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Lactate and Venoarterial Carbon Dioxide Difference/Arterial-Venous Oxygen Difference Ratio, but Not Central Venous Oxygen Saturation, Predict Increase in Oxygen Consumption in Fluid Responders*

Monnet, Xavier MD, PhD1,2; Julien, Florence MD1,2; Ait-Hamou, Nora MD1; Lequoy, Marie MD1,2; Gosset, Clément MD1,2; Jozwiak, Mathieu MD1,2; Persichini, Romain MD1,2; Anguel, Nadia MD1,2; Richard, Christian MD1,2; Teboul, Jean-Louis MD, PhD1,2

doi: 10.1097/CCM.0b013e318275cece
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Objectives: During circulatory failure, the ultimate goal of treatments that increase cardiac output is to reduce tissue hypoxia. This can only occur if oxygen consumption depends on oxygen delivery. We compared the ability of central venous oxygen saturation and markers of anaerobic metabolism to predict whether a fluid-induced increase in oxygen delivery results in an increase in oxygen consumption.

Design: Prospective study.

Setting: ICU.

Patients: Fifty-one patients with an acute circulatory failure (78% of septic origin).

Measurements: Before and after a volume expansion (500mL of saline), we measured cardiac index, o2- and Co2-derived variables and lactate.

Main Results: Volume expansion increased cardiac index ≥15% in 49% of patients (“volume-responders”). Oxygen delivery significantly increased in these 25 patients (+32% ± 16%, p < 0.0001). An increase in oxygen consumption ≥15% concomitantly occurred in 56% of these 25 volume-responders (+38% ± 28%). Compared with the volume-responders in whom oxygen consumption did not increase, the volume-responders in whom oxygen consumption increased ≥15% were characterized by a higher lactate (2.3 ± 1.1 mmol/L vs. 5.5 ± 4.0 mmol/L, respectively) and a higher ratio of the veno-arterial carbon dioxide tension difference (P(va)Co2) over the arteriovenous oxygen content difference (C(av)o2). A fluid-induced increase in oxygen consumption greater than or equal to 15% was not predicted by baseline central venous oxygen saturation but by high baseline lactate and (P(va)Co2/C(av)o2 ratio (areas under the receiving operating characteristics curves: 0.68 ± 0.11, 0.94 ± 0.05, and 0.91 ± 0.06). In volume-nonresponders, volume expansion did not significantly change cardiac index, but the oxygen delivery decreased due to a hemodilution-induced decrease in hematocrit.

Conclusions: In volume-responders, unlike markers of anaerobic metabolism, central venous oxygen saturation did not allow the prediction of whether a fluid-induced increase in oxygen delivery would result in an increase in oxygen consumption. This suggests that along with indicators of volume-responsiveness, the indicators of anaerobic metabolism should be considered instead of central venous oxygen saturation for starting hemodynamic resuscitation.

1 AP-HP, Hôpitaux universitaires Paris-Sud, Hôpital de Bicêtre, service de réanimation médicale, Le Kremlin-Bicêtre, France.

2 Univ Paris-Sud, Faculté de médecine Paris-Sud, EA 4533, Le Kremlin-Bicêtre, France.

*See also p. 1570 and 1572.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Professors Monnet and Teboul are members of the Medical Advisory Board of Pulsion Medical Systems. The authors received funding from Assistance Publique des Hôpitaux de Paris. Drs. Monnet and Teboul consulted for Pulsion Medical Systems. The remaining authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: xavier.monnet@bct.aphp.fr

© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins