Central venous O₂ saturation and venous-to-arterial CO₂ difference as complementary tools for goal-directed therapy during high-risk surgery

Emmanuel Futier, Emmanuel Robin, Matthieu Jabaudon, Renaud Guerin, Antoine Petit, Jean-Etienne Bazin, Jean-Michel Constantin, Benoit Vallet, Emmanuel Futier, Emmanuel Robin, Matthieu Jabaudon, Renaud Guerin, Antoine Petit, Jean-Etienne Bazin, Jean-Michel Constantin, Benoit Vallet

Abstract

Introduction: Central venous oxygen saturation (ScvO2) is a useful therapeutic target in septic shock and high-risk surgery. We tested the hypothesis that central venous-to-arterial carbon dioxide difference (P(cv-a)CO2), a global index of tissue perfusion, could be used as a complementary tool to ScvO2 for goal-directed fluid therapy (GDT) to identify persistent low flow after optimization of preload has been achieved by fluid loading during high-risk surgery.

Methods: This is a secondary analysis of results obtained in a study involving 70 adult patients (ASA I to III), undergoing major abdominal surgery, and treated with an individualized goal-directed fluid replacement therapy. All patients were managed to maintain a respiratory variation in peak aortic flow velocity below 13%. Cardiac index (CI), oxygen delivery index (DO2i), ScvO2, P(cv-a)CO2 and postoperative complications were recorded blindly for all patients.

Results: A total of 34% of patients developed postoperative complications. At baseline, there was no difference in demographic or haemodynamic variables between patients who developed complications and those who did not. In patients with complications, during surgery, both mean ScvO2 (78 ± 4 versus 81 ± 4%, P = 0.017) and minimal ScvO2 (minScvO2) (67 ± 6 versus 72 ± 6%, P = 0.0017) were lower than in patients without complications, despite perfusion of similar volumes of fluids and comparable CI and DO2i values. The optimal ScvO2 cut-off value was 70.6% and minScvO2 < 70% was independently associated with the development of postoperative complications (OR = 4.2 (95% CI: 1.1 to 14.4), P = 0.025). P(cv-a)CO2 was larger in patients with complications (7.8 ± 2 versus 5.6 ± 2 mmHg, P < 10-6). In patients with complications and ScvO2 ≥ 71%, P(cv-a)CO2 was also significantly larger (7.7 ± 2 versus 5.5 ± 2 mmHg, P < 10-6) than in patients without complications. The area under the receiver operating characteristic (ROC) curve was 0.785 (95% CI: 0.74 to 0.83) for discrimination of patients with ScvO2 ≥ 71% who did and did not develop complications, with 5 mmHg as the most predictive threshold value.

Conclusions: ScvO2 reflects important changes in O2 delivery in relation to O2 needs during the perioperative period. A P(cv-a)CO2 < 5 mmHg might serve as a complementary target to ScvO2 during GDT to identify persistent inadequacy of the circulatory response in face of metabolic requirements when an ScvO2 ≥ 71% is achieved.

Trial registration: Clinicaltrials.gov Identifier: NCT00852449.

Figures

Figure 1
Figure 1
Flow diagram of the original study.
Figure 2
Figure 2
Cardiac index, oxygen delivery index (DO2i), stroke volume and mean arterial pressure (MAP) in patients who did (n = 24) and did not (n = 46) develop postoperative complications. There was no difference in any variable between groups at any time point. Data are expressed as means ± 95% CI.
Figure 3
Figure 3
Trends in ScvO2 (a) and P(cv-a)CO2 (b) in patients who did (n = 24) and did not (n = 46) develop postoperative complications. Data are expressed as means ± 95% CI. * P < 0.05.
Figure 4
Figure 4
Individual values of P(cv-a)CO2 according to the occurrence of postoperative complications in patients with ScvO2 ≥71%. Abbreviations: C, patients with complications; UC, patients without complications.

