Mecher CE, Rackow EC, Astiz ME, Weil MH (1990) Venous hypercarbia associated with severe sepsis and systemic hypoperfusion. Crit Care Med 18:585–589
Bakker J, Vincent JL, Gris P, Leon M, Coffernils M, Kahn RJ (1992) Veno-arterial carbon dioxide gradient in human septic shock. Chest 101:509–515
Wendon JA, Harrison PM, Keays R, Gimson AE, Alexander G, Williams R (1991) Arterial-venous pH differences and tissue hypoxia in patients with fulminant hepatic failure. Crit Care Med 19:1362–1364
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 23:545–552
Mekontso-Dessap A, Castelain V, Anguel N et al (2002) Combination of venoarterial PCO2 difference with arteriovenous O2 content difference to detect anaerobic metabolism in patients. Intensive Care Med 28:272–277
Cuschieri J, Rivers EP, Donnino MW et al (2005) Central venous-arterial carbon dioxide difference as an indicator of cardiac index. Intensive Care Med 31:818–822
van Beest PA, Lont MC, Holman ND, Loef B, Kuiper MA, Boerma EC (2013) Central venous-arterial pCO2 difference as a tool in resuscitation of septic patients. Intensive Care Med 39:1034–1039
Mallat J, Benzidi Y, Salleron J et al (2014) Time course of central venous-to-arterial carbon dioxide tension difference in septic shock patients receiving incremental doses of dobutamine. Intensive Care Med 40:404–411
Vallet B, Pinsky MR, Cecconi M (2013) Resuscitation of patients with septic shock: please “mind the gap”! Intensive Care Med 39:1653–1655
Vallée F, Vallet B, Mathe O et al (2008) Central venous-to-arterial carbon dioxide difference: an additional target for goal-directed therapy in septic shock? Intensive Care Med 34:2218–2225
Du W, Liu DW, Wang WT et al (2013) Combining central venous-to-arterial partial pressure of carbon dioxide difference and central venous oxygen saturation to guide resuscitation in septic shock. J Crit Care 28:1110e1–1110e5
Mallat J, Pepy F, Lemyze M et al (2014) Central venous-to-arterial carbon dioxide partial pressure difference in early resuscitation from septic shock: a prospective observational study. Eur J Anaesthesiol 31:371–380
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Teboul, JL., Monnet, X. (2015). Assessing Global Perfusion During Sepsis: SvO2, Venoarterial PCO2 Gap or Both?. In: Vincent, JL. (eds) Annual Update in Intensive Care and Emergency Medicine 2015. Annual Update in Intensive Care and Emergency Medicine 2015, vol 2015. Springer, Cham. https://doi.org/10.1007/978-3-319-13761-2_19
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DOI: https://doi.org/10.1007/978-3-319-13761-2_19
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