Escolar Documentos
Profissional Documentos
Cultura Documentos
• pH
• HCO3
• BE
• SVO2 (AVO2, OER)
• CO2 (SvCO2-SaCO2)
• lactate
Common Cardiac Surgical
Procedures
• Arterial switch operation
• Repair of tetralogy of Fallot
• VSD closure
• ASD closure
• AVC repair
• Rastelli operation
• Norwood operation
• Bi-Glenn
• Fontan
• Repair IAA
• BTS
• Central shunt
• Ross
• MV replacement
• AV replacement
• Aortic Valvotomy
• Konno
• Ross-Konno
• Repair TAPVC
• Repair coarctation
• Repair DORV
• Senning
• Mustard
• Double switch
Single Goal of PO Care
1 – Hypoxemia
2 – Increased metabolic rate
3
– Low cardiac output
4 – anemia
OER: Oxygen Extraction Ratio
• OER = O2 consumption/O2 delivery
• OER = O2 Sat art - O2 Sat sys ven
O2 Sat art
• normal relationship of 5/1 DO2/VO2
• normal OER = 0.2
• Omega is the reciprocal of the OER (normal value is
5)
• higher omega and lower OER are associated with an
improved relationship of DO2 to VO2.
Relation of DO2 to VO2: Under normal conditions, the cardiovascular
system delivers approximately 5 times as much oxygen as the body uses.
This would be reflected by an SvO2 of 80%, an A-VO2 difference of 20 or an
oxygen extraction ratio (OER) of 0.2. As oxygen delivery (DO2) decreases,
SvO2 decreases, the A-VO2 difference increases and the OER increases.
Oxygen consumption (VO2) should not be affected by DO2. At the critical
point of DO2, further decreases in DO2 are associated with a pathologic
decrease in VO2. This pathologic relationship is associated with increased
lactate production.
*
0.5 0.2 OER
VO2
critical point of DO2
(VO2 , lactate )
DO2
* Decreasing CV Reserve
Relation of DO2 to VO2: The graph now shows how decreasing cardiac
output (or more appropriately DO2) is associated with an SvO2 which drops
from 80 to 50 while the AVO2 difference increases from 20 to 50. This
graphic demonstration of the pathologic relationship of VO2 to DO2 will look
somewhat different under various pathologic conditions, such as sepsis.
The principles are similar however. Also, remember that the SvO2 is the
sum of all systemic venous return. Lactate elevation does not correlate
precisely with SVO2.
*
SVO2=50 SVO2=80
AVO2=50 AVO2=20
VO2
critical point of DO2
(VO2 , lactate )
Bad CO Excellent CO
* Decreasing CV Reserve
AVO2 difference vs. OER
0.3
Non Survivors
0.2
0.1
0
Admit 6 hours 12 18 24
hours hours hours
time after admission to CICU
Rossi, Seiden, Gross, et al. Annals Thorac Surg. 1999
-15 -10 -5 0 5 10 15
Base Excess
10
2.2
normal lactate normal lactate
- base excess r2 = 0.27 + base excess
-10 -5 5 10
Base excess
The base excess does not predict blood lactate levels. Pts with a positive
base excess can have severe hyperlactatemia.
Lactate Monitoring after CHS: A number of studies have shown
the predictive value of blood lactate levels after CHS.
Lactate Normal
or No Changes
Diminishing
MCH Goal Directed Lactate
Management Strategy in
Postoperative Patients
pH normal?
pCO2 appropriate?
7/01-
(0-72 yrs) (0.4-114 kg)
12/07 1810 445 1365
166 d 5.8 kg
P < 0.01 P < 0.01
Adapted and updated from: Point of Care Testing and Goal Directed Therapy
Improve Outcomes after Congenital Heart Surgery. Rossi et al. Intensive
Care Med. 2005
Total Oxygen Debt is Related to Outcome: The concept of “lactime” was
described by Bakker and colleagues in 1999. The peak lactate alone may
not be the best predictor of mortality in critical illness, the total area under the
curve that one spends with an elevated lactate, or in oxygen debt, may be a
better predictor.
12
10
8
lactate
Pt 1
6
Pt 2
4
2
0
admit 6 hrs 12 18 24
hrs hrs hrs
80
66.7
70
60
% mortality
50 44.4
40
30
20 11.5
10 1.6
0
<5 5-10 10-20 > 20
peak lactate
Lactate on admission to the CICU and peak lactate correlated with
outcome in our study. The time it took to reach the peak lactate
level was also higher in nonsurvivors. So pts who die not only have
higher levels of lactate but also take longer to peak and spend more
time in “oxygen debt.”
18
16 15.3
N=41
14
blood lactate or time in hours
P<0.001 P<0.001
12
9.9
10
8.4 8.1
8 6.7
6
4 3.1
2
0
Admission lactate Peak lactate (mmol/l) Time to peak lactate
(mmol/l) (hours)
NONSURVIVORS SURVIVORS
Lactate Monitoring in Pts Who Survive: Individual pts who survive congenital
heart surgery can have differing lactate curves. Pt number 1 is admitted after a
high risk operation with a markedly elevated lactate that returns to baseline fairly
rapidly with aggressive medical therapy. Pt 2 has a more delayed response to
medical therapy but ultmately improves the DO2/VO2 relationship and survives.
Low risk cardaic pts exhibit only mild elevations in blood lactate (pt 3).
10
9 9
8
7 7
6 PT1
5 5 5 5 PT2
4 4 4 4 PT3
3 3 3
2 2 2 2 2
1.5
1
0
ADMIT 6 HR 12 HR 18 HR 24 HR
Category 1-4 Survivors (excluding CPS patients)
n=127
10 Category 1 Mean
Category 2 Mean
8
Category 3 Mean
lactate(mmol/L)
6 Category 4 Mean
0
0 10 20 30 40 50
hours postop
Patterns of Lactate Values after Congenital Heart Surgery and Timing of Cardiopulmonary
Support. Robert L. Hannan, MD * , Marion A. Ybarra, BS, Jeffrey A. White, MS, Jorge W. Ojito,
CCP, Anthony F. Rossi, MD, Redmond P. Burke, MD Ann Thorac Surg 2005;80:1468-1474
Category 1-4 Survivors (excluding CPS patients)
10
n=127
8
lactat (mmol/L)
0
0 10 20 30 40 50
hours postop
Patterns of Lactate Values after Congenital Heart Surgery and Timing of Cardiopulmonary Support.
Robert L. Hannan, MD * , Marion A. Ybarra, BS, Jeffrey A. White, MS, Jorge W. Ojito, CCP, Anthony
F. Rossi, MD, Redmond P. Burke, MD Ann Thorac Surg 2005;80:1468-1474
Survivors Excluding CPS Patients
8
7 Category 1-4
Category 6
6
lactate (mmol/L)
5 3 2
y = 0.0002x - 0.0176x + 0.3418x + 3.0448
4
1 3 2
y = 4E-05x - 0.0018x - 0.0197x + 2.5738
0
0 10 20 30 40 50
hours postop
Patterns of Lactate Values after Congenital Heart Surgery and Timing of Cardiopulmonary Support.
Robert L. Hannan, MD * , Marion A. Ybarra, BS, Jeffrey A. White, MS, Jorge W. Ojito, CCP, Anthony F.
Rossi, MD, Redmond P. Burke, MD Ann Thorac Surg 2005;80:1468-1474
Non Survivors (excluding CPS Patients)
20
18
16
14
lactate (mmol/L)
12
10
8
6
4
2
0
0 10 20 30 40 50
hours postop
Patterns of Lactate Values after Congenital Heart Surgery and Timing of Cardiopulmonary Support. Robert
L. Hannan, MD * , Marion A. Ybarra, BS, Jeffrey A. White, MS, Jorge W. Ojito, CCP, Anthony F. Rossi, MD,
Redmond P. Burke, MD Ann Thorac Surg 2005;80:1468-1474
Lactate Monitoring in Pts Who Die: Pt 1 exhibits a typical lactate pattern of a pt
who dies after congenital heart surgery. The lactate on admission is high and
despite attempts to improve the DO2/VO2 relation, lactate continues to rise.
Rarely, a pt will be admitted after surgery with a low lactate that rises despite
therapy and dies. Some pts may “honeymoon” and show deterioration later
(pt 3). Serial lactate monitoring is valuable even in pts who are admitted and
appear clinically well.
14
12 12
11
10 11 11 10
8 8 PT 1
PT 2
6 7 7
6 PT 3
4 5
4
2 3 3
2 2
0
ADMIT 6 HR 12 HR 18 HR 24 HR
Venous Blood Gas Monitoring
• VBG monitoring allows you to calculate the a-vCO2
(the difference b/w the arterial and venous pCO2) and
a-vpH (the difference b/w the arterial and venous pH)
gradients in the critically ill
• a-vCO2 is directly related to Cardiac Output
– This difference, also known as the CO2 GAP, is a better
indicator of cardiac output than the a-vO2 difference
• The larger the a-vCO2 gradient, the lower the cardiac
output
• pH gradient has been used to access pts in shock
Effect of Cardiac Output on
vCO2
aCO2=40 aCO2=40
CO2 CO2
CELL CELL
Normal CO Low CO
vCO2=45 vCO2=52
AVCO2, AV pH, Lactate and
OER in Survivors After Heart
Surgery
9 0.45
8
0.4 lactate
AVCO2, AVpH, Lactate
7
6 0.35 AVCO2
OER
5 0.3 AVpH
4 OER
0.25
3
2 0.2
admit 6 hours 12 hours 18 hours 24 hours
Objective Indicators of DO2 in Varying
Physiologic States
VpH SvO2 AVO2 O2 EF OER AVCO2 Lactate