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Abstract Background: Post-operative delirium is a serious complication in patients undergoing major abdominal surgery. It remains unclear whether peri-operative hemodynamic and perfusion variables affect the risk for postoperative delirium. The objective of this pilot study was to evaluate the association between perfusion and hemodynamics peri-operative with the appearance of post-operative delirium. Methods: Prospective cohort study of adults 60 years or older undergoing elective open colon surgery. Multimodal hemodynamic and perfusion variables were monitored, including central venous oxygenation (ScvO2), lactate levels, and non-invasive cerebral oxygenation (rSO2), according to a standard anesthesia protocol. Fisher's exact test or Student's t-test were used to compare patients who developed post-operative delirium with those who did not (p < 0.05). Results: We studied 28 patients, age 73 ± 7 years, 60.7% female. Two patients developed post-operative delirium (7.1%). These two patients had fewer years of education than those without delirium (p = 0.031). None of the peri-operative blood pressure variables were associated with incidence of post-operative delirium. In terms of perfusion parameters, postoperative ScvO2 was lower in the delirium than the non-delirium group, without reaching statistical significance (65 ± 10% vs. 74 ± 5%; p = 0.08), but the delta-ScvO2 (the difference between means post-operative and intra-operative) was associated with post-operative delirium (p = 0.043). Post-operative lactate and rSO2 variables were not associated with delirium. Conclusions: Our pilot study suggests an association between delta ScvO2 and post-operative delirium, and a tendency to lower post-operative ScvO2 in patients who developed delirium. Further studies are necessary to elucidate this association.
Resumo Justificativa: O delírio pós-operatório é uma complicação séria em pacientes submetidos à cirurgia abdominal de grande porte. Ainda não está claro se as variáveis hemodinâmicas e de perfusão no período perioperatório afetam o risco de delírio pós-operatório. O objetivo deste estudo piloto foi avaliar a associação entre perfusão e hemodinâmica no perioperatório com o surgimento de delírio pós-operatório. Métodos: Estudo prospectivo de coorte de adultos com 60 anos ou mais, submetidos à cirurgia eletiva aberta do cólon. As variáveis multimodais de hemodinâmica e perfusão foram monitoradas, inclusive oxigenação venosa central (ScvO2), níveis de lactato e oxigenação cerebral não invasiva (rSO2), de acordo com um protocolo-padrão de anestesia. O teste exato de Fisher ou o teste t de Student foram usados para comparar os pacientes que desenvolveram delírio pós-operatório com aqueles que não desenvolveram p < 0,05. Resultados: Avaliamos 28 pacientes, 73 ± 7 anos, 60,7% do sexo feminino. Dois pacientes desenvolveram delírio pós-operatório (7,1%). Esses dois pacientes tinham menos anos de escolaridade do que aqueles sem delírio pós-operatório (p = 0,031). Nenhuma das variáveis de pressão arterial no perioperatório foi associada à incidência de delírio. Quanto aos parâmetros de perfusão, ScvO2 foi menor no grupo que apresentou delírio pós-operatório do que no grupo que não apresentou delírio, sem atingir significância estatística (65 ± 10% vs. 74 ± 5%; p = 0,08), mas o delta-ScvO2 (a diferença entre as médias no pós-operatório e intraoperatório) foi associado ao delírio (p = 0,043). As variáveis de lactato e rSO2 no pós-operatório não foram associadas ao delírio. Conclusões: Nosso estudo piloto sugere uma associação entre delta-ScvO2 e delírio e uma tendência à diminuição da ScvO2 no pós-operatório de pacientes com delírio. Estudos adicionais são necessários para elucidar essa associação.
Subject(s)
Humans , Male , Female , Aged, 80 and over , Postoperative Complications/epidemiology , Colonic Diseases/surgery , Delirium/epidemiology , Postoperative Complications/etiology , Regional Blood Flow , Digestive System Surgical Procedures , Pilot Projects , Prospective Studies , Colonic Diseases , Colonic Diseases/complications , Delirium/etiology , Hypotension/complicationsABSTRACT
Objective To study the effect of light sedation and traditional sedation (moderate sedation with daily sedation interruption) on hemodynamic indexes and prognosis in critically ill patients after cardiac surgery. Methods A total of 134 patients who were ventilated delay after heart surgery in our hospital from January to June 2017 were enrolled in this study. The patients were randomly divided into light sedation group (RASS score-1-1, n=65) and traditional sedation group (RASS score -3--2, n=69). All patients received sufentanil for postoperative analgesia. The light sedation group received propofol and/or dexmedetomidine as sedative drugs after operation, and the conventional sedation group used midazolam for postoperative sedation. The hemodynamic indexes, the first time of weaning off the ventilator, the duration of mechanical ventilation and ICU stay were compared between the two groups. Patients with low cardiac output syndrome after surgery were analyzed in subgroups. Results (1) There were no significant differences in heart function, operative complications and other indicators between the two groups after surgery (all P＞0.05). The low cardiac output syndrome was found in 12 patients in the light sedation group and 10 cases in the traditional sedation group. (2) Hemodynamic monitoring results displayed that the sedation/central venous oxygen saturation (SvO2/ScvO2) and cardiac index (CI) were higher after sedation than before sedation in both groups (all P＜0.05), but there was no significant difference between the two groups (all P＞0.05). Subgroup analysis showed that the SvO2/ScvO2index was higher in patients with low cardiac output syndrome in the traditional sedative group than that in the light sedation group (P＜0.05). There was no difference in the SvO2/ScvO2 index in patients with non-low cardiac output syndrome between two groups. (3) Compared with the traditional sedation group, the first off-line time, the total mechanical ventilation after surgery and the ICU stay time were significantly shortened, and the incidence of postoperative delirium was decreased in the light sedation group (all P＜0.05). Subgroup analysis showed that in patients with non-low cardiac output syndrome, the first off-line time, total postoperative mechanical ventilation time and total ICU stay were significantly shorter in the light sedation group than those in the traditional sedation group (all P＜0.05). There was no significant difference in patients with low cardiac output syndrome between the two groups (P＞0.05). Conclusion Patients with non-low cardiac output syndrome after cardiac surgery benefit significantly from the superficial sedative strategy, and the postoperative mechanical ventilation time and ICU residence time are reduced. The moderate sedation may contribute to the early cardiac function recovery in patients with low cardiac output syndrome.
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Objective To evaluate the prognostic value of arterial blood lactate clearance based on central venous oxygen saturation and perfusion index in patients with septic shock related myocardial injury after early goal-directed therapy.Methods One hundred and fifty-seven patients with septic shock after early resuscitation were enrolled from August 2013 to July 2016 in ICU at Peking Union Medical College Hospital.Parameters indicating early resuscitation included central venous pressure (CVP) 8-12 mmHg (1 mmHg=0.133 kPa),mean arterial pressure (MAP)＞65 mmHg,central venous oxygen saturation(ScvO2)＞70％ and urine volume (UO) ＞0.Sml · kg-1 · h-1 and arterial blood lactatc (Lac) ＞2 mmoL/L.Patients were divided into group A [ScvO2＞80％ and perfusion index (PI)＞1.4],group B(ScvO2＞80％ and PI＜1.4),group C (ScvO2＜80％ and PI＞1.4),group D(ScvO2＜80％ and Pl＜l.4).Hemodynamic parameters and tissue perfusion indexes at 2 hours(T2),4 hours(T4) and 6 hours(T6) after early resuscitation and troponin Ⅰ which indicated myocardial damage,on day 1 2 3 in ICU were recorded.Results (1)Lac clearance in group C was the quickest,which was 34.57％ (21.44％,44.20％),58.33％ (30.19％,70.79％),71.43％ (53.75％,82.79％) at T2,T4,T6 respectively.(2)The maximal incidence of myocardial damage was in group B(85.0％) and the lowest in group A (45.7％) on day 1 in ICU.Whereas on day 2,group C showed the lowest incidence of myocardial damage (29.3％) and group B the highest(70.0％).On day 3,the proportion of elevated troponin Ⅰ in group B was 70.0％,which was significantly higher than that of group B (29.3％,P＜0.008).(3)Logistic regression analysis suggested that the rate of Lac clearance at T4 in group B was related to the incidence of myocardial damage on day 2 and 3 in ICU.Conclusions The combination of PI and ScvO2 as a resuscitation target in patients with septic shock facilitates Lac clearance as the goal of resuscitation.The rate of arterial Lac clearance based on ScvO2 and PI is correlated with myocardial injury in patients with septic shock after early goal-directed therapy.
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Objective To investigate the roles of cerebral metabolic rate for oxygen (CMRO2) monitoring in the evaluation of cerebral function after cardiopulmonary resuscitation (CPR) through transcranial doppler (TCD) and SjvO2. Methods In this prospective/retrospective analysis, we included 46 cases admitted to the general intensive care unit (GICU) of the Second Affiliated Hospital of Soochow University from January 2012 to December 2014. Upon admission, TCD and SjvO2 were performed,and the patients' characteristics were recorded. Based on the CPC score upon GICU discharge, the patients were divided into two groups with satisfactory cerebral function and poor cerebral function, respectively. Then the clinical symptoms, cerebral blood flow (CBF), a-vDO2, SjvO2 and CMRO2 were analyzed, followed by investigating their correlation with the prognosis of cerebral function. The measurement data that were normally distributed were presented by mean ± standard deviation. Student's t test was utilized for the inter-group comparison. Correlation analysis was performed. ROC was plotted, followed by evaluating roles of each index in the specificity and sensitivity of nervous prognosis. Results No statistical differences were noted in the gender, age, initial monitoring indicators, ICU duration and initial GCS between the two groups (P>0.05). The CA-ROSC time and APACHE II score in the satisfactory cerebral function group were significantly shorter than those of the poor cerebral function group (P<0.05). The SjvO2 in the satisfactory cerebral function group was significantly lower than that of the poor function group (67.33±10.30 vs. 76.89±13.08, t=-3.579, P<0.05). The Vs and Vd as revealed by TCD in the satisfactory function group were higher than those of the poor function group, together with the CBF. Significant decrease was noted in the PI and RI in the satisfactory function group compared with that of the poor function group (P<0.05). Besides, the CMRO2 and a-vDO2 in the satisfactory function group showed significant increase compared with those of the poor function group (P<0.05). ROC indicated that CMRO2, CBF, a-vDO2 and SjvO2 could be utilized for the evaluation of cerebral function, among which CMRO2 showed the highest accuracy for the cerebral function prognosis. Conclusions CMRO2, CBF, a-vDO2 and SjvO2 were associated with cerebral function prognosis. CMRO2 was the most appropriate parameter to evaluate the oxygen metabolism in brain tissues, which could evaluate the prognosis of cerebral function.
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Abstract Background and objectives Although there is controversy regarding the role of venous oxygen saturation in the initial resuscitation of septic patients with hypoperfusion these markers are still widely used. This study aimed to evaluate the correlation and concordance between central (SvcO2) and mixed (SvO2) oxygen saturation in septic shock patients with or without hypoperfusion in addition to the impact of these differences in patient conduction. Methods Patients with septic shock were monitored with pulmonary artery catheter and the following subgroups of hypoperfusion were analyzed: 1) lactate > 28 mg.dL-1; 2) base excess ≤ -5 mmol.L-1; 3) venoarterial CO2 gradient > 6 mmHg; 4) SvO2 < 65%; 5) SvcO2 < 70%; 6) lactate > 28 mg.dL-1 and SvO2 < 70%; 7) lactate > 28 mg.dL-1 and SvcO2 < 75%. Results Seventy-seven samples from 24 patients were included. There was only a moderate correlation between SvO2 and SvcO2 (r = 0.72, p = 0.0001) and there was no good concordance between these variables (7.35% bias and 95% concordance limits of -3.0% to 17.7%). Subgroup analysis according to the presence of hypoperfusion showed no differences in concordance between variables. There was discordance regarding clinical management in 13.8% (n = 9) of the cases. Conclusions There is a moderate correlation between SvO2 and SvcO2; however, the concordance between them is inadequate. It was not possible to demonstrate that the presence of hypoperfusion alters the concordance between SvO2 and SvcO2. The use of SvO2 instead of SvcO2 may lead to changes in clinical management in a small but clinically relevant portion of patients.
Resumo Justificativa e objetivos Embora haja controvérsias sobre o papel das saturações venosas de oxigênio na ressuscitação inicial do paciente séptico com hipoperfusão, esses marcadores são ainda bastante usados. Este estudo procurou avaliar a correlação e a concordância entre as saturações venosas central (SvcO2) e mista (SvO2) de oxigênio em pacientes com choque séptico, na presença ou não de hipoperfusão, além do impacto dessas diferenças na condução clínica do paciente. Métodos Foram incluídos pacientes com choque séptico monitorados com cateter de artéria pulmonar e analisados os seguintes subgrupos de hipoperfusão: 1) Lactato > 28 mg.dL-1; 2) Excesso de bases ≤ -5 mmoL.L-1; 3) Gradiente venoarterial de CO2 > 6 mmHg; 4) SvO2 < 65%; 5) SvcO2 < 70%; 6) Lactato > 28 mg.dL-1 e SvO2 < 70%; 7) Lactato > 28 mg.dL-1 e SvcO2 < 75%. Resultados Foram incluídas 70 amostras de 24 pacientes. Houve apenas correlação moderada entre SvO2 e SvcO2 (r = 0,72; p = 0,0001) e não houve boa concordância entre essas variáveis (viés de 7,35% e limites de concordância de 95% de -3,0%-17,7%). A análise dos subgrupos de acordo com a presença de hipoperfusão não mostrou diferenças na concordância entre as variáveis. Houve discordância na conduta clínica em 13,8% dos casos (n = 9). Conclusões Existe correlação moderada entre SvO2 e SvcO2, entretanto a concordância entre elas é inadequada. Não foi possível demonstrar que a presença de hipoperfusão altera a concordância entre a entre SvO2 e SvcO2. O uso da SvO2 em vez da SvcO2 pode levar a alterações na conduta clínica numa parcela pequena, porém clinicamente relevante, dos pacientes.
Subject(s)
Humans , Male , Female , Aged , Oxygen/metabolism , Shock, Septic/metabolism , Shock, Septic/physiopathology , Shock, Septic/blood , Veins , Severity of Illness Index , Blood Circulation , Prospective Studies , Middle AgedABSTRACT
Objetivo: determinar si la saturación venosa central de oxigeno inicial (SvCO2) anormal (alta o baja) es un factor predictor de mortalidad en los pacientes con choque séptico que ingresan al área critica de emergencia del hospital "Carlos Andrade Marín". Diseño y lugar: estudio analítico, observacional, prospectivo sobre una cohorte de pacientes que ingresaron al área crítica de emergencia de este hospital. Pacientes: 107 sujetos ingresaron en los meses de junio a septiembre del 2015, con seguimiento para la mortalidad a 28 días. Medidas y resultados: se midió la SvcO2 inicial a través de un catéter venoso central al momento del diagnóstico de choque. La mortalidad a los 28 días fue de 46,2%. Solo los valores de APACHE II (OR:1,11; IC: 1,04 a 1,19 p=< 0,01); la asistencia ventilatoria mecánica (OR:0,19; IC: 0,05 a 0,62, p=<0,01) tuvieron un valor estadístico significativo en regresión logística. APACHE II fue el factor individual más importante, en el modelo CART, el pH arterial y procalcitonina fueron útiles. Conclusiones: la saturación venosa central de O2 inicial (SvcO2) anormal alta o baja no mostró tener utilidad para predecir mortalidad a los 28 días. La medición de la SvcO2 es un método simple que refleja de manera indirecta la oxigenación tisular. El APACHE II es un predictor independiente de mortalidad a 28 días y la ventilación mecánica tuvo una relación inversa con la mortalidad. (AU)
Objective: to determine the central venous saturation of abnormal initial oxygen (SvCO2) (high or low) as a predictor of mortality in patients with septic shock admitted to the emergency area of Carlos Andrade Marín Hospital. Design and location: this is an analytical, observational, prospective study on a cohort of patients admitted to the critical area of emergency of this health unit. Subjects: 107 patients admitted in the months of June to September 2015, with a mortality follow-up of 28-day. Measurements and results: initial SvcO2 was measured by central venous catheter at the time of shock diagnosis. Mortality at 28 days was 46.2%. Only APACHE II values (OR 1.11, CI 1.04-1.19 p = <0.01) and mechanical ventilation (OR 0.19, CI 0.05-0.62, p = 0.01) had significant statistical value in the logistic regression. APACHE II was the most important single factor, in the CART model arterial pH and procalcitonin were useful. Conclusion: Central venous saturation of abnormal or high initial O2 (SvcO2) was not found to be useful in predicting mortality at 28 days of follow-up. Measurement of SvcO2 is a simple method that indirectly reflects tissue oxygenation. The APACHE II is an independent predictor of mortality at 28 days and the use of mechanical ventilation had an inverse relationship with mortality. (AU)
