Tissue oxygen saturation as a goal, but when and where should we measure it?
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COMMENTARY
Tissue oxygen saturation as a goal, but when and where should we measure it? Paul A. van Beest • Thomas W. L. Scheeren
Received: 18 January 2013 / Accepted: 18 January 2013 / Published online: 6 February 2013 Ó Springer Science+Business Media New York 2013
Global tissue hypoxia as a result from systemic inflammatory response or circulatory failure is an important indicator of shock preceding multiple organ dysfunction syndrome (MODS). The development of MODS determines outcome of the septic patient [1]. Unrecognized and untreated global tissue hypoxia increases morbidity and mortality. Accurate detection of global tissue hypoxia is therefore of vital importance. Physical findings, conventional hemodynamic monitoring and urinary output are important factors, but usually fail at detecting global tissue hypoxia [2, 3]. A decreased central venous saturation (ScvO2) obtained from a central venous catheter can reveal a mismatch between oxygen supply and oxygen demand, hence global tissue hypoxia [1]. Decreased ScvO2 values predict poor prognosis in septic shock [4, 5]. However, low ScvO2 values are uncommon in the setting of an intensive care unit (ICU) and additional monitoring is necessary [6]. In recent years, monitoring of tissue oxygenation by nearinfrared spectroscopy has become available and has been applied in several clinical settings in order to detect global tissue hypoxia non-invasively [7]. In this issue of Journal of Clinical Monitoring and Computing Nardi et al. [8] explore the use of this technology with the aim of implementing tissue oxygen saturation (StO2) as an additional goal for hemodynamic optimisation. An association between low StO2 values and bad outcome has been described before [7] and Nardi et al. This is the commentary to Olivier Nardi et al. (doi:10.1007/s10877013-9432-y). P. A. van Beest T. W. L. Scheeren (&) Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands e-mail: [email protected]
suggest that a treatment algorithm which includes StO2 may lead to treatment intensification after finishing the resuscitation bundle as suggested by international guidelines [1]. The purpose of their pilot study with 30 subjects was assessing the feasibility of StO2 monitoring in this particular setting as preparation for a larger multicentre study (NCT00167596). Several issues should be discussed here: Patients were randomized into two groups (control vs. treatment). All patients received treatment according to the Surviving Sepsis Campaign (SSC), i.e. early goal-directed therapy (EGDT) [1, 4] and the patients in the treatment arm additionally received transfusion or dobutamine to increase StO2 (target StO2 C 80 %). Such design is as clinically practical as it is unfortunate: not only did both groups receive blood transfusions and dobutamine infusions but they also received equal amounts and dosages thereof. Hence it is not surprising that they found no difference in both primary and secondary endp
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