Summary
Background
Patients with massive pulmonary embolism and obstructive shock usually require hemodynamic stabilization and thrombolysis. Little is known about the optimal and proper use of volume infusion and vasoactive drugs, or about the titration of thrombolytic agents in patients with relative contraindication for such treatment. The aim of the study was to find the most rapidly changing hemodynamic variable to monitor and optimize the treatment of patients with obstructive shock following massive pulmonary embolism.
Patients and methods
Ten consecutive patients hospitalized in the medical intensive care unit in the community General Hospital with obstructive shock following massive pulmonary embolism were included in the prospective observational study. Heart rate, systolic arterial pressure, central venous pressure, mean pulmonary-artery pressure, cardiac index, total pulmonary vascular-resistance index, mixed venous oxygen saturation, and urine output were measured on admission and at 1, 2, 3, 4, 8, 12, and 16 hours. Patients were treated with urokinase through the distal port of a pulmonary-artery catheter.
Results
At 1 hour, mixed venous oxygen saturation, systolic arterial pressure and cardiac index were higher than their admission values (31±10 vs. 49±12%, p<0.0001; 86±12 vs. 105±17 mmHg, p<0.01; 1.5±0.4 vs. 1.9±0.7 L/min/m2, p<0.05; respectively), whereas heart rate, central venous pressure, mean pulmonaryartery pressure and urine output remained unchanged. Total pulmonary vascular-resistance index was lower than at admission (29±10 vs. 21±12 mmHg/L/min/m2, p<0.05). The relative change of mixed venous oxygen saturation at hour 1 was higher than the relative changes of all other studied variables (p<0.05). Serum lactate on admission and at 12 hours correlated to mixed venous oxygen saturation (r=−0.855, p<0.001).
Conclusion
In obstructive shock after massive pulmonary embolism, mixed venous oxygen saturation changes more rapidly than other standard hemodynamic variables.
Article PDF
Similar content being viewed by others
Avoid common mistakes on your manuscript.
References
Podbregar M, Voga G, Krivec B, et al (2001) Should we confirm our clinical diagnostics certainty by autopsy. Int Care Med 27: 1750–1755
Pablinger I, Grafenhofer H (2003) Pregnancy-associated thrombosis. Wien Klin Wochenschr 115: 482–484
Kyrle PA, Eichinger S (2003) The risk of recurrent venous thromboembolism: the Austrian study on recurrent venous thromboembolism. Wien Klin Wochenschr 115: 471–474
Watzke HH (2003) Clinical significance of gene-diagnosis for defects in coagulation factors and inhibitors. Wien Klin Wochenschr 115: 475–481
Schobersberger W, Hauer B, Sumann G, et al (2002) Travelers thrombosis: incidence, etiology, prevention. Wien Klin Wochenschr 114: 14–20
Janata K, Holzer M, Domanovitis H, et al. (2002) Mortality of patients with pulmonary embolism. Wien Klin Wochenschr 114: 766–772
Urokinase Pulmonary Emboly Trial (1970) Phase 1 results: a cooperative study. JAMA 214: 2163–2172
Tapson VF, Witty LA (1995) Massive pulmonary embolism: diagnostic and therapeutic strategies. Clinics in Chest Medicine 16: 329–338
Meyer G, Sors H, Charbonnier B, Kasper W, Bassand JP, Kerr IH, et al (1992) Effects of intravenous urokinase versus alteplase on total pulmonary resistance in acute massive pulmonary embolism: a European multicenter double-blind trial. J Am Coll Cardiol 19: 239–245
Nunez S, Maisel A (1998) Comparison between mixed venous oxygen saturation and thermodilution cardiac output in monitoring patients with severe heart failure treated with milrinone and dobutamine. Am Heart J 135: 383–338
Krivec B, Voga G, Žuran I, Skale R, Pareznik R, Podbregar M, et al (1997) Diagnosis and treatment of shock due to massive pulmonary embolism: approach with transesophageal echocardiography and intrapulmonary thrombolysis. Chest 112: 1310–1316
Podbregar M, Krivec B, Voga G (2002) Impact of morphologic characteristics of central pulmonary thromboemboli in massive pulmonary embolism. Chest 122: 973–979
Prospective investigation of pulmonary embolism diagnosis (PIOPED) investigators (1990) Tissue plasminogen activator for the treatment of acute pulmonary embolism: a collaborative study by the PIOPED investigators. Chest 97: 528–533
Kasper W, Konstantinidis S, Geibel A, Olschewski M, Heinrich F, Grosser KD, et al (1997) Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registy. J Am Coll Cardiol 30: 1165–1171
Michard F, Meyer G, Wysocki M, Diehl JL, Mercat A, Sors H (1999) Cardiorespiratory efficacy of thrombolytic therapy in acute massive pulmonary embolism: identification of predicitive factors. Eur Respir J 13: 610–615
Mercat A, Diehl JL, Meyer G, Teboul JL, Sors H (1999) Hemodynamic effects of fluid loading in acute massive pulmonary embolism. Crit Care Med 27: 540–544
Molloy WD, Lee KY, Girling L (1984) Treatment of shock in a canine model of pulmonary embolism. Am Rev Respir Dis 130: 870–874
Jardin F, Genevray B, Brun-Ney D, Margairaz A (1985) Dobutamine: a hemodynamic evaluation in pulmonary embolism and shock. Crit Care Med 13: 1009–1012
Sors H, Pacouret G, Azarian R (1994) Hemodynamic effects of bolus vs 2-h infusion of alteplase in acute massive pulmonary embolism: a randomized controlled multicenter trial. Chest 106: 712–717
Bline A, Francis CW (1996) Transport processes in fibrinolysis and fibrinolytic therapy. Thromb Haemost 76: 481–491
Lee HS, Quinn T, Boyler RM (1995) Safety of thrombolytic treatment in patients with central venous cannulation, Br Heart J 73: 359–362
Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. (2001) Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345: 1368–1377
Reinhart K, Rudolph T, Bredle DL, Hannemann L, Cain SM (1989) Comparison of central-venous to mixed-venous oxygen saturation during changes in oxygen supply/demand. Chest 95: 1216–1221
Edwards JD, Mayall RM (1998) Importance of the sampling site for measurement of mixed venous oxygen. Crit Care Med 26: 1356–1360
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Krivec, B., Voga, G. & Podbregar, M. Monitoring mixed venous oxygen saturation in patients with obstructive shock after massive pulmonary embolism. Wien Klin Wochenschr 116, 326–331 (2004). https://doi.org/10.1007/BF03040904
Received:
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/BF03040904