Deconstructing Hyperlactatemia in Sepsis Using Central Venous Oxygen Saturation and Base Deficit.
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SUBMITTER: Semler MW
PROVIDER: S-EPMC6727157 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:ContextGoal-directed resuscitation for severe sepsis and septic shock has been reported to reduce mortality when applied in the emergency department.ObjectiveTo test the hypothesis of noninferiority between lactate clearance and central venous oxygen saturation (ScvO2) as goals of early sepsis resuscitation.Design, setting, and patientsMulticenter randomized, noninferiority trial involving patients with severe sepsis and evidence of hypoperfusion or septic shock who were admitted to the emergency department from January 2007 to January 2009 at 1 of 3 participating US urban hospitals.InterventionsWe randomly assigned patients to 1 of 2 resuscitation protocols. The ScvO2 group was resuscitated to normalize central venous pressure, mean arterial pressure, and ScvO2 of at least 70%; and the lactate clearance group was resuscitated to normalize central venous pressure, mean arterial pressure, and lactate clearance of at least 10%. The study protocol was continued until all goals were achieved or for up to 6 hours. Clinicians who subsequently assumed the care of the patients were blinded to the treatment assignment.Main outcome measureThe primary outcome was absolute in-hospital mortality rate; the noninferiority threshold was set at Delta equal to -10%.ResultsOf the 300 patients enrolled, 150 were assigned to each group and patients were well matched by demographic, comorbidities, and physiological features. There were no differences in treatments administered during the initial 72 hours of hospitalization. Thirty-four patients (23%) in the ScvO2 group died while in the hospital (95% confidence interval [CI], 17%-30%) compared with 25 (17%; 95% CI, 11%-24%) in the lactate clearance group. This observed difference between mortality rates did not reach the predefined -10% threshold (intent-to-treat analysis: 95% CI for the 6% difference, -3% to 15%). There were no differences in treatment-related adverse events between the groups.ConclusionAmong patients with septic shock who were treated to normalize central venous and mean arterial pressure, additional management to normalize lactate clearance compared with management to normalize ScvO2 did not result in significantly different in-hospital mortality.Trial registrationclinicaltrials.gov Identifier: NCT00372502.
| S-EPMC2918907 | biostudies-literature
Project description:ObjectivesLactate clearance (LC) and central venous oxygen saturation (ScvO(2)) have been proposed as goals of early sepsis resuscitation. The authors sought to determine the agreement and prognostic value of achieving ScvO(2) or LC goals in septic shock patients undergoing emergency department (ED)-based early resuscitation.MethodsThis was a preplanned analysis of a multicenter ED randomized controlled trial of early sepsis resuscitation targeting three variables: central venous pressure, mean arterial pressure, and either ScvO(2) or LC. Inclusion criteria included suspected infection, two or more systemic inflammation criteria, and either systolic blood pressure of <90 mm Hg after intravenous fluid bolus or lactate level of >4 mmol/L. Both ScvO(2) and LC were measured simultaneously. The ScvO(2) goal was defined as ≥70%. Lactate was measured at enrollment and every 2 hours until the goal was reached or up to 6 hours. LC goal was defined as a decrease of ≥10% from initial measurement. The primary outcome was in-hospital mortality.ResultsA total of 203 subjects were included, with an overall mortality of 19.7%. Achievement of the ScvO(2) goal only was associated with a mortality rate of 41% (9/22), while achievement of the LC goal only was associated with a mortality rate of 8% (2/25; proportion difference = 33%; 95% confidence interval [CI] = 9% to 55%). No agreement was found between goal achievement (κ = -0.02), and exact test for matched pairs demonstrated no significant difference between discordant pairs (p = 0.78).ConclusionsNo agreement was found between LC and ScvO(2) goal achievement in early sepsis resuscitation. Achievement of a ScvO(2) ≥ 70% without LC ≥ 10% was more strongly associated with mortality than achievement of LC ≥ 10% with failure to achieve ScvO(2) ≥ 70%.
| S-EPMC3313083 | biostudies-literature
Project description:Central venous oxygen saturation (ScvO2) in the superior vena cava is predominantly determined by cardiac output, arterial oxygen content, and oxygen consumption by the upper body. While abnormal ScvO2 levels are associated with morbidity and mortality in non-uremic populations, ScvO2 has received little attention in hemodialysis patients. From 1/2012 to 8/2015, 232 chronic hemodialysis patients with central venous catheters as vascular access had their ScvO2 monitored during a 6-month baseline period and followed for up to 36 months. Patients were stratified into upper and lower two tertiles by a ScvO2 of 61.1%. Survival analysis employed Kaplan-Meier curves and adjusted Cox proportional hazards models. Patients in the lower tertiles of ScvO2 were older, had longer hemodialysis vintage, lower systolic blood pressure, lower ultrafiltration rates, higher leukocyte counts and neutrophil-to-lymphocyte ratios. Kaplan-Meier analysis indicated a shorter survival time in the lower tertiles of ScvO2 (P?=?0.005, log-rank test). In adjusted Cox analysis, a 1 percent point decrease in mean ScvO2 was associated with a 4% increase in mortality (HR 1.04 [95% CI 1.01-1.08], P?=?0.044), indicating that low? ScvO2 is associated with poor outcomes. Research on the relative contributions of cardiac output and other factors is warranted to further elucidate the pathophysiology underlying this novel finding.
