Prognostic significance of the difference between mixed venous and jugular bulb oxygen saturation in comatose patients resuscitated from a cardiac arrest
Introduction
Since the introduction of closed chest cardiac massage in 1960 by Kouwenhoven et al. [1] and the improvement of pre-hospital care [2] many patients with an out-of-hospital cardiac arrest are rescued and admitted to the hospital. Some of these patients will recover completely, but others develop a persistent vegetative state or even become brain dead. Several methods have been studied to predict neurological outcome of comatose patients resuscitated from a cardiac arrest. These are the Glasgow Coma Scale [3], electro-encephalography (EEG) [4], [5] and somatosensory evoked potentials (SSEP) [6], [7]. However, these methods do not have a 100% sensitivity and specificity, and therefore supplementary methods are useful.
Cohan et al. [8] found delayed-onset cerebral hyperaemia in patients who died in coma, but not in patients who regained consciousness. Della Corte et al. [9], and Takasu et al. [10] found a strong correlation between a low arterio-jugular oxygen content difference and a bad neurological outcome after cardiac arrest. Gayle and Frewen [11] concluded that cross brain oxygen extraction may be a useful predictor of neurologic recovery in children following severe hypoxic ischaemic injury. These data suggest that the cerebral extraction of oxygen may be useful for determination of the prognosis of comatose post-arrest patients. Cerebral oxygen extraction can easily be measured as the jugular bulb oxygen saturation. Under normal conditions mixed venous oxygen saturation is about 10% above jugular bulb oxygen saturation, and may act as a reference to interpret jugular bulb oxygen saturation carefully. Therefore, we conducted the following study to compare the course and difference of mixed venous oxygen saturation (SmvO2) and jugular bulb oxygen saturation (SjO2) in survivors and non-survivors of an out-of-hospital cardiac arrest.
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Materials and methods
After approval of the study by the hospital ethical committee, we studied 30 comatose patients (Glasgow Coma Score≤6) successfully resuscitated from an out-of-hospital cardiac arrest. Written informed consent was obtained from the nearest relative.
Immediately after restoration of spontaneous circulation, patients were transferred from the emergency department to the medical intensive care unit. All patients were intubated and mechanically ventilated. For haemodynamic monitoring a 7.5-F
Results
We studied 30 consecutive patients successfully resuscitated from an out-of-hospital cardiac arrest. There were nine survivors and 21 non-survivors, 22 men and eight women, median age 67 years (range 24–83). Twenty-two patients had a cardiac arrest due to heart disease, four due to respiratory failure and in four patients the primary cause was unknown.
Cerebral (MFV, PI, SjO2) and systemic parameters (MAP, CI, SmvO2 and PaCO2) are shown in Table 1. In the non-survivors we observed a significant
Discussion
Our study shows a difference in cerebral blood flow and metabolism between survivors and non-survivors after cardiac arrest. The non-survivors showed a gradual decrease in pulsatility index (read: cerebrovascular resistance) and an increase in mean flow velocity in the middle cerebral artery (read: cerebral blood flow). This was accompanied by a gradual but significant increase in jugular bulb oxygen saturation. This can be explained by a relative increase in cerebral oxygen delivery in
Conclusion
In conclusion there is a difference in the course of cerebral blood flow and metabolism in survivors and non-survivors of a cardiac arrest. In the non-survivors the jugular bulb oxygen saturation increased significantly and crossed the mixed venous oxygen saturation in 12/21 patients. In the survivors we observed a small increase in jugular bulb oxygen saturation and only 1/9 patients crossed the mixed venous oxygen saturation. This suggest that a SjO2>SmvO2 is an indicator of poor outcome.
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2020, American Journal of Emergency MedicineCitation Excerpt :In a study by Gopinath et al., patients with excessive desaturation episodes and patients without desaturation episodes were compared and patients with excessive desaturation episodes were found to have worse neurological damage [6]. Buunk et al. measured SjVO2 after cardiac arrest in 30 comatose patients and found a significant relationship between mortality and SjVO2 values [16]. In the studies conducted by Croughwell et al. on 255 patients, it was reported that the consciousness states of the patients after resuscitation were related to desaturation [17,18].