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

Jihad Mallat, Malcolm Lemyze, Mehdi Meddour, Florent Pepy, Gaelle Gasan, Stephanie Barrailler, Emmanuelle Durville, Johanna Temime, Nicolas Vangrunderbeeck, Laurent Tronchon, Benoît Vallet, Didier Thevenin, Jihad Mallat, Malcolm Lemyze, Mehdi Meddour, Florent Pepy, Gaelle Gasan, Stephanie Barrailler, Emmanuelle Durville, Johanna Temime, Nicolas Vangrunderbeeck, Laurent Tronchon, Benoît Vallet, Didier Thevenin

Abstract

Background: To evaluate the ability of the central venous-to-arterial CO2 content and tension differences to arteriovenous oxygen content difference ratios (∆ContCO2/∆ContO2 and ∆PCO2/∆ContO2, respectively), blood lactate concentration, and central venous oxygen saturation (ScvO2) to detect the presence of global anaerobic metabolism through the increase in oxygen consumption (VO2) after an acute increase in oxygen supply (DO2) induced by volume expansion (VO2/DO2 dependence).

Methods: We prospectively studied 98 critically ill mechanically ventilated patients in whom a fluid challenge was decided due to acute circulatory failure related to septic shock. Before and after volume expansion (500 mL of colloid solution), we measured cardiac index, VO2, DO2, ∆ContCO2/∆ContO2 and ∆PCO2/∆ContO2 ratios, lactate, and ScvO2. Fluid-responders were defined as a ≥15 % increase in cardiac index. Areas under the receiver operating characteristic curves (AUC) were determined for these variables.

Results: Fifty-one patients were fluid-responders (52 %). DO2 increased significantly (31 ± 12 %) in these patients. An increase in VO2 ≥ 15 % ("VO2-responders") concurrently occurred in 57 % of the 51 fluid-responders (45 ± 16 %). Compared with VO2-non-responders, VO2-responders were characterized by higher lactate levels and higher ∆ContCO2/∆ContO2 and ∆PCO2/∆ContO2 ratios. At baseline, lactate predicted a fluid-induced increase in VO2 ≥ 15 % with AUC of 0.745. Baseline ∆ContCO2/∆ContO2 and ∆PCO2/∆ContO2 ratios predicted an increase of VO2 ≥ 15 % with AUCs of 0.965 and 0.962, respectively. Baseline ScvO2 was not able to predict an increase of VO2 ≥ 15 % (AUC = 0.624).

Conclusions: ∆ContCO2/∆ContO2 and ∆PCO2/∆ContO2 ratios are more reliable markers of global anaerobic metabolism than lactate. ScvO2 failed to predict the presence of global tissue hypoxia.

Keywords: Acute circulatory failure; Anaerobic metabolism; Lactate; Oxygen consumption; Septic shock; Tissue hypoxia; Venous oxygen saturation; Venous-to-arterial carbon dioxide difference.

Figures

Fig. 1
Fig. 1
Flow chart showing the original 98 patients separated according to their response to volume expansion in terms of cardiac index, fluid responsiveness, and oxygen consumption (VO2)
Fig. 2
Fig. 2
Receiver operating characteristic (ROC) curves showing the ability of baseline ∆ContCO2/∆ContO2, ∆PCO2/∆ContO2, lactate, and ScvO2 to predict an increase in oxygen consumption of ≥15 % induced by volume expansion

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