PurposeTo evaluate the prognostic value of the Cv-aCO2/Da-vO2 ratio combined with lactate levels during the early phases of resuscitation in septic shock.MethodsProspective observational study in a 60-bed mixed ICU. One hundred and thirty-five patients with septic shock were included. The resuscitation protocol targeted mean arterial pressure, pulse pressure variations or central venous pressure, mixed venous oxygen saturation, and lactate levels. Patients were classified into four groups according to lactate levels and Cv-aCO2/Da-vO2 ratio at 6 h of resuscitation (T6): group 1, lactate ≥2.0 mmol/L and Cv-aCO2/Da-vO2 >1.0; group 2, lactate ≥2.0 mmol/L and Cv-aCO2/Da-vO2 ≤1.0; group 3, lactate <2.0 mmol/L and Cv-aCO2/Da-vO2 >1.0; and group 4, lactate <2.0 mmol/L and Cv-aCO2/Da-vO2 ≤1.0.ResultsCombination of hyperlactatemia and high Cv-aCO2/Da-vO2 ratio was associated with the worst SOFA scores and lower survival rates at day 28 [log rank (Mantel–Cox) = 31.39, p < 0.0001]. Normalization of both variables was associated with the best outcomes. Patients with a high Cv-aCO2/Da-vO2 ratio and lactate <2.0 mmol/L had similar outcomes to hyperlactatemic patients with low Cv-aCO2/Da-vO2 ratio. The multivariate analysis revealed that Cv-aCO2/Da-vO2 ratio at both T0 (RR 3.85; 95 % CI 1.60–9.27) and T6 (RR 3.97; 95 % CI 1.54–10.24) was an independent predictor for mortality at day 28, as well as lactate levels at T6 (RR 1.58; 95 % CI 1.13–2.22).ConclusionComplementing lactate assessment with Cv-aCO2/Da-vO2 ratio during early stages of resuscitation of septic shock can better identify patients at high risk of adverse outcomes. The Cv-aCO2/Da-vO2 ratio may become a potential resuscitation goal in patients with septic shock.Electronic supplementary materialThe online version of this article (doi:10.1007/s00134-015-3720-6) contains supplementary material, which is available to authorized users.

IntroductionVenous-to-arterial carbon dioxide difference (Pv-aCO2) may reflect the adequacy of blood flow during shock states. We sought to test whether the development of Pv-aCO2 during the very early phases of resuscitation is related to multi-organ dysfunction and outcomes in a population of septic shock patients resuscitated targeting the usual oxygen-derived and hemodynamic parameters.MethodsWe conducted a prospective observational study in a 60-bed mixed ICU in a University affiliated Hospital. 85 patients with a new septic shock episode were included. A Pv-aCO2 value ≥ 6 mmHg was considered to be high. Patients were classified in four predefined groups according to the Pv-aCO2 evolution during the first 6 hours of resuscitation: (1) persistently high Pv-aCO2 (high at T0 and T6); (2) increasing Pv-aCO2 (normal at T0, high at T6); (3) decreasing Pv-aCO2 (high at T0, normal at T6); and (4) persistently normal Pv-aCO2 (normal at T0 and T6). Multiorgan dysfunction at day-3 was compared for predefined groups and a Kaplan Meier curve was constructed to show the survival probabilities at day-28 using a log-rank test to evaluate differences between groups. A Spearman-Rho was used to test the agreement between cardiac output and Pv-aCO2. Finally, we calculated the mortality risk ratios at day-28 among patients attaining normal oxygen parameters but with a concomitantly increased Pv-aCO2.ResultsPatients with persistently high and increasing Pv-aCO2 at T6 had significant higher SOFA scores at day-3 (p < 0.001) and higher mortality rates at day-28 (log rank test: 19.21, p < 0.001) compared with patients who evolved with normal Pv-aCO2 at T6. Interestingly, a poor agreement between cardiac output and Pv-aCO2 was observed (r2 = 0.025, p < 0.01) at different points of resuscitation. Patients who reached a central venous saturation (ScvO)2 ≥ 70% or mixed venous oxygen saturation (SvO2) ≥ 65% but with concomitantly high Pv-aCO2 at different developmental points (i.e., T0, T6 and T12) had a significant mortality risk ratio at day-28.ConclusionThe persistence of high Pv-aCO2 during the early resuscitation of septic shock was associated with more severe multi-organ dysfunction and worse outcomes at day-28. Although mechanisms conducting to increase Pv-aCO2 during septic shock are insufficiently understood, Pv-aCO2 could identify a high risk of death in apparently resuscitated patients.

