ScvO2 Monitoring Research Articles

The relationship between perioperative central venous oxygen saturation and postoperative complications in highly invasive gastroenterological surgery.

Operations for malignant diseases of the bile duct, pancreas, and esophagus are the most invasive gastroenterological surgeries. The frequency of complications after these surgeries is high, which affects the postoperative course and mortality. In patients who undergo these types of surgeries, continuous monitoring of the perioperative central venous oxygen saturation (ScvO2) is possible via a central venous catheter. We aimed to investigate the relationship between continuously monitored perioperative ScvO2 values and postoperative complications. The medical records of 115 patients who underwent highly invasive gastroenterological surgeries and ScvO2 monitoring from April 2012 to March 2014 were analyzed. Sixty patients met the inclusion criteria, and their ScvO2 levels were continuously monitored perioperatively. The relationship between ScvO2 levels and major postoperative complications, defined as Clavien-Dindo grade ≥ III, was examined using uni- and multivariate analysis. Thirty patients developed major postoperative complications. The adequate cut-off value derived from receiver operating curves of the postoperative average ScvO2 levels for predicting major complications was 75%. Multivariate analysis revealed that low average postoperative ScvO2 levels (p = 0.016) and blood loss ≥ 1000 mL (p = 0.039) were significant predictors of major postoperative complications. Low perioperative ScvO2 values were associated with an increased risk of major postoperative complications. Continuous ScvO2 monitoring will help prevent postoperative complications.

#4200 INTERACTIONS BETWEEN INTRADIALYTIC CENTRAL VENOUS OXYGEN SATURATION, RELATIVE BLOOD VOLUME, AND ALL-CAUSE MORTALITY IN HEMODIALYSIS PATIENTS

Abstract Background and Aims In maintenance hemodialysis patients, low central venous oxygen saturation (ScvO2) and small decline in relative blood volume (RBV) have been associated with adverse outcomes [1,2]. Here we explore the interactions between ScvO2 and RBV change in relation to all-cause mortality. Method We conducted a retrospective study in maintenance hemodialysis patients with central venous catheters as vascular access. During a 6-month baseline period, Crit-Line (Fresenius Medical Care, Waltham, MA) was used to measure continuously intradialytic ScvO2 and hematocrit-based RBV. We defined four groups per median change of RBV and median ScvO2. Patients with ScvO2 above median and RBV change below median were defined as reference. The follow up period was 3-years. We constructed a Cox proportional hazards model with adjustment for age, diabetes, and dialysis vintage to assess the association between ScvO2 and RBV and all-cause mortality during follow-up. Results Baseline comprised 5,231 dialysis sessions in 216 patients. The median RBV change was –5.5% and median ScvO2 was 58.8%. During follow-up, 44 patients (20.4%) died. Kaplan-Meier analysis is shown in Figure 1. In the adjusted model, all-cause mortality was highest in patients with ScvO2 below median and RBV change above median (HR 6.32; 95% confidence interval [CI] 1.37 to 29.06), followed by patients with ScvO2 below median and RBV change below median (HR 5.04; 95% CI 1.14 to 22.35) and ScvO2 above median and RBV change above median (HR 4.52; 95% CI 0.95 to 21.36). Conclusion Concurrent combined monitoring of intradialytic ScvO2 and RBV change may provide additional insights into a patient's circulatory status. Patients with low ScvO2 and small changes in RBV may represent a specifically vulnerable group of patients at particularly high risk for adverse outcomes, possibly related to poor cardiac reserve and fluid overload.

Interactions between intradialytic central venous oxygen saturation, relative blood volume, and all-cause mortality in maintenance hemodialysis patients.

In maintenance hemodialysis (HD) patients, low central venous oxygen saturation (ScvO2 ) and small decline in relative blood volume (RBV) have been associated with adverse outcomes. Here we explore the joint association between ScvO2 and RBV change in relation to all-cause mortality. We conducted a retrospective study in maintenance HD patients with central venous catheters as vascular access. During a 6-month baseline period, Crit-Line (Fresenius Medical Care, Waltham, MA) was used to measure continuously intradialytic ScvO2 and hematocrit-based RBV. We defined four groups per median change of RBV and median ScvO2 . Patients with ScvO2 above median and RBV change below median were defined as reference. Follow-up period was 3 years. We constructed Cox proportional hazards model with adjustment for age, diabetes, and dialysis vintage to assess the association between ScvO2 and RBV and all-cause mortality during follow-up. Baseline comprised 5231 dialysis sessions in 216 patients. The median RBV change was -5.5% and median ScvO2 was 58.8%. During follow-up, 44 patients (20.4%) died. In the adjusted model, all-cause mortality was highest in patients with ScvO2 below median and RBV change above median (HR 6.32; 95% confidence interval [CI] 1.37-29.06), followed by patients with ScvO2 below median and RBV change below median (HR 5.04; 95% CI 1.14-22.35), and ScvO2 above median and RBV change above median (HR 4.52; 95% CI 0.95-21.36). Concurrent combined monitoring of intradialytic ScvO2 and RBV change may provide additional insights into a patient's circulatory status. Patients with low ScvO2 and small changes in RBV may represent a specifically vulnerable group of patients at particularly high risk for adverse outcomes, possibly related to poor cardiac reserve and fluid overload.

Comparison of Intermittent versus Continuous Superior Venal Caval Oxygen Saturation Monitoring in Early Goal Directed Therapy in Septic Shock: A Systematic Review.

Early goal directed therapy (EGDT) is a bundle of care (monitoring ScvO 2 and lactate along with clinical parameters and instituting therapy) that has shown to improve outcomes in patients with septic shock. We conducted a systematic review of clinical trials and observational studies to compare intermittent versus continuous monitoring of ScvO 2 . We did major database searches till August 2020. Hospitalized children (>2 months age) and adults with septic shock were included. The intervention was "intermittent ScvO 2 monitoring," and the comparator was "continuous ScvO 2 monitoring." The primary outcome is "all-cause mortality." Of 564 citations, 3 studies ( n = 541) including both children and adults were included in the analysis. There was no significant difference in the "overall/all-cause mortality" (two randomized controlled trials; 258 participants) between the "intermittent" and "continuous" ScvO 2 monitoring groups (relative risk [RR]: 1.00; 95% confidence interval [CI]: 0.8-1.24). However, a single observational study (283 participants) showed a significant increase in mortality in the intermittent group (RR: 1.46; 95% CI: 1.03-2.05). The GRADE evidence generated for "overall/all-cause mortality" was of "moderate certainty." To conclude, the present meta-analysis did not find any significant difference between "intermittent" and "continuous" ScvO 2 monitoring in patients with septic shock.

Early Goal-Directed Therapy With and Without Intermittent Superior Vena Cava Oxygen Saturation Monitoring in Pediatric Septic Shock: A Randomized Controlled Trial

To compare early goal-directed therapy (EGDT) 'With' and 'Without' intermittent superior vena cava oxygen saturation (ScvO2) monitoring in pediatric septic shock. Open label randomized controlled trial. Pediatric intensive care unit in a tertiary care center. Children aged 1 month to 12-year with septic shock. Patients not responding to fluid resuscitation (up to 40 ml/kg) were randomized to EGDT 'With' (n=59) and 'Without' (n=61) ScvO2 groups. Resuscitation was guided by ScvO2 monitoring at 1-hour, 3-hour, and later on six-hourly in the '' ScvO2 group and by clinical variables in the 'Without' ScvO2 group. Primary outcome was all-cause 28-day mortality. Secondary outcomes were time to and proportion of patient achieved therapeutic endpoints (at 6 hours and PICU stay), need for organ supports, new organ dysfunction (at 24 hours and PICU stay), and length of PICU and hospital stay. The study was stopped after interim analysis due to lower mortality in the intervention group. There was significantly lower all-cause 28-day mortality in EDGT with ScvO2 than without ScvO2 group [37.3% vs. 57.5%, adjusted hazard ratio 0.57, 95%CI 0.33 to 0.97, P=0.04]. Therapeutic endpoints were achieved early in 'With' ScvO2 group [mean (SD) 3.6 (1.6) vs. 4.2 (1.6) h, P=0.03]. Organ dysfunction by sequential organ assessment score during PICU stay was lower in with ScvO2 group [median (IQR) 5 (2,11) vs. 8 (3,13); P=0.03]. There was no significant difference in other secondary outcomes. EGDT with intermittent ScvO2 monitoring was associated with reduced mortality and improved organ dysfunction in pediatric septic shock.

