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Re: Shock and circulatory support in the Emergency Department

Dear Editor

I enjoyed the article on shock and circulatory support in the Emergency Department.[1] Early and aggressive resuscitation of patients with shock is known to improve outcome, as shown in the Emmanuel Rivers et al paper used as the first reference.[2] I was disappointed, however, to find an important component of that study had not been mentioned.

Following the establishment of an adequate central venous pressure and mean arterial blood pressure, the next step of the protocol was to measure the patients’ mixed central venous saturations. This was used as an indication of the oxygen delivery and consumption. If the ScvO2 fell below 70%, the patient was given red blood cell transfusions to achieve a haematocrit of at least 30% to optimise oxygen delivery. If ScvO2 remained below 70% after these measures, dobutamine was administered to improve cardiac output. This method of balancing systemic oxygen delivery and consumption was shown to improve subsequent oxygen delivery to tissues, pH, lactate, base deficit and severity-of-illness scores.

The optimisation of the three parameters in the first six hours of presentation significantly reduced mortality(2) .Dr Rivers said himself of goal directed therapy, “Mainly the key is to look at three things: volume, pressure and oxygen delivery (via central venous oxygen)…”. While Graham and Parke’s review covered the first two, it was a shame that the equally important third was omitted.

References

1. Graham C, Parke T. Critical care in the emergency department: shock and circulatory support. Emerg Med J 2005;22: 17-21.