Prognostic value of venous to arterial carbon dioxide difference during early resuscitation in critically ill patients with septic shock
Tamer Helmy, Ehab El-reweny, Farahat Ghazy
lactate, partial pressure carbon dioxide gap,Acute Physiology and Chronic Health Evaluation II score
Citation Information :
Helmy T, El-reweny E, Ghazy F. Prognostic value of venous to arterial carbon dioxide difference during early resuscitation in critically ill patients with septic shock. Indian J Crit Care Med 2017; 21 (9):589-593.
Context: The partial pressure of venous to arterial carbon dioxide gradient (PCO2gap) is considered as an alternative marker of tissue hypoperfusion and has been used to guide treatment for shock.
Aims: The aim of this study was to investigate the prognostic value of venous-to-arterial carbon dioxide difference during early resuscitation of patients with septic shock and compared it with that of lactate clearance and Acute Physiology and Chronic Health Evaluation II (APACHE-II) score. Settings and Design: Forty patients admitted to one Intensive Care Unit were enrolled.
Subjects and Methods: APACHE-II score was calculated on admission. An arterial blood gas, central venous, and lactate samples were obtained on admission and after 6 h, and lactate clearance was calculated. Patients were classified retrospectively into Group I (survivors) and Group II (nonsurvivors). Pv-aCO2difference in the two groups was evaluated. Statistical Analysis Used: Data were fed to the computer and analyzed using IBM SPSS software package version 20.0.
Results: At T0, Group II showed high PCO2gap (8.37 ± 1.36 mmHg) than Group I (7.55 ± 0.95 mmHg) with statistically significant difference (P = 0.030). While at T6, Group II showed higher PCO2gap (9.48 ± 1.47 mmHg) with statistically significant difference (P < 0.001) and higher mean lactate values (62.71 ± 23.66 mg/dl) with statistically significant difference (P < 0.001) than Group I where PCO2gap and mean lactate values became much lower, 5.91 ± 1.12 mmHg and 33.61 ± 5.80 mg mg/dl, respectively. Group I showed higher lactate clearance (25.42 ± 6.79%) with statistically significant difference (P < 0.001) than Group II (−69.40–15.46%). Conclusions: High PCO2gap >7.8 mmHg after 6 h from resuscitation of septic shock patients is associated with high mortality.
Linde-Zwirble WT, Angus DC. Severe sepsis epidemiology: Sampling, selection, and society. Crit Care 2004;8:222-6.
Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003;31:1250-6.
Annane D, Bellissant E, Cavaillon JM. Septic shock. Lancet 2005;365:63-78.
Troskot R, Šimurina T, Žižak M, Majstorović K, Marinac I, Mrakovčić-Šutić I, et al. Prognostic value of venoarterial carbon dioxide gradient in patients with severe sepsis and septic shock. Croat Med J 2010;51:501-8.
Yazigi A, Abou-Zeid H, Haddad F, Madi-Jebara S, Hayeck G, Jabbour K, et al. Correlation between central venous-arterial carbon dioxide tension gradient and cardiac index changes following fluid therapy. Ann Card Anaesth 2010;13:269-71.
Vallet B, Teboul JL, Cain S, Curtis S. Venoarterial CO(2) difference during regional ischemic or hypoxic hypoxia. J Appl Physiol (1985) 2000;89:1317-21.
Bakker J, Vincent JL, Gris P, Leon M, Coffernils M, Kahn RJ, et al. Veno-arterial carbon dioxide gradient in human septic shock. Chest 1992;101:509-15.
Dres M, Monnet X, Teboul JL. Hemodynamic management of cardiovascular failure by using PCO(2) venous-arterial difference. J Clin Monit Comput 2012;26:367-74.
Hernandez G, Castro R, Romero C, de la Hoz C, Angulo D, Aranguiz I, et al. Persistent sepsis-induced hypotension without hyperlactatemia: Is it really septic shock? J Crit Care 2011;26:435.e9-14.
Palizas F, Dubin A, Regueira T, Bruhn A, Knobel E, Lazzeri S, et al. Gastric tonometry versus cardiac index as resuscitation goals in septic shock: A multicenter, randomized, controlled trial. Crit Care 2009;13:R44.
Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368-77.
Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580-637.
Mesquida J, Borrat X, Lorente JA, Masip J, Baigorri F. Objectives of hemodynamic resuscitation. Med Intensiva 2011;35:499-508.
Green RS, Djogovic D, Gray S, Howes D, Brindley PG, Stenstrom R, et al. Canadian Association of Emergency Physicians Sepsis Guidelines: The optimal management of severe sepsis in Canadian emergency departments. CJEM 2008;10:443-59.
Jansen TC, van Bommel J, Schoonderbeek FJ, Sleeswijk Visser SJ, van der Klooster JM, Lima AP, et al. Early lactate-guided therapy in Intensive Care Unit patients: A multicenter, open-label, randomized controlled trial. Am J Respir Crit Care Med 2010;182:752-61.
Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA, et al. Lactate clearance vs. central venous oxygen saturation as goals of early sepsis therapy: A randomized clinical trial. JAMA 2010;303:739-46.
Vallet B, Pinsky MR, Cecconi M. Resuscitation of patients with septic shock: Please “mind the gap”! Intensive Care Med 2013;39:1653-5.
van Beest PA, Lont MC, Holman ND, Loef B, Kuiper MA, Boerma EC, et al. Central venous-arterial pCO2 difference as a tool in resuscitation of septic patients. Intensive Care Med 2013;39:1034-9.
Sheehan A, Columb M. Two goals, one shot at survival: ΔPCO2 and ScvO2. Eur J Anaesthesiol 2014;31:361-2.
Ospina-Tascón GA, Bautista-Rincón DF, Umaña M, Tafur JD, Gutiérrez A, García AF, et al. Persistently high venous-to-arterial carbon dioxide differences during early resuscitation are associated with poor outcomes in septic shock. Crit Care 2013;17:R294.
Vallée F, Vallet B, Mathe O, Parraguette J, Mari A, Silva S, et al. Central venous-to-arterial carbon dioxide difference: An additional target for goal-directed therapy in septic shock? Intensive Care Med 2008;34:2218-25.
Marty P, Roquilly A, Vallée F, Luzi A, Ferré F, Fourcade O, et al. Lactate clearance for death prediction in severe sepsis or septic shock patients during the first 24 hours in Intensive Care Unit: An observational study. Ann Intensive Care 2013;3:3.
Robin E, Futier E, Pires O, Fleyfel M, Tavernier B, Lebuffe G, et al. Central venous-to-arterial carbon dioxide difference as a prognostic tool in high-risk surgical patients. Crit Care 2015;19:227.