Tissue Oxygenation

Tom Ahrens DNS RN CCNS FAAN Research Scientist Barnes-Jewish Hospital St. Louis, MO

Preparing A Case for Better Monitoring

Understanding the principles

Patient Monitoring in the 21st Century

Non invasive Measures parameters of interest

Vital Signs of the 20th Century

Blood pressure Respiratory rate Temperature Heart rate

These were inaccurate, slow to change, misleading

Yet were considered standard of care
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The New Vital Signs

Ventilation
Capnography

Arterial oxygenation
Pulse oximetry

Oxygen Delivery
Stroke volume & cardiac output

Tissue oxygenation
NIRS
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Can clinicians identify what is wrong with a patient by physical assessment?

Prediction of blood flow Drugs like dobutamine and fluid bolus
Designed to change stroke volume Can SV be measured non Invasively

Are Physical Signs Early or Late Indicators of Clinical Status

When will blood pressure change? level of consciousness? Urine output? Signs of hypoperfusion
LV dysfunction Hypovolemia Sepsis

Which signs are similar with all three?

BP HR LOC Urine output
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References Physical Assessment

Connors AF Jr, Dawson NV, Shaw PK, Montenegro HD, Nara AR, Martin L. Hemodynamic status in critically ill patients with and without acute heart disease. Chest. 1990 Nov;98(5):1200-6. Dawson NV, Connors AF Jr, Speroff T, Kemka A, Shaw P, Arkes HR. Hemodynamic assessment in managing the critically ill: is physician confidence warranted? Med Decis Making. 1993 Jul-Sep;13(3):258-66. Eisenberg PR, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med. 1984 Jul;12(7):549-53. Iregui MG, Prentice D, Sherman G, Schallom L, Sona C, Kollef MH. Physicians' estimates of cardiac index and intravascular volume based on clinical assessment versus transesophageal Doppler measurements obtained by critical care nurses. Am J Crit Care. 2003 Jul;12(4):336-42. Neath SX, Lazio L, Guss DA. Utility of impedance cardiography to improve physician estimation of hemodynamic parameters in the emergency department. Congest Heart Fail. 2005 Jan-Feb;11(1):17-20. Staudinger T, Locker GJ, Laczika K, et al. Diagnostic validity of pulmonary artery catheterization for residents at an intensive care unit. J Trauma. 1998 May;44(5):902-6.
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Understanding Oxygen Delivery and Utilization

Oxygen Carrying capacity
CO Hgb SaO2 PaO2

Oxygen Consumption Oxygen extraction

Clinical Examples
Does Oxygen Therapy Work?
reducing chest pain reducing shortness of breath

Concepts In Oxygen Delivery

Oxygen transported in humans by
cardiac outputprimary role hemoglobinmajor role oxyhemoglobinminor role dissolved oxygen (PaO2) insignificant

Oxygen delivery normally 6001000 cc/min

DO2 = CO x CaO2 x 10

Pulse Oximetry is Highly Limited

Tells only how much hemoglobin coming from the lungs is in the shape of oxyhemoglobin Is a safety parameter for lung function Does not tell anything about how much hemoglobin is present Does not reveal any information on blood flow Does not reveal anything regarding oxygen demand

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Limited Role of Pulse Oximetry in Assessing Ventilation

Normal SaO2 determined by PaO2 If patient hypoventilates, PaCO2 increases and will drive PaO2 downward in direct proportion to PaCO2 increase
If PaCO2 increases by 10, PaO2 will decrease by 10 If PaO2 is 90, will decrease to 80 mm Hg
SaO2 will decrease from 98 to 97.

Oximeter is not sensitive to rises in PaCO2 When oxygen therapy is added or increased, rise in PaCO2 is completely obscured

Case Example of Limited Role of Oximetry in Hypoventilation

PaO2 95 80 99

SpO2
FIO2 PetCO2 pH

.98
RA 39 7.38

.96
RA 54 7.25

.98
.30 60 7.23

A 56 year old man admitted to the outpatient procedure area for a follow-up colonoscopy. The patient had a colonoscopy 3 years earlier where a pre cancerous polyp was removed. During this procedure, the physician elects to use Propofol instead of Midazolam due to its more rapid elimination and shorter recovery time. Twenty minutes into the procedure, you note the PetCO2 listed below. What would your actions be based on this information?

