Advertisement

Continuous central venous oximetry and shock index in the emergency department: Use in the evaluation of clinical shock

      This paper is only available as a PDF. To read, Please Download here.

      Abstract

      Initial therapy of shock in the emergency department (ED) emphasizes the normalization of physiologic variables such as heart rate (HR), mean arterial pressure (MAP), and central venous pressure (CVP) rather than restoration of adequate tissue oxygenation. After hemodynamic stabilization of MAP, CVP, and HR, the authors examined tissue oxygenation as indicated by continuous central venous oximetry (SCVO2), lactic acid concentration, and shock index (SI). Sixteen consecutive nonrandomized patients presenting to the ED of a large urban hospital in shock (MAP < 60 mm Hg, HR > 120 beats/min, and altered sensorium) were initially resuscitated with fluid, blood, inotropes, and/or vasoactive drug therapy to normalize MAP, CVP, and HR. In addition, SCVO2, arterial lactate concentration, and SI were measured after completion of resuscitation in the ED. Eight patients (group no. 1) had inadequate tissue oxygenation reflected by low SCVO2 (less than 65%). Four patients in group no. 1 had elevated arterial lactic acid concentration. All group no. 1 patients had an elevated SI (>0.7) suggesting persistent impairment of left ventricular stroke work. Eight patients (group no. 2) had normal or elevated SCVO2 (>65%). In group no. 2, arterial lactic acid concentration was elevated in six and SI in seven patients. Normalization of hemodynamic variables does not adequately reflect the optimal endpoint of initial therapy in shock in the ED. Most (94%) of these patients continue to have significant global ischemia and cardiac dysfunction as indicated by reduced SCVO2 and elevated lactic acid concentration and SI. Systemic tissue oxygenation shoudl be monitored and optimized in the ED in these critically III patients. Measurement of SCVO2, arterial lactic acid concentration, and SI may provide valuable additional information on the adequacy of systemic oxygenation and cardiac function during initial therapy of shock in the ED.

      Keywords

      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Baek SM
        • Makabali G
        • Bryan-Brown CW
        • et al.
        Plasma expansion in surgical patients with high central venous pressure (CVP); the relationship of blood volume to hematocrit, CVP, pulmonary wedge pressure and cardiorespiratory changes.
        Surgery. 1975; 78: 304
        • Shoemaker WC
        • Appel PL
        • Bland R
        • et al.
        Clinical trial of an algorithm for outcome prediction in acute circulatory failure.
        Crit Care Med. 1982; 10: 390
        • Bland R
        • Shoemaker WC
        • Abraham E
        • et al.
        Haemodynamic and oxygen transport patterns in surviving and nonsurviving postoperative patients.
        Crit Care Med. 1985; 13: 85
        • Shoemaker WC
        Relationship of oxygen transport patterns to the pathophysiology and therapy of shock states.
        Intensive Care Med. 1987; 13: 230
        • Shoemaker WC
        • Appel PL
        • Waxman K
        • et al.
        Clinical trial of survivors' cardiorespiratory patterns as therapeutic goals in critically ill postoperative patients.
        Crit Care Med. 1982; 10: 398
        • Shoemaker WC
        • Appel PL
        • Kram HB
        • et al.
        Prospective trial of supranormal values of survivors as therapeutic goals in high risk surgical patients.
        Chest. 1988; 94: 1176
        • Shoemaker WC
        • Appel PL
        • Kram HB
        Tissue oxygen debt as a determinant of lethal and nonlethal postoperative organ failure.
        Crit Care Med. 1988; 16: 1117
        • Reinhardt K
        • Rudolph T
        • Bredle DL
        • et al.
        Comparison of central-venous to mixed-venous oxygen saturation during changes in oxygen supply/demand.
        Chest. 1989; 95: 1216
        • Reinhardt K
        Principles and practice of SVO2 monitoring.
        Intensive Care World. 1988; 5: 121
        • Kasnitz P
        • Druger GL
        • Yorra F
        • et al.
        Mixed venous oxygen tension and hyperlactataemia severe cardiopulmonary disease.
        JAMA. 1976; 236: 570
        • Richard C
        • Thuillez C
        • Pezzano M
        • et al.
        Relationship between mixed venous oxygen saturation and cardiac index in patients with chronic congestive heart failure.
        Chest. 1989; 95: 1289
        • Scalea TM
        • Houman M
        • Fuortes M
        • et al.
        Central venous blood oxygen saturation: An early accurate measurement of volume during hemorrhage.
        J Trauma. 1988; 28: 725
        • Nelson D
        Mixed venous oximetery.
        in: Synder JV Pinskey MR Oxygen Transport In The Critically III. Year Book Medical Publishers, Chicago, IL1987: 235
        • Rivers EP
        • Martin GB
        • Rady MY
        • et al.
        The clinical implication of continuous central venous oxygen saturation monitoring during human CPR.
        Ann Emerg Med. 1992; (in press)
        • Rady MY
        • Nightingale P
        • Edwards JD
        • et al.
        Shock index: A re-evaluation in acute circulatory failure.
        Resuscitation. 1992; 23: 227-234
      1. Rady MY, Nightingale P, Edwards JD, et al: Evaluation of shock index in human septic shock. Intensive Care Med (in press)

        • Edwards JD
        • Brown GC
        • Nightingale P
        • et al.
        Use of cardiorespiratory values as therapeutic goals in septic shock.
        Crit Care Med. 1989; 17: 1098
        • Cain SM
        O2 deficit incurred during hypoxia and its relation to lactate and excess lactate.
        Am J Physiol. 1967; 213: 57-63
        • Cain SM
        Relative rates of arterial lactate and oxygen deficit accumulation in hypoxic dogs.
        Am J Physiol. 1973; 224: 1190
        • Perret C
        • Enrico J
        • Poli S
        Acid-base disturbances and lactate metabolism in shock.
        Eur J Clin Invest. 1970; 1: 387
        • Czer LS
        • Shoemaker WC
        Optimal hematocrit value in critically ill postoperative patients.
        Surg Gynecol Obstet. 1978; 147: 363
        • Shoemaker WC
        • Appel PL
        • Kram HB
        Haemodynamic and oxygen transport effects of dobutamine in critically ill general surgical patients.
        Crit Care Med. 1986; 14: 1032
        • Aubier M
        • Viires N
        • Syllie G
        • et al.
        Respiratory muscle contribution to lactic acidosis in low cardiac output.
        Am Rev Respir Dis. 1982; 126: 648
        • Shah DM
        • Newell JC
        • Saba TM
        Defects in peripheral oxygen utilization following trauma and shock.
        Arch Surg. 1981; 116: 1277
        • Wolf YG
        • Cotev S
        • Perel A
        • et al.
        Dependence of oxygen consumption on cardiac output in sepsis.
        Crit Care Med. 1987; 15: 198
        • Black PR
        • Devanter SV
        • Cohn LH
        Effects of hypothermia on systemic and organ system metabolism and function.
        J Surg Res. 1976; 20: 49
        • Demling RH
        Current concepts on adult respiratory distress syndrome.
        Circ Shock. 1990; 30: 297
        • Rivers EP
        • Rady MY
        • Martin GB
        • et al.
        Characterization of a defect in systemic oxygen consumption after human cardiac arrest.
        Crit Care Med. 1992; 20: S73