O046 / #741: SUPERIOR VENACAVAL OXYGEN SATURATION MONITORING BASED GOAL DIRECTED THERAPY VS STANDARD CARE IN CHILDREN WITH SEPTIC SHOCK: AN OPEN LABEL RANDOMIZED CONTROL TRIAL

Aims & Objectives: Early goal directed therapy improves septic shock outcomes, however data from India is scarce. We studied feasibility of achieving and maintaining ScvO2 based goal directed therapy (GDT) versus prevalent practice Methods:Design: Randomized Control Trial Setting: Tertiary care teaching institute Participants: Children (6 month-12 years) with fluid refractory septic shock. Inotrope at arrival, chronic illnesses and contraindications for central line were exclusions Interventions: GDT group (n=46) received fluids, inotrope and packed red cells targeting ScvO2 of >70%. Standard therapy (ST) (n=46) group received usual care as per prevalent unit practice Main Outcome Measures: Mortality; shock endpoints and ScvO2 trend Results: Baseline characteristics were comparable in the two groups. However, children with baseline ScvO2 <70% were more in GDT arm compared to ST arm [21/42(50%) vs 4/14(28%), p=0.22]. More children attained endpoints within 5-day intervention period in the ST group vs GDT group[31(67%) vs 24(52%) (p=0.13)]. Endpoints were attained earlier in GDT arm vs ST arm [median(IQR) 9 hrs (6,21) vs 12 hours (6,24) (p=0.42)]. Significantly more children died in the GDT arm [35(76.1%) vs 21(45.7%); p=0.03]. Figure 1 shows outcome of GDT patients based on their baseline and subsequent ScvO2.Conclusions: GDT patients were relatively sicker. ScvO2 monitoring helped in identifying children with lower baseline ScvO2 and those with inability to attain ScvO2 >70%. The latter ones had higher mortality. The median duration to attain endpoints in the studied clinical setting seems to be delayed compared to high income countries probably due to limitation of material and human resources.

'Intermittent' versus 'continuous' ScvO2 monitoring in children with septic shock: a randomised, non-inferiority trial.

To compare the effect of 'intermittent' central venous oxygen saturation (ScvO2) monitoring with 'continuous' ScvO2 monitoring on shock resolution and mortality in children with septic shock. Primary outcome was the achievement of therapeutic goals or shock resolution in the first 6h. We randomly assigned children < 17years' age with septic shock to 'intermittent ScvO2' or 'continuous ScvO2' groups. All children were subjected to subclavian/internal jugular line insertion and managed as per Surviving Sepsis Campaign Guidelines. To guide resuscitation, we used ScvO2 estimated at other clinical and laboratory parameters were monitored similarly in both groups. We enrolled 75 and 77 children [median (IQR) age: 6 (1.5-10) years] in the 'intermittent' and 'continuous' groups, respectively. Baseline characteristics were comparable between the groups. When compared to the 'continuous' group, fewer children in the 'intermittent' group achieved shock resolution within first 6h [19% vs. 36%; relative risk (RR) 0.51; 95% CI 0.29-0.89; risk difference - 18.0%; 95% CI - 32.0 to - 4.0]. The lower bound of confidence interval, however, crossed the pre-specified non-inferiority margin. There was no difference in the proportion of children attaining shock resolution within 24h (63% vs. 69%; RR 0.86; 95% CI 0.68-1.08) or risk of mortality between the groups (47% vs. 43%; RR 1.06; 95% CI 0.74-1.51). Given that a greater proportion of children attained therapeutic end points in the first 6h, continuous monitoring of ScvO2 should preferably be used to titrate therapy in the first few hours in children with septic shock. In the absence of such facility, intermittent monitoring of ScvO2 can be used to titrate therapy in these children, given the lack of difference in the proportion of patients achieving shock resolution at 24h or in risk of mortality between the intermittent and continuous groups.

