Central venous-to-arterial carbon dioxide partial pressure difference in early resuscitation from septic shock

Mallat, Jihad; Pepy, Florent; Lemyze, Malcolm; Gasan, Gaëlle; Vangrunderbeeck, Nicolas; Tronchon, Laurent; Vallet, B.; Thévenin, Didier

doi:10.1097/eja.0000000000000064

Cited by 93 publications

(67 citation statements)

References 28 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Central venous blood gases or measurement of cardiac index might aid in making this distinction. [23][24][25] Second, an increase in pH increases binding of calcium to circulating protein, thereby reducing the ionized fraction and depressing cardiovascular function. 18 This alteration should occur with any base that increases the pH of critical compartments and is compounded by evidence that calcium concentration can be decreased in lactic acidosis itself.…”

Section: Discussionmentioning

confidence: 99%

Lactic Acidosis: Current Treatments and Future Directions

Kraut

Madias

2016

American Journal of Kidney Diseases

View full text Add to dashboard Cite

Mortality rates associated with severe lactic acidosis (blood pH<7.2) due to sepsis or low-flow states are high. Eliminating the triggering conditions remains the most effective therapy. Although recommended by some, administration of sodium bicarbonate does not improve cardiovascular function or reduce mortality. This failure has been attributed to both reduction in serum calcium concentration and generation of excess carbon dioxide with intracellular acidification. In animal studies, hyperventilation and infusion of calcium during sodium bicarbonate administration improves cardiovascular function, suggesting that this approach could allow expression of the positive aspects of sodium bicarbonate. Other buffers, such as THAM or Carbicarb, or dialysis might also provide base with fewer untoward effects. Examination of these therapies in humans is warranted. The cellular injury associated with lactic acidosis is partly due to activation of NHE1, a cell-membrane Na(+)/H(+) exchanger. In animal studies, selective NHE1 inhibitors improve cardiovascular function, ameliorate lactic acidosis, and reduce mortality, supporting future research into their possible use in humans. Two main mechanisms contribute to lactic acid accumulation in sepsis and low-flow states: tissue hypoxia and epinephrine-induced stimulation of aerobic glycolysis. Targeting these mechanisms could allow for more specific therapy. This Acid-Base and Electrolyte Teaching Case presents a patient with acute lactic acidosis and describes current and future approaches to treatment.

show abstract

Section: Discussionmentioning

confidence: 99%

Lactic Acidosis: Current Treatments and Future Directions

Kraut

Madias

2016

American Journal of Kidney Diseases

View full text Add to dashboard Cite

show abstract

“…Elevated P (v-a) CO 2 (above 6 mmHg) occurs in cases of decreased systemic blood flow. Normalization of P (v-a) CO 2 during resuscitation was associated with normalization of serum lactate [24]. …”

Section: Markers Of Global Perfusionmentioning

confidence: 99%

“…P (v-a) CO 2 is negatively correlated with cardiac output in septic shock patients [25]; thus, P (v-a) CO 2 is a useful parameter to assess the adequacy of tissue perfusion during resuscitation of patients in septic shock [24]. Persistence of high P (v-a) CO 2 during early resuscitation of septic shock is associated with poor outcomes [26].…”

Section: Markers Of Global Perfusionmentioning

confidence: 99%

Perfusion indices revisited

2017

View full text Add to dashboard Cite

Monitoring of tissue perfusion is an essential step in the management of acute circulatory failure. The presence of cellular dysfunction has been a basic component of shock definition even in the absence of hypotension. Monitoring of tissue perfusion includes biomarkers of global tissue perfusion and measures for assessment of perfusion in non-vital organs.The presence of poor tissue perfusion in a shocked patient is usually associated with worse outcome. Persistently impaired perfusion despite adequate resuscitation is also associated with worse outcome. Thus, normalization of some perfusion indices has become one of the resuscitation targets in patients with septic shock.Although the collective evidence shows the clear relation between impaired peripheral perfusion and mortality, the use of different perfusion indices as a resuscitation target needs more research.

