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What is the relevance of central or mixed venous oxygen saturation ? K. Reinhart MD

ATS / ESICM / ERS / SCCM / SRLF 7th International Consensus Conference Paris, 2006. What is the relevance of central or mixed venous oxygen saturation ? K. Reinhart MD Dept. of Anaesthesiology and Intensive Care Medicine Friedrich-Schiller-University Jena, Germany.

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What is the relevance of central or mixed venous oxygen saturation ? K. Reinhart MD

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  1. ATS / ESICM / ERS / SCCM / SRLF 7th International Consensus Conference Paris, 2006 What is the relevance of central or mixed venous oxygen saturation ? K. Reinhart MD Dept. of Anaesthesiology and Intensive Care Medicine Friedrich-Schiller-University Jena, Germany

  2. Shock is defined as inadequate tissue oxygenation

  3. Which are the most appropriate cardio-respiratory variables to detect and to monitor the course of tissue hypoxia in the clinical setting ?

  4. What can we learn from physiology ?

  5. Conventional cardio-respiratory parameters are of limited value for the assessment of the adequacy of tissue oxygenation !

  6. The cardio-respiratory system fullfills its physiological task by guaranteeing cellular oxygen supply and to remove the waste products of metabolism Pflüger 1872

  7. It was fatal for the development of our understanding of circulation, that blood flow is relatively difficult to measure, whereas blood pressure is easily measured: This is the reason why the blood pressure meter has gained such a fascinating influence, although most organs do not need pressure, but blood flow. A. Jarisch, “Kreislauffragen“ 1928

  8. The two main determinants of oxygen supply to the tissues are arterial oxygen content and cardiac output

  9. 180 150 120 90 60 n= 1232 30 100 300 500 700 900 1100 Correlation Between Arterial Pressure And Oxygen Delivery MAP mmHg DO2 ml*m-2*min-1

  10. 180 150 120 90 60 n= 1236 30 100 300 500 700 900 1100 Correlation Between Heart Rate And Oxygen Delivery HR b/min DO2 ml*m-2*min-1

  11. 12 10 8 6 4 260 220 180 140 100 60 0 2 4 6 8 10 12 Control Oxygen Consumption ml/ min/ kg Control Cardiac Output ml/ min/ kg Control A-VO2 vol.% Shepard AP et al. 1973 Am.J.Physiol. 225: 747

  12. 8 6 4 2 0 0 5 10 15 20 25 Individual points of limb O2 uptake vs. O2 delivery over range of progressive ischemia O2 Uptake (ml*kg-1*min-1 ) O2 Delivery (ml*kg-1*min-1 ) Reinhart K et al. (1989) Am J Physiol 257: H238

  13. Oxygen Debt: To Pay or Not to Pay?

  14. 3.5 3.0 ** 2.5 2.0 1.5 n=9 n=29 n=150 n=110 n=77 n=148 n=27 1.0 50 60 70 80 90 Lactate (mMol/l) SvO2 (%) **p < 0.01

  15. 12 10 1100 8 900 6 700 500 4 300 2 4 6 8 10 12 Cardic Index l/min/m2 O2 Uptake ml/min/m2 A-V Oxygen Content Difference Vols. % Donald K.W. et al. (1954) J.Clin.Invest. 33: 1146

  16. 8 6 Cardic Index l/min/m2 4 O2 Uptake ml/min/m2 500 400 2 300 200 100 0 2 4 6 8 10 12 14 16 A-V Oxygen Content Difference Vols. % Kenneth WD et al. (1954) J.Clin.Invest. 33: 1146

  17. The arterio-venous oxygen content difference informs on the extent to which the compensatory mechanisms of the cardio-respiratory system are exhausted

  18. 9.3 8.2 7.1 6.0 4.9 3.8 2.7 r= -0.864 y= 12.7 -0.12x n= 1191 1.6 0.5 25 40 55 70 85 100 Correlation of Arterio- Venous Oxygen Content Difference with Mixed Venous Oxygen Saturation avDO2 ml/dl SO2 %

  19. 8.0 7.0 6.0 5.0 4.0 3.0 2.0 r= -0.707 n= 447 avDO2= 11.4 -0.1*ScvO2 1.0 0 30 40 50 60 70 80 90 100 ScvO2 vs. avDO2 avDO2 ml/dl ScvO2 % Rudolph, T., et al., 1989

  20. 10.0 8.2 6.4 4.6 2.8 r= 0.906 y= -9.58 + 0.19*x n= 1149 1.0 25 40 55 70 85 100 Correlation of Oxygen - Supply to - Demand Ratio with Mixed Venous Oxygen Saturation DO2/ VO2 SO2 %

  21. Factors that influence mixed and central venous SO2 75% _ +

  22. What can we learn from clinical studies ?

  23. November 8, 2001

  24. Mortality Control Treatment RR (95% C.I.) P-value In-hospital 46.5 30.5 0.58 (0.38-0.87) 0.009 28-day Mortality 49.2 33.3 0.58 (0.39 – 0.87) 0.01 60-day Mortality 56.9 44.3 0.67 (0.46-0.96) 0.03

  25. * * 8 80 * * Treatment * * * Control * 6 70 * 2 * * Lactate ScvO 60 4 50 2 40 0 0 3 6 12 24 36 48 60 72 0 3 6 12 24 36 48 60 72 7.45 * * * * 10 * 7.40 * * * 6 Base Deficit * pH * 7.35 * * 2 7.30 -2 7.25 0 3 6 12 24 36 48 60 72 0 3 6 12 24 36 48 60 72 Hours Resuscitation Endpoints

  26. Global Tissue Hypoxia (Cryptic Shock)Despite Normalization of Vital Signs • 39.8% of control vs. 5.1% of treatment group had global tissue hypoxia ( ScvO2 and  lactate) at 6 hours.

