Abstract
Background Achieving hemodynamic stabilization does not prevent progressive tissue hypoperfusion and organ dysfunction during resuscitation of septic shock patients. Many indicators have been proposed to judge the optimization of oxygen delivery to meet tissue oxygen consumption. Methods A prospective observational study was conducted to evaluate and validate combining CO2 gap and oxygen-derived variables with lactate clearance during early hours of resuscitation of adults presenting with septic shock. Results Our study included 456 adults with a mean age of 63.2 ± 6.9 years, with 71.9% being males. Respiratory and urinary infections were the origin of about 75% of sepsis. Mortality occurred in 164 (35.9%) patients. The APACHE II score was 18.2 ± 3.7 versus 34.3 ± 6.8 (p < 0.001), the initial SOFA score was 5.8 ± 3.1 versus 7.3 ± 1.4 (p=0.001), while the SOFA score after 48 hours was 4.2 ± 1.8 versus 9.4 ± 3.1 (p < 0.001) in the survivors and nonsurvivors, respectively. Hospital mortality was independently predicted by hyperlactatemia (OR: 2.47; 95% CI: 1.63–6.82, p=0.004), PvaCO2 gap (OR: 2.62; 95% CI: 1.28–6.74, p=0.026), PvaCO2/CavO2 ratio (OR: 2.16; 95% CI: 1.49–5.74, p=0.006), and increased SOFA score after 48 hours of admission (OR: 1.86; 95% CI: 1.36–8.13, p=0.02). A blood lactate cutoff of 40 mg/dl at the 6th hour of resuscitation (T6) had a 92.7% sensitivity and 75.3% specificity for predicting hospital mortality (AUROC = 0.902) with 81.6% accuracy. Combining the lactate cutoff of 40 mg/dl and PvaCO2/CavO2 ratio cutoff of 1.4 increased the specificity to 93.2% with a sensitivity of 75.6% in predicting mortality and with 86.8% accuracy. Combining the lactate cutoff of 40 mg/dl and PvaCO2 gap of 6 mmHg increased the sensitivity to 93% and increased the specificity to 98% in predicting mortality with 91% accuracy. Conclusion Combining the carbon dioxide gap and arteriovenous oxygen difference with lactate clearance during early hours of resuscitation of septic shock patients helps to predict hospital mortality more accurately.
Highlights
Achieving hemodynamic stabilization does not prevent progressive tissue hypoperfusion and organ dysfunction during resuscitation of septic shock patients
Recent guidelines from the Surviving Sepsis Campaign for management of septic shock patients focused on hemodynamic support through a systematic protocol of fluids and vasopressor therapy. e goal was to improve tissue perfusion and meet tissue oxygen demands [2]. e guidelines recommended continuing resuscitation and restoring mean arterial pressure (MAP) ≥ 65 mmHg with lactate clearance. is was based on the understanding that lactate clearance could serve as a surrogate for the reversal of global tissue hypoxia [3, 4]
In a multivariate regression analysis, hospital mortality was independently predicted by hyperlactatemia (OR: 2.47; 95% CI: 1.63–6.82, p 0.004), PvaCO2 gap (OR: 2.62; 95% CI: 1.28–6.74, p 0.026), PvaCO2/CavO2 ratio (OR: 2.16; 95% CI: 1.49–5.74, p 0.006), and increased Sequential Organ Failure Assessment (SOFA) score after 48 hours (OR: 1.86; 95% CI: 1.36–8.13, p 0.02) (Table 6)
Summary
Detection of tissue hypoperfusion and rapid, efficient resuscitation is fundamental in the successful management of patients presenting with septic shock [1]. No consistent advantages have been found for lactate guided resuscitation over using oxygen indicators [8,9,10]. E venoarterial carbon dioxide difference (PvaCO2) has been proposed as an indicator of tissue hypoperfusion [11,12,13]. Us, the ratio between the PvaCO2 and the arteriovenous oxygen content difference (CavO2) may detect patients with anaerobic metabolism. E goal of this prospective observational study was to evaluate predictors of outcomes by combining the CO2 gap to CavO2, PvaCO2/CavO2 ratio, and lactate clearance during early hours of resuscitation of adult patients presenting with septic shock
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