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Category: Volume 08 Issue 02 February 2020
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Title: A Cross Sectonal Observational Study of Prognostic Value of Veno-Arterial Carbon Dioxide Difference in Septic Shock Patients in ICU

Authors: Dr Kambhampati S L N Sunanda Kameswari, Dr A.Satyanarayana, MD

 DOI: https://dx.doi.org/10.18535/jmscr/v8i2.63

Abstract

Background and Aim: Early identification of tissue hypoperfusion helps in decreasing mortality due to septic shock. This tissue hypoperfusion not only occurs due to decreased perfusion pressures due to hypotension, caused by reduced cardiac output (CO), but also due to the abnormal regional distribution of blood flow.Metabolic variables like central venous oxygen saturation(scvo2), serum lactate are established markers of tissue hypoperfusion. Recently, the central venous-to-arterial carbon dioxide  difference (v-a)CO2 has been proposed as an alternative marker of tissue hypoperfusion.So we deigned this study aiming to know the porognostic value of venous-to-arterial carbon dioxide  difference in septic shock.

Materials and Methods: Patients ,admitted in ICU,satisfying the criteria of septic shock were studied. Arterial blood gas,central venous samples are obtained, on admission ,6h,12h,24h.sixty patients were studied.Patients were classified into survivors and nonsurvivors. venous-to-arterial carbon dioxide difference difference and serum were evaluated and correlated to outcome.

Results: The mean Veno-arterial carbon dioxide difference in Survivors at the time of admission (T0), 6 hours after admission (T6), 12 hours after admission (T12), 24 hours after admission (T24),  was 7.23+1.41, 5.8+0.87, 5.71+0.80, 5.52+0.82 mmHg respectively and in Non-survivors was 8.51+1.31, 9.4+0.88, 9.84+1.01, 9.78+0.78 mmHg respectively with a statistically significant difference between survivors and Non-survivors(P<0.05). The mean serum lactate in Survivors at the T0, T6, T12, T24 was 7.74+1.54, 5.70+1.29, 3.9+1.18, 2.45+1.09 mmol/l respectively and in Non-survivors was 8.69+2.08, 9.09+1.58, 8.94+1.34, 8.79+1.33 mmol/l respectively. There was no significant statistical difference at the time of admission T0(p>0.05), and a statistically significant difference was observed at T6, T12, T24(p<0.05). The lactate clearance at the end of 6hours in survivors and non-survivors was 26% and 11%, and at the end of 24 hours was 68% and 16%, respectively. A positive correlation between veno-arterial carbon dioxide difference and serum lactate was also observed at T0,T6, T12, T24.

Conclusion: veno-arterial carbon dioxide difference  can be used as markers of prognosis in septic shock and it has a positive correlation with serum lactate.

References

  1. Singer M, Deutschman CS, Seymour CW et al (2016) The Third Inter‑ national Consensus Definitions for Sepsis and Septic Shock (Sepsis‑3). JAMA 315(8):801–810.
  2. Kumar, V.; Abbas, A.K.; Fausto, N.; et al., eds. (2007). Robbins Basic Pathology(8th ed.). Saunders, Elsevier. pp. 102–3.
  3. Ince C, Sinaasappel M, et al., Microcirculatory oxygenation and shunting in sepsis and shock.Crit Care Med 1999; July 27(7):1369-77.
  4. Hollenberg SM. Think locally: Evaluation of the microcirculation in sepsis. Intensive Care Med. 2010;36:1807–9.
  5. Trzeciak S, Rivers EP. Clinical manifestations of disordered microcirculatory perfusion in severe sepsis. Crit Care. 2005;9(Suppl 4):S20–6.
  6. 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. 
  7. 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
  8. 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. 
  9. Mesquida J, Borrat X, Lorente JA, Masip J, Baigorri F. Objectives of hemodynamic resuscitation. Med Intensiva. 2011;35:499–508
  10. 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`
  11. Hollenberg SM, Ahrens TS, Annane D, Astiz ME, Chalfin DB, Dasta JF, Heard SO, Martin C, Napolitano LM, Susla GM. et al.Practice parameters for hemodynamic support of sepsis in adult patients: 2004 update. Crit Care Med. 2004;32:1928–1948
  12. Marty P, Roquilly A, Vallée F, 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(1):3.
  13. Mallat, B.Vallet.Difference in venous-arterial carbon dioxide in septic shock. Minerva Anestesiol, 81 (2015), pp. 419-425.
  14. Lind.Veno-arterial carbon dioxide and pH gradients and survival in critical illness.Eur J Clin Invest, 25 (1995), pp. 201-205.
  15. Ospina-Tascón GA, Bautista-Rincón DF, Umaña M, 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.
  16. Helmy TA, El-Reweny EM, Ghazy FG.et al.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 Sep;21(9):589-593.

Corresponding Author

Dr Kambhampati S L N Sunanda Kameswari