Efficacy of minimal invasive cardiac output and ScVO2 monitoring during controlled hypotension for double-jaw surgery

BackgroundControlled hypotension (CH) provides a better surgical environment and reduces operative time. However, there are some risks related to organ hypoperfusion. The EV1000/FloTrac system can provide continuous cardiac output monitoring without the insertion of pulmonary arterial catheter. The present study investigated the efficacy of this device in double jaw surgery under CH.MethodsWe retrospectively reviewed the medical records of patients who underwent double jaw surgery between 2010 and 2015. Patients were administered conventional general anesthesia with desflurane; CH was performed with remifentanil infusion and monitored with an invasive radial arterial pressure monitor or the EV1000/FloTrac system. We allocated the patients into two groups, namely an A-line group and an EV1000 group, according to the monitoring methods used, and the study variables were compared.ResultsEighty-five patients were reviewed. The A-line group reported a higher number of failed CH (P = 0.005). A significant correlation was found between preoperative hemoglobin and intraoperative packed red blood cell transfusion (r = 0.525; P < 0.001). In the EV1000 group, the mean arterial pressure (MAP) was significantly lower 2 h after CH (P = 0.014), and the cardiac index significantly decreased 1 h after CH (P = 0.001) and 2 h after CH (P = 0.007). Moreover, venous oxygen saturation (ScVO2) decreased significantly at both 1 h (P = 0.002) and 2 h after CH (P = 0.029); however, these values were within normal limits.ConclusionThe EV1000 group reported a lower failure rate of CH than the A-line group. However, EV1000/FloTrac monitoring did not present with any specific advantage over the conventional arterial line monitoring when CH was performed with the same protocol and same mean blood pressure. Preoperative anemia treatment will be helpful to decrease intraoperative transfusion. Furthermore, ScVO2 monitoring did not present with sufficient benefits over the risk and cost.

Relationships Between Intraoperative Hemodynamic Parameters and Delayed Hemodynamic Recovery After Valve Deployment in Transcatheter Aortic Valve Replacement

To determine the relationships between intraoperative hemodynamic parameters and delayed hemodynamic recovery after valve deployment and identify the predictive factors of delayed hemodynamic recovery by focusing on intraoperative hemodynamics in patients with transcatheter aortic valve replacement (TAVR). A retrospective study. A single university hospital. Sixty-four patients who underwent elective TAVR between 2015 and 2017. No intervention. The 64 patients were divided into the following 2 groups according to the time for recovery: systolic arterial pressure exceeded 90 mmHg and central venous oxygen saturation (ScvO2) exceeded 65%-delayed recovery (DR) (n = 36) group, and early recovery (ER) (n = 28) group. ScvO2 in the DR group was not lower than that in the ER group after induction of anesthesia. However, ScvO2 in the DR group gradually decreased and was lower than that in the ER group before valve deployment, despite improvement in blood pressure through the administration of vasopressor agents. ScvO2 monitoring during TAVR is useful to predict delayed recovery greater than 60 seconds after valve deployment in TAVR.

Abstract O-12: INTERMITTENT VERSUS CONTINUOUS SCVO2 MONITORING DURING EARLY GOAL DIRECTED THERAPY IN SEPTIC SHOCK: A RANDOMIZED TRIAL

