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Yuriditsky E, Zhang RS, Bakker J, Horowitz JM, Zhang P, Bernard S, Greco AA, Postelnicu R, Mukherjee V, Hena K, Elbaum L, Alviar CL, Keller NM, Bangalore S. Relationship Between the Mixed Venous-to-Arterial Carbon Dioxide Gradient and Cardiac Index in Acute Pulmonary Embolism. Eur Heart J Acute Cardiovasc Care 2024:zuae031. [PMID: 38454794 DOI: 10.1093/ehjacc/zuae031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/27/2024] [Accepted: 03/06/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Among patients with acute pulmonary embolism (PE) undergoing mechanical thrombectomy, the cardiac index (CI) is frequently reduced even among those without clinically apparent shock. The purpose of this study was to describe the mixed venous-to-arterial carbon dioxide gradient (CO2 gap), a surrogate of perfusion adequacy, among patients with acute PE undergoing mechanical thrombectomy. METHODS This was a single-center retrospective study of consecutive patients with PE undergoing mechanical thrombectomy and simultaneous pulmonary artery catheterization over a 3-year period. RESULTS Of 107 patients, 97 had simultaneous mixed venous and arterial blood gas measurements available. The CO2 gap was elevated (>6 mmHg) in 51% of the cohort and in 49% of patients with intermediate-risk PE. A reduced CI (≤2.2 L/min/m2) was associated with an increased odds (OR = 7.9; 95% CI 3.49-18.1, p < 0.001) for an elevated CO2 gap. There was an inverse relationship between CI and CO2 gap. For every 1 L/min/m2 decrease in the CI, the CO2 gap increased by 1.3 mmHg (p = 0.001). Among patients with an elevated baseline CO2 gap >6 mmHg, thrombectomy improved CO2 gap, CI, and mixed venous oxygen saturation. When the CO2 gap was dichotomized above and below 6, there was no difference in in-hospital mortality (9% vs. 0%; p = 0.10, HR: 1.24; 95% CI: 0.97-1.60; P = 0.085). CONCLUSIONS Among patients with acute PE undergoing mechanical thrombectomy, the CO2 gap is abnormal in nearly 50% of patients and inversely related to CI. Further studies should examine the relationship between markers of perfusion and outcomes in this population to refine risk stratification.
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Affiliation(s)
- Eugene Yuriditsky
- Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Robert S Zhang
- Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Jan Bakker
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - James M Horowitz
- Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Peter Zhang
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Samuel Bernard
- Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Allison A Greco
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Radu Postelnicu
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Vikramjit Mukherjee
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Kerry Hena
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Lindsay Elbaum
- Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Carlos L Alviar
- Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Norma M Keller
- Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Sripal Bangalore
- Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
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Orso D, Molinari C, Bacchetti G, Zanini V, Montanar V, Copetti R, Guglielmo N, Bove T. Correlation and Agreement Between the CO2 Gap Obtained From Peripheral Venous Blood and From Mixed Venous Blood in Mechanically Ventilated Septic Patients. Semin Cardiothorac Vasc Anesth 2024; 28:18-27. [PMID: 38037887 DOI: 10.1177/10892532231219917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
BACKGROUND Venous-arterial CO2 difference (Pv-aCO2) is a valuable marker that can identify a subset of patients in shock with inadequate cardiac output to meet tissue metabolic requirements. Some authors have found that Pv-aCO2 levels calculated from mixed vs central venous blood demonstrate a linear relationship. The purpose of this study is to determine whether there is a linear relationship between Pv-aCO2 obtained with peripheral venous blood (Pv-aCO2p) and with mixed venous blood, and the agreement between the 2 measures. METHODS This was a prospective, single-center, observational clinical study enrolling mechanically ventilated patients in septic shock during the first 24 hours following admission to the intensive care unit. RESULTS The Bravais-Pearson r-coefficient between Pv-aCO2 and Pv-aCO2p was .70 in 38 determinations (95%CI .48-.83; P-value = 1.25 x 10^-6). The Bland-Altman bias was 4.11 mmHg (95%CI 2.82-5.39), and the repeatability coefficient was 11.05. Using the Taffe approach, the differential and proportional biases were 2.81 (95%CI .52-5.11) and 1.29 (95%CI .86-1.72), respectively. CONCLUSION There was linear correlation between Pv-aCO2p and Pv-aCO2 in mechanically ventilated patients with septic shock. The bias showed a gradual increase in high Pv-aCO2 values in an upward trend.
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Affiliation(s)
- Daniele Orso
- Anaesthesia and Intensive Care Medicine Department, ASUFC University Hospital of Udine and Department of Medical Science (DAME), University of Udine, Udine, Italy
| | - Chiara Molinari
- Anaesthesia and Intensive Care Medicine Department, ASUFC University Hospital of Udine and Department of Medical Science (DAME), University of Udine, Udine, Italy
| | - Giacomo Bacchetti
- Anaesthesia and Intensive Care Medicine Department, ASUFC University Hospital of Udine and Department of Medical Science (DAME), University of Udine, Udine, Italy
| | - Victor Zanini
- Anaesthesia and Intensive Care Medicine Department, ASUFC University Hospital of Udine and Department of Medical Science (DAME), University of Udine, Udine, Italy
| | - Valentina Montanar
- Anaesthesia and Intensive Care Medicine Department, ASUFC University Hospital of Udine and Department of Medical Science (DAME), University of Udine, Udine, Italy
| | - Roberto Copetti
- Department of Emergency Medicine, Community Hospital of Latisana, Latisana, Italy
| | - Nicola Guglielmo
- Department of Emergency Medicine, Community Hospital of Latisana, Latisana, Italy
| | - Tiziana Bove
- Anaesthesia and Intensive Care Medicine Department, ASUFC University Hospital of Udine and Department of Medical Science (DAME), University of Udine, Udine, Italy
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Hutchings SD, Naumann DN, Watts S, Wilson C, Burton C, Wendon J, Kirkman E. Microcirculatory perfusion shows wide inter-individual variation and is important in determining shock reversal during resuscitation in a porcine experimental model of complex traumatic hemorrhagic shock. Intensive Care Med Exp 2016; 4:17. [PMID: 27342821 PMCID: PMC4920780 DOI: 10.1186/s40635-016-0088-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 05/30/2016] [Indexed: 01/28/2023] Open
Abstract
Background Traumatic hemorrhagic shock (THS) is a leading cause of preventable death following severe traumatic injury. Resuscitation of THS is typically targeted at blood pressure, but the effects of such a strategy on systemic and microcirculatory flow remains unclear. Failure to restore microcirculatory perfusion has been shown to lead to poor outcomes in experimental and clinical studies. Systemic and microcirculatory variables were examined in a porcine model of complex THS, in order to investigate inter-individual variations in flow and the effect of microcirculatory perfusion on reversal of the shock state. Methods Baseline standard microcirculatory variables were obtained for 22 large white pigs using sublingual incident dark field (IDF) video-microscopy. All animals were subjected to a standardised hind-limb injury followed by a controlled haemorrhage of approximately 35 % of blood volume (shock phase). This was followed by 60 min of fluid resuscitation with either 0.9 % saline or component blood products and a target SBP of 80 mmHg (early resuscitation phase). All animals were then given blood products to a target SBP of 110 mmHg for 120 min (mid-resuscitation phase), and a further 100 min (late resuscitation phase). IDF readings were obtained at the midpoint of each of these phases. Cardiac output was measured using a pulmonary artery catheter. Animals were divided into above average (A) and below average (B) perfused vessel density (PVD) groups based on the lowest recorded PVD measurement taken during the shock and early resuscitation phases. Results There was minimal inter-individual variation in blood pressure but wide variation of both systemic and microcirculatory flow variables during resuscitation. During shock and early resuscitation, group A (n = 10) had a mean PVD of 10.5 (SD ± 2.5) mm/mm2 and group B (n = 12) 5.5 (SD ± 4.1) mm/mm2. During the later resuscitation phases, group A maintained a significantly higher PVD than group B. Group A initially had a higher cardiac output, but the difference between the groups narrowed as resuscitation progressed. At the end of resuscitation, group A had significantly lower plasma lactate, higher lactate clearance, lower standard base deficit and smaller mixed venous-arterial CO2 gradient. There was no significant difference in blood pressure between the two groups at any stage. Conclusion There was a wide variation in both macro- and microcirculatory flow variables in this pressure-targeted experimental model of THS resuscitation. Early changes in microvascular perfusion appear to be key determinants in the reversal of the shock state during resuscitation. Microcirculatory flow parameters may be more reliable markers of physiological insult than pressure-based parameters and are potential targets for goal-directed resuscitation. Electronic supplementary material The online version of this article (doi:10.1186/s40635-016-0088-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sam D Hutchings
- Royal Centre for Defence Medicine, Birmingham Research Park, Vincent Drive, Birmingham, B15 2SQ, UK. .,Department of Critical Care, King's College Hospital London, Denmark Hill, London, SE5 9RS, UK. .,Defence Science and Technology Laboratory, Porton Down, Salisbury, Wiltshire, SP4 0JQ, UK.
| | - David N Naumann
- Royal Centre for Defence Medicine, Birmingham Research Park, Vincent Drive, Birmingham, B15 2SQ, UK.,NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, B152TH, UK
| | - Sarah Watts
- Defence Science and Technology Laboratory, Porton Down, Salisbury, Wiltshire, SP4 0JQ, UK
| | - Callie Wilson
- Defence Science and Technology Laboratory, Porton Down, Salisbury, Wiltshire, SP4 0JQ, UK
| | - Clare Burton
- Defence Science and Technology Laboratory, Porton Down, Salisbury, Wiltshire, SP4 0JQ, UK
| | - Julia Wendon
- Department of Critical Care, King's College Hospital London, Denmark Hill, London, SE5 9RS, UK
| | - Emrys Kirkman
- Defence Science and Technology Laboratory, Porton Down, Salisbury, Wiltshire, SP4 0JQ, UK
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