PurposeSeptic shock has been associated with microvascular alterations and these in turn with the development of organ dysfunction. Despite advances in video microscopic techniques, evaluation of microcirculation at the bedside is still limited. Venous-to-arterial carbon dioxide difference (Pv-aCO2) may be increased even when venous O2 saturation (SvO2) and cardiac output look normal, which could suggests microvascular derangements. We sought to evaluate whether Pv-aCO2 can reflect the adequacy of microvascular perfusion during the early stages of resuscitation of septic shock.MethodsProspective observational study including 75 patients with septic shock in a 60-bed mixed ICU. Arterial and mixed-venous blood gases and hemodynamic variables were obtained at catheter insertion (T0) and 6 h after (T6). Using a sidestream dark-field device, we simultaneously acquired sublingual microcirculatory images for blinded semiquantitative analysis. Pv-aCO2 was defined as the difference between mixed-venous and arterial CO2 partial pressures.ResultsProgressively lower percentages of small perfused vessels (PPV), lower functional capillary density, and higher heterogeneity of microvascular blood flow were observed at higher Pv-aCO2 values at both T0 and T6. Pv-aCO2 was significantly correlated to PPV (T0: coefficient −5.35, 95 % CI −6.41 to −4.29, p < 0.001; T6: coefficient, −3.49, 95 % CI −4.43 to −2.55, p < 0.001) and changes in Pv-aCO2 between T0 and T6 were significantly related to changes in PPV (R2 = 0.42, p < 0.001). Absolute values and changes in Pv-aCO2 were not related to global hemodynamic variables. Good agreement between venous-to-arterial CO2 and PPV was maintained even after corrections for the Haldane effect.ConclusionsDuring early phases of resuscitation of septic shock, Pv-aCO2 could reflect the adequacy of microvascular blood flow.Electronic supplementary materialThe online version of this article (doi:10.1007/s00134-015-4133-2) contains supplementary material, which is available to authorized users.

Background: Ventilation/perfusion inequalities impair gas exchange in acute respiratory distress syndrome (ARDS). Although increased dead-space ventilation (V D /V T ) has been described in ARDS, its mechanism is not clearly understood. We sought to evaluate the relationships between dynamic variations in V D /V T and extra-pulmonary microcirculatory blood flow detected at sublingual mucosa hypothesizing that an altered microcirculation, which is a generalized phenomenon during severe inflammatory conditions, could influence ventilation/perfusion mismatching manifested by increases in V D /V T fraction during early stages of ARDS.Methods: Forty-two consecutive patients with early moderate and severe ARDS were included. PEEP was set targeting the best respiratory-system compliance after a PEEP-decremental recruitment maneuver. After 60 min of stabilization, hemodynamics and respiratory mechanics were recorded and blood gases collected. V D /V T was calculated from the CO 2 production ( V CO 2 ) and CO 2 exhaled fraction ( F ECO 2 ) measurements by volumetric capnography. Sublingual microcirculatory images were simultaneously acquired using a sidestream dark-field device for an ulterior blinded semi-quantitative analysis. All measurements were repeated 24 h after.Results: Percentage of small vessels perfused (PPV) and microcirculatory flow index (MFI) were inverse and significantly related to V D /V T at baseline (Spearman's rho = − 0.76 and − 0.63, p < 0.001; R 2 = 0.63, and 0.48, p < 0.001, respectively) and 24 h after (Spearman's rho = − 0.71, and − 0.65; p < 0.001; R 2 = 0.66 and 0.60, p < 0.001, respectively). Other respiratory, macro-hemodynamic and oxygenation parameters did not correlate with V D /V T . Variations in PPV between baseline and 24 h were inverse and significantly related to simultaneous changes in V D /V T (Spearman's rho = − 0.66, p < 0.001; R 2 = 0.67, p < 0.001). Conclusion:Increased heterogeneity of microcirculatory blood flow evaluated at sublingual mucosa seems to be related to increases in V D /V T , while respiratory mechanics and oxygenation parameters do not. Whether there is a cause-effect relationship between microcirculatory dysfunction and dead-space ventilation in ARDS should be addressed in future research.