Aims & Objectives: To compare the effect of ‘intermittent’ central venous oxygen saturation (ScvO2) monitoring with ‘continuous’ ScvO2 monitoring on shock resolution and mortality in children with septic shock. Methods We randomly assigned children <17 years’ age with septic shock to ‘intermittent ScvO2’ or ‘continuous ScvO2’ groups. All children were subjected to subclavian/internal jugular line insertion and managed as per the Surviving Sepsis Campaign Guidelines. ScvO2 – estimated at 1, 3, 6, 12, 24, 48 and 72 hours in the ‘intermittent’ group and continuously using the central venous oximetry catheter in the ‘continuous’ group – was used to guide resuscitation; other clinical and laboratory parameters were monitored similarly in the two groups. Major outcomes were achievement of therapeutic goals within first 6 hours and in-hospital mortality. Data were analysed using STATA 13. Results We enrolled 101 [62 boys; median (IQR) age: 6 (1.5 to 10) years] children: 50 and 51 in ‘intermittent’ and ‘continuous’ groups, respectively. Baseline characteristics including organ dysfunction and mortality risk scores were comparable between the groups. When compared to ‘intermittent’ group, more children in the ‘continuous’ group achieved therapeutic end points within first 6 hours (33% vs. 16%; RR 2.08, 95% CI 0.98 to 4.38) but there was no difference in mortality (43% vs. 46%; RR 1.06, 0.69 to1.64) between the groups. Conclusions Continuous ScvO2 monitoring resulted in higher proportion of children attaining therapeutic end points in the first 6 hours. However, this did not seem to affect the mortality. Larger studies are required to compare the effect on mortality.

Comparative study on the outcome of Early Goal Directed Therapy (EGDT) versus standard care in pediatric septic shock patients: A prospective open labeled randomized controlled trial

Background : Sepsis in children is a noteworthy cause of morbidity and mortality all over the world. Given the crucial need to reduce the mortality from sepsis, conflicting results from adult studies and lack of high quality pediatric controlled study warrant a trial to examine the effectiveness of early goal directed therapy (EGDT) versus standard care in Indian patients. Methods : The trial was a prospective open labeled randomized controlled trial conducted from 1st July 2015 to 30th June 2017. All children from one month of age to 12 years with septic shock fulfilling the inclusion criteria were enrolled in the study. Eligible patients were randomized and allocated one of the two study groups (EGDT Group and standard care group). If the patient was assigned to EGDT, the EGDT protocol adapted from Rivers et al. was commenced by the treating team within one hour of enrollment. If the patient was assigned to standard care, no changes were made to the plan of the treating team. Results : The 110 patients were recruited from July 2015 to June 2017. Out of 110 patients, 54 patients were randomized to the EGDT group and 56 randomized to the standard care group. The trial had to be stopped after an interim analysis by the independent data monitoring committee indicated the futility of the study. The overall all-cause mortality at 28 days of the study population was 53.6%. Children in the EGDT group had 46.3% mortality while children in the standard care group had 60.7% mortality (p=0.13). There was 14.4% absolute risk reduction of mortality in the EGDT group. There was no difference in any secondary outcome regarding the proportion of patients achieving therapeutic end points at 6 hours, use and duration of organ support, SOFA and PeLOD score and length of PICU and hospital stay. Conclusion : Our study suggests that the implementation of the early goal directed therapy (EGDT) by the addition of intermittent ScvO2 monitoring and protocolized management did not improve mortality in the EGDT group compared to standard care group. The implementation of EGDT needed the greater intensity of treatment in the form of inotrope and packed RBCs transfusion requirement.

Predictive value of ScvO2 monitoring for pericardial tamponade after cardiac surgery.

We examined the predictive value of central venous oxygen saturation (ScvO2) changes regarding the occurrence of pericardial tamponade following cardiac surgery. We retrospectively identified 66consecutive patients in whom ScvO2 and arterial lactate levels were analyzed during an 8‑h time interval preceding pericardiotomy due to pericardial tamponade (PT), and at equivalent time points in 30control patients(C) who had an uncomplicated course. The median age of the patients was 74years (interquartile range, 63-78). Three percent of procedures were re-operations. There were no differences between the baseline values of PT andC patients. Pericardiotomy was performed on average 1day (0-3.5) after cardiac surgery. PT patients displayed asignificant decline (p< 0.001) to lower ScvO2 levels (p< 0.001) and asignificant increase (p= 0.005) to higher arterial lactate levels (p= 0.019) during the 8 h preceding pericardiotomy, whereas Cpatients did not (p= 0.440 and p= 0.279, respectively). PT was associated with alonger hospital stay (p= 0.04) and ahigher in-hospital mortality (p= 0.008). AnScvO2 decline below 60% (p= 0.018), adelta ScvO2 decline greater than 5% (p= 0.001), and adelta lactate increase greater than 0.18 mmol/l (p= 0.002) during the 8 h preceding pericardiotomy were independently associated with PT. None of these parameters predicted in-hospital mortality. Deteriorations in ScvO2 might serve as an early marker of PT following cardiac surgery.