P Admission 5 minutes into procedure 20 minutes into procedure 72 76

RR 12 10

BP 132/72 128/70

SpO2 100 100

PetCO2 37 42

73

10

134/78

100

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Case 2
A 76 year old female is being weaned from mechanical ventilation. He has a mainstream CO2 analyzer in his ventilator circuit. Fifteen minutes into the weaning attempt, the following information is available. Based on this information, what would you do?

RR

BP

SpO2

PetCO2

0730 (weaning 71 initiated)

15

130/86

98

35

0745

82

19

128/88

97

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Case 3
A 73 year old man is on your unit with the diagnosis of CHF and COPD. He has been improving and is expected to be discharged tomorrow. He is on oxygen therapy at 4 LPM and is simultaneously be monitored by capnography via the nasal cannula, sidestream method. At 0300, you hear the CO2 alarm and go into investigate. He is difficult to arouse. The following information is available to you. What would your actions be based on this information?

0100 0200

87 79

14 10

138/82 134/84

95 97

31 33

0300

83

10

138/78

95

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Case 4 A 44 yr old male admitted to MICU with unknown fever, SOB, hypoxemia. pH 7.34, PaCO2 38, PaO2 44, SpO2 .78. He is intubated, IMV 12/44. Extubates himself, is reintubated. Sedation is increased. RR decreases to 12. .What is the effect of sedation on ventilation?
Pulse Pre extubation Extubated 114 102 RR 44 38 NIBP 132/64 138/60 SpO2 98 97 PetCO2 Meds 34 33 2 mg Midazolam, 50 mcg/Fentanyl 5 mg bolus Gtt to 4 mg Midazolam, Gtt to 100 mcg/Fentanyl

Post reintubation and sedation

76

12

128/88

99

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Case Studies
How is the pulse oximeter to be used in these cases?

Case Study 1
A 68 year old male in an intermediate care unit has a diagnosis of pneumonia & COPD:
Oxygen was changed to 2 LPM nasal cannula from a 35% Venti mask SpO2 changed from 96 to 91

Should an ABG be obtained since the saturation dropped?

Case Study 2
A 37-year-old male is in the ICU following a fall, causing a right sided flail chest. On your shift, you notice these changes:
SpO2 changes from 97 to 87 RR rises from 18 to 28 HR rises from 87 to 108

Unchanged:
SvO2 .67 (unchanged) from the distal tip of a triple lumen FIO2 is not changed

Case Study 3
Patient: 47-year-old female recent resection of breast cancer. In her 2nd post op day, her arterial line becomes disconnected and she loses an unknown amount of blood and now has:
Heart rate of 122 BP of 82/58 (normal was about 90/60). The SpO2 is reading 98 (unchanged)

The physician states her oxygenation is adequate based on the oximeter. What is your interpretation?

Case Study 4
54 Year old male is in the CCU following MI induced pulmonary edema.
Current SpO2 is 98 on 40% oxygen BP= 128/64; P= 110; RR= 26 CI= 2.2; SvO2= .49 AMV= 12/18; Vt= 800, PAP= 38 Medications= 2 mg/hr Midazolam

MD states his oxygenation is adequate. Do you agree?

Oxygenation as a Hemodynamic End Point

Background Physiology

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What would you do?

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No Ventilation CPR

ABCs or CABs
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In a cardiopulmonary arrest, which type of blood gas is most useful to assess the resuscitation effort- arterial or venous?
Arterial blood
SO2 - .98
SO2 - .65

SO2 - .60 SO2 - .65

SO2 ..60

SO2 - 62

SO2 - 61

SO2 - .65

Venous blood
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Triple Lumen Oximetry

Triple lumen oximetry expands ability to assess tissue oxygenation Values obtained from distal tip
RA reading Similar to PA values

Used as end point in therapy

Potential to improve patient outcomes
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Measures of Tissue Oxygenation

Lactate/pH
Normal lactate 1-2 mmol pH normal 7.35-7.45 If lactate > 4 mmol and pH is less than 7.30, consider tissue hypoxia
Lactate/pyruvate
Lactate normally 10 x pyruvate If lactate rising proportionately faster than pyruvate, consider tissue hypoxia (Type A lactic acidosis)