| S-EPMC5561134 | biostudies-literature
Project description:Background:Cardiac disease is highly prevalent in hemodialysis (HD) patients. Decreased tissue perfusion, including cardiac, due to high ultrafiltration volumes (UFVs) is considered to be one of the drivers of cardiac dysfunction. While central venous oxygen saturation (ScvO2) is frequently used as an indicator of cardiac output in non-uremic populations, the relationship of ScvO2 and UFV in HD patients remains unclear. Our aim was to determine how intradialytic ScvO2 changes associate with UFV. Methods:We conducted a 6-month retrospective cohort study in maintenance HD patients with central venous catheters as vascular access. Intradialytic ScvO2 was measured with the Critline monitor. We computed treatment-level slopes of intradialytic ScvO2 over time (ScvO2 trend) and applied linear mixed effects models to assess the association between patient-level ScvO2 trends and UFV corrected for body weight (cUFV). Results:We studied 6042 dialysis sessions in 232 patients. In about 62.4% of treatments, ScvO2 decreased. We observed in nearly 80% of patients an inverse relationship between cUFV and ScvO2 trend, indicating that higher cUFV is associated with steeper decline in ScvO2 during dialysis. Conclusions:In most patients, higher cUFV volumes are associated with steeper intradialytic ScvO2 drops. We hypothesize that in a majority of patients the intradialytic cardiac function is fluid dependent, so that in the face of high ultrafiltration rates or volume, cardiac pre-load and consequently cardiac output decreases. Direct measurements of cardiac hemodynamics are warranted to further test this hypothesis.
| S-EPMC6113642 | biostudies-literature
Project description:BackgroundCentral venous oxygen saturation (ScvO2) is often used to help to guide resuscitation of critically ill patients. The standard gold technique for ScvO2 measurement is the co-oximetry (Co-oximetry_ScvO2), which is usually incorporated in most recent blood gas analyzers. However, in some hospitals, those machines are not available and only calculated ScvO2 (Calc_ScvO2) is provided. Therefore, we aimed to investigate the agreement between Co-oximetry_ScvO2 and Calc_ScvO2 in a general population of critically ill patients and septic shock patients.MethodsA total of 100 patients with a central venous catheter were included in the study. One hundred central venous blood samples were collected and analyzed using the same point-of-care blood gas analyzer, which provides both the calculated and measured ScvO2 values. Bland and Altman plot, intra-class correlation coefficient (ICC), and Cohen's Kappa coefficient were used to assess the agreement between Co-oximetry_ScvO2 and Calc_ScvO2. Multiple linear regression analysis was performed to investigate the independent explanatory variables of the difference between Co-oximetry_ScvO2 and Calc_ScvO2.ResultsIn all population, Bland and Altman's analysis showed poor agreement (+4.5 [-7.1, +16.1]%) between the two techniques. The ICC was 0.754 [(95% CI: 0.393-0.880), P< 0.001], and the Cohen's Kappa coefficient, after categorizing the two variables into two groups using a cutoff value of 70%, was 0.470 (P <0.001). In septic shock patients (49%), Bland and Altman's analysis also showed poor agreement (+5.6 [-6.7 to 17.8]%). The ICC was 0.720 [95% CI: 0.222-0.881], and the Cohen's Kappa coefficient was 0.501 (P <0.001). Four independent variables (PcvO2, Co-oximetry_ScvO2, venous pH, and Hb) were found to be associated with the difference between the measured and calculated ScvO2 (adjusted R2 = 0.8, P<0.001), with PcvO2 being the main independent explanatory variable because of its highest absolute standardized coefficient. The area under the receiver operator characteristic curves (AUC) of PcvO2 to predict Co-oximetry_ScvO2 ? 70% was 0.911 [95% CI: 0.837-0.959], in all patients, and 0.903 [95% CI: 0.784-0.969], in septic shock patients. The best cutoff value was ? 36 mmHg (sensitivity, 88%; specificity, 83%), in all patients, and ? 35 mmHg (sensitivity, 94%; specificity, 71%) in septic shock patients.ConclusionsThe discrepancy between the measured and calculated ScvO2 is clinically not acceptable. We do not recommend the use of calculated ScvO2 to guide resuscitation in critically ill patients. In situations where the Co-oximetry technique is not available, relying on PcvO2 to predict the measured ScvO2 value above or below 70% could be an option.
