This document discusses several parameters for assessing occult hypoperfusion in sepsis patients, including lactate, ScvO2, ΔCO2, ΔCO2/C(a-v)O2, and respiratory quotient. It provides reference ranges for normal values and cites studies examining how elevations in these parameters can indicate tissue hypoxia and predict outcomes like organ failure and mortality in sepsis patients. Graphs and diagrams are included to help explain the relationships between these parameters and cellular metabolism during sepsis and shock.

2. HIPOPERFUSÃO OCULTA
PRATICANDO PARÂMETROS
SERGIO KIFFER MACEDO

4. Microvascular Blood Flow Is Altered in Patients with Sepsis
Am J Respir Crit Care Med 2002;166:98–104

5. Persistent microcirculatory alterations
are associated with organ failure and
death in patients with septic shock
Sakr Y, et al Crit Care Med 2004; 32:1825–1831

6. PARÂMETROS ABORDADOS:

7. PARÂMETROS ABORDADOS:
• LACTATO

8. PARÂMETROS ABORDADOS:
• LACTATO

9. PARÂMETROS ABORDADOS:
• LACTATO
• ScvO2

10. PARÂMETROS ABORDADOS:
• LACTATO
• ScvO2

11. PARÂMETROS ABORDADOS:
• LACTATO
• ScvO2
• ∆ CO2

12. PARÂMETROS ABORDADOS:
• LACTATO
• ScvO2
• ∆ CO2

13. PARÂMETROS ABORDADOS:
• LACTATO
• ScvO2
• ∆ CO2
• ∆ CO2/C(a-v)O2

15. Lactato
VN: < 2 mmol/ L

16. Citoplasma
Mitocôndria
Ciclo de Krebs

17. •LACTATO / PIRUVATO = 10:1
Citoplasma •AERÓBICO = 673KCal
ADR
Glicose
Mitocôndria
O2
Gliceraldeido-3-fosfato
ALCALOSE Acetil-CoA
NAD+ CO2
NADH + H+ NAD+
ALCALOSE
SEPSE
Piruvato Ciclo de Krebs
ENDOTOXEMIA
1,3-difosfoglicerato
TIAMINA ATP
PDH
NA
Piruvato
DH
+
H+
CO2
NA
LD H2O
D+
H
Lactato

18. metabolismo celular
= MRO 2 36 ATP
VO2
< MRO 2 2 ATP
repercussões sobre a SvO 2
extração ∫ débito ...... ∫ SvO2
débito ∫ Hgb ...... ∫ SvO2
Hgb ∫ SaO2 ...... ∫ SvO2
DO2 ácido lático
∫ extração ...... SvO2
SaO 2 ......
metabolismo SvO2
alterado
arterial venoso
CHOQUE QUANDO VO 2 < MRO 2

19. metabolismo celular
= MRO 2 36 ATP
VO2
< MRO 2 2 ATP
repercussões sobre a SvO 2
extração ∫ débito ...... ∫ SvO2
débito ∫ Hgb ...... ∫ SvO2
∫ SaO2 ...... ∫ SvO2
Hgb DO2 Lactato
ácido lático
∫ extração ...... SvO2
SaO 2 ......
metabolismo SvO2
alterado
arterial venoso
CHOQUE QUANDO VO 2 < MRO 2

20. Interpretation of
De Baker D Intensive Care Med (2003) 29:699–702

21. Prolonged lactate clearance is associated with
increased mortality in the surgical intensive care
unit
100 100
80
60
42, 5
40
20 13, 3
3, 9
0
<24 h 24- 48 h 48- 96 Abnormal
unt il 96 h
McNellis J, et al. Am J Surg. 2001 Nov;182(5):481-5

22. Serial blood lactate levels can predict the
development of multiple organ failure
following septic shock.
Bakker J, et al. Am J Surg 1996 Feb;171(2):221-6

23. CLEARENCE DE LACTATO
(Lactato basal – Lactato após 6 h) x 100
Lactato basal

25. ScvO2
VN: > 70%

26. Time course of continuously
measured SvO2 and ScvO2
Reinhart K, et al.Intensive Care Med (2004) 30:1572–1578

27. Limits of mixed venous
oxygen saturation
Bloos F and Reinhart K. Intensive Care Med (2005) 31:911–913

28. Variables that affect mixed
venous oxygen saturation
Rivers EP, et al Curr Opin Crit Care 2001, 7:204–211

29. Resuscitation of the critically ill in the ED: responses
of blood pressure, heart rate, shock index, central
venous oxygen saturation, and lactate.
Occult Tissue Hypoxia
• Phase 1 – Triage
• Phase 2 – After VS
stabilization, 31 of
36 patients had
– ScvO2 < 65%
– Lactate > 2 mM/L
• Phase 3 – Relief of
occult tissue
hypoxia
Rady and Rivers, Am J Emerg Med. 1996 Mar;14(2):218-25

33. ∆CO2
VN: 4-6mmHg

34. Citoplasma
ADR
Glicose
Mitocôndria
O2
Gliceraldeido-3-fosfato
ALCALOSE Acetil-CoA
NAD+ CO2
NADH + H+ NAD+
ALCALOSE
SEPSE
Piruvato Ciclo de Krebs
ENDOTOXEMIA
1,3-difosfoglicerato
TIAMINA ATP
PDH
NA
Piruvato
DH
+
H+
CO2
NA
LD H2O
D+
H
Lactato

35. Citoplasma ↑CO2
ADR
Glicose
Mitocôndria
O2
Gliceraldeido-3-fosfato
ALCALOSE Acetil-CoA
NAD+ CO2
NADH + H+ NAD+
ALCALOSE
SEPSE
Piruvato Ciclo de Krebs
ENDOTOXEMIA
1,3-difosfoglicerato
TIAMINA ATP
PDH
NA
Piruvato
DH
+
H+
CO2
NA
LD H2O
D+
H
Lactato
O2

36. Veno-Arterial CO2 Gradient

37. Veno-Arterial CO2 Gradient
ΔPCO2 = PvCO2 - PaCO2 NORMAL = 4-6mmHg
CO2 production (VCO2)= CO x (CvCO2 - CaCO2)
ΔPCO2 = k x VCO2
CO
ΔPCO2 IS INVERSELY RELATED TO CARDIAC OUTPUT

42. ∆CO2 / C(a-
v)O2
VN: até 1,4 mmHg

44. ∆CO2 / C(a-v)O2
CaO2 = (1.34 x SaO2 x Hb) + (0.003 x PaO2)

45. ∆CO2 / C(a-v)O2
CaO2 = (1.34 x SaO2 x Hb) + (0.003 x PaO2)
CvO2 = (1.34 x SvO2 x Hb) + (0.003 x PvO2)

48. Respiratory Quotient Could Be a Better Perfusion
Variable to Predict Mortality in Septic Shock
0.76 (cut-off value 1.0 (sensitivity 63%
Rezende E et al Submitted to SCCM