Subject(s)
Humans , Male , Female , Adolescent , Adult , Middle Aged , Young Adult , Shock, Septic , Blood Physiological Phenomena , Hemic and Immune Systems , Pathologic Processes , Pathological Conditions, Signs and Symptoms , Systemic Inflammatory Response SyndromeABSTRACT
Objective To investigate the correlation between mixed venous oxygen saturation(SVO2),mixed venous-arterial partial pressure of carbon dioxide[P(v-a)CO2] and blood lactate(LAC) with the Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ) score and Sequential Organ Failure Assessment (SOFA) score,and to investigate the value of SVO2,P(v-a)CO2,LAC in assessing the disease condition.Methods A total of 104 patients with heart operation in the Chengdu Municipal Third People's Hospital from December 2011 to March 2015 were collected and divide into survival group and non-survival group according to the prognosis.The correlation between SvO2,P(v-a)CO2 and LAC with the APACHE Ⅱ score and SOFA score was analyzed by using the Pearman correlation analysis.The correlation between SvO2,P(v-a)CO2 and LAC with the disease condition was also analyzed.The Receiver Operating Characteristic (ROC) curvewas utilized to evaluating the accuracy of SvO2,P(v-a)CO2 and LAC for assessing the prognosis.Results Compared with the survival group,the difference of P(v-a)CO2,LAC,APACHE Ⅱ scores in the non-survival group had statistical significance(P＜0.05).SOFA score was 11.22 vs.7.35 (t=-3.433,P＜0.01),all were significantly increased,but SvO2 was significantly decreased(0.65 vs.0.71,t=2.794,P＜0.05).The values of SvO2 and LAC were significantly correlated with SOFA score (r=-0.268,P=0.006;r=0.200,P =0.041).But P(v-a) CO2 had no correlation with SOFA score(r=0.190,P=0.054).The values of SvO2,P(v-a)CO2 and LAC were correlated with APACHE Ⅱ score(r=-0.3,76,P=0.000;r=0.282,P=0.004;r=0.264,P =0.007).The values of SvO2,P (v-a) CO2 and LAC were correlated with prognosis (r=0.308,P=0.001;r=-0.248,P=0.011;r=-0.400,P=0.000).The areas under ROC curve of SvO2,P(v-a)CO2 and LAC corresponding practical mortality all were less than 0.70.Conclusion SvO2,P(v-a)CO2 and LAC have a certain correlation with the APACHE Ⅱ score,SOFA score and severity of disease condition,but which can not serve as the evaluation indicators of prognosis.
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Objective To determine the predictive value of central venous oxygen saturation (ScvO2) in volume response by comparing the relationship between variation of ScvO2 and cardiac output (CO) variability before and after volume expansion in elderly patients with septic shock.Methods Forty-five patients who diagnosed septic shock were enrolled in the study,inserted CVC and were carried out continuous cardiac output monitoring(PICCO) before volume expansion.Every patient was treated by rapid intravenous infusion of 250 mL physiological saline,then take blood gas analysis before and after treated which the blood samples were collected from central venous catheter.The value of ScvO2 and the value of cardiac output was recorded.Degree of variation between two sets of data were tested by Student t-test.The correlation was determined by using Pearson's correlation test.Operating characteristics curve analysis was used to test their ability to distinguish R and NR.Results The mean arterial pressure (MAP)、heart rate(HR)、CO、ScvO2 were demonstrated and have statistical significance (P＜ 0.05) compared with before treated.CO and ScvO2 indexes were positively correlated (P＜0.01) before and after volume expansion.ScvO2 variations after VE were significantly correlated with CO changes after VE (r=0.781,P＜0.01).Conclusion ScvO2 dynamic changes can be used as a criterion for determining the fluid responsiveness.
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Objective To explore relationship between the change of serum N terminal brain natriuretic peptide (NT-proBNP) , central venous oxygen saturation (SCVO2 ) and venous-arterial partial pressure of carbon dioxide [P(v-a)CO2 ] levels and prognosis in elderly patients with septic shock .Methods 94 cases of elderly patients with septic shock ,treated from March 2015 to July 2016 in Intensive Care Unit (ICU) of our hospital ,were chosen as the observation group A ,another 80 cases of nonsevere sepsis patients were chosen as the observation group B ,and a total of 56 patients healthy volunteers with the physical examination at the same peri-od of time in our hospital as normal control group .The serum NT-proBNP level was detected by electrochemiluminescence immuno-assay ,and PvCO2 ,PaCO2 and SCVO2 levels were detected by blood gas analyzer .records of patients with central venous blood car-bon dioxide .The NT-proBNP and P (v-a) CO2 levels in the serum of the three groups were compared between the groups of pa-tients in the observation group (SCVO2 ) .Logistic regression analysis was used to analyze the prognostic factors in elderly patients with septic shock ,and the receiver operating characteristic curve (ROC) was used to analyze the predictive value of NT-proBNP ,P (v-a)SCVO2 and SCVO2 levels .Results The serum NT-proBNP level of the observation group A was higher than that in the the observation group B and the control group (P<0 .05) .The SCVO2 level of the A group was lower than that in the B group ,and the P(v-a)CO2 level of the A group was higher than that in the B group ,the difference was statistically significant (P<0 .05) .The age , NT-proBNP ,P(v-a)CO2 ,lactic acid level and APACHE II score in the death group were higher than those in the survival group , and the difference was statistically significant (P< 0 .05) .SCVO2 level in the death group was lower than that in the survival group ,and the difference was statistically significant (P<0 .05) .Logistic multivariate regression analysis showed that NT-proBNP , P(v-a)CO2 and SCVO2 levels were the risk factors for the prognosis of elderly patients with septic shock .ROC curve showed AUC and the sensitivity of P(v-a)CO2 were higher than those of NT-proBNP ,SCVO2 .Conclusion The levels of serum NT-proBNP ,SC-VO2 and P(v-a)CO2 are related to the prognosis of elderly patients with septic shock ,and P(v-a)CO2 has a high value in the prog-nosis of the patients with septic shock ,and has a good clinical value .