| S-EPMC6224192 | biostudies-literature
Project description:IntroductionLow cardiac output states such as left heart failure are characterized by preserved oxygen extraction ratio, which is in contrast to severe sepsis. Near infrared spectroscopy (NIRS) allows noninvasive estimation of skeletal muscle tissue oxygenation (StO2). The aim of the study was to determine the relationship between StO2 and mixed venous oxygen saturation (SvO2) in patients with severe left heart failure with or without additional severe sepsis or septic shock.MethodsSixty-five patients with severe left heart failure due to primary heart disease were divided into two groups: groups A (n = 24) and B (n = 41) included patients without and with additional severe sepsis/septic shock, respectively. Thenar muscle StO2 was measured using NIRS in the patients and in 15 healthy volunteers.ResultsStO2 was lower in group A than in group B and in healthy volunteers (58 +/- 13%, 90 +/- 7% and 84 +/- 4%, respectively; P < 0.001). StO2 was higher in group B than in healthy volunteers (P = 0.02). In group A StO2 correlated with SvO2 (r = 0.689, P = 0.002), although StO2 overestimated SvO2 (bias -2.3%, precision 4.6%). In group A changes in StO2 correlated with changes in SvO2 (r = 0.836, P < 0.001; DeltaSvO2 = 0.84 x DeltaStO2 - 0.67). In group B important differences between these variables were observed. Plasma lactate concentrations correlated negatively with StO2 values only in group A (r = -0.522, P = 0.009; lactate = -0.104 x StO2 + 10.25).ConclusionSkeletal muscle StO2 does not estimate SvO2 in patients with severe left heart failure and additional severe sepsis or septic shock. However, in patients with severe left heart failure without additional severe sepsis or septic shock, StO2 values could be used to provide rapid, noninvasive estimation of SvO2; furthermore, the trend in StO2 may be considered a surrogate for the trend in SvO2.
| S-EPMC2147710 | biostudies-literature
Project description:Using a novel noninvasive, visible-light optical diffusion oximeter (T-Stat VLS Tissue Oximeter; Spectros Corporation, Portola Valley, CA) to measure the tissue oxygen saturation (StO2) of the buccal mucosa, the correlation between StOz and central venous oxygen saturation (ScvO2) was examined in children with congenital cyanotic heart disease undergoing a cardiac surgical procedure. Paired StO2 and serum ScvO2 measurements were obtained postoperatively and statistically analyzed for agreement and association. Thirteen children (nine male) participated in the study (age range, 4 days to 18 months). Surgeries included Glenn shunt procedures, Norwood procedures, unifocalization procedures with Blalock-Taussig shunt placement, a Kawashima/ Glenn shunt procedure, a Blalock-Taussig shunt placement, and a modified Norwood procedure. A total of 45 paired StO2-ScvO2 measurements was obtained. Linear regression demonstrated a Pearson's correlation of .58 (95% confidence interval [CI], .35-.75; p < .0001). The regression slope coefficient estimate was .95 (95% CI, .54-1.36) with an interclass correlation coefficient of .48 (95% CI, .22-.68). Below a clinically relevant average ScvO2 value, a receiver operator characteristic analysis yielded an area under the curve of .78. Statistical methods to control for repeatedly measuring the same subjects produced similar results. This study shows a moderate relationship and agreement between StO2 and ScvO2 measurements in pediatric patients with a history of congenital cyanotic heart disease undergoing a cardiac surgical procedure. This real-time monitoring device can act as a valuable adjunct to standard noninvasive monitoring in which serum SyvO2 sampling currently assists in the diagnosis of low cardiac output after pediatric cardiac surgery.
| S-EPMC4360981 | biostudies-literature
Project description:The brain has high oxygen extraction, thus the regional cerebral tissue oxygen saturation (rSO2) is lower than the central venous oxygen saturation (ScvO2). We hypothesised that diabetes widens the physiological saturation gap between ScvO2 and rSO2 (gSO2), and the width of this gap may vary during various phases of cardiac surgery. Cardiac surgery patients with (n = 48) and without (n = 91) type 2 diabetes mellitus (T2DM) underwent either off-pump coronary artery bypass (OPCAB) or other cardiac surgery necessitating cardiopulmonary bypass (CPB) were enrolled. rSO2 was measured by near-infrared spectroscopy (NIRS) and ScvO2 was determined simultaneously from central venous blood. rSO2 was registered before and after anaesthesia induction and at different stages of the surgery. ScvO2 did not differ between the T2DM and control patients at any stage of surgery, whereas rSO2 was lower in T2DM patients, compared to the control group before anaesthesia induction (60.4 ± 8.1%[SD] vs. 67.2 ± 7.9%, p<0.05), and this difference was maintained throughout the surgery. After anaesthesia induction, the gSO2 was higher in diabetic patients undergoing CPB (20.2 ± 10.4% vs. 12.4 ± 8.6%, p < 0.05) and OPCAB grafting surgeries (17.0 ± 7.5% vs. 9.5 ± 7.8%, p < 0.05). While gSO2 increased at the beginning of CPB in T2DM and control patients, no significant intraoperative changes were observed during the OPCAB surgery. The wide gap between ScvO2 and rSO2 and their uncoupled relationship in patients with diabetes indicate that disturbances in the cortical oxygen saturation cannot be predicted from the global clinical parameter, the ScvO2. Thus, our findings advocate the monitoring value of NIRS in T2DM.
