Skip to main content

Variation in central venous oxygen saturation to assess volume responsiveness in hemodynamically unstable patients under mechanical ventilation: a prospective cohort study

Trial registration: NCT NCT02142985. Registered 05 May 2014.

Intravenous fluid administration is a cornerstone of hemodynamic resuscitation. Its goal is to restore effective circulating blood volume and correct tissue perfusion as quickly as possible to avoid multi-organ failure [1]. In extreme clinical situations, the diagnosis of hypovolemia is easy; the problem arises when hypovolemia is latent or when associated with a patent left ventricular dysfunction. It is often the case with critically ill patients, for whom the diagnosis of hypovolemia is rarely possible without the use of accurate hemodynamic indicators [2, 3]. The use of central venous oxygen saturation (ScvO2) measurement has been proposed to guide fluid therapy [4]. The rationale behind assessing fluid responsiveness by ScvO2 is to identify patients on the ascending portion of the Frank-Starling curve who would likely to be fluid-responsive [5]. We studied the ability of SCVO2 variation (ΔScvO2) to define fluid responsiveness in critically ill emergency department (ED) patients needing volume expansion (VE). Here, we present a comprehensive summary of 88 adult patients under mechanical ventilation who required VE. VE consisted of 500 ml normal saline infused within 10 min. Cardiac output (CO) was measured by thermodilution method before and after VE. Fluid responsiveness was defined as increase in CO ≥ 15% after VE, while fluid non-responsiveness was defined as no increase or increase in CO < 15%. Hemodynamic assessment and blood gases measurements were performed at baseline and immediately after the end of VE. It included heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), central venous pressure (CVP), ScvO2, CO, cardiac index (CI), oxygen delivery (DO2), oxygen consumption (VO2) and blood lactate. The most common underlying clinical condition was septic shock. All patients received catecholamine and 46 patients (52.3%) died during hospitalization. Overall, 61 patients (69.3%) responded to VE. Before VE, ScvO2 did not differ between responders and non-responders. Patients’ characteristics and hemodynamic variables before VE are summarized in Table1. The increase in SBP, DBP and CI after VE was significantly higher in responders compared to non-responders. CI increased significantly from 2.62 ± 0.75 to 3.47 ± 0.8 L/min/m2 (p < 0.001) and ScvO2 from 70.5 ± 6.8% to 75.2 ± 6.6% (p < 0.001) in responders. CI and ScvO2 did not change significantly in non-responders after VE. Figure 1 shows the relative changes from baseline of hemodynamic variables after VE. Relative changes of ScvO2 were 7 ± 8.4% in responders and − 1.4 ± 9.6% in non-responders. The difference was statistically significant between the two groups (p < 0.001). ΔScvO2 was positively and significantly correlated with CO variation after VE (r = 0.46, p < 0.001). When analyzed using multivariate logistic regression, ΔScvO2 was the only factor associated with fluid responsiveness [OR: 1.44 (95% CI: 1.15–1.79)]. Diagnostic performance of ΔScvO2 and ΔCVP after VE showed areas under ROC curves of 0.84 (95% CI; 0.72–0.96) and 0.56 (95% CI; 0.43–0.68), respectively. The AUC of ΔScvO2 was significantly greater than that of ΔCVP (z statistic = 3.033, p = 0.0024). The best cut-off value found was 4%, allowing discrimination between responders and non-responders with a sensitivity of 78.7%, a specificity of 81.5% and a percentage of correct classification of 61.1%. It is important to mention that our results would work when ScvO2 is low and when there is no significant change in VO2 and haemoglobin. However, changes depend on the amount of fluid administered. Also, ScvO2 may not change if VO2 is dependent on DO2. We concluded that in patients with acute circulatory failure, ΔScvO2 has an adequate correlation with ΔCI and could be very helpful alternative tool when CO measurement or surrogates aren’t possible or not applicable. Further studies with larger populations are required to confirm these results on the role of ScvO2 monitoring in assessing fluid responsiveness instead of a cardiac output measurement during a fluid challenge.

Table 1 Baseline characteristics and hemodynamic variables before volume expansion in the responders and the non-responders groups
Fig. 1
figure1

Relative changes from baseline of hemodynamic variables after volume expansion

Availability of data and materials

The data are fully available, please contact the corresponding author.

Abbreviations

ScvO2 :

Central venous oxygen saturation

∆ScvO2 :

ScvO2 variation

CO:

Cardiac output

CI:

Cardiac index

∆CI:

Cardiac index variation

ED:

Emergency department

VE:

Volume expansion

VO2 :

Oxygen consumption

DO2 :

Oxygen delivery

SBP:

Systolic blood pressure

DBP:

Diastolic blood pressure

CI:

Cardiac index

CVP:

Central venous pressure

ΔCVP:

CVP variation

References

  1. 1.

    Vincent JL, De Backer D. Circulatory shock. N Eng J Med. 2013;369:1726–34.

    CAS  Article  Google Scholar 

  2. 2.

    Holler JG, Bech CN, Henriksen DP, Mikkehlsen S, Pedersen C, Lassen AT. Nontraumatic hypotension and shock in the emergency department and the prehospital setting, prevalence, etiology, and mortality: a systematic review. PLoS ONE. 2015;10(3):e0119331.

    Article  Google Scholar 

  3. 3.

    Bentzer P, Griesdale DE, Boyd J, MacLean K, Sirounis D, Ayas NT. Will this hemodynamically unstable patient respond to a bolus of intravenous fluids? JAMA. 2016;316:1298–309.

    Article  Google Scholar 

  4. 4.

    Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:4698–777.

    Article  Google Scholar 

  5. 5.

    Jalil BA, Cavallazzi R. Predicting fluid responsiveness: a review of literature and a guide for the clincian. Am J Emerg Med. 2018;36:2093–102.

    Article  Google Scholar 

Download references

Acknowledgements

The authors acknowledge all of our Research Laboratory LR12SP18 University of Monastir members who contributed greatly to this study.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Author information

Affiliations

Authors

Consortia

Contributions

MHK and SN conceived of the study and participated in its design and coordination and helped to revise the manuscript. AS participated in the design of the study and revised the manuscript. MHK and WZ collected the data and wrote the first draft of the manuscript. AZ and HBS collected the data. MHK and WZ participated in the design of the study and performed the statistical analysis. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Semir Nouira.

Ethics declarations

Ethics approval and consent to participate

All patients and/or their surrogates received written information about the study and provided their verbal consent to participate. The study’s objectives and procedures were approved by the independent Ethics Committee of the Medical University of Monastir.

Consent for publication

Not applicable.

Competing interests

None.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Khalil, M.H., Sekma, A., Zhani, W. et al. Variation in central venous oxygen saturation to assess volume responsiveness in hemodynamically unstable patients under mechanical ventilation: a prospective cohort study. Crit Care 25, 245 (2021). https://doi.org/10.1186/s13054-021-03683-6

Download citation