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Background: Compromised ventricular function complicates the postoperative course after open heart surgery. Incidence of low-output syndrome (LOS) after cardiopulmonary bypass(CPB) is 30%. Vaso active therapy is required for weaning from bypass. Levosimendan is one of the new class of inodilator useful in refractory cardiac failure. Objective: The aim of this randomized control trial is to detect whether prophylactic levosimendan infusion is superior to milrinone in preserving better tissue perfusion, in decreasing complications related to low output syndromes and better hemodynamic control and to evaluate the efficacy of intravenous levosimendan infusion in decreasing the use of high dose of conventional inotropes and consequent prolonged hospitalization in open heart surgery patients with preoperative compromised ventricular function. Methods: Thirty consecutive patients with compromised cardiac function belongs to American Society of Anesthesiologists(ASA) physical status III who underwent open-heart surgery with CBP were randomly divided into two groups. Gr-L received levosimendan (loading dose of 12 μg/kg over 10 mins followed by infusion dose of (0.1 μg/kg /min ) and Gr-M received milrinone loading dose of 50 μg/kg over 10 mins followed by infusion dose of (0.5 μg/kg/ min )after anesthesia induction. Hemodynamic profile, mixed or central venous oxygen saturation (SVO2, SCVO2) which are surrogate markers for cardiac output, tissue perfusion were recorded, and blood obtained for troponin level. Results: SVO2 and SCVO2 were significantly higher in Gr L versus Gr M. Postoperative troponin- I concentrations, need of other inotropes incidence of arrhythmia, re-intubation, Intensive care unit(ICU) stay and hospital stay were significantly decreased in Gr L. Conclusion: Prophylactic levosimendan infusion maintains better hemodynamic control, tissue perfusion, myocardial protection and lesser complications in patients with compromised ventricular function.
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Background: Lactate and central venous oxygen saturation (ScVO2) are well known biomarkers for adequacy of tissue oxygenation. Endothelin, an inflammatory marker has been associated with patient’s nutritional status and degree of cyanosis. The aim of this study was to explore the hypothesis that lactate, ScVO2 and endothelin before induction may be predictive of mortality in pediatric cardiac surgery. Methods: We conducted a prospective observational study of 150 pediatric (6 months to 12 years) patients who were posted for intracardiac repair for tetralogy of fallot and measured lactate, ScVO2 and endothelin before induction (T1), 20 minutes after protamine administration (T2) and 24 hours after admission to ICU (T3). Results: Preinduction lactate and endothelin levels were found to predict mortality in patients of tetralogy of fallot with an odds ratio of 6.020 (95% CI 2.111-17.168) and 1.292(95% CI 1.091-1.531) respectively. In the ROC curve analysis for lactate at T1, the AUC was 0.713 (95% CI 0.526–0.899 P = 0.019). At the cutoff value of 1.750mmol/lt, the sensitivity and specificity for the prediction of mortality was 63.6% and 65.5%, respectively. For endothelin at T1, the AUC was 0.699 (95% CI 0.516–0.883, P = 0.028) and the cutoff value was ≤2.50 (sensitivity, 63.6%; specificity, 58.3 %). ScVO2 (odds ratio 0.85) at all three time intervals, suggested that improving ScVO2 can lead to 15% reduction in mortality. Conclusions: Lactate, ScVO2 and endothelin all showed association with mortality with lactate having the maximum prediction. Lactate was found to be an independent, reliable and cost-effective measure of prediction of mortality in patients with tetralogy of fallot.
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Hemodynamic management of sepsis-induced circulatory failure is complex since this pathological state includes multiple cardiovascular derangements that can vary from patient to patient according to the degree of hypovolemia, of vascular tone depression, of myocardial depression and of microvascular dysfunction. The treatment of the sepsis-induced circulatory failure is thus not univocal and should be adapted on an individual basis. As physical examination is insufficient to obtain a comprehensive picture of the hemodynamic status, numerous hemodynamic variables more or less invasively collected, have been proposed to well assess the severity of each component of the circulatory failure and to monitor the response to therapy. In this article, we first describe the hemodynamic variables, which are the most relevant to be used, emphasizing on their physiological meaning, their validation and their limitations in patients with septic shock. We then proposed a general approach for managing patients with septic shock by describing the logical steps that need to be followed in order to select and deliver the most appropriate therapies. This therapeutic approach is essentially based on knowledge of physiology, of pathophysiology of sepsis, and of published data from clinical studies that addressed the issue of hemodynamic management of septic shock.
Subject(s)
Humans , Depression , Hemodynamics , Hypovolemia , Lactates , Logic , Physical Examination , Physiology , Sepsis , Shock , Shock, SepticABSTRACT
Objective To investigate the application value of the ratio of lactic acid(LAC)divided by central venous oxygen saturation (ScvO2 ) to judge the illness severity and prognosis in shock patients. Methods Sixty-four shock patients were divided into two groups:survival group (n=35) and death group (n=29) based on death in 28-d admission. The gender, age, LAC/ScvO2, LAC, 6 h-lactate clearance rate (6 h-LCR), ScvO2 and acute physiology and chronic health Ⅱ(APACHEⅡ) score were compared between two groups. The correlation of LAC/ScvO2 with APACHEⅡscore was analysised in two groups. The receiver operating characteristic (ROC) curve was used to analyse the values of LAC/ScvO 2, LAC, 6 h-LCR, ScvO2 and APACHEⅡscore in the treatment and prognosis of shock. Results There were significant differences in LAC, ScvO2, 6h-LCR and APACHEⅡbetween two groups. There was a lower LAC/ScvO2 in survival group compared with that of death group (P<0.01). LAC/ScvO2 was positively correlated with APACHEⅡscore (rs=0.706,P<0.01). The sensitivity and speciality of LAC/ScvO2 were the highest compared with those of LAC, ScvO2, 6 h-LCR and APACHEⅡ score, the best threshold was 13.92. Conclusion LAC/ScvO2 is a better indicator for shock patients to evaluate the severity degree and prognosis.
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Hemodynamic management of sepsis-induced circulatory failure is complex since this pathological state includes multiple cardiovascular derangements that can vary from patient to patient according to the degree of hypovolemia, of vascular tone depression, of myocardial depression and of microvascular dysfunction. The treatment of the sepsis-induced circulatory failure is thus not univocal and should be adapted on an individual basis. As physical examination is insufficient to obtain a comprehensive picture of the hemodynamic status, numerous hemodynamic variables more or less invasively collected, have been proposed to well assess the severity of each component of the circulatory failure and to monitor the response to therapy. In this article, we first describe the hemodynamic variables, which are the most relevant to be used, emphasizing on their physiological meaning, their validation and their limitations in patients with septic shock. We then proposed a general approach for managing patients with septic shock by describing the logical steps that need to be followed in order to select and deliver the most appropriate therapies. This therapeutic approach is essentially based on knowledge of physiology, of pathophysiology of sepsis, and of published data from clinical studies that addressed the issue of hemodynamic management of septic shock.
Subject(s)
Humans , Depression , Hemodynamics , Hypovolemia , Lactates , Logic , Physical Examination , Physiology , Sepsis , Shock , Shock, SepticABSTRACT
BACKGROUND: The beach chair position (BCP) is associated with hypotension that may lead to cerebral ischemia. Arginine vasopressin (AVP), a potent vasoconstrictor, has been shown to prevent hypotension in BCP. It also improves cerebral oxygenation in different animal models. The present study examined the effect of escalating doses of AVP on systemic hemodynamics and cerebral oxygenation during surgery in BCP under general anesthesia. METHODS: Sixty patients undergoing arthroscopic shoulder surgery in BCP under general anesthesia were randomly allocated to receive either saline (control, n = 15) or three different doses of AVP (0.025, 0.05, or 0.075 U/kg; n = 15 each) 2 minutes before BCP. Mean arterial pressure (MAP), heart rate (HR), regional cerebral oxygen saturation (SctO2), and jugular venous oxygen saturation (SjvO2) were measured after induction of anesthesia and before (presitting in supine position) and after BCP. RESULTS: AVP per se given before BCP increased MAP, and decreased SjvO2, SctO2, and HR in all patients (P 20% SctO2 decrease from the baseline value) with no differences in SjvO2 and the incidence of SjvO2 < 50% or SjvO2 < 40% among the groups. CONCLUSIONS: AVP ameliorates hypotension associated with BCP in a dose-dependent manner in patients undergoing shoulder surgery under general anesthesia. However, AVP may have negative effects on SctO2 before and after BCP and on SjvO2 before BCP.
Subject(s)
Humans , Anesthesia , Anesthesia, General , Arginine Vasopressin , Arterial Pressure , Brain Ischemia , Heart Rate , Hemodynamics , Hypotension , Incidence , Models, Animal , Oxygen , Shoulder , VasopressinsABSTRACT
Introduction: Educational programs in pediatric life support endorse a capillary refill time > 2 s as an indicator of shock. In the emergency room, a barrier to the implementation of an early goal directed therapy, aiming at central venous oxygen saturation (ScvO2) ≥ 70% is the insertion of central venous catheter (CVC). Objective: To establish the predictive value of capillary refill time > 2 s to detect ScvO2 < 70% in children admitted to Intensive Care Units. Patients and Method: Prospective study. We included 48 children admitted in the first 24 hours in ICU with superior vena cava CVC. Simultaneously, we measured ScvO2 and capillary refill time in the heel of upper extremity or toe. Results: There were 75 paired measurements ScvO2 (75,9 ± 8,4%) and capillary refill capillary (1,9 ± 1,0 s). We found an inverse correlation between capillary refill time and ScvO2 (r - 0,58 ). The ROC curve analysis revealed an excellent ability for the capillary fill time > 2 s to predict ScvO2 < 70% (AUC 0,94) (95% CI 0,87-0,98). Conclusions: A prolonged capillary refill time > 2 s, is a predictor of ScvO2 < 70% in children admitted to ICU, which supports the current recommendations. This finding may be relevant in emergency units where the use of CVC is limited and ScvO2 is not available.