Study of central venous oxygen saturation monitoring applicated in fluid resuscitation of patients with severe sepsis and septic shock

Objective To guide the fluid resuscitation in patients with severe sepsis and septic shock by monitoring the central venous oxygen saturation(ScvO2), and to improve the rescue success rate and prognosis of patients with sepsis. Methods Based on the standard of ScvO2 of 6h, 45 patients with severe sepsis and septic shock were divided into two groups: observation group(n=28) and control group(n=17). The ScvO2, mean arterial pressure(MAP) and central venous pressure(CVP) levels were measured in the two groups after fluid resuscitation, and then the mortality, MAP compliance rate and CVP compliance rate were compared between the two groups. Results Compared with mortality in the control group(52.94%), the mortality in the observation group(14.29%) was significantly lower, the difference was significant (χ2=5.927, P=0.015), but after 6h's fluid resuscitation, the MAP and CVP standard number in the two groups did not exist significant difference(χ2=1.182, P>0.05). Conclusion ScvO2 with or without reaching the standard level(more than 65%) was positively correlated with the severity of the disease after fluid resuscitation in patients with severe sepsis and septic shock.Therefore, the monitoring of ScvO2 plays an important role in guiding the treatment of fluid resuscitation and judging the prognosis. Key words: Sepsis; Shock, Septic; Resuscitation

High central venous saturation after cardiac surgery is associated with increased organ failure and long-term mortality: an observational cross-sectional study

IntroductionCentral venous saturation (ScvO2) monitoring has been suggested to address the issue of adequate cardiocirculatory function in the context of cardiac surgery. The aim of this study was to determine the impact of low (L) (<60%), normal (N) (60%-80%), and high (H) (>80%) ScvO2 measured on intensive care unit (ICU) admission after cardiac surgery.MethodsWe conducted a retrospective, cross-sectional, observational study at three ICUs of a university hospital department for anaesthesiology and intensive care. Electronic patient records of all adults who underwent cardiac surgery between 2006 and 2013 and available admission measurements of ScvO2 were examined. Patients were allocated to one of three groups according to first ScvO2 measurement after ICU admission: group L (<60%), group N (60%-80%), and group H (>80%). Primary end-points were in-hospital and 3-year follow-up survival.ResultsData from 4,447 patients were included in analysis. Low and high initial measurements of ScvO2 were associated with increased in-hospital mortality (L: 5.6%; N: 3.3%; H: 6.8%), 3-year follow-up mortality (L: 21.6%; N: 19.3%; H: 25.8%), incidence of post-operative haemodialysis (L: 11.5%; N: 7.8%; H: 15.3%), and prolonged hospital length of stay (L: 13 days, 9–22; N: 12 days, 9–19; H: 14 days, 9–21). After adjustment for possible confounding variables, an initial ScvO2 above 80% was associated with adjusted hazard ratios of 2.79 (95% confidence interval (CI) 1.565-4.964, P <0.001) for in-hospital survival and 1.31 (95% CI 1.033-1.672, P = 0.026) for 3-year follow-up survival.ConclusionsPatients with high ScvO2 were particularly affected by unfavourable outcomes. Advanced haemodynamic monitoring may help to identify patients with high ScvO2 who developed extraction dysfunction and to establish treatment algorithms to improve patient outcome in these patients.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-015-0889-6) contains supplementary material, which is available to authorized users.

Monitoring tissue blood oxygen saturation in the internal jugular venous area using near infrared spectroscopy.