References

    1. Shoemaker WC, Appel PL, Kram HB. Role of oxygen debt in the development of organ failure sepsis, and death in high-risk surgical patients. Chest. 1992;102:208–215. doi: 10.1378/chest.102.1.208.
    1. Mythen MG, Webb AR. The role of gut mucosal hypoperfusion in the pathogenesis of post-operative organ dysfunction. Intensive Care Med. 1994;20:203–209. doi: 10.1007/BF01704701.
    1. Lees N, Hamilton M, Rhodes A. Clinical review: Goal-directed therapy in high risk surgical patients. Crit Care. 2009;13:231. doi: 10.1186/cc8039.
    1. Giglio MT, Marucci M, Testini M, Brienza N. Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials. Br J Anaesth. 2009;103:637–646. doi: 10.1093/bja/aep279.
    1. Bundgaard-Nielsen M, Holte K, Secher NH, Kehlet H. Monitoring of peri-operative fluid administration by individualized goal-directed therapy. Acta Anaesthesiol Scand. 2007;51:331–340. doi: 10.1111/j.1399-6576.2006.01221.x.
    1. Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial (ISRCTN38797445) Crit Care. 2005;9:R687–693. doi: 10.1186/cc3887.
    1. Gan TJ, Soppitt A, Maroof M, el-Moalem H, Robertson KM, Moretti E, Dwane P, Glass PS. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology. 2002;97:820–826. doi: 10.1097/00000542-200210000-00012.
    1. Noblett SE, Snowden CP, Shenton BK, Horgan AF. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg. 2006;93:1069–1076. doi: 10.1002/bjs.5454.
    1. Lopes MR, Oliveira MA, Pereira VO, Lemos IP, Auler JO Jr, Michard F. Goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery: a pilot randomized controlled trial. Crit Care. 2007;11:R100. doi: 10.1186/cc6117.
    1. Mythen MG, Webb AR. Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Arch Surg. 1995;130:423–429.
    1. Marjanovic G, Villain C, Juettner E, zur Hausen A, Hoeppner J, Hopt UT, Drognitz O, Obermaier R. Impact of different crystalloid volume regimes on intestinal anastomotic stability. Ann Surg. 2009;249:181–185. doi: 10.1097/SLA.0b013e31818b73dc.
    1. Kimberger O, Arnberger M, Brandt S, Plock J, Sigurdsson GH, Kurz A, Hiltebrand L. Goal-directed colloid administration improves the microcirculation of healthy and perianastomotic colon. Anesthesiology. 2009;110:496–504. doi: 10.1097/ALN.0b013e31819841f6.
    1. Donati A, Loggi S, Preiser JC, Orsetti G, Munch C, Gabbanelli V, Pelaia P, Pietropaoli P. Goal-directed intraoperative therapy reduces morbidity and length of hospital stay in high-risk surgical patients. Chest. 2007;132:1817–1824. doi: 10.1378/chest.07-0621.
    1. Collaborative Study Group on Perioperative ScvO2 Monitoring. Multicentre study on peri- and postoperative central venous oxygen saturation in high-risk surgical patients. Crit Care. 2006;10:R158. doi: 10.1186/cc5094.
    1. Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED. Changes in central venous saturation after major surgery, and association with outcome. Crit Care. 2005;9:R694–699. doi: 10.1186/cc3888.
    1. Reinhart K, Rudolph T, Bredle DL, Hannemann L, Cain SM. Comparison of central-venous to mixed-venous oxygen saturation during changes in oxygen supply/demand. Chest. 1989;95:1216–1221. doi: 10.1378/chest.95.6.1216.
    1. Futier E, Constantin JM, Petit A, Chanques G, Kwiatkowski F, Flamein R, Slim K, Sapin V, Jaber S, Bazin JE. Conservative versus restrictive individualized goal-directed fluid administration in major abdominal surgery: a prospective randomized trial. Arch Surg. 2010. in press .
    1. Pearse RM, Hinds CJ. Should we use central venous saturation to guide management in high-risk surgical patients? Crit Care. 2006;10:181. doi: 10.1186/cc5122.
    1. Pope JV, Jones AE, Gaieski DF, Arnold RC, Trzeciak S, Shapiro NI. Multicenter study of central venous oxygen saturation (ScvO(2)) as a predictor of mortality in patients with sepsis. Ann Emerg Med. 2010;55:40.e1–46.e1. doi: 10.1016/j.annemergmed.2009.08.014.
    1. Vallee F, Vallet B, Mathe O, Parraguette J, Mari A, Silva S, Samii K, Fourcade O, Genestal M. Central venous-to-arterial carbon dioxide difference: an additional target for goal-directed therapy in septic shock? Intensive Care Med. 2008;34:2218–2225. doi: 10.1007/s00134-008-1199-0.