  27. SVO2 Monitoring in Cardiac Surgery • Polonen et al have studied a cohort 403 of cardiac surgical patients • The control group received standard care whilst in the protocol group, SvO2 was maintained above 70% and lactate below 2mmol/l with fluid and inotropes • The study was undertaken in the immediate 8 hour post-operative period Polonen Anesth. Analg 2000

  28. Goal oriented hemodynamic therapy in cardiac surgical patients n = 411 Goals: SvO2 > 70% and lactate  2mmol/l from admission to the ICU and 8 hrs thereafter goal orientedcontrol hospital stay (days) 6 p<0,0057 ICU stay n.s. morbidity at hospital discharge 1,1% p<0,0016,1% (Polonen et al., Anesthesia and Analgesia 2000)

  29. Failure of Vital Signs • 31 of 36 medical shock patients: • Resuscitated to normal MAP and CVP • Have global tissue hypoxia (Scv02 < 70% and lactate >2 mmol/L). Rady, AJEM, 1994

  30. SCVO2 Can Predict Occult Shock in CHF Patients enrolled in decompensated CHF with EF<30% No difference in vital signs or clinical category of HF between groups. Ander Am J Card 98

  31. ScvO2 is superior to CVP to reflect reduced central blood volume (Madsen et al., Scand J Clin Lab Invest 1993)

  32. SCVO2 Monitoring in Trauma • 26 consecutive patients with injury suggestive of blood loss. • HR, BP, Urine output, CVP and SCVO2 measured. • Blood loss estimated. • SCVO2 most sensitive indicator blood loss • SCVO2 <65% associated with increased injury, blood loss and transfusion requirements. Scalea J Trauma 1990

  33. Continuous central venous ScvO2 monitoring can reliably indicate ROSC during CPR (n = 100) Patients with ROSC had higher initial mean and maximal ScvO2. No ROSC in patients without ScvO2 > 30% A ScvO2 > 75% was 100% predictive of ROSC. (Rivers et al., Ann Emerg. Med. 1992)

  34. Complications in patients with high vs. low ScvO2 after major surgery

  35. Evolution of ScvO2, base excess, and lactate in 65 patients with septic shock Parks M et al. CLINICS 2006;61(1):47

  36. Does it matter wether we measure central venous or mixed venous oxygen saturation ?

  37. 100 Shock 80 r= 0.73 60 Normal r= 0.88 40 20 0 20 40 60 80 100 % SsvcO2 % SO2 Lee J et al. (1972) Anaesthesiology 36: 472

  38. Gemischt-venös 80 Zentral-venös 60 40 20 Hyperoxie Normoxie Normoxie Volumentherapie (HAES) Blutung Blutung Hypoxie 0 0 30 60 90 120 150 180 210 240 SvO2 closely correlates with ScvO2 % Sat Zeit (min) Reinhart K et al, Chest, 1989; 95:1216-1221

  39. 100 ScvO2 90 80 70 SvO2 60 50 40 0 10 20 30 40 50 60 % t (min)

  40. 100 90 80 70 60 50 SvO2 ScvO2 40 0 10 20 30 40 % Zeit (min)

  41. All Determinations R.A. O2 and C.V. O2 - %Saturation C.V. O2 (r= 0.90) R.A. O2 (r= 0.95) M.V. O2- % Saturation Scheinmann MM et al. 1969 Circulation 40: 165

  42. 80 r= 0.9761 p< 0.001 n= 131 60 40 20 0 -20 -40 -60 -80 -80 -60 -40 -20 0 20 40 60 80 ScvO2 % Sat SvO2 % Sat Reinhart K et al, Chest, 1989; 95:1216-1221

  43. Changes in SvO2 and ScvO2 in general anesthesia during neurosurgery Conclusion: Despite some large differences between absolute values, in patients with varying hemodynamic situations, the trend in ScvO2 may be used as a surrogate variable for the trend in SvO2. Dueck MH et al. Anesthesiology 2005; 103:249

  44. Changes in mixed venous oxygen saturation are well matched by changes in central venous oxygen saturation !

  45. Differences between SvO2 and ScvO2 in different patient groups Reinhart K et al., unpublished

  46. 40 30 20 10 Normalbereich 0 -10 60 62 64 66 68 70 72 74 76 78 80 82 Differences between mixed venous and hepato-venous O2 saturation in patients with septic shock SvO2 - ShO2 [%] SvO2 [%]

  47. Percentage of splanchnic O2 consumption from total body O2 consumption in septic shock patients 60% (n=34)

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