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Session Number 218 ExpoEd Session CLINICAL APPLICATION OF CONTINUOUS SCVO2 MONITORING Patricia A. Meehan, RN, MS, CCRN(a) Education Consultant Edwards Lifesciences, LLC Content Description Continuous venous oxygen saturation monitoring is available both from the pulmonary artery (SvO2) and central vena cava (ScvO2) and is utilized to evaluate the status of global tissue oxygenation because it reflects oxygen delivery and oxygen utilization. Acquiring accurate values with the appropriate interpretation provides additional valuable information for the bedside clinician. This session discusses the monitoring of ScvO2: in assessing the adequacy of oxygen delivery in the critically ill patient; early detection of tissue hypoxia in sepsis; and in early goal directed therapy. Learning Objectives At the end of this session, the participant will be able to: 1. Describe the components of Oxygen Delivery 2. Discuss the correlation between mixed venous oxygen saturation (SvO2) and central venous oxygen saturation (ScvO2). 3. Discuss the value of monitoring continuous ScvO2 in critically ill and septic patients. 4. Discuss the protocol for EGDT. Key Points: 1. Venous Oxygen Saturation Monitoring a) Purpose of Venous Oxygen Saturation Monitoring Assess adequacy of blood flow & oxygen delivery Venous Oxygen Saturation ­ Global Indicator Oxygen Delivery = Oxygen Demand b) Components of Oxygen Delivery Oxygen Delivery = Cardiac Output x Oxygen Content Cardiac Output = Heart Rate x Stroke Volume Stroke Volume - Preload, Afterload, Contractility

TRENDS ­ Exhibit ­ ScvO2 ­ Meehan

Oxygen Content Hemoglobin, Arterial O2 Saturation c) Oxygen Consumption Pain, fever, shivering, anxiety 2. Methods to Measure Venous Oxygen Saturation a) SvO2 - Mixed Venous ­ Pulmonary Artery Distal port of PA Catheter ­ intermittent or continuous b) ScvO2 - Superior Vena Cava Central Venous Catheter ­ Fiberoptic c) Normal Values - 60% - 80% SvO2 and ScvO2 ­ Trend well ScvO2 ­ typically ­ 5-10% > than SvO2 c) Compensatory Mechanisms Increase heart rate and cardiac output Increase extraction

3. Abnormal Venous Oxygen Saturation Values - <60% - >80% a) Decreased ScvO2 Decreased Delivery Decreased Cardiac output ­ Heart Rate, Preload, Afterload, Contractility Decreased Oxygen Content Hemoglobin, Arterial Oxygen Saturation Increased Consumption Fever, pain, seizures, shivering, early sepsis b) Increased ScvO2 Decreased Demand Hypothermia, anesthesia, paralysis, late sepsis

5. Clinical Application of Central Venous Oxygen Saturation Monitoring - Monitoring and early warning system - Guide for assessing and adjusting interventions

TRENDS ­ Exhibit ­ ScvO2 ­ Meehan

- Means for interpreting other variables a) Sepsis ­ Early Goal Directed TherapyTM (Rivers) Aggressive algorithm for early sepsis Volume : CVP - 8 ­ 12mm Hg Pressure: MAP - 60 ­ 90mm Hg ** O2 Delivery ­ ScvO2 >70% Mortality; Without EGDT 46% - With EGDT ­ 30% - 2001 Mean relative & absolute risk reduction ­ 46% & 20.3% - 2008 b) Trauma, Hemorrhagic Shock c) Cardiogenic Shock d) Post Cardiac Arrest e) Respiratory Weaning Protocols f) Post op Cardiac Surgery Patients g) AACN Practice Alert: Severe Sepsis Role of ScvO2 in the early detection & treatment of tissue hypoxia in sepsis Critical Care Nurses role in patient assessment for signs and symptoms of SIRS References: 1. Ahrens, T: Tuggle, D. Surviving Severe Sepsis: Early Recognition and Treatment. Critical Care Nurse. 24 (supplement): 2-13, 2004 2. Goodrich C. Continuous Central Venous Oximetry Monitoring. Crit Care Nurs Clinic NA. 2006; 203-209. 3. Ising, P; Smith,T.W.; Simpson, S.Q. Effect of Intermittent vs Continuous ScvO2 Monitoring in Sepsis Bundle Compliance and Mortality, Chest 2009. 4. Kleinpell, RM. The Role of the Critical Care Nurse in the Assessment and Management of the Patient in Severe Sepsis. Crit Care Nurs Clinics N.A. ­ 15(1): 27-34, 2003. 5. Nogueira et al. Central Venous Saturation: A Prognostic Tool in Cardiac Surgery. Journal of Intensive Care Medicine ­ 2009. 6. Rivers, E.P.; Nguyen, B; Havstad, S et al. Early Goal Directed Therapy in the Treatment of Severe Sepsis and Septic Shock. New England Journal of Medicine. 345(19): 1368 ­ 1370, 2001. 7. Rivers, E.P.; Coba,V.; Whitmill,M. Early Goal Directed Therapy in Severe Sepsis and Septic Shock: A Contemporary Review of the Literature. Current Opinions in Anesthesiology 21: 128-140. 8. Texeira, C; daSilva, N.B.; Savi,A. et al. Central Venous Saturation is a Predictor of Reintubation in Difficult to Wean Patients. Critical Care Medicine, 2010;38(2):491-6.

TRENDS ­ Exhibit ­ ScvO2 ­ Meehan

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CLINICAL APPLICATION OF CONTINUOUS SCVO2 MONITORING

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