Introducción: Programas educativos de reanimación pediátrica establecen que un tiempo de llene capilar > 2 s es un indicador de shock. En unidades de emergencia, una barrera para la implementación de una reanimación precoz guiada por metas, teniendo como objetivo una saturación venosa central de oxígeno (ScvO2) ≥ 70%, es la inserción de un catéter venoso central (CVC). Objetivo: Determinar el valor predictivo de un tiempo de llene capilar > 2 s en la detección de ScvO2 < 70% en niños ingresados a la Unidad de Cuidados Intensivos. Pacientes y Método: Estudio prospectivo. Se incluyeron 48 niños ingresados en las primeras 24 h en UCI con CVC en la vena cava superior. De manera simultánea se determinaron ScvO2 y tiempo de llene capilar en talón o dedo de extremidad superior. Resultados: Se obtuvieron 75 mediciones pareadas de ScvO2 (75,9 ± 8,4%) y llene capilar (1,9 ± 1,0 s), observándose una correlación inversa entre llene capilar y ScvO2 (r = -0,58). El análisis de la curva ROC reveló una excelente capacidad del tiempo de llene capilar > 2 s para predecir una ScvO2 < 70% (AUC = 0,94, IC 95% = 0,87-0,98). Conclusiones: La prolongación del tiempo de llene capilar > 2 s es predictor de ScvO2 < 70% en niños críticamente enfermos. Este hallazgo apoya las recomendaciones actuales y podría ser relevante en unidades de emergencia donde el uso de CVC es limitado y la ScvO2 no está disponible.
Subject(s)
Adolescent , Child , Child, Preschool , Female , Humans , Infant , Male , Catheterization, Central Venous/methods , Oxygen/blood , Shock, Septic/blood , Capillaries/physiology , Intensive Care Units , Predictive Value of Tests , Prospective Studies , Time Factors , Vena Cava, SuperiorABSTRACT
Objective To explore the value of early arterial blood lactate clearance rate and central venous oxygen saturation (ScvO2 ) monitoring in patients with severe pneumonia .Methods A total of 56 patients with severe pneumonia treated during the period from January 2012 to December 2013 were reviewed retrospectively .The arterial blood lactate concentration and ScvO2 were determined immediately after admission to hospital and 6 hours after admission to calculate the 6‐hour lactate clearance rate .APACHE II score was evaluated at the same time .The patients were divided into three groups according to APACHE II score:10 to ＜20 (group A) ,20 to ＜30 (group B) ,≥30 (group C) .The three groups were compared in terms of early arterial blood lactate clearance rate and ScvO2 and estimate their association with the prognosis of patients .Results The initial arterial blood lactate concentration did not show significant difference between the three groups (P>0 .05) .The early lactate clearance rate and ScvO2 at 6 hours in group C were significantly lower than in group B .The values in group B were significantly lower than in group A (P＜0 .05) .The mortality rate in group C was significantly higher than in group B ,and the mortality rate in group B was significantly higher than in group A (P＜0 .05) .The APACHE II score of the dead patients was higher than that of the suevivors ,but early lactate clearance rate and ScvO2 level were lower than those of the survivors (P＜0 .05) .APACHE II score was negatively correlated to early lactate clearance rate (r=0 .661 ,P＜0 .01) and early ScvO2 level (r=0 .579 , P＜ 0 .01) .Conclusions Early lactate clearance rate and ScvO2 level are good indicators to reflect the severity of disease and predict the outcome in the patients with severe pneumonia .
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Objective To explore the impact of lung-protective mechanical ventilation (low tidal volume and optimal positive end-expiratory pressure (PEEP) on cerebral perfusion pressure (CPP) and cerebral oxygen metabolism.Methods Forty patients with severe cerebral injury along with respiratory failure were randomly assigned into two groups:lung-protective ventilation group A and conventional ventilation group B.Group A was planned to prescribe tidal volume 6 ～ 8 mL/kg,initial FiO240％,PEEP gradually increasing from 2 cmH2O to matched with FiO2 elevation,but the FiO2 was kept at permissive lower level.Group B was formulated with tidal volume 8 ～ 12 mL/kg,PEEP stepwise increasing from 0 2 cmH2O to match with FiO2 elevation,but PEEP was kept at permissive lower pressure.The intracranial pressure (ICP),mean arterial pressure (MAP),CPP,arterial and jugular venous blood gas were monitored.Results PEEP (8.2±3.32 cmH2O),ICP (19.7 ±3.6 mmHg),PaCO2 (54±7.3 mmHg),jugular venous carbon dioxide partial pressure (PjV CO2,56.7 ± 9.6 mmHg) in group A were higher than those (5.7±2.3 cmH2O,16.9±3.8 mmHg,41 ±5.2 mmHg,49.8 ±6.9 mmHg) in group B (P＜ 0.05 or P ＜ 0.01).VT,FiO2 in the group A were lower than those in the group B.There were no differences in PaO2/FiO2,jugular venous oxygen saturation (SjVO2),MAP,and CPP between two groups.PaCO2 were significantly correlated with CPP (r =0.368,P =0.019) while there was no correlation with ICP,PaO2,SjVO2,PjVCO2 (all P ＞0.05).CPP (69.7 ± 12.3 mmHg) was higher in case of PaCO2 (46 ～60mmHg) than those (61.5 ±9.1 mmHg) in case of PaCO2 (35 ～45 mmHg).There was correlation between PEEP and ICP (r =0.436,P =0.005).When PEEP was divided into three groups:≤52 cmH2O,6 ～ 102 cmH2O and ＞ 102 cmH2O,ICPs were different one another among three groups.When PEEP ＞ 102 cmH2O,it had a distinguished negative correlation with CPP (r =-0.395,P =0.017),while PEEP ≤ 102 cmH2O,CPP presented decreasing tendency.SjVO2 correlated with PaO2 (r =0.403,P =0.014) and PjVCO2 (r =-0.502,P =0.001) respectively.There were no significant relationships between SjVO2 and CPP,ICP,MAP,PEEP,respectively.Conclusions Lung-protective mechanical ventilation was relatively safer in patients with severe cerebral injury compared with conventional mechanical ventilation.Mild PaCO2 elevation (46 ～ 60 mmHg) combined with higher PEEP (＜ 102 cmH2O) did not decrease CPP.There was no difference in SjVO2 between the two modes of mechanical ventilation,suggesting no changes in cerebral metabolism occurred.
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Objective To explore the clinic values of early goal directed treatment (EGDT)with the target of mixed venous oxygen saturation (SvO2)and difference of mixed venous-arterial partial pressure of carbon dioxide (Pv-aCO2) in monitoring of oxygen metabolism and treatment for patients post open-heart operation. Methods A prospective study was conducted. The adult patients admitted to Third People's Hospital of Chengdu from December 2011 to March 2014 with SvO22 mmol/L when admitted in intensive care unit(ICU)were selected on whom elective open-heart operation and pulmonary artery catheter examination were done. All patients received EGDT with the target of SvO2≥0.65 and Pv-aCO2<6 mmHg (1 mmHg=0.133 kPa)and were divided into three groups by the values of SvO2 and Pv-aCO2 at 6-hour after ICU admission:A group with SvO2≥0.65 and Pv-aCO2<6 mmHg,B group with SvO2≥0.65 and Pv-aCO2≥6 mmHg,and C group with SvO2<0.65. Then the changes and prognosis of the patients in different groups were observed. Results 103 cases were included,44 in A group,31 in B group and 28 in C group. The acute physiology and chronic health evaluationⅡ (APACHEⅡ)score in group A were significantly lower than that in group B or C at 6,24,48 and 72 hours (T6,T24,T48,T72)of ICU admission (T6:11.4±5.8 vs. 13.9±5.4,13.7±6.4;T24:8.8±3.7 vs. 10.8±4.8,11.8±5.4;T48:8.7±4.1 vs. 9.6 ±4.2,10.2 ±5.1;T72:7.5 ±3.4 vs. 8.6 ±2.9,9.2 ±4.2,all P<0.05),and the sequential organ failure assessment (SOFA)showed the same tendency (T6:6.5±4.3 vs. 8.0±3.8,9.1±4.5;T24:6.6±3.6 vs. 8.6±3.9, 8.5±3.3;T48:5.2±3.4 vs. 7.0±3.6,7.6±5.1;T72:4.6±2.4 vs. 5.8±2.5,6.8±3.5,all P<0.05). The values of blood lactic acid (mmol/L)in group A and B were significant lower than that in group C at T6,T24,T48 and T72 (T6:1.60 ±0.95,2.20 ±1.02 vs. 2.55 ±1.39;T24:2.26 ±1.26,2.70 ±1.36 vs. 3.34 ±2.36;T48:2.01 ±1.15, 2.17 ±1.51 vs. 2.42 ±1.63;T72:1.62 ±1.14,1.64 ±0.75 vs. 2.11 ±1.29,all P<0.05). The time of machine ventilation(days)in group A or B was significantly shorter than that in group C(2.8±2.0,3.6±2.3 vs. 5.0±3.1,both P<0.05). ICU day (days)in group A was significant shorter than that in group C (4.6±2.5 vs. 6.5±3.7,P<0.05). The 7-day mortalities after operation in three groups were significantly different. Compared with group A (2.3%),the odds ratio (OR)in group B (22.6%)was 12.5 (P<0.05),group C (25.0%)14.3 (P<0.05). The morbidity and 28-day mortality in three groups were not significantly different. Pv-aCO2 negatively correlated with cardiac index(CI, r=-0.685,P=0.000),but not correlated with blood lactic acid(r=0.187,P=0.080). Conclusions EGDT with the target of SvO2≥0.65 and Pv-aCO2<6 mmHg improved the general condition and tissue hypoxia,shortened the time of machine ventilation and duration of hospitalization in ICU,and decrease the 7-day mortality.
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Objective To compare the procotol of EGDT +Pt (cv-a ) CO2 with EGDT in fluid resuscitation and management after evaluate fluid responsiveness in shock patients by Vigileo and passive leg raising test.Metheds Prospectively collect patients who meet the criteria between 2013.5.1-2013.1 1.30 in our ICU.Randomly (random number)divided into Vigileo group (first evaluate the fluid responsiveness then give EGDT +Pt (cv-a) CO2 ) and CVP group (give EGDT).Compare the hospital mortality and morbility of MODS,the volume given in the first 6 hours and the first 7 days,consume of blood products , the ICU and hospital stay.Results Collected 46 patients,Vigileo group (21 )and CVP group (25 ). There’s no significant difference between groups at baseline.In the first 6 hours the CVP group had received more fluids (3656.281678.57 vs. 2639.141326.59 ) mL, P =0.03;and more blood products (573.00172.57 vs. 190.4770.82)mL,P=0.04,respictivily.Vigileo group significantly short the ICU stay ,(6.384.34 vs. 12.165.77)d,P=0.04.But there’s no significant difference in hospital motality and the morbility of MODS.The ROC of Age ,the accumulative volume of balance in 7 days,APACHEⅡscore in the first day to predict death is 0.84 (0.68-0.99)、0.82 (0.69-0.95)、0.80 (0.66-0.94),all P>0.05,respectively.By 7 days the accumulative volume of balance 3454.51mL as cutoff to predict death with the sensitivity of 0.67,specificity of 0.84.Conclusions 1.Given EGDT +Pt (cv-a) CO2 after evaluate the fluid responsiveness can reduce fluid and blood products given in the first 6 hours,significantly short the ICU stay,without worsen the tissue flow or increase the morbility of MODS;2.Consecutive positive fluid balance is a risk factor about poor prognosis,and also a sensitive indicator to predict death.