Venous hyperoxia after cardiac arrest. Characterization of a defect in systemic oxygen utilization.
BACKGROUND
Supranormal mixed venous oxygen saturation (mixed venous hyperoxia), although reported, has never been characterized in humans resuscitated from cardiac arrest (postarrest cardiogenic shock). By contrast, cardiogenic shock without cardiopulmonary arrest (primary cardiogenic shock) is accompanied by mixed venous hypoxia under similar conditions of low oxygen delivery (DO2). The appearance of mixed venous hyperoxia indicates an excessive supply relative to demand in perfused tissue or cellular impairment of oxygen utilization, ie, low systemic oxygen consumption (VO2). Failure to improve VO2 has been associated with a poor outcome in other shock states.


OBJECTIVE
This study evaluates the clinical significance of mixed venous hyperoxia and its implications for impaired systemic oxygen utilization. The oxygen transport patterns in surviving and nonsurviving cardiac arrest patients are compared for their prognostic and therapeutic implications.


METHODS
Consecutive, nonrandomized series.


METHODS
Large urban emergency department (ED).


METHODS
Adult normothermic, nontraumatic out-of-hospital cardiac arrest patients presenting to the ED who develop a return of spontaneous circulation (ROSC).


METHODS
On arrival to the ED, a fiberoptic catheter was placed in the central venous position for continuous central venous oxygen saturation monitoring (ScvO2). A proximal aortic catheter was placed via the femoral artery for blood pressure monitoring. Upon ROSC, the fiberoptic catheter was advanced to the pulmonary artery. Mean arterial pressure (MAP), cardiac index (CI), VO2, DO2, systemic oxygen extraction ratio (OER), and systemic vascular resistance index (SVRI-dynes.s/cm5.m2) were measured immediately and every 30 min. The duration of cardiac arrest (DCA) in minutes and amount of epinephrine (milligrams) administered during ACLS was recorded.


RESULTS
Twenty-three patients were entered into the study. Survivors (living more than 24 h) and nonsurvivors (living less than 24 h) were compared.


CONCLUSIONS
These findings indicate an impairment of systemic oxygen utilization in postarrest cardiogenic shock patients. In spite of a lower DO2 than survivors, the OER in nonsurvivors remained lower than expected. Venous hyperoxia is a clinical manifestation of this derangement. Epinephrine dose may have a causal relationship. The inability to attain a VO2 of greater than 90 ml/min.m2 after the first 6 h of aggressive therapy was associated with a 100 percent mortality in 24 h.
Rivers
E P
EP
Department of Emergency Medicine, Henry Ford Health Systems, Detroit, MI 48202.
Rady
M Y
MY
Martin
G B
GB
Fenn
N M
NM
Smithline
H A
HA
Alexander
M E
ME
Nowak
R M
RM
D000368:Aged; D004837:Epinephrine / Q000008:administration & dosage / Q000627:therapeutic use; D005260:Female; D006323:Heart Arrest / Q000097:blood* / Q000503:physiopathology / Q000628:therapy; D006801:Humans; D007773:Lactates / Q000097:blood; D019344:Lactic Acid; D008297:Male; D008875:Middle Aged; D010100:Oxygen / Q000008:administration & dosage / Q000097:blood*; D010101:Oxygen Consumption / Q000502:physiology*; D010102:Oxygen Inhalation Therapy; D011379:Prognosis; D012151:Resuscitation; D015996:Survival Rate; D013997:Time Factors; D014655:Vascular Resistance / Q000502:physiology; D014680:Veins
D007773:Lactates; D019344:Lactic Acid; D010100:Oxygen; D004837:Epinephrine