Clinical Predictors of a Low Central Venous Oxygen Saturation after Major Surgery: A Prospective Prevalence Study

Litton, Edward; Silbert, Brendan; Ho, Kwok-ming

doi:10.1177/0310057x1504300109

Cited by 8 publications

(11 citation statements)

References 41 publications

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“…acute pulmonary embolism), use of fluid boluses to increase CVP to a high level may be harmful, as the right heart is very prone to dilate with excessive filling and the left heart can be paradoxically under-filled due to interventricular dependency 12 . Other studies have also shown that CVP has no discriminative value in predicting adequacy of systemic oxygen delivery for patients after major surgery 13 and is not reliable in predicting the size or collapsibility of the superior vena cava 14 . Despite the use of ultrasound technology, serious mechanical complications related to central venous catheterisation can still occur 15 .…”

Section: Central Venous Pressurementioning

confidence: 98%

“…This result was subsequently confirmed by similar studies and mathematical modelling [28][29][30] . Even in patients without obvious extreme hyperoxaemia, PaO 2 remains the most important factor in determining CvO 2 in patients after major surgery 13 . In fact, hyperoxaemia (mean PaO 2 >120 mmHg) was common in patients recruited in the RCT on EGDT 22 , making the algorithm aiming at a high CvO 2 without considering the effect of hyperoxaemia on CvO 2 vulnerable to uncontrolled bias.…”

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confidence: 99%

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Pitfalls in Haemodynamic Monitoring in the Postoperative and Critical Care Setting

2016

Anaesth Intensive Care

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Haemodynamic monitoring is a vital part of daily practice in anaesthesia and intensive care. Although there is evidence to suggest that goal-directed therapy may improve outcomes in the perioperative period, which haemodynamic targets we should aim at to optimise patient outcomes remain elusive and controversial. This review highlights the pitfalls in commonly used haemodynamic targets, including arterial blood pressure, central venous pressure, cardiac output, central venous oxygen saturation and dynamic haemodynamic indices. Evidence suggests that autoregulation in regional organ circulation may change either due to chronic hypertension or different disease processes such as traumatic brain injury, cerebrovascular ischaemia or haemorrhage; this will influence the preferred blood pressure target. Central venous pressure can be influenced by multiple pathophysiological factors and, unless central venous pressure is very low, it is rarely useful as a predictor for fluid responsiveness. Central venous oxygen saturation can be easily increased by a high arterial oxygen tension, making it useless as a surrogate marker of good cardiac output or systemic oxygen delivery in the presence of hyperoxaemia. Many dynamic haemodynamic indices have been reported to predict fluid responsiveness, but they all have their own limitations. There is also insufficient evidence to support that giving fluid until the patient is no longer fluid responsive can improve patient-centred outcomes. With the exception in the context of preventing contrast-induced nephropathy, large randomised controlled studies suggest that excessive fluid treatment may prolong duration of mechanical ventilation without preventing acute kidney injury in the critically ill.

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Section: Central Venous Pressurementioning

confidence: 98%

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confidence: 99%

Pitfalls in Haemodynamic Monitoring in the Postoperative and Critical Care Setting

2016

Anaesth Intensive Care

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“…Central venous pressure has previously been used to guide peri‐operative fluid therapy, but a CVP of between 5 mmHg to 20 mmHg has certainly almost no predictive value, and changes in CVP with a fluid bolus have not been shown to be predictive of fluid status . Central venous pressure is well‐known to be affected by other variables, such as intrathoracic pressure, venous resistance and pulmonary vascular resistance, and a recent study demonstrated that there is little value in using CVP as a marker of adequate systemic oxygen delivery after major surgery .…”

Section: Haemodynamic Monitoring and Variablesmentioning

confidence: 99%

Haemodynamic monitoring in the peri‐operative period: the past, the present and the future

Watson

Cecconi

2017

Anaesthesia

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Summary Over recent years there has been an increase in the implementation of goal‐directed therapy using minimally invasive haemodynamic monitoring techniques to guide peri‐operative care. Since the introduction of the pulmonary artery flotation catheter in the 1980s, various haemodynamic monitors have been developed, each associated with their own benefits and limitations. Goal‐directed therapy has been well‐established as a standard of care in the peri‐operative period and has largely been associated with a reduction in morbidity and mortality. However, evidence over the last few years from major studies has led us to question: what is the future for goal‐directed therapy? Care of the peri‐operative patient has significantly evolved over the last decade and this needs to be taken into account when assessing the results of these studies. We should therefore not look at the effects of goal‐directed therapy in isolation but as part of a progressive care bundle. Additionally, other markers of haemodynamic status have also begun to be further appreciated and these are worthy of further investigation. We feel that the future for haemodynamic monitoring remains promising with new areas of interest continuously emerging, but further research is still required.

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“…Arterial oxygen content = (1.34 × arterial oxygen saturation Inadequate systemic oxygen delivery or occult tissue hypoperfusion was defined by an O 2 ER >0.3 in this study, because a S CV O 2 <70% is widely considered as signifying inadequate systemic oxygen delivery resulting in increased tissue oxygen extraction 1,2,6 . CO 2 gap: central venous CO 2 tension -arterial CO 2 tension.…”

Section: Haemodynamic Calculationsmentioning

confidence: 99%

Central Venous-to-Arterial Carbon Dioxide Gradient as a Marker of Occult Tissue Hypoperfusion after Major Surgery

Silbert

Litton

2015

Anaesth Intensive Care

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The central venous-arterial carbon dioxide tension gradient ('CO 2 gap') has been shown to correlate with cardiac output and tissue perfusion in septic shock. Compared to central venous oxygen saturation (S CV O 2), the CO 2 gap is less susceptible to the effect of hyperoxia and may be particularly useful as an adjunctive haemodynamic target in the perioperative period. This study investigated whether a high CO 2 gap was associated with an increased systemic oxygen extraction (O 2 ER >0.3) or occult tissue hypoperfusion in 201 patients in the immediate postoperative period. The median CO 2 gap of all patients was 8 mmHg (IQR 6 to 9), and a large CO 2 gap was very common (>6 mmHg in 139 patients [69%], 95% CI 63 to 75; >5 mmHg in 170 patients [85%], 95% CI 79 to 89). A CO 2 gap <5 mmHg had a higher sensitivity (93%) and negative predictive value (74%) than a CO 2 gap <6 mmHg in excluding occult tissue hypoperfusion. Of the four variables that were predictive of an increased O 2 ER in the multivariate analysis-CO 2 gap, arterial pH, haemoglobin and arterial lactate concentrations-the CO 2 gap (odds ratio 4.41 per mmHg increment, 95% CI 1.7 to 11.2, P=0.002) was most important and explained about 34% of the variability in the risk of occult tissue hypoperfusion. In conclusion, a normal CO 2 gap (<5 mmHg) had a high sensitivity and negative predictive value in excluding inadequate systemic oxygen delivery and may be useful as an adjunct to other haemodynamic targets in avoiding occult tissue hypoperfusion in the perioperative setting when high inspired oxygen concentrations are used.

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Clinical Predictors of a Low Central Venous Oxygen Saturation after Major Surgery: A Prospective Prevalence Study

Cited by 8 publications

References 41 publications

Pitfalls in Haemodynamic Monitoring in the Postoperative and Critical Care Setting

Pitfalls in Haemodynamic Monitoring in the Postoperative and Critical Care Setting

Haemodynamic monitoring in the peri‐operative period: the past, the present and the future

Central Venous-to-Arterial Carbon Dioxide Gradient as a Marker of Occult Tissue Hypoperfusion after Major Surgery

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