StO2
Reflects tissue perfusion Should not be the same as ScvO2 Potentially earliest indicator of a threat to tissue oxygenation
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Lactate Levels and SBP

Lactate N= 529 SBP > 90 < 2 (N=219) 2-4 (N=177) > 4 (N = 104)

158/219 (72%)

116/177 (65%)

64/104 (62%)

SBP < 90

61/219 (28%)

61/177 (34%)

40/104 (38%)

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StO2 Monitoring
Should be used as an adjunct or possible replacement of SV/SI measurement
StO2 %

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Potential Value in StO2 and Hemodynamic Monitoring Drug Therapy

48 yr with GSW to head Levophed at 50 mcg BP 114/74 StO2 91 Lactate 5.2 Does he need further treatment?
What BP is really needed
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Potential Value in StO2 and Hemodynamic Monitoring Drug Therapy

33 yr with GSW to chest 4 units of PRBC due to Hct of 27 SV 80 after each unit of blood StO2 80% Lactate 1.2 Does he need further treatment?

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Temporal Order of Heart Dysfunction

Sarcomere changes (not measurable yet) Weakening heart or loss of volume
EF, PV decrease

Stroke volume falls

May be compensated by increase in heart rate

Cardiac output falls Tissues extract more oxygen

StO2, SvO2 fall

Hypoxia develops
Lactate increases
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Non Invasive Devices To Measure Blood Flow

Doppler Based
Esophageal External

Impedance

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Hemodynamics Optimizing Stroke Volume

Improving End Points in Fluid Resuscitation

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Stroke volume optimization

Chytra I, Pradl R, Bosman R, Pelnar P, Kasal, Zidkova A. Esophageal Doppler-guided fluid management decreases blood lactate levels in multiple-trauma patients: a randomized controlled trial. Critical Care 2007 Feb 22;11(1):1-9. Conway DH, Mayall R, Abdul-Latif MS, Gilligan S, Tackaberry C. Randomized controlled trial investigating the influence of intravenous fluid titration using esophageal Doppler monitoring during bowel surgery. Anesthesia 2002 Sept;57(9):845-849. Gan TJ, Soppitt A, Maroof M, El-Moalem H, Robertson K, Moretti E, Dwane P, Glass PS. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology 2002;97:820826. Mark JB, Steinbrook RA, Gugino LD, et al. Continuous noninvasive monitoring of cardiac output with esophageal Doppler during cardiac surgery. Anesth Anlg 1986;61:1013-1020. McKendry M, McGloin H, Saberi D, Caudwell L, Brady AR, Singer M. Randomized controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimization of circulatory status after cardiac surgery. BMJ 2004;329(7460):258 (31 July), doi:10.1136/bmj.38156.767118.7C. Mythen MG, Webb AR. Peri-operative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Archives of Surgery 1995;130:423-429. Sinclair S, James S, Singer M. Intraoperative intravascular volume optimization and length of hospital stay after repair of proximal femoral fracture: randomized controlled trial. BMJ 1997 October 11;315:909-912. Valtier B, Cholley BP, Belot JP, Coussay JE, Mateo J, Payen DM. Noninvasive monitoring of cardiac output in critically ill patients using transesophageal Doppler. Am J Respir Crit Care Med. 1998;158:77-83. Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, Newman P. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. British Journal of Anesthesia 2002;88:65-71. Wakeling HG, McFall MR, Jenkins CS, Woods WGA, Miles WFA, Barclay GR, Fleming SC. Intraoperative esophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth. 2005 Nov;95(5):634-42. www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=196

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Identifying Shock States with Best Technology

Assessing the 3 Threats to Tissue Oxygenation (shock states)

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Normal Hemodynamic Values

StO2 Stroke Index Stroke Volume Cardiac Index/Output Lactate
.75- .90

25-45 ml/m2 50-100 ml 2.5-4 L/m2 4-8 L/min 1-2 mmol

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Normal Hemodynamic Information regarding Cardiac state

