Prospective Trial of Supranormal Values of Survivors as Therapeutic Goals in High-Risk Surgical Patients

Shoemaker, William C.; Appel, Paul L.; Kram, Harry B.; Waxman, Kenneth; Lee, Tai-Shion

doi:10.1378/chest.94.6.1176

Cited by 1,654 publications

(702 citation statements)

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“…Nine participants (four women) completed symptom-limited tests, after which three had definitive surgery and six were referred for palliative treatment. [2][3][4][5][6][7][8][9][10][11][12][13][14]) days, at which time all participants were still jaundiced. Oxygen consumption and oxygen pulse increased during exercise (Fig.…”

Section: Resultsmentioning

confidence: 99%

“…Stringer et al showed that femoral venous oxygen saturation continues to fall after the lactate threshold but without a fall in femoral venous oxygen pressure, due to the rightshift of the haemoglobin dissociation curve in response to metabolic acidosis [7]. These changes represent normal microcirculatory responses to reduced oxygen delivery.Resuscitated septic patients have increased cardiac output, increased oxygen delivery and increased oxygen consumption [8][9][10]. However, the increase in oxygen delivery exceeds the increase in oxygen consumption, due to decreased oxygen extraction (the arterial -venous difference in oxygen content).…”

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Peripheral oxygen extraction in patients with malignant obstructive jaundice

2013

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SummaryMalignant obstructive jaundice is associated with poor aerobic capacity. We measured oxygen consumption and oxygen extraction (arterial-venous oxygen content) in the legs of nine patients during cardiopulmonary exercise testing before pancreaticoduodenectomy. The median (IQR [range]) peak oxygen consumption was 67 (49-77 [32-84])% of predicted. Normal patterns of oxygen extraction were seen with increasing power towards lactate threshold. Near maximal oxygen extraction occurred at peak exercise. Femoral venous oxygen pressure and saturation exceeded baseline values whilst recovering from exercise. These findings suggest that peripheral oxygen extraction is normal during exercise in patients with malignant obstructive jaundice. The primary limitation in oxygen consumption is reduced oxygen delivery. We observed that patients with obstructive jaundice, presenting for major hepato-pancreatico-biliary surgery, were often unfit on cardiopulmonary exercise testing (CPET), with less than expected oxygen consumptions at peak exercise and at the lactate threshold. Reduced oxygen consumption may be due to reduced delivery or reduced extraction.Our patients did not have documented heart disease or abnormal resting trans-thoracic echocardiograms, but these do not exclude contractile dysfunction. Clinical studies have demonstrated that raised bilirubin is associated with raised endotoxin and inflammatory cytokine levels [1][2][3], as well as cardiovascular dysfunction characterised by hypovolaemia and reduced left ventricular systolic function [4,5]. Weber and Janicki demonstrated maximal peripheral oxygen extraction (> 70%) in patients with varying degrees of heart failure during exercise [6]. The authors demonstrated that reduced cardiac output was the primary cause of reduced aerobic capacity rather than impaired oxygen extraction. Stringer et al. showed that femoral venous oxygen saturation continues to fall after the lactate threshold but without a fall in femoral venous oxygen pressure, due to the rightshift of the haemoglobin dissociation curve in response to metabolic acidosis [7]. These changes represent normal microcirculatory responses to reduced oxygen delivery.Resuscitated septic patients have increased cardiac output, increased oxygen delivery and increased oxygen consumption [8][9][10]. However, the increase in oxygen delivery exceeds the increase in oxygen consumption, due to decreased oxygen extraction (the arterial -venous difference in oxygen content). 32© 2013 The Association of Anaesthetists of Great Britain and Ireland Anaesthesia 2014Anaesthesia , 69, 32-36 doi:10.1111 We hypothesised that poor exercise capacity in patients with obstructive jaundice was, like in septic patients, secondary to reduced oxygen extraction and a normal or raised cardiac output. MethodsThe Institutional and regional ethics committee approved the recruitment of 10 patients to this invasive pilot study. All participants provided written informed consent.We included patients eligible for pancreaticoduodenectomy, with el...

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Section: Resultsmentioning

confidence: 99%

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confidence: 99%

Peripheral oxygen extraction in patients with malignant obstructive jaundice

2013

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“…Oxygen consumption has been used as a predictor of outcome from critical illness [9], a target for goal directed therapy [10,11] and an end point for resuscitation [12]. It also forms the basis of calculating energy expenditure and assessing nutritional status [13].…”

Section: Measurement Of Oxygen Consumption (Vomentioning

confidence: 99%

Clinical evaluation of a continuous oxygen consumption monitor in mechanically ventilated patients

Donaldson¹,

Dodds²,

Walsh

2003

Anaesthesia

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SummaryWe measured oxygen consumption using a new noninvasive modular metabolic monitor, M-COVX TM , in ventilated critically ill patients. Oxygen consumption was measured continuously as part of routine monitoring for up to 24 h following mechanical ventilation in 27 patients admitted to a general intensive care unit. We explored several possible sources of error. Most errors related to inaccurate tidal volume measurement, which resulted in rejection of a median 14% (interquartile range 8-34%) of data. Water accumulation in the pneumotachograph was responsible and occurred more frequently with water bath humidifiers. After manual removal of erroneous data mean oxygen consumption values were virtually identical to calculated values in 24 of 27 patients. We conclude that in most ventilated patients averaging of continuous oxygen consumption data with the M-COVX module results in small errors.

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“…37 Un travail recent sur le CAP vient de suggErer que les valeurs <~ normales >> chez les patients en Etat critique peuvent ne pas 8tre appropriEes. Shoemaker et al 38 ont montrE qu'une thErapie menEe h l'aide d'un CAP, avec comme objectif des valeurs supra-normales de debit cardiaque et de livraison d'oxygEne chez des patients en post-opEratoire, amenait une diminution de la mortalitE lorsque comparEe h celle de patients traitEs avec ou sans CAP, et o3 la ~ normalitE >> Etait l'objectif thErapeutique.…”

Section: Indications Et B~n~fices Pour Les Patientsunclassified

The pulmonary artery catheter: When and why it should be used

Finegan

1992

Can J Anaesth

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Prospective Trial of Supranormal Values of Survivors as Therapeutic Goals in High-Risk Surgical Patients

Cited by 1,654 publications

References 20 publications

Peripheral oxygen extraction in patients with malignant obstructive jaundice

Peripheral oxygen extraction in patients with malignant obstructive jaundice

Clinical evaluation of a continuous oxygen consumption monitor in mechanically ventilated patients

The pulmonary artery catheter: When and why it should be used

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