Value of Central Venous to Arterial CO2 Difference after Early Goal-directed Therapy in Septic Shock Patients
David Theophilo Araujo, Vinícius Brenner Felice, Andre Felipe Meregalli
Central venous saturation, Lactate, Mortality, Septic shock, Venous to arterial difference of CO2
Citation Information :
Araujo DT, Felice VB, Meregalli AF. Value of Central Venous to Arterial CO2 Difference after Early Goal-directed Therapy in Septic Shock Patients. Indian J Crit Care Med 2019; 23 (10):449-453.
Background and aims: Venous to arterial difference of carbon dioxide (Pv–aCO2) tracks tissue blood flow. We aimed to evaluate if Pv–aCO2 measured from a superior central vein sample is a prognostic index (ICU length of stay, SOFA score, 28th mortality rate) just after early goal-directed therapy (EGDT)comparing its ICU admission values between patients with normal and abnormal (>6 mm Hg) Pv–aCO2. As secondary objectives, we evaluated the relationship of Pv–aCO2 with other variables of perfusion during the 24 hours that followed EGDT.
Materials and methods: Prospective observational study conducted in an academic ICU adult septic shock patients after a 6-hour complete EGTD. Hemodynamic measurements, arterial/central venous blood gases, and arterial lactate were obtained on ICU admission and after 6, 18 and 24 hours.
Results: Sixty patients were included. Admission Pv–aCO2 values showed no prognostic value. Admission Pv–aCO2 (ROC curve 0.527 [CI 95% 0.394 to 0.658]) values showed low specificity and sensitivity as predictors of mortality. There was a difference observed in the mean Pv–aCO2 between nonsurvivors (NS) and survivors (S) after 6 hours. Central venous oxygen saturation (ScvO2) and Pv–aCO2 showed significant correlation (R2 = –0.41, P < 0.0001). Patients with normal ScvO2 (>70%) and abnormal Pv–aCO2 (>6 mm Hg) showed higher SOFA scores. Normal Pv–aCO2 group cleared their lactate levels in comparison to the abnormal Pv–aCO2 group.
Conclusion: In septic shock, admission Pv–aCO2 after EGDT is not related to worse outcomes. An abnormal Pv–aCO2 along with a normal ScvO2 is related to organ dysfunction.
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(2):580–637.
Hernandez G, Cavalcanti AB, Ospina-Tascon G, Zampieri FG, Dubin A, Hurtado FJ et al. Early goal-directed therapy using a physiological holistic view: the ANDROMEDA-SHOCK-a randomized controlled trial. Ann Intensive Care 2018;8(1):52.
Meregalli A, Oliveira RP, Friedman G. Occult hypoperfusion is associated with increased mortality in hemodynamically stable, high-risk, surgical patients. Crit Care 2004;8(2):R60–R65.
Puskarich MA, Trzeciak S, Shapiro NI, Heffner AC, Kline JA, Jones AE. Outcomes of patients undergoing early sepsis resuscitation for cryptic shock compared with overt shock. Resuscitation 2011;82(10):1289–1293.
Friedman G, De Backer D, Shahla M, Vincent JL. Oxygen supply dependency can characterize septic shock. Intensive Care Med 1998;24(2):118–123.
Bakker J, Vincent JL, Gris P, Leon M, Coffernils M, Kahn RJ. Veno-arterial carbon dioxide gradient in human septic shock. Chest 1992;101(2):509–515.
Rackow EC, Astiz ME, Mecher CE, Weil MH. Increased venous-arterial carbon dioxide tension difference during severe sepsis in rats. Crit Care Med 1994;22(1):121–125.
Zhang H, Vincent JL. Arteriovenous differences in PCO2 and pH are good indicators of critical hypoperfusion. Am Rev Respir Dis 1993;148(4 Pt 1):867–871.
Durkin R, Gergits MA, Reed JF, III, Fitzgibbons J. The relationship between the arteriovenous carbon dioxide gradient and cardiac index. J Crit Care 1993;8(4):217–221.
Cuschieri J, Rivers E, Donnino M, Katilius M, Jacobsen G, Nguyen B et al. Central venous-arterial carbon dioxide difference as an indicator of cardiac index. Intensive Care Med. 2005;31(6):818–822.
Tsaousi GG, Karakoulas KA, Amaniti EN, Soultati ID, Zouka MD, Vasilakos DG. Correlation of central venous-arterial and mixed venous-arterial carbon dioxide tension gradient with cardiac output during neurosurgical procedures in the sitting position. Eur J Anaesthesiol 2010;27(10):882–889.
Vallet B, Teboul JL, Cain S, Curtis S. Venoarterial CO2 difference during regional ischemic or hypoxic hypoxia. J Appl Physiol (1985) 2000;89(4):1317–1321.
