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Thorax 2002;57:170177
A
lthough traditionally interested in conditions tained.
affecting gas exchange within the lungs, the Recognition of inadequate global DO2 can be
respiratory physician is increasingly, and difficult in the early stages because the clinical
appropriately, involved in the care of critically ill features are often non-specific. Progressive meta-
patients and therefore should be concerned with bolic acidosis, hyperlactataemia, and falling
systemic as well as pulmonary oxygen transport. mixed venous oxygen saturation (SvO2), as well as
Oxygen is the substrate that cells use in the great- organ specific features such as oliguria and
est quantity and upon which aerobic metabolism impaired level of consciousness, suggest inad-
equate DO2. Serial lactate measurements can indi-
and cell integrity depend. Since the tissues have no
cate both progression of the underlying problem
storage system for oxygen, a continuous supply at a
rate that matches changing metabolic require-
ments is necessary to maintain aerobic metabolism .................................................
and normal cellular function. Failure of oxygen
Abbreviations: SO2, oxygen saturation (%); PO2, oxygen
See end of article for supply to meet metabolic needs is the feature com- partial pressure (kPa); PIO2, inspired PO2; PEO2, mixed
authors affiliations mon to all forms of circulatory failure or shock. expired PO2; PECO2, mixed expired PCO2; PAO2, alveolar
.......................
Prevention, early identification, and correction of PO2; PaO2, arterial PO2; SaO2, arterial SO2; SvO2, mixed
Correspondence to: tissue hypoxia are therefore necessary skills in venous SO2; Qt, cardiac output; Hb, haemoglobin; CaO2,
Dr D Treacher; arterial O2 content; CvO2, mixed venous O2 content; VO2,
managing the critically ill patient and this requires oxygen consumption; VCO2, CO2 production; O2R, oxygen
David.Treacher@
gstt.sthames.nhs.uk an understanding of oxygen transport, delivery, return; DO2, oxygen delivery; Vi/e, minute volume,
....................... and consumption. inspiratory/expiratory.
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Oxygen delivery and consumption in the critically ill 171
Diffusion of O2 in tissues
LV
LA
Inspired (dry) Capillary
Interstitial
Intracellular
(2.71.3)
Expired (dry)
PEO2 (15.9)
(14) (200)
Qt O 2R
Hb (150) Qt (5)
(750)
Figure 1 Oxygen transport from atmosphere to mitochondria. Values in parentheses for a normal 75 kg individual (BSA 1.7 m2) breathing air
(FIO2 0.21) at standard atmospheric pressure (PB 101 kPa). Partial pressures of O2 and CO2 (PO2, PCO2) in kPa; saturation in %; contents (CaO2,
CvO2) in ml/l; Hb in g/l; blood/gas flows (Qt, Vi/e) in l/min. P50 = position of oxygen haemoglobin dissociation curve; it is PO2 at which 50%
of haemoglobin is saturated (normally 3.5 kPa). DO2 = oxygen delivery; VO2 = oxygen consumption, VCO2 = carbon dioxide production; PIO2,
PEO2 = inspired and mixed expired PO2; PEC O2 = mixed expired PC O2; PAO2 = alveolar PO2.
and the response to treatment. Raised lactate levels increases markedly above 100 g/l. This impairs flow and
(>2 mmol/l) may be caused by either increased production or oxygen delivery, particularly in smaller vessels and when the
reduced hepatic metabolism. Both mechanisms frequently perfusion pressure is reduced, and will therefore exacerbate
apply in the critically ill patient since a marked reduction in tissue hypoxia.1 Recent evidence suggests that even the
DO2 produces global tissue ischaemia and impairs liver traditionally accepted Hb concentration for critically ill
function. patients of approximately 100 g/l may be too high since an
Table 1 illustrates the calculation of DO2 from the oxygen improved outcome was observed if Hb was maintained
content of arterial blood (CaO2) and cardiac output (Qt) with between 70 and 90 g/l with the exception of patients with cor-
examples for a normal subject and a patient presenting with onary artery disease in whom a level of 100 g/l remains
hypoxaemia, anaemia, and a reduced Qt. The effects of provid- appropriate.2 With the appropriate Hb achieved by transfu-
ing an increased inspired oxygen concentration, red blood cell sