Abstract 10679: Tissue-to-Arterial Carbon Dioxide Partial Pressure Gradient as a Useful Measure for Monitoring Tissue Perfusion in a Pig Model of Hemorrhagic Shock and Resuscitation

Circulation ◽  
2021 ◽  
Vol 144 (Suppl_2) ◽  
Author(s):  
Yusuke Endo ◽  
Lance B Becker ◽  
Ryosuke Takegawa ◽  
Santiago J Miyara ◽  
Ernesto P Molmenti ◽  
...  
Keyword(s):  
Cardiac Output ◽  
Blood Transfusion ◽  
Pulmonary Artery ◽  
Hemorrhagic Shock ◽  
Laboratory Data ◽  
Tissue Perfusion ◽  
Pig Model ◽  
Carbon Dioxide Partial Pressure ◽  
End Diastolic Volume ◽  
O2 Supply

Introduction: Transcutaneous CO 2 (tcPCO 2 ) and arterial CO 2 (artPCO 2 ) become decoupled during shock. Aim: To test the hypotheses the gradient between tcPCO 2 and artPCO 2 (tc-artPCO 2 ) can be an early, sensitive measure to detect inadequate tissue perfusion in a pig model of hemorrhage shock. Methods: Six female pigs were used. A transcutaneous monitor was attached to the ear for measuring transcutaneous O 2 (tcPO 2 ) and tcPCO 2 . Pulmonary artery catheter and the pulse index continuous cardiac output (PiCCO) were instrumented for monitoring a variety of hemodynamic parameters. To induce massive hemorrhagic shock, blood was withdrawn stepwisely. Then, animals were resuscitated in stages with transfusions of the stored blood. The parameters were measured at the timings of 10, 20, and 30 ml/kg of blood withdrawals and the completions of 10, 20, and 30 ml/kg of blood transfusion . Levels of systemic oxygen delivery (DO 2 ) were also calculated at all measurement points. Results: Hemorrhage and blood transfusion impacted hemodynamic and laboratory data, such as cardiac output (CO), stroke volume, MAP, heart rate, pulmonary artery wedge pressure, global end-diastolic volume, hemoglobin, and arterial lactate. The tc-artPCO 2 markedly increased as CO decreased ( Figure A ). The critical level of DO 2 (DO 2crit ) was defined as 11.72 ml/kg/min according to tcPO 2 (a threshold as 30 mmHg). There was significant correlation between tc-artPCO 2 and DO 2 (r = -0.83, P<.0001). ROC analyses revealed that the AUCs to predict DO 2crit for tc-artPCO 2 , shock index (SI), and lactate were 0.94 (95% CI, 0.87-1.00), 0.78 (0.63-0.93), and 0.65 (0.47-0.82), respectively. The AUC for tc-artPCO 2 was greater with respect to the prediction of DO 2crit than for SI (P<.05) ( Figure B ). Conclusions: The tc-artPCO 2 strongly correlated with CO and DO 2 during hemorrhage shock and resuscitation. The less-invasive tc-artPCO 2 monitoring can sensitively detect systemic inadequate O2 supply in hemorrhagic shock.

scholarly journals Monitoring the tissue perfusion during hemorrhagic shock and resuscitation: Tissue-to-arterial carbon dioxide partial pressure gradient in a pig model

2021 ◽  
Author(s):  
Yusuke Endo ◽  
Taku Hirokawa ◽  
Taku Miyasho ◽  
Ryosuke Takegawa ◽  
Koichiro Shinozaki ◽  
...  
Keyword(s):  
Cardiac Output ◽  
Pulmonary Artery ◽  
Hemorrhagic Shock ◽  
Oxygen Delivery ◽  
Laboratory Data ◽  
Tissue Perfusion ◽  
Carbon Dioxide Partial Pressure ◽  
Large Animal ◽  
Transcutaneous Oxygen ◽  
Large Animal Models

Abstract Background: Transcutaneous CO2 (tcPCO2) and arterial CO2 (artPCO2) decoupling occurs during shock states. Our study aimed to test the hypothesis that the gradient between tcPCO2 and artPCO2 (tc-artPCO2) can detect inadequate tissue perfusion during hemorrhagic shock and resuscitation. Methods: This prospective animal study was performed by a qualified and experienced research team using female pigs (LWD, weighing 29–34 kg) at university-based experimental laboratory. Progressive massive hemorrhagic shock was induced in mechanically-ventilated pigs by stepwise blood withdrawal. Next, all the animals were then resuscitated by transfusing the stored blood in stages. A transcutaneous monitor was attached to the animals’ ear to measure the tcPCO2 and transcutaneous oxygen pressure (tcPO2). The pulmonary artery catheter (PAC) and pulse index continuous cardiac output (PiCCO) were used to monitor several hemodynamic parameters. Results: Hemorrhage and blood transfusion precisely impacted hemodynamic and laboratory data, such as cardiac output (CO), stroke volume, mean arterial pressure, heart rate, pulmonary artery wedge pressure, global end-diastolic volume, hemoglobin, and arterial lactate. The tc-artPCO2 level markedly increased as CO decreased. In the analyses of the 42 paired measurements, there were significant correlations of tc-artPCO2 with systemic oxygen delivery (DO2) and CO (DO2: r = -0.83, CO by PAC: r = -0.79; CO by PiCCO: r = -0.74; all P < 0.0001) levels. The critical level of oxygen delivery (DO2crit) was 11.72 mL/kg/min according to tcPO2 (at a threshold of 30 mmHg). The receiver operating characteristic curve analyses revealed that the area under the curves (AUCs) that predicted DO2crit for tc-artPCO2, shock index (SI), and lactate were 0.94 (95% confidence interval, 0.87-1.00); 0.78 (0.63-0.93); and 0.65 (0.47-0.82), respectively. The AUC for tc-artPCO2 was greater in predicting DO2crit than that for SI.Conclusions: tc-artPCO2 was strongly correlated with DO2 during hemorrhagic shock and resuscitation. This less-invasive tc-artPCO2 monitoring can sensitively detect inadequate systemic O2 supply during hemorrhagic shock. Further evaluations are required in different forms of shock in other large animal models and in humans to assess its usefulness, safety, and ability to predict outcomes in critical illnesses.

scholarly journals Monitoring the Tissue Perfusion During Hemorrhagic Shock and Resuscitation: Tissue-to-arterial Carbon Dioxide Partial Pressure Gradient in a Pig Model

2021 ◽  
Author(s):  
Yusuke Endo ◽  
Taku Hirokawa ◽  
Taku Miyasho ◽  
Ryosuke Takegawa ◽  
Koichiro Shinozaki ◽  
...  
Keyword(s):  
Cardiac Output ◽  
Pulmonary Artery ◽  
Hemorrhagic Shock ◽  
Oxygen Delivery ◽  
Laboratory Data ◽  
Tissue Perfusion ◽  
Carbon Dioxide Partial Pressure ◽  
Large Animal ◽  
Transcutaneous Oxygen ◽  
Large Animal Models

Abstract Background: Transcutaneous CO2 (tcPCO2) and arterial CO2 (artPCO2) decoupling occurs during shock states. Our study aimed to test the hypothesis that the gradient between tcPCO2 and artPCO2 (tc-artPCO2) can detect inadequate tissue perfusion during hemorrhagic shock and resuscitation. Methods: This prospective animal study was performed by a qualified and experienced research team using female pigs (LWD, weighing 29–34 kg) at university-based experimental laboratory. Progressive massive hemorrhagic shock was induced in mechanically-ventilated pigs by stepwise blood withdrawal. Next, all the animals were then resuscitated by transfusing the stored blood in stages. A transcutaneous monitor was attached to the animals’ ear to measure the tcPCO2 and transcutaneous oxygen pressure (tcPO2). The pulmonary artery catheter (PAC) and pulse index continuous cardiac output (PiCCO) were used to monitor several hemodynamic parameters. Results: Hemorrhage and blood transfusion precisely impacted hemodynamic and laboratory data, such as cardiac output (CO), stroke volume, mean arterial pressure, heart rate, pulmonary artery wedge pressure, global end-diastolic volume, hemoglobin, and arterial lactate. The tc-artPCO2 level markedly increased as CO decreased. In the analyses of the 42 paired measurements, there were significant correlations of tc-artPCO2 with systemic oxygen delivery (DO2) and CO (DO2: r = -0.83, CO by PAC: r = -0.79; CO by PiCCO: r = -0.74; all P < 0.0001) levels. The critical level of oxygen delivery (DO2crit) was 11.72 mL/kg/min according to tcPO2 (at a threshold of 30 mmHg). The receiver operating characteristic curve analyses revealed that the area under the curves (AUCs) that predicted DO2crit for tc-artPCO2, shock index (SI), and lactate were 0.94 (95% confidence interval, 0.87-1.00); 0.78 (0.63-0.93); and 0.65 (0.47-0.82), respectively. The AUC for tc-artPCO2 was greater in predicting DO2crit than that for SI.Conclusions: tc-artPCO2 was strongly correlated with DO2 during hemorrhagic shock and resuscitation. This less-invasive tc-artPCO2 monitoring can sensitively detect inadequate systemic O2 supply during hemorrhagic shock. Further evaluations are required in different forms of shock in other large animal models and in humans to assess its usefulness, safety, and ability to predict outcomes in critical illnesses.

scholarly journals Monitoring the tissue perfusion during hemorrhagic shock and resuscitation: tissue-to-arterial carbon dioxide partial pressure gradient in a pig model

2021 ◽  
Vol 19 (1) ◽  
Author(s):  
Yusuke Endo ◽  
Taku Hirokawa ◽  
Taku Miyasho ◽  
Ryosuke Takegawa ◽  
Koichiro Shinozaki ◽  
...  
Keyword(s):  
Carbon Dioxide ◽  
Cardiac Output ◽  
Partial Pressure ◽  
Hemorrhagic Shock ◽  
Oxygen Delivery ◽  
Tissue Perfusion ◽  
Carbon Dioxide Partial Pressure ◽  
Large Animal ◽  
Hemodynamic Parameters ◽  
Systemic Oxygen

Abstract Background Despite much evidence supporting the monitoring of the divergence of transcutaneous partial pressure of carbon dioxide (tcPCO2) from arterial partial pressure carbon dioxide (artPCO2) as an indicator of the shock status, data are limited on the relationships of the gradient between tcPCO2 and artPCO2 (tc-artPCO2) with the systemic oxygen metabolism and hemodynamic parameters. Our study aimed to test the hypothesis that tc-artPCO2 can detect inadequate tissue perfusion during hemorrhagic shock and resuscitation. Methods This prospective animal study was performed using female pigs at a university-based experimental laboratory. Progressive massive hemorrhagic shock was induced in mechanically ventilated pigs by stepwise blood withdrawal. All animals were then resuscitated by transfusing the stored blood in stages. A transcutaneous monitor was attached to their ears to measure tcPCO2. A pulmonary artery catheter (PAC) and pulse index continuous cardiac output (PiCCO) were used to monitor cardiac output (CO) and several hemodynamic parameters. The relationships of tc-artPCO2 with the study parameters and systemic oxygen delivery (DO2) were analyzed. Results Hemorrhage and blood transfusion precisely impacted hemodynamic and laboratory data as expected. The tc-artPCO2 level markedly increased as CO decreased. There were significant correlations of tc-artPCO2 with DO2 and COs (DO2: r = − 0.83, CO by PAC: r = − 0.79; CO by PiCCO: r = − 0.74; all P < 0.0001). The critical level of oxygen delivery (DO2crit) was 11.72 mL/kg/min according to transcutaneous partial pressure of oxygen (threshold of 30 mmHg). Receiver operating characteristic curve analyses revealed that the value of tc-artPCO2 for discrimination of DO2crit was highest with an area under the curve (AUC) of 0.94, followed by shock index (AUC = 0.78; P < 0.04 vs tc-artPCO2), and lactate (AUC = 0.65; P < 0.001 vs tc-artPCO2). Conclusions Our observations suggest the less-invasive tc-artPCO2 monitoring can sensitively detect inadequate systemic oxygen supply during hemorrhagic shock. Further evaluations are required in different forms of shock in other large animal models and in humans to assess its usefulness, safety, and ability to predict outcomes in critical illnesses.

scholarly journals The contemporary pulmonary artery catheter. Part 1: placement and waveform analysis

2021 ◽  
Author(s):  
I. T. Bootsma ◽  
E. C. Boerma ◽  
F. de Lange ◽  
T. W. L. Scheeren
Keyword(s):  
Cardiac Output ◽  
Pulmonary Artery ◽  
Pulmonary Artery Catheter ◽  
Supply And Demand ◽  
Waveform Analysis ◽  
Volume Index ◽  
End Diastolic Volume ◽  
Venous Oxygen Saturation ◽  
History Of ◽  
The Difference

AbstractNowadays, the classical pulmonary artery catheter (PAC) has an almost 50-year-old history of its clinical use for hemodynamic monitoring. In recent years, the PAC evolved from a device that enabled intermittent cardiac output measurements in combination with static pressures to a monitoring tool that provides continuous data on cardiac output, oxygen supply and-demand balance, as well as right ventricular (RV) performance. In this review, which consists of two parts, we will introduce the difference between intermittent pulmonary artery thermodilution using cold bolus injections, and the contemporary PAC enabling continuous measurements by using a thermal filament which at random heats up the blood. In this first part, the insertion techniques, interpretation of waveforms of the PAC, the interaction of waveforms with the respiratory cycle and airway pressure as well as pitfalls in waveform analysis are discussed. The second part will cover the measurements of the contemporary PAC including measurement of continuous cardiac output, RV ejection fraction, end-diastolic volume index, and mixed venous oxygen saturation. Limitations of all of these measurements will be highlighted there as well. We conclude that thorough understanding of measurements obtained from the PAC are the first step in successful application of the PAC in daily clinical practice.

Evidence favoring a cardiac mechanism in irreversible hemorrhagic shock

1961 ◽  
Vol 201 (5) ◽  
pp. 893-896 ◽  
Author(s):  
Jack W. Crowell ◽  
Arthur C. Guyton
Keyword(s):  
Cardiac Output ◽  
Oxygen Consumption ◽  
Pulmonary Artery ◽  
Hemorrhagic Shock ◽  
Left Atrial ◽  
Peripheral Resistance ◽  
Arterial System ◽  
Operating Parameters ◽  
The Right ◽  
Oxygen Difference

Shock was induced in 55 dogs by removing blood until the arterial pressure had fallen to 30 mm Hg. The pressure was kept at this level for as long as 10 hr by constantly adding additional blood to the reservoir. The hematocrit was kept constant to prevent large variations in the viscosity. Mean pressures of the right and left atrium, the pulmonary artery, and the systemic arterial system were recorded as well as oxygen consumption and A-V oxygen difference. Total peripheral resistance and cardiac output were calculated. That period of time during which the animal passed from a reversible stage of shock to an irreversible stage of shock was studied. It was found that no significant change occurred in oxygen consumption, cardiac output, or peripheral resistance during this transition phase. However, changes did occur in the operating parameters of the heart. The left atrial pressure began rising with the transition from reversible to irreversible shock and continued rising until death of the animal. It is suggested that irreversible hemorrhagic shock is due to acute cardiac failure.

Gender dimorphic tissue perfusion response after acute hemorrhage and resuscitation: role of vascular endothelial cell function

2003 ◽  
Vol 284 (6) ◽  
pp. H2162-H2169 ◽  
Author(s):  
Zheng F. Ba ◽  
Joachim F. Kuebler ◽  
Loring W. Rue ◽  
Kirby I. Bland ◽  
Ping Wang ◽  
...  
Keyword(s):  
Cardiac Output ◽  
Endothelial Function ◽  
Hemorrhagic Shock ◽  
Tissue Perfusion ◽  
Left Ventricular ◽  
Specific Response ◽  
Organ Perfusion ◽  
Acute Hemorrhage ◽  
Midline Laparotomy ◽  
Endothelial Cell Function

Proestrous female rodents are protected from the deleterious effects of trauma-hemorrhage that are observed in males. We hypothesized that the gender dimorphic outcome after trauma-hemorrhage might be related to gender differences in endothelial function and organ perfusion under such conditions. Male and cycle-matched proestrous female Sprague-Dawley rats underwent a midline laparotomy, hemorrhagic shock (40 mmHg for ∼90 min), and resuscitation (Ringer lactate, 4× shed blood volume over 60 min). Various parameters were measured 2 h after completion of resuscitation. In the first set of animals, the left ventricle was cannulated and heart performance (maximal rate of left ventricular pressure increase) as well as cardiac output and organ perfusion rates were determined with 85Sr microspheres. In the second set of animals, aortic vessel rings were harvested and relaxation in response to acetylcholine and nitroglycerin was measured. In the third set of animals, in situ isolated small intestine was perfused to measure the response of the splanchnic vessel bed to acetylcholine and nitroglycerin. After trauma-hemorrhage and resuscitation, females maintained cardiac output and demonstrated increased splanchnic and cardiac perfusion compared with males. Moreover, female intestines did not manifest the endothelial dysfunction that was observed in male intestines after hemorrhagic shock. We conclude that proestrous females show improved endothelial function and tissue perfusion patterns after hemorrhagic shock and that this gender-specific response might be a potential mechanism contributing to the beneficial effects of the proestrus stage under such conditions.

scholarly journals Dobutamine-sparing versus dobutamine-to-all strategy in cardiac surgery: a randomized noninferiority trial

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Rafael Alves Franco ◽  
Juliano Pinheiro de Almeida ◽  
Giovanni Landoni ◽  
Thomas W. L. Scheeren ◽  
Filomena Regina Barbosa Gomes Galas ◽  
...  
Keyword(s):  
Cardiac Output ◽  
Cardiac Surgery ◽  
Prolonged Mechanical Ventilation ◽  
Kidney Injury ◽  
Composite Endpoint ◽  
Tissue Perfusion ◽  
Hospital Length Of Stay ◽  
Low Cardiac Output Syndrome ◽  
Low Cardiac Output ◽  
Noninferiority Trial

Abstract Background The detrimental effects of inotropes are well-known, and in many fields they are only used within a goal-directed therapy approach. Nevertheless, standard management in many centers includes administering inotropes to all patients undergoing cardiac surgery to prevent low cardiac output syndrome and its implications. Randomized evidence in favor of a patient-tailored, inotrope-sparing approach is still lacking. We designed a randomized controlled noninferiority trial in patients undergoing cardiac surgery with normal ejection fraction to assess whether an dobutamine-sparing strategy (in which the use of dobutamine was guided by hemodynamic evidence of low cardiac output associated with signs of inadequate tissue perfusion) was noninferior to an inotrope-to-all strategy (in which all patients received dobutamine). Results A total of 160 patients were randomized to the dobutamine-sparing strategy (80 patients) or to the dobutamine-to-all approach (80 patients). The primary composite endpoint of 30-day mortality or occurrence of major cardiovascular complications (arrhythmias, acute myocardial infarction, low cardiac output syndrome and stroke or transient ischemic attack) occurred in 25/80 (31%) patients of the dobutamine-sparing group (p = 0.74) and 27/80 (34%) of the dobutamine-to-all group. There were no significant differences between groups regarding the incidence of acute kidney injury, prolonged mechanical ventilation, intensive care unit or hospital length of stay. Discussion Although it is common practice in many centers to administer inotropes to all patients undergoing cardiac surgery, a dobutamine-sparing strategy did not result in an increase of mortality or occurrence of major cardiovascular events when compared to a dobutamine-to-all strategy. Further research is needed to assess if reducing the administration of inotropes can improve outcomes in cardiac surgery. Trial registration ClinicalTrials.gov, NCT02361801. Registered Feb 2nd, 2015. https://clinicaltrials.gov/ct2/show/NCT02361801

End-tidal CO2 pressure in the monitoring of cardiac output during canine hemorrhagic shock

1990 ◽  
Vol 5 (1) ◽  
pp. 42-46 ◽  
Author(s):  
Arnaldo Dubin ◽  
Carlos Silva ◽  
Gladys Calvo ◽  
Javier Valli ◽  
Osvaldo Fariña ◽  
...  
Keyword(s):  
Cardiac Output ◽  
Hemorrhagic Shock ◽  
End Tidal ◽  
End Tidal Co2
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