Brazilian Journal of Anesthesiology
https://app.periodikos.com.br/journal/rba/article/doi/10.1590/S0034-70942010000600005
Brazilian Journal of Anesthesiology
Artigo Científico

Influência da saturação venosa central de oxigênio na mortalidade hospitalar de pacientes cirúrgicos

Influence of central venous oxygen saturation on in-hospital mortality of surgical patients

João Manoel Silva Junior; Amanda Maria Ribas Rosa Oliveira; Sandra Zucchi de Morais; Luciana Sales de Araújo; Luiz Gustavo F Victoria; Lauro Yoiti Marubayashi

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Resumo

RESUMO JUSTIFICATIVA E OBJETIVOS: Saturação venosa central de oxigênio (SvcO2) baixa indica desequilíbrio entre oferta e consumo de oxigênio celular e, consequentemente, pior prognóstico em pacientes graves. No entanto, ainda não está claro qual o valor desse marcador em pacientes cirúrgicos. O objetivo deste estudo foi avaliar se SvcO2 baixa no perioperatório determina pior prognóstico. MÉTODO: Estudo observacional, durante 6 meses, em um hospital terciário. Foram incluídos pacientes que necessitassem de pós-operatório em terapia intensiva (UTI) com idade > 18 anos, submetidos a cirurgias de grande porte. Pacientes com cirurgias paliativas e pacientes com insuficiên cia cardíaca grave foram excluídos. Valores de SvcO2 foram mensurados antes da cirurgia, durante o procedimento e após a cirurgia na UTI. RESULTADOS: Foram incluídos 66 pacientes e não sobreviveram 25,8%. Os valores médios de SvcO2 dos pacientes foram maiores no intraoperatório, 84,7 ± 8,3%, do que no pré-operatório e UTI, respectivamente 74,1 ± 7,6% e 76,0 ± 10,5% (p = 0,0001). Porém, somente os valores de SvcO2 no pré-operatório dos pacientes não sobreviventes foram significativamente mais baixos que os sobreviventes. Pela regressão logística SvcO2 pré-operatória, OR = 0,85 (IC 95% 0,74-0,98) p = 0,02 foi fator independente de mortalidade hospitalar. Pacientes com SvcO2 < 70% no pré-operatório apresentaram maior necessidade de transfusão sanguínea (80,0% versus 37,0% p = 0,001) e reposição volêmica no intraoperatório 8.000,0 (6.500,0 - 9.225,0) mL versus 6.000,0 (4.500,0 - 8.500,0) mL p = 0,04), com maiores chances de complicações pós-operatórias (75% versus 45,7% p = 0,02) e maior tempo de internação na UTI 4,0 (2,0-5,0) dias versus 3,0 (1,7 - 4,0) dias p = 0,02. CONCLUSÕES: Os valores de SvcO2 no intraoperatório são maiores que os do pré- e pós-operatório. Contudo, a SvcO2 baixa no pré-operatório determina pior prognóstico.

Palavras-chave

COMPLICAÇÕES, OXIGÊNIO, níveis sanguíneos, RISCO

Abstract

BACKGROUND AND OBJECTIVES: Low central venous oxygen saturation (ScvO2) indicates an imbalance between cellular oxygen supply and consumption and, consequently, worse prognosis for critical patients. However, it is not clear what the value of this marker in surgical patients. The objective of the present study was to evaluate whether low perioperative ScvO2 determines a worse prognosis. METHODS: This is a 6-month observational study carried on in a tertiary hospital. Patients who needed to be in the intensive care unit (ICU) postoperatively, with age > 18 years, who underwent large surgeries, were included. Patients who underwent palliative surgeries and those with severe heart failure were excluded. Levels of ScvO2 were measured before the surgery, during the procedure, and after the surgery in the ICU. RESULTS: Sixty-six patients were included in this study, but 25.8% of them did not survive. Mean ScvO2 levels were higher intraoperatively, 84.7 ± 8.3%, than preoperatively and in the ICU, 74.1 ± 7.6% and 76.0 ± 10.5% (p = 0.0001), respectively. However, only preoperative SvcO2 levels of non-surviving patients were significantly lower than those who survived. By logistic regression, preoperative ScvO2, OR = 0.85 (95% CI 0.74-0.98) (p = 0.02), was an independent factor of in-hospital mortality. Patients with preoperative ScvO2 < 70% had greater need of intraoperative blood transfusion (80.0% versus 37.0%, p = 0.001) and volume replacement, 8,000.0 (6,500.0-9,225.0) mL versus 6,000.0 (4,500.0-8,500.0) mL (p = 0.04), with greater chances of postoperative complications (75% versus 45.7%, p = 0.02) and longer time in the ICU, 4.0 (20.0-5.0) days versus 3.0 (1.7-4.0) days (p = 0.02). CONCLUSIONS: Intraoperative ScvO2 levels are higher than those both in the pre- and postoperative period. However, low preoperative ScvO2 determines worse prognosis.

Keywords

COMPLICATIONS, OXYGEN, blood levels, RISK

Referências

Weiser TG, Regenbogen SE, Thompson KD. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet. 2008;372:139-144.

Pearse RM, Harrison DA, James P. Identification and characterisation of the high-risk surgical population in the United Kingdom. Crit Care. 2006;10.

Jhanji S, Thomas B, Ely A. Mortality and utilisation of critical care resources amongst high-risk surgical patients in a large NHS trust. Anaesthesia. 2008;63:695-700.

Haynes AB, Weiser TG, Berry WR. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491-499.

Juul AB, Wetterslev J, Gluud C. Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial. BMJ. 2006;332:1482.

Khuri SF, Henderson WG, DePalma RG. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg. 2005;242:326-343.

Shoemaker WC, Montgomery ES, Kaplan E. Physiologic patterns in surviving and nonsurviving shock patients: Use of sequential cardiorespiratory variables in defining criteria for therapeutic goals and early warning of death. Arch Surg. 1973;106:630-636.

Jhanji S, Lee C, Watson D. Microvascular flow and tissue oxygenation after major abdominal surgery: association with post-operative complications. Intensive Care Med. 2009;35:671-677.

Pearse RM, Belsey JD, Cole JN. Effect of dopexamine infusion on mortality following major surgery: individual patient data meta-regression analysis of published clinical trials. Crit Care Med. 2008;36:1323-1329.

Pearse R, Dawson D, Fawcett J. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay: A randomised, controlled trial [ISRCTN38797445]. Crit Care. 2005;9:R687-693.

Silva Jr JM, Toledo DO, Magalhaes DD. Influence of tissue perfusion on the outcome of surgical patients who need blood transfusion. J Crit Care. 2009;24:426-434.

Rivers E, Nguyen B, Havstad S. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368-1377.

Pearse R, Dawson D, Fawcett J. Changes in central venous saturation after major surgery, and association with outcome. Crit Care. 2005;9:R694-699.

Mayr VD, Dunser MW, Greil V. Causes of death and determinants of outcome in critically ill patients. Crit Care. 2006;10.

Marshall JC, Cook DJ, Christou NV. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med. 1995;23:1638-1652.

Knaus WA, Draper EA, Wagner DP. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818-829.

Prytherch DR, Whiteley MS, Higgins B. POSSUM and Portsmouth POSSUM for predicting mortality: Physiological and Operative Severity Score for the enumeration of Mortality and morbidity. Br J Surg. 1998;85:1217-1220.

Rezende E, Silva Jr JM, Isola AM. Epidemiology of severe sepsis in the emergency department and difficulties in the initial assistance. Clinics (Sao Paulo). 2008;63:457-464.

Poeze M, Ramsay G, Greve JW. Prediction of postoperative cardiac surgical morbidity and organ failure within 4 hours of intensive care unit admission using esophageal Doppler ultrasonography. Crit Care Med. 1999;27:1288-1294.

Polonen P, Hippelainen M, Takala R. Relationship between intra- and postoperative oxygen transport and prolonged intensive care after cardiac surgery: a prospective study. Acta Anaesthesiol Scand. 1997;41:810-817.

Ander DS, Jaggi M, Rivers E. Undetected cardiogenic shock in patients with congestive heart failure presenting to the emergency department. Am J Cardiol. 1998;82:888-891.

Moomey Jr CB, Melton SM, Croce MA. Prognostic value of blood lactate, base deficit, and oxygen-derived variables in an LD50 model of penetrating trauma. Crit Care Med. 1999;27:154-161.

Harms MP, van Lieshout JJ, Jenstrup M. Postural effects on cardiac output and mixed venous oxygen saturation in humans. Exp Physiol. 2003;88:611-616.

Madsen P, Iversen H, Secher NH. Central venous oxygen saturation during hypovolaemic shock in humans. Scand J Clin Lab Invest. 1993;53:67-72.

Jenstrup M, Ejlersen E, Mogensen T. A maximal central venous oxygen saturation (SvO2max) for the surgical patient. Acta Anaesthesiol Scand. 1995:29-32.

Rivers EP, Ander DS, Powell D. Central venous oxygen saturation monitoring in the critically ill patient. Curr Opin Crit Care. 2001;7:204-211.

Shepherd SJ, Pearse RM. Role of central and mixed venous oxygen saturation measurement in perioperative care. Anesthesiology. 2009;111:649-656.

van Beest PA, Hofstra JJ, Schultz MJ. The incidence of low venous oxygen saturation on admission to the intensive care unit: a multi-center observational study in The Netherlands. Crit Care. 2008;12.

Fenwick E, Wilson J, Sculpher M. Pre-operative optimisation employing dopexamine or adrenaline for patients undergoing major elective surgery: a cost-effectiveness analysis. Intensive Care Med. 2002;28:599-608.

Mythen MG, Webb AR. Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Arch Surg. 1995;130:423-429.

Kern JW, Shoemaker WC. Meta-analysis of hemodynamic optimization in high-risk patients. Crit Care Med. 2002;30:1686-1692.

Nguyen HB, Rivers EP, Knoblich BP. Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med. 2004;32:1637-1642.

Edwards JD, Mayall RM. Importance of the sampling site for measurement of mixed venous oxygen saturation in shock. Crit Care Med. 1998;26:1356-1360.

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