show abstract

“…A poor prognosis was usually linked to this increase. More interestingly, this gradient remained enlarged even in patients with a normal mixed venous oxygen saturation (ScvO 2 ) [14]. Using video microscopic imaging, Ospina-Tascon et al [16] were able to show that patients experiencing a large p(mv-a)CO 2 despite a normal value of ScvO 2 had lower functional capillary density and higher heterogeneity of microvascular blood flow.…”

mentioning

confidence: 98%

“…Most of the authors observed in septic shock an increased p(mv-a)CO 2 , largely ascribed to a reduced systemic or microvascular blood flow [12][13][14][15]. A poor prognosis was usually linked to this increase.…”

mentioning

confidence: 99%

The venous–arterial partial pressure of carbon dioxide as a new monitoring of circulatory disorder: no so simple

Viale

2016

J Clin Monit Comput

View full text Add to dashboard Cite

Restoring or maintaining an optimal oxygen supply adjusted to oxygen demand remains the key aim of all clinicians facing a circulatory dysfunction, whatever the cause. Many therapeutic tools are available, ranging from adequate fluid resuscitation, cardio or vaso-active agents, to adjuvant therapies and various ventilatory supports. Most of the challenges for clinicians are the choice of therapeutics, their dosage, and management of their potential interactions. In addition, in the course of circulatory distress, it would be of great help to identify patients at risk of developing organ dysfunction, in order to intensify and adapt treatment of such individuals. As a guide to achieve these purposes, normalisation of mixed venous oxygen saturation and blood lactate has been proposed as endpoint resuscitations but revealed unsuccessful in several clinical studies [1][2][3]. The monitoring of the mixed venous-arterial gradient in partial pressure of carbon dioxide [p(mv-a)CO 2 ] has been recently put forward and revealed promising. A high CO 2 gradient would indicate an inadequate organ perfusion and a risk of delayed organ dysfunction. Have we reached a satisfactory answer to a main clinical question?In this issue Morel et al.[4] retrospectively analysed 220 consecutive patients admitted in intensive care unit after an elective cardiac surgery. Monitoring p(mv-a)CO 2 , they observed at the 6th postoperative hour a group of 55 patients having a gradient greater than 6 mm Hg. Surprisingly and contrary to previous published results, these patients experienced a lower SOFA score, hospital and 6 month mortality. The authors concluded that in this clinical setting, the CO 2 gradient is not predictive of poor outcome. This apparently paradoxical results is on line with other works underlying the poor discriminative value of the gradient [5]. Rather than the premature conclusion of a promising story, this is more likely a plea to gain more insight in our knowledge about a complex indicator.The p(mv-a)CO 2 is the difference between two partial pressures of CO 2 : the mixed venous and the arterial. The normal value is commonly held as lower than 6 mm Hg. The venous pressure depends on several components, the content of mixed venous in CO 2 , and the relationship between the concentration and the pressure. The content itself is a concentration, that is to say the ratio of the amount of CO 2 driven from peripheral organs to the amount of blood arising from the same organs or segments of organs. The arterial pressure depends on the lung function and is strictly proportional to the alveolar ventilation. Given a constant alveolar ventilation, this arterial pressure remains stable provided that the venous pressure is not modified. If an increase in mixed venous pCO 2 occurs, the amount of CO 2 exhaled by the lung will increase, enlarging the venous-arterial gradient. This role of the lung is schematically illustrated by the increase in end-tidal partial pressure of CO 2 occurring soon after the release of a tourniquet. Any small i...

show abstract

Central venous-to-arterial carbon dioxide partial pressure difference in early resuscitation from septic shock

Cited by 93 publications

References 28 publications

Lactic Acidosis: Current Treatments and Future Directions

Lactic Acidosis: Current Treatments and Future Directions

Perfusion indices revisited

The venous–arterial partial pressure of carbon dioxide as a new monitoring of circulatory disorder: no so simple

Contact Info

Product

Resources

About