Central venous blood oxygen saturation (ScvO2) is an important monitoring index of fluid resuscitation. However, monitoring of ScvO2 is not continuous and invasive. Near infrared spectroscopy (NIRS) is an optical technology for the noninvasive detection of hemodynamic changes, with advantages of being real-time, continuous, low-cost, and portable. The present study aimed to determine whether a correlation exists between the tissue blood oxygen saturation in the internal jugular venous area (StO2) data obtained with NIRS and the ScvO2 and whether these two quantities are equivalent. Data were collected from 13 patients. We used ultrasound to locate the placement site for the NIRS light source outside the internal jugular vein. Meanwhile, a sample for blood gas analysis was obtained through the central venous catheter. A correlation analysis between the StO2 and ScvO2 of 13 samples was performed (Pearson correlation coefficient), suggesting a high correlation between them (r = 0.906, StO2 =1.0018 ScvO2 +2.8524). Bland-Altman analysis was also performed between the StO2 and ScvO2. Results were as follows: 100% of monitored points fell within the range of the mean ± 1.96 SD of the difference between the StO2 and ScvO2; range of the mean ± 1.96 SD of the difference between the StO2 and ScvO2 was 3 ± 10.2; confidence interval of the difference between the StO2 and ScvO2 was -7.2 to 13.2%. The StO2 monitored with NIRS correlated highly with the ScvO2 measured in the internal jugular vein. Therefore, the StO2 can be used for directing clinical treatment with further research.

Fluid resuscitation in severe sepsis and septic shock: Shifting goalposts.

Fluid resuscitation in severe sepsis and septic shock: Shifting goalposts.

Venous oxygen saturation.

Early detection and rapid treatment of tissue hypoxia are important goals. Venous oxygen saturation is an indirect index of global oxygen supply-to-demand ratio. Central venous oxygen saturation (ScvO2) measurement has become a surrogate for mixed venous oxygen saturation (SvO2). ScvO2 is measured by a catheter placed in the superior vena cava. After results from a single-center study suggested that maintaining ScvO2 values >70% might improve survival rates in septic patients, international practice guidelines included this target in a bundle strategy to treat early sepsis. However, a recent multicenter study with >1500 patients found that the use of central hemodynamic and ScvO2 monitoring did not improve long-term survival when compared to the clinical assessment of the adequacy of circulation. It seems that if sepsis is recognized early, a rapid initiation of antibiotics and adequate fluid resuscitation are more important than measuring venous oxygen saturation.

Journal Scan

Journal Scan

Influence of Arterial Dissolved Oxygen Level on Venous Oxygen Saturation

Dissolved oxygen (i.e., unbound to hemoglobin) is often neglected as a determinant of central venous oxygen saturation (ScvO2) in review articles and textbooks. These statements may lead to potential misinterpretation of SCvO2 value across FiO2 changes. In this study, we aimed to explore the influence of PaO2 and FiO2 on ScvO2 in ventilated critically ill patients. This was a prospective observational study in two surgical intensive care units. Mechanically ventilated and sedated patients with cardiac output and ScvO2 monitoring and PaO2/FiO2 > 200 with inspiratory oxygen (FiO2) ≤ 0.5 were enrolled (cohort [ScvO2]). A second cohort of brain-injured patients with jugular venous oxygen saturation monitoring was studied to assess the application of the results to regional circulation (cohort [SjvO2]). Central venous oxygen saturation was measured at baseline FiO2 and at FiO2 = 1. We finally estimated the participation of the dissolved oxygen (PadissolvO2) to the ScvO2 variations. Twenty patients formed the cohort ScvO2 and eight formed the cohort SjvO2. Central venous oxygen saturation rose from 71% (69%-76%) to 84% (78%-88%) after increasing FiO2, whereas PaO2 rose from 100 (85-124) mmHg to 387 (360-449) mmHg. The rise of ScvO2 was mostly ascribable to the dissolved oxygen. The increase of ScvO2 was not explained by changes in cardiac output or hemoglobin levels. Jugular venous oxygen saturation rose from 71% (58%-78%) to 83% (78%-89%) after increasing FiO2. Arterial dissolved oxygen level can significantly influence the ScvO2 value. Therefore, PaO2 should not be overlooked while considering the ScvO2 value as a therapeutic goal. Interpretation of ScvO2 variations in response to a therapeutic challenge (i.e., fluid challenge, inotropic drug initiation) should be performed at constant FiO2.

Case Scenario: Hemodynamic Management of Postoperative Acute Kidney Injury

Case Scenario: Hemodynamic Management of Postoperative Acute Kidney Injury