| S-EPMC6930198 | biostudies-literature
Project description:BackgroundSerum lactate and central venous oxygen saturation (ScvO2) are commonly used and commonly recommended as markers of tissue oxygenation in shock states. Medical literature has both explicitly stated and implied that the two biomarkers are interchangeable in the management of patients with shock. However, there have been relatively few direct comparisons of these tests in clinical circumstances, and the relationship between them is uncertain. The objective of our study was to evaluate whether simultaneous or near-simultaneous measurements of lactate and ScvO2 reveal a consistent relationship between these two biomarkers.MethodsA retrospective cohort study was conducted in an urban, academic US hospital. All adults in ICUs between March 2007 and March 2017 who had a lactate measurement and ScvO2 or mixed venous oxygen saturation (SvO2) measurement made +/- 1 h from the lactate were included. Linear and non-linear correlations of ScvO2 and lactate were assessed in a variety of shock states.ResultsTwo thousand sixty-two patients were included. Lactate and ScvO2 correlated poorly (r 2 = 0.0041, p = 0.0019). This was true for patients with ScvO2 ≤ 65% (r 2 = 0.0431, p < 0.001), patients with normal kidney and liver function (r 2 = 0.0517, p < 0.001), and septic shock patients (r 2 = 0.0037, p = 0.17). For patients with an O2 extraction ratio ≥ 50%, lactate and ScvO2 were strongly correlated (r 2 = 0.93, p = 0.0019), but these patients represented only 2.8% of patients in whom the ratio could be calculated.ConclusionsLactate can predict ScvO2 when patients are at or below the critical oxygen delivery threshold, but relatively few shock patients meet this criterion. In the overall population of critically ill patients, serum lactate predicts ScvO2 poorly, even after controlling for factors that may affect lactate production. Lactate and ScvO2 should not be assumed to be interchangeable markers of tissue oxygenation/perfusion.
| S-EPMC6728973 | biostudies-literature
Project description:Major abdominal surgery is associated with significant risk of morbidity and mortality in the perioperative period. Optimising intraoperative fluid administration may result in improved outcomes. Our aim was to compare the effects of central venous pressure (CVP), and central venous oxygen saturation (ScvO2)-assisted fluid therapy on postoperative complications in patients undergoing high risk surgery.Patients undergoing elective major abdominal surgery were randomised into control and ScvO2 groups. The target level of mean arterial pressure (MAP) was???60 mmHg in both groups. In cases of MAP?<?60 mmHg patients received either a fluid or vasopressor bolus according to the CVP?<?8 mmHg in the control group. In the ScvO2 group, in addition to the MAP, an ScvO2 of <75% or a >3% decrease indicated need for intervention, regardless of the actual MAP. Data are presented as mean?±?standard deviation or median (interquartile range).We observed a lower number of patients with complications in the ScvO2 group compared to the control group, however it did not reach statistical significance (ScvO2 group: 10 vs.19; p?=?0.07). Patients in the ScvO2 group (n?=?38) received more colloids compared to the control group (n?=?41) [279(161) vs. 107(250) ml/h; p?<?0.001]. Both groups received similar amounts of crystalloid (1126?±?471 vs. 1049?±?431 ml/h; p?=?0.46) and norepinephrine [37(107) vs. 18(73) mcg/h; p?=?0.84]. Despite similar blood loss in both groups, the ScvO2 group received more blood transfusions (63% vs. 37%; p?=?0.018). More patients in the control group had a postoperative PaO2/FiO2?<?200 mmHg (23 vs. 10, p?<?0.01). Twenty eight day survival was significantly higher in the ScvO2 group (37/38 vs. 33/41 p?=?0.018).ScvO2-assisted intraoperative haemodynamic support provided some benefits, including significantly better postoperative oxygenation and 28 day survival rate, compared to CVP-assisted therapy without a significant effect on postoperative complications during major abdominal surgery.ClinicalTrials.gov NCT02337010.
| S-EPMC4453106 | biostudies-literature