Contractility
EF - >60% Peak velocity >50 -120 cm/sec

Preload
Flow time 330-360 msec PAOP 8-12 mm Hg CVP 2-6 mm Hg
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LV Dysfunction (systolic)
BP P SI CI Flow time Peak velocity StO2 100/58 110 16 1.8 310 48 .49
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Hypovolemic Shock
BP P SI CI Flow time Peak velocity StO2 82/50 118 14 1.8 315 70 .39
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Septic (low SVR) Shock

BP P SI CI PA PAOP StO2 76/44 128 50 5.6 24/9 6 .92

Moving toward Blood Flow and Tissue Oxygenation Measurement

Stroke Volume and StO2 as an End point

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Sample Stroke Volume Optimization Protocol

Measure SI Give 200 ml of colloid Or 500 ml of crystalloid

Is the heart Pumping enough Blood?

YES (SI increased < 10%)

NO (SI increased > 10%)

Stop giving fluids Monitor SI as indicated Repeat SI measurement as indicated - Is the Patient Stable?

YES (SI decreased < 10%)

NO SI decreased >10%

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Could StO2 Optimization work?

Measure StO2 Give 200 ml of colloid Or 500 ml of crystalloid

Is the heart Pumping enough Blood?

YES (Sto2 increased < 10%)

NO (StO2 increased > 10%)

Stop giving fluids Monitor StO2 as indicated Repeat StO2 measurement as indicated - Is the Patient Stable?

YES (StO2 decreased < 10%)

NO StO2 decreased >10%

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Any Change in Blood Flow (CO) Should be Compared against an Oxygenation End Point
StO2

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End Point Application Combining Blood flow and tissue oxygenation

SI - (by any method) 26 to 22
StO2 .79 to .77
If heart rate unchanged, Suspect measurement error

SI - 28 to 20
StO2 .81 to .69
Suspect clinical deterioration

Lactate can be used in place of StO2 but is slower to change

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How to Clearly Identify Threats to Tissue Oxygenation in the ED, ICU, RRT Step 1 Assess StO2
Low levels indicate hypoperfusion
Hypovolemia Early sepsis Heart failure

High levels indicate hyperperfusion, impaired utilization of oxygen Obtain lactate to confirm
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How to Clearly Identify Threats to Tissue Oxygenation Step 2 Assess SV/SI

Low levels indicate hypoperfusion
Hypovolemia Early sepsis Heart failure

High levels indicate hyperperfusion, impaired utilization of oxygen

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How to Clearly Identify Threats to Tissue Oxygenation Step 3

Assess Peak velocity
Low levels indicate a weak LV
Heart failure

Normal levels with a low SV/SI indicate hypovolemia

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Acceptance of Non Invasive Technology

Who is being harmed by our current practices?

Establishing a sense of urgency
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Email Address
TSA2109@bjc.org

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Term

Definition

Normal

Stroke Volume

Amount of blood pumped with each beat

50-100 ml

Stroke Index

Amount of blood pumped with each beat / body surface area (BSA) Amount of blood pumped in one minute

25-45 ml/m2

Cardiac output

4-8 LPM

Cardiac index

Amount of blood pumped in one minute / BSA Average driving pressure of blood in the arterial tree Amount of resistance the heart faces to eject blood Central venous pressure in the right atrium Pressure in the left atrium as measured through the pulmonary artery occlusive pressure

2.5-4 LPM/m2

Mean arterial pressure

65-100 mm Hg

Systemic vascular resistance

900-1300 dynes/sec/cm5

CVP

2-6 cm Hg

PAOP

8-12 mm Hg

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Method of measuring stroke volume

Indications

Advantages/disadvanages

Non invasive Doppler (USCOM)

Any patient who does not require continuous readings and access to the chest or neck is possible

Non invasive, safe, relatively easy to use. Disadantages requires careful education on use, non continuous readings

Esophageal doppler

Patients who require continuous readings and are at least lightly sedated

Almost non invasive, safe, very easy to use Disadvantages patient needs to be lightly sedated

Non calibrated pulse contour (Flo Trac)

Patients who require continuous readings and have an arterial line

Continuous, Disadvantages - Requires arterial line

Pulmonary artery catheter

Patients who have a need for pulmonary arterial pressure readings

Advantage continuous, can also provide central venous oxygen saturation Disadvantages requires central line, extensive training, complications range from BSI to death

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