BGA MONITORING

in “occult” hypoperfusion ….a look from inside…. in “occult” hypoperfusion ScvO2 LACTATE DELTA PCO2 …helps to evaluate therapy effects…

The Supply-Dependency 50 100 150 200 250 300 350 400 20 40 60 80 120 140 2 4 6 8 10 12 VO2 ml/min Lactate mmol/L OER DO2 ml/min/m2

SaO2 CO ScvO2 Hb VO2

Ann Emerg Med. 2010;55:40-46

LACT & normal pH HYPERLACTATEMIA (PFK, shuttle, messenger) LACT & low pH LACTIC ACIDOSIS * Low Mitho Activity * Low ATP/ADP * High NADH/NAD * Low pHi and pHo

“instantaneous” LACTATE CONCENTRATION vs LIVER & KIDNEY METABOLISM PRODUCTION vs

EARLY LACTATE CLEARANCE IS ASSOCIATED WITH IMPROVED OUTCOME Lactate start - Lactate 6 H Lactate start x 100 NGUYEN HB, RIVERS EP (2004) CCM 32;8:1637-42

Circulation 1989;80:684-692

CO2 AS MONITOR OF PERFUSION

The CO2 lung presentation & low flow V O2 demand DO2 PCO2 VO2 ATP AMP + H+ Lact- + H+ H+ + HCO3-

∆ CO2 = 9.2 ∆ CO2 = 5.3 OER = 36 OER = 33.5 FS 1993

= the future…? VO2 If low = O2 debt ÷ ScvO2 DO2 O2 Demand + low pH = lactic acidosis VCO2 flow ÷ ΔvaPCO2 + low pH = tissue acidosis = the future…? ↓micro-flow ÷ ΔtaPCO2 Δva PCO2 : next ????? ΔavO2 Content

KEY POINTS Micro vs Macro Serial Lactate better (fast vs slow clearance) ScvO2 vs Delta PCO2 monitoring Perspective: Lact/Pyr, pHi, Lactate Gaps…… Think about the “FULL PICTURE”