Our observations suggest that dynamic changes in the heterogeneity of microvascular blood flow at the gut mucosa are closely related to mesenteric O2 extraction, thus supporting the role of decreasing functional capillary density and increased intercapillary distances on alterations of O2 uptake during development and resuscitation from septic shock. Addition of a low-fixed dose of dobutamine might reverse such flow heterogeneity, improving microcirculatory flow distribution and tissue O2 consumption.

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Objetivo: El propósito del estudio fue establecer el perfil orofacial de las personas adultas mayores institucionalizados de la ciudad de Bucaramanga y su área metropolitana. Materiales y Métodos: Se realizó un estudio observacional descriptivo en adultos mayores de 60 años, residentes permanentes de instituciones geriátricas, que aceptaron participar en el estudio. Se estableció la prevalencia de alteraciones en el examen facial, mucosa oral, articulación temporomandibular (ATM), índice COP(d), Indice de caries radicular (RCI), estado periodontal (CPITN), higiene oral y estado protésico. Resultados: Se examinaron 284 adultos mayores, 55% del género masculino con un promedio de edad de 77.7 años, carecían de seguridad social el 35%; consumía algún medicamento el 65% y el 39% registró hipertensión arterial. Las mejillas presentaron la mayor frecuencia de anormalidad (80.6%); en mucosa oral, la lengua presentó el mayor número de lesiones (66.2%) y la alteración de ATM más frecuente fue el ruido articular (60%).El promedio de COP fue 26.4 ±3.3, el Indice de Caries radicular (RCI) tuvo un promedio de 31 y una mediana de 40, con un rango entre 0 y 50. El estado periodontal de moderado a severo se presentó en el 63% y edentulismo total en 55%. Conclusión: El adulto mayor institucionalizado presenta una condición oral muy deficiente. Su manejo y control requiere de investigaciones multidisciplinarias que orienten las estrategias de intervención en una forma integral. [Bermúdez W, Concha S, Camargo D. Perfil orofacial de las personas mayores institucionalizadas de la ciudad de Bucaramanga y su área metropolitana. Ustasalud 2003;1:13-19] ABSTRACT Purpose: The purpose of the study was to establish the orofacial profile of institutionalized elderly people from Bucaramanga and metropolitan area. Material and Methods: A descriptive study in institutionalized adults oldest than 60 years was carried out, who accepted participate. A whole orofacial profile were established by facial, mucosa and TMJ examination, DMFT index, RCI, CPITN, oral hygiene and prosthesis status. Results: Two hundred and eigthy four elderly persons was evaluated, 55% male, with an average of total age 77.7 years old; 35% have no social security. The medical condition more frequent was hypertension (39%) and nervous system disease (38%); medical attendance (57.7%) and pharmacologic treatment (65%). In a facial examination cheek, exhibit high prevalence of alterations (80%), TMJ noises was (60%). Medial pterigoid muscle exhibit pain in 44% and in the oral mucosa, white lesion on lateral borders of the tongue was the more frequent (66.2%).The average of DMFT index was 26.4 ±3.3, RCI index 31, median 40 and range between 0 and 50. Mild to severe periodontal condition by CPITN index was 63% and total edentulism was 55%. Conclusion: Institutionalized elderly people have a deficient oral condition. Its management and control request multidisciplinary research and integral intervention strategies.

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