The Correlation between Central Venous-to-arterial Carbon Dioxide Difference/Arterial-to-venous Oxygen Difference Ration and Lactate in Patients with Sepsis_Chinese Journal of Respiratory and Critical Care Medicine

Authors：

ZhangBeiyuan ,  GuQin , LiuNing

Department of Critical Care Medicine, Drum-tower Hospital Affiliated to Medical School, Nanjing University, Nanjing, Jiangsu, 210008, China;

Corresponding author：

GuQin, Email: icuguqin1133@gmail.com

Keywords：

Central venous-to-arterial carbon dioxide difference/arterial-to-venous oxygen difference ration; Lactate; Sepsis; Oxygen metabolism

DOI：

10.7507/1671-6205.2016033

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Objective To explore the relationship between central venous-to-arterial carbon dioxide difference/arterial-to-venous oxygen difference ration [P(cv-a)CO₂/C(a-cv)O₂] and arterial lactate in patients with sepsis. Methods A retrospective analysis was carried on 36 septic patients who were admitted to the Intensive Care Unit of Nanjng Drum-tower Hospital affiliated to Medical School of Nanjing University from May 2013 to November 2013. Cardiac index was measured by transpulmonary thermodilution. At the same time, femoral artery and central venous blood were collected to measure the value of arterial lactate and central venous oxygen saturation (ScvO₂) by blood gas analysis and calculate central venous-to-arterial carbon dioxide difference [P(cv-a)CO₂], arterial-to-venous oxygen difference [C(a-cv)O₂], and their ration [P(cv-a)CO₂/C(a-cv)O₂], oxygen delivery (DO₂) and oxygen consumption (VO₂). The subjects were divided intoahyperlactatemia group (≥2 mmol/L) andanormal lactate group (< 2 mmol/L) according to arterial lactate value. P(cv-a)CO₂/C(a-cv)O₂ and other oxygen metabolism parameters were compared between two groups. Receiver operating characteristic (ROC) curve was used to evaluate the accuracy of P(cv-a)CO₂/C(a-cv)O₂ and other parameters for diagnosis of hyperlactatemia. Results A total of 36 patients with 119 data were collected. Compared with the normal lactate group, P(cv-a)CO₂/C(a-cv)O₂ was significantly higher [(1.38±0.76)mm Hg/mL vs. (2.31±1.01) mm Hg/mL, P < 0.01], ScvO₂, DO₂ and VO₂ were significantly lower in the hyperlactatemia group [ScvO₂: (74.26±9.13)% vs. (70.29±9.72)%; DO₂: (505.52±208.39) mL/(min·m²) vs. (429.98±173.63) mL/(min·m²)]; VO₂: (129.01±54.94) mL/(min·m²) vs. (109.99±38.79) mL/(min·m²), P < 0.05]. P(cv-a)CO₂ had no significant difference between two groups [(5.76±3.70) mm Hg vs. (6.59±3.70) mm Hg, P > 0.05]. P(cv-a)CO₂/C(a-cv)O₂ was positively correlated with lactate (r=0.646, P < 0.01). ScvO₂ was negatively correlated with lactate (r=-0.277, P < 0.01). DO₂ and VO₂ had no significant correlation with lactate (P > 0.05). The area under ROC curve (AUC) of P(cv-a)CO₂ /C(a-cv)O₂ for diagnosis of hyperlactatemia was 0.820, with 95% confidence interval (95%CI) of 0.715 - 0.925(P < 0.001); The AUC of ScvO₂ was 0.622, with 95%CI of 0.520 - 0.724(P=0.025). Conclusion Compared with the traditional oxygen metabolism parameters, P(cv-a)CO₂/C(a-cv)O₂ can accurately diagnose hyperlactatemia, and isareliable parameter to reflect oxygen metabolism in patients with sepsis.

Citation： ZhangBeiyuan, GuQin, LiuNing. The Correlation between Central Venous-to-arterial Carbon Dioxide Difference/Arterial-to-venous Oxygen Difference Ration and Lactate in Patients with Sepsis. Chinese Journal of Respiratory and Critical Care Medicine, 2016, 15(2): 136-141. doi: 10.7507/1671-6205.2016033 Copy

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2.	Daviaud F, Grimaldi D, Dechartres A, et al. Timing and causes of death in septic shock. Ann Intensive Care, 2015, 5:58.
3.	Ranieri VM, Thompson BT, Barie PS, et al. Drotrecogin alfa (activated) in adults with septic shock. N Engl J Med, 2012, 366:2055-2064.
4.	Hayes MA, Timmins AC, Yau EH, et al. Oxygen transport patterns in patients with sepsis syndrome or septic shock: influence of treatment and relationship to outcome. Crit Care Med, 1997, 25:926-936.
5.	van Beest P, Wietasch G, Scheeren T, et al. Clinical review: use of venous oxygen saturations as a goal - a yet unfinished puzzle. Crit Care, 2011, 15:232.
6.	Cuschieri J, Rivers EP, Donnino MW, et al. Central venous-arterial carbon dioxide difference as an indicator of cardiac index. Intensive Care Med, 2005, 31:818-822.
7.	Mekontso-Dessap A, Castelain V, Anguel N, et al. Combination of venoarterial PCO₂ difference with arteriovenous O₂ content difference to detect anaerobic metabolism in patients. Intensive Care Med, 2002, 28:272-277.
8.	Marik PE. Obituary: pulmonary artery catheter 1970 to 2013. Ann Intensive Care, 2013, 3:38.
9.	Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest, 1992, 101:1644-1655.
10.	Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international Guidelines for Management of Severe Sepsis and Septic Shock: 2008. Crit Care Med, 2008, 36:296-327.
11.	Mesquida J, Saludes P, Gruartmoner G, et al. Central venous-to-arterial carbon dioxide difference combined with arterial-to-venous oxygen content difference is associated with lactate evolution in the hemodynamic resuscitation process in early septic shock. Crit Care, 2015, 19:126.
12.	Bakker J, Gris P, Coffernils M, et al. Serial blood lactate levels can predict the development of multiple organ failure following septic shock. Am J Surg, 1996, 171:221-226.
13.	Chertoff J, Chisum M, Garcia B, et al. Lactate kinetics in sepsis and septic shock: a review of the literature and rationale for further research. J Intensive Care, 2015, 3:39.
14.	王东浩, 吕扬, 夏睿, 等.中心静脉-动脉血二氧化碳分压差评估肿瘤危重患者的血流动力学状态.中国危重病急救医学, 2011, 23:669-672.
15.	Vallet B, Teboul JL, Cain S, et al. Venoarterial CO₂ difference during regional ischemic or hypoxic hypoxia. J Appl Physiol (1985), 2000, 89:1317-1321.
16.	Boyd O, Grounds RM, Bennett ED. A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients. JAMA, 1993, 270:2699-2707.
17.	秦伟毅, 易仁亮, 邹霞英.慢性肺源性心脏病急性加重期氧代谢变化.中国呼吸与危重监护杂志, 2006, 5:445-447.
18.	Hayes MA, Timmins AC, Yau EHF, et al. Elevation of systemic oxygen delivery in the treatment of critically ill patients. N Engl J Med, 1994, 330:1717-1722.
19.	Squara P, Journois D, Formela JF, et al. Value of elementary, combined, and modeled hemodynamic variables. J Crit Care, 1994, 9:223-235.
20.	刘兆润, 吴国刚, 张殿红.中心静脉血氧饱和度监测在重症加强治疗病房中的临床应用.中国呼吸与危重监护杂志, 2011, 10:194-196.
21.	Pope JV, Jones AE, Gaieski DF, et al. Multicenter study of central venous oxygen saturation (ScvO₂) as a predictor of mortality in patients with sepsis. Ann Emerg Med, 2010, 55:40-46.
22.	Groeneveld AB, Vermeij CG, Thijs LG. Arterial and mixed venous blood acid-base balance during hypoperfusion with incremental positive end-expiratory pressure in the pig. Anesth Analg, 1991, 73:576-582.
23.	Cohen IL, Sheikh FM, Perkins RJ, et al. Effect of hemorrhagic shock and reperfusion on the respiratory quotient in swine. Crit Care Med, 1995, 23:545-552.
24.	Jakob SM, Kosonen P, Ruokonen E, et al. The Haldane effect--an alternative explanation for increasing gastric mucosal PCO₂ gradients? Br J Anaesth, 1999, 83:740-746.
25.	Hernandez G, Bruhn A, Castro R, et al. The holistic view on perfusion monitoring in septic shock. Curr Opin Crit Care, 2012, 18:280-286.
26.	Marty P, Roquilly A, Vallee 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, 3:3.
27.	徐勋宏.早期乳酸清除率对重症感染患者预后的评估研究.中国呼吸与危重监护杂志, 2012, 11:596-598.
28.	马升军, 陈虹, 段均.早期乳酸清除率对呼吸衰竭患者预后评估的作用.中国呼吸与危重监护杂志, 2012, 11:562-565.

1. Angus DC, van der Poll T. Severe sepsis and septic shock. N Engl J Med, 2013, 369:2063.
2. Daviaud F, Grimaldi D, Dechartres A, et al. Timing and causes of death in septic shock. Ann Intensive Care, 2015, 5:58.
3. Ranieri VM, Thompson BT, Barie PS, et al. Drotrecogin alfa (activated) in adults with septic shock. N Engl J Med, 2012, 366:2055-2064.
4. Hayes MA, Timmins AC, Yau EH, et al. Oxygen transport patterns in patients with sepsis syndrome or septic shock: influence of treatment and relationship to outcome. Crit Care Med, 1997, 25:926-936.
5. van Beest P, Wietasch G, Scheeren T, et al. Clinical review: use of venous oxygen saturations as a goal - a yet unfinished puzzle. Crit Care, 2011, 15:232.
6. Cuschieri J, Rivers EP, Donnino MW, et al. Central venous-arterial carbon dioxide difference as an indicator of cardiac index. Intensive Care Med, 2005, 31:818-822.
7. Mekontso-Dessap A, Castelain V, Anguel N, et al. Combination of venoarterial PCO₂ difference with arteriovenous O₂ content difference to detect anaerobic metabolism in patients. Intensive Care Med, 2002, 28:272-277.
8. Marik PE. Obituary: pulmonary artery catheter 1970 to 2013. Ann Intensive Care, 2013, 3:38.
9. Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest, 1992, 101:1644-1655.
10. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international Guidelines for Management of Severe Sepsis and Septic Shock: 2008. Crit Care Med, 2008, 36:296-327.
11. Mesquida J, Saludes P, Gruartmoner G, et al. Central venous-to-arterial carbon dioxide difference combined with arterial-to-venous oxygen content difference is associated with lactate evolution in the hemodynamic resuscitation process in early septic shock. Crit Care, 2015, 19:126.
12. Bakker J, Gris P, Coffernils M, et al. Serial blood lactate levels can predict the development of multiple organ failure following septic shock. Am J Surg, 1996, 171:221-226.
13. Chertoff J, Chisum M, Garcia B, et al. Lactate kinetics in sepsis and septic shock: a review of the literature and rationale for further research. J Intensive Care, 2015, 3:39.
14. 王东浩, 吕扬, 夏睿, 等.中心静脉-动脉血二氧化碳分压差评估肿瘤危重患者的血流动力学状态.中国危重病急救医学, 2011, 23:669-672.
15. Vallet B, Teboul JL, Cain S, et al. Venoarterial CO₂ difference during regional ischemic or hypoxic hypoxia. J Appl Physiol (1985), 2000, 89:1317-1321.
16. Boyd O, Grounds RM, Bennett ED. A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients. JAMA, 1993, 270:2699-2707.
17. 秦伟毅, 易仁亮, 邹霞英.慢性肺源性心脏病急性加重期氧代谢变化.中国呼吸与危重监护杂志, 2006, 5:445-447.
18. Hayes MA, Timmins AC, Yau EHF, et al. Elevation of systemic oxygen delivery in the treatment of critically ill patients. N Engl J Med, 1994, 330:1717-1722.
19. Squara P, Journois D, Formela JF, et al. Value of elementary, combined, and modeled hemodynamic variables. J Crit Care, 1994, 9:223-235.
20. 刘兆润, 吴国刚, 张殿红.中心静脉血氧饱和度监测在重症加强治疗病房中的临床应用.中国呼吸与危重监护杂志, 2011, 10:194-196.
21. Pope JV, Jones AE, Gaieski DF, et al. Multicenter study of central venous oxygen saturation (ScvO₂) as a predictor of mortality in patients with sepsis. Ann Emerg Med, 2010, 55:40-46.
22. Groeneveld AB, Vermeij CG, Thijs LG. Arterial and mixed venous blood acid-base balance during hypoperfusion with incremental positive end-expiratory pressure in the pig. Anesth Analg, 1991, 73:576-582.
23. Cohen IL, Sheikh FM, Perkins RJ, et al. Effect of hemorrhagic shock and reperfusion on the respiratory quotient in swine. Crit Care Med, 1995, 23:545-552.
24. Jakob SM, Kosonen P, Ruokonen E, et al. The Haldane effect--an alternative explanation for increasing gastric mucosal PCO₂ gradients? Br J Anaesth, 1999, 83:740-746.
25. Hernandez G, Bruhn A, Castro R, et al. The holistic view on perfusion monitoring in septic shock. Curr Opin Crit Care, 2012, 18:280-286.
26. Marty P, Roquilly A, Vallee 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, 3:3.
27. 徐勋宏.早期乳酸清除率对重症感染患者预后的评估研究.中国呼吸与危重监护杂志, 2012, 11:596-598.
28. 马升军, 陈虹, 段均.早期乳酸清除率对呼吸衰竭患者预后评估的作用.中国呼吸与危重监护杂志, 2012, 11:562-565.

Chinese Journal of Respiratory and Critical Care Medicine

The Correlation between Central Venous-to-arterial Carbon Dioxide Difference/Arterial-to-venous Oxygen Difference Ration and Lactate in Patients with Sepsis

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