    1. Cuschieri J, Rivers EP, Donnino MW, Katilius M, Jacobsen G, Nguyen HB, Pamukov N, Horst HM. Central venous-arterial carbon dioxide difference as an indicator of cardiac index. Intensive Care Med. 2005;31:818–822. doi: 10.1007/s00134-005-2602-8.
    1. Vallet B, Teboul JL, Cain S, Curtis S. Venoarterial CO(2) difference during regional ischemic or hypoxic hypoxia. J Appl Physiol. 2000;89:1317–1321.
    1. Lamia B, Monnet X, Teboul JL. Meaning of arterio-venous PCO2 difference in circulatory shock. Minerva Anestesiol. 2006;72:597–604.
    1. Bakker J, Vincent JL, Gris P, Leon M, Coffernils M, Kahn RJ. Veno-arterial carbon dioxide gradient in human septic shock. Chest. 1992;101:509–515. doi: 10.1378/chest.101.2.509.
    1. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003;31:1250–1256. doi: 10.1097/01.CCM.0000050454.01978.3B.
    1. Rahbari NN, Zimmermann JB, Schmidt T, Koch M, Weigand MA, Weitz J. Meta-analysis of standard, restrictive and supplemental fluid administration in colorectal surgery. Br J Surg. 2009;96:331–341. doi: 10.1002/bjs.6552.
    1. Slama M, Masson H, Teboul JL, Arnould ML, Nait-Kaoudjt R, Colas B, Peltier M, Tribouilloy C, Susic D, Frohlich E, Andrejak M. Monitoring of respiratory variations of aortic blood flow velocity using esophageal Doppler. Intensive Care Med. 2004;30:1182–1187. doi: 10.1007/s00134-004-2190-z.
    1. Monnet X, Rienzo M, Osman D, Anguel N, Richard C, Pinsky MR, Teboul JL. Esophageal Doppler monitoring predicts fluid responsiveness in critically ill ventilated patients. Intensive Care Med. 2005;31:1195–1201. doi: 10.1007/s00134-005-2731-0.
    1. Bennett-Guerrero E, Welsby I, Dunn TJ, Young LR, Wahl TA, Diers TL, Phillips-Bute BG, Newman MF, Mythen MG. The use of a postoperative morbidity survey to evaluate patients with prolonged hospitalization after routine, moderate-risk, elective surgery. Anesth Analg. 1999;89:514–519. doi: 10.1097/00000539-199908000-00050.
    1. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–213. doi: 10.1097/.
    1. Hosmer DW, Hosmer T, Le Cessie S, Lemeshow S. A comparison of goodness-of-fit tests for the logistic regression model. Stat Med. 1997;16:965–980. doi: 10.1002/(SICI)1097-0258(19970515)16:9<965::AID-SIM509>;2-O.
    1. Kwiatkowski F, Girard M, Hacene K, Berlie J. Sem: a suitable statistical software adaptated for research in oncology. Bull Cancer. 2000;87:715–721.
    1. Grocott MP, Mythen MG, Gan TJ. Perioperative fluid management and clinical outcomes in adults. Anesth Analg. 2005;100:1093–1106. doi: 10.1213/.
    1. Chappell D, Jacob M, Hofmann-Kiefer K, Conzen P, Rehm M. A rational approach to perioperative fluid management. Anesthesiology. 2008;109:723–740. doi: 10.1097/ALN.0b013e3181863117.
    1. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368–1377. doi: 10.1056/NEJMoa010307.
    1. Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA. 2010;303:739–746. doi: 10.1001/jama.2010.158.
    1. Groeneveld AB. Interpreting the venous-arterial PCO2 difference. Crit Care Med. 1998;26:979–980. doi: 10.1097/00003246-199806000-00002.
    1. Neviere R, Chagnon JL, Teboul JL, Vallet B, Wattel F. Small intestine intramucosal PCO(2) and microvascular blood flow during hypoxic and ischemic hypoxia. Crit Care Med. 2002;30:379–384. doi: 10.1097/00003246-200202000-00019.
    1. Mecher CE, Rackow EC, Astiz ME, Weil MH. Venous hypercarbia associated with severe sepsis and systemic hypoperfusion. Crit Care Med. 1990;18:585–589. doi: 10.1097/00003246-199006000-00001.
    1. Shepherd SJ, Pearse RM. Role of central and mixed venous oxygen saturation measurement in perioperative care. Anesthesiology. 2009;111:649–656. doi: 10.1097/ALN.0b013e3181af59aa.
    1. Mekontso-Dessap A, Castelain V, Anguel N, Bahloul M, Schauvliege F, Richard C, Teboul JL. Combination of venoarterial PCO2 difference with arteriovenous O2 content difference to detect anaerobic metabolism in patients. Intensive Care Med. 2002;28:272–277. doi: 10.1007/s00134-002-1215-8.

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner