Elsevier

Resuscitation

Volume 41, Issue 3, August 1999, Pages 257-262
Resuscitation

Prognostic significance of the difference between mixed venous and jugular bulb oxygen saturation in comatose patients resuscitated from a cardiac arrest

https://doi.org/10.1016/S0300-9572(99)00060-XGet rights and content

Abstract

To determine the prognostic significance of the difference between mixed venous and jugular bulb oxygen saturation in survivors and non-survivors of a cardiac arrest, we studied 30 comatose patients (21 non-survivors and 9 survivors) resuscitated from a cardiac arrest. We measured mixed venous oxygen saturation (SmvO2) and jugular bulb oxygen saturation (SjO2) immediately after haemodynamic stabilisation (always within 6 h after cardiac arrest) and 6, 12 and 24 h later. In all patients the SjO2 was about 10% lower than the SmvO2 in the first measurement. In the survivors the SjO2 did not change and remained lower than SmvO2 in eight of nine survivors. However, in the non-survivors the SjO2 increased significantly and was finally higher than the SmvO2 in 12 of 20 patients 24 h after cardiac arrest suggesting a decrease in cerebral oxygen consumption due to extensive loss of functional brain tissue. The positive predictive value of (SmvO2−SjO2)≤0 for predicting irreversible brain damage at 24 h after cardiac arrest is 93% and the negative predictive value of (SmvO2−SjO2)>0 is 53%. Sensitivity and specificity are 65 and 89%, respectively. In a previous study we concluded that early jugular bulb oximetry (within 4 h after cardiac arrest) cannot predict cerebral outcome in comatose patients after cardiac arrest. More studies are needed to clarify the role of prolonged monitoring in the prediction of cerebral outcome after 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.

Section snippets

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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