Monitoring Blood Flow, Oxygenation, and Acid Base Status

Monitoring Blood Flow, Oxygenation, and Acid Base Status
Copyright 2008 Society of Critical Care Medicine
Objectives
Outline determinants of oxygen balance Recognize disorders of blood flow and oxygenation Identify principles and limitations of techniques for monitoring oxygen balance Explain the use of acid-base status as a monitor in the seriously ill patient
Case Study
40-year-old with malaise and lethargy Initial vital signs: HR 145/min, BP 118/82 mm Hg, RR 22/min, SpO2 98% (room air) Becomes more tachypneic and anxious What monitoring should be implemented? What are the goals of monitoring in this patient?
Tissue Oxygenation
Cannot be directly measured or monitored
Oxygen Delivery Oxygen Balance Oxygen Consumption
Which component is more amenable to clinical interventions?

Determinants of O2 Delivery
Cardiac output (blood flow) O2 content of arterial blood Hemoglobin Oxyhemoglobin saturation PaO2
Arterial O2 Content
Red blood cell Hemoglobin Oxygen Saturation 75% Saturation 95-100% 1.34 mL O2/gram of hemoglobin
Venous
Tissues
Arterial
Oxygen Reserve
Oxygen unloaded from hemoglobin during normal metabolism Oxygen reserves that can be unloaded from hemoglobin to tissues with increased demands
Cardiac Output
Stroke Volume Ventricular Preload
Heart rate Stroke volume Preload Afterload Contractility
Case Study
40-year-old with malaise and lethargy Initial vital signs: HR 145/min, BP 118/82 mm Hg, RR 22/min, SpO2 98% (room air) Becomes more tachypneic and anxious How would you measure oxygen delivery in this patient? Cardiac output Arterial oxygen content
Pulse Oximetry
What does a pulse oximeter measure? SpO2 vs SaO2
What factors might affect the accuracy of the pulse oximeter measurement?
10
Blood Pressure Measurement

Driving pressure for oxygen delivery Blood pressure = cardiac output x systemic vascular resistance
What options would you consider for monitoring blood pressure in this patient?
Automated noninvasive device Arterial cannulation

11
Case Study
Automated blood pressure device and pulse oximeter applied SpO2 91% (room air), HR 140/min, BP 100/60 mm Hg Hemoglobin 13.5 g/dL Is oxygen delivery sufficient in this patient to maintain an adequate oxygen balance?
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Tissue Oxygenation
Central venous oxyhemoglobin saturation Lactate concentration

13
Venous Oxyhemoglobin Saturation

Red blood cell
Hemoglobin Oxygen
Saturation 75%
Saturation 100% Venous Tissues

Arterial
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Central Venous Oxyhemoglobin Saturation

low ScvO What does a normal ScvO 2 mean? 2 mean?
O2
ScvO2 SvO2 O2 Content
Venous
Arterial Cardiac Output
O2 Return
O2 Consumption
O2 Delivery
Capillary Beds
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Lactate
Product of anaerobic metabolism with cellular hypoxia Elevated concentrations Inadequate oxygen supply Hepatic dysfunction Drugs
Mortality
Lactate
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Case Study
SpO2 91% (room air), HR 140/min, BP 100/60 mm Hg Hemoglobin 13.5 g/dL Central venous catheter inserted Central venous pressure 8 mm Hg ScvO2 60% Lactate concentration 6 mg/dL Is oxygen delivery sufficient in this patient to maintain adequate oxygen balance?
17
Case Study
50-year-old with hypertension and nephrotic syndrome has cough and fever BP 108/52 mm Hg, HR 115/min, RR 20/min, T 101F (38.3C) pH 7.34, PaCO2 40 mm Hg (5.3 kPa), PaO2 68 mm Hg (9.1 kPa), SpO2 92% Na 132 mmol/L, K 4.0 mmol/L, Cl 103 mmol/L, HCO3 17 mmol/L Albumin 1.5 g/dL, Creatinine 1.0 mg/dL Does the acid-base status suggest this patient is seriously ill?
18
Acid-Base Analysis
Overall acid-base condition (acidemia or alkalemia) Metabolic or respiratory process Acute or chronic process if respiratory disturbance present Appropriate respiratory compensation if metabolic process present Anion gap Delta gap if anion gap acidosis present
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Case Study
pH 7.34, PaCO2 38 mm Hg (5.3 kPa), PaO2 68 mm Hg (9.1 kPa) Na 132 mmol/L, K 4.0 mmol/L, Cl 103 mmol/L, HCO3 17 mmol/L
Acidemia or alkalemia Acidemia Respiratory or metabolic
Metabolic
Appropriate respiratory compensation No

1.5 x 17 + 8 = 33 PaCO2 = 1.5[HCO3] + 8 2 PaCO2 = 1.2 x [HCO3]
20
Case Study
pH 7.34, PaCO2 38 mm Hg (5.3 kPa), PaO2 68 mm Hg (9.1 kPa) Na 132 mmol/L, K 4.0 mmol/L, Cl 103 mmol/L, HCO3 17 mmol/L Albumin 1.5 g/dL, Creatinine 1.0 mg/dL
Anion gap
AG = [Na] ([Cl] + [HCO3]) 132 120 = 12 Expected AG decreases by 2.5-3 mmol/L for every 1 g/dL decrease in albumin Expected AG=12 (6-7) = 5-6
21
Case Study
pH 7.34, PaCO2 38 mm Hg (5.3 kPa), PaO2 68 mm Hg (9.1 kPa) Na 132 mmol/L, K 4.0 mmol/L, Cl 103 mmol/L, HCO3 17 mmol/L Albumin 1.5 g/dL, Creatinine 1.0 mg/dL
Delta gap
gap = (deviation of AG from normal) (deviation of [HCO3] from normal) 6 7 = -1 Anion gap acidosis + respiratory acidosis
22
Questions
23
Key Points
Oxygen delivery is dependent on cardiac output and arterial oxygen content Hemoglobin is the major contributor of oxygen for tissue demands Normal filling pressures may not indicate adequate preload ScvO2 and lactate are useful measures of global oxygen balance Low ScvO2 values suggest oxygen imbalance
24
Key Points
Pulse oximetry values do not reflect adequacy of oxygen delivery Arterial cannulation is preferable to automated devices for blood pressure monitoring in unstable patients Assessment of acid-base status may suggest specific diagnoses and/or interventions
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Monitoring Blood Flow, Oxygenation, and Acid Base Status

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Monitoring Blood Flow, Oxygenation, and Acid Base Status

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Monitoring Blood Flow, Oxygenation, and Acid Base Status

Copyright 2008 Society of Critical Care Medicine

Which component is more amenable to clinical interventions?

Copyright 2008 Society of Critical Care Medicine

Copyright 2008 Society of Critical Care Medicine

Heart rate Stroke volume Preload Afterload Contractility

Copyright 2008 Society of Critical Care Medicine

Copyright 2008 Society of Critical Care Medicine

Blood Pressure Measurement

Automated noninvasive device Arterial cannulation

Central venous oxyhemoglobin saturation Lactate concentration

Venous Oxyhemoglobin Saturation

Saturation 100% Venous Tissues

Central Venous Oxyhemoglobin Saturation

ScvO2 SvO2 O2 Content

Arterial Cardiac Output

Copyright 2008 Society of Critical Care Medicine

Acidemia or alkalemia Acidemia Respiratory or metabolic

Appropriate respiratory compensation No

Copyright 2008 Society of Critical Care Medicine

Copyright 2008 Society of Critical Care Medicine

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