Neviere R, Chagnon JL, Teboul JL, Vallet B, Wattel F. Small intestine intramucosal PCO(2) and microvascular blood flow during hypoxic and ischemic hypoxia. Crit Care Med 2002;30(2):379–384.
Dubin A, Murias G, Estenssoro E, Canales H, Badie J, Pozo M et al. Intramucosal-arterial PCO2 gap fails to reflect intestinal dysoxia in hypoxic hypoxia. Crit Care 2002;6(6):514–520.
Dubin A, Estenssoro E. Mechanisms of tissue hypercarbia in sepsis. Front Biosci 2008;13:1340–1351.
Ospina-Tascon GA, Bautista-Rincon DF, Umana M, Tafur JD, Gutierrez A, Garcia 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(6):R294.
Muller G, Mercier E, Vignon P, Henry-Lagarrigue M, Kamel T, Desachy A et al. Prognostic significance of central venous-to-arterial carbon dioxide difference during the first 24 hours of septic shock in patients with and without impaired cardiac function. Br J Anaesth 2017;119(2):239–248.
Akamatsu T, Inata Y, Tachibana K, Hatachi T, Takeuchi M. Elevated Central Venous to Arterial CO2 Difference Is Not Associated With Poor Clinical Outcomes After Cardiac Surgery With Cardiopulmonary Bypass in Children. Pediatr Crit Care Med 2017;18(9):859–862.
Morel J, Grand N, Axiotis G, Bouchet JB, Faure M, Auboyer C et al. High veno-arterial carbon dioxide gradient is not predictive of worst outcome after an elective cardiac surgery: a retrospective cohort study. J Clin Monit Comput 2016;30(6):783–789.
Boulain T, Garot D, Vignon P, Lascarrou JB, Desachy A, Botoc V et al. Prevalence of low central venous oxygen saturation in the first hours of intensive care unit admission and associated mortality in septic shock patients: a prospective multicentre study. Crit Care 2014;18(6):609.
Mouncey PR, Osborn TM, Power GS, Harrison DA, Sadique MZ, Grieve RD et al. Protocolised Management In Sepsis (ProMISe): a multicentre randomised controlled trial of the clinical effectiveness and cost-effectiveness of early, goal-directed, protocolised resuscitation for emerging septic shock. Health Technol Assess 2015;19(97):i–150.
Peake SL, Delaney A, Bailey M, Bellomo R, Cameron PA, Cooper DJ et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014;371(16):1496–1506.
Yealy DM, Kellum JA, Huang DT, Barnato AE, Weissfeld LA, Pike F et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med 2014;370(18):1683–1693.
Vallee 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(12):2218–2225.
Mallat J, Lemyze M, Tronchon L, Vallet B, Thevenin D. Use of venous-to-arterial carbon dioxide tension difference to guide resuscitation therapy in septic shock. World J Crit Care Med 2016;5(1):47–56.
Ho KM, Harding R, Chamberlain J. A comparison of central venous-arterial and mixed venous-arterial carbon dioxide tension gradient in circulatory failure. Anaesth Intensive Care 2007;35(5):695–701.
Mallat J, Pepy F, Lemyze M, Gasan G, Vangrunderbeeck N, Tronchon L et al. Central venous-to-arterial carbon dioxide partial pressure difference in early resuscitation from septic shock: a prospective observational study. Eur J Anaesthesiol 2014;31(7):371–380.
Mahajan RK, Peter JV, John G, Graham PL, Rao SV, Pinsky MR. Patterns of central venous oxygen saturation, lactate and veno-arterial CO2 difference in patients with septic shock. Indian J Crit Care Med 2015;19(10):580–586.
Vincent JL, Quintairos E Silva, Couto L, Jr., Taccone FS. The value of blood lactate kinetics in critically ill patients: a systematic review. Crit Care 2016;20(1):257.
Ospina-Tascon GA, Umana M, Bermudez WF, Bautista-Rincon DF, Valencia JD, Madrinan HJ et al. Can venous-to-arterial carbon dioxide differences reflect microcirculatory alterations in patients with septic shock? Intensive Care Med 2016;42(2):211–221.
Fink MP. Cytopathic hypoxia. Mitochondrial dysfunction as mechanism contributing to organ dysfunction in sepsis. Crit Care Clin 2001;17(1):219–237.
Hernandez G, Ospina-Tascon GA, Damiani LP, Estenssoro E, Dubin A, Hurtado J et al. Effect of a resuscitation strategy targeting peripheral perfusion status vs serum lactate levels on 28-day mortality among patients with septic shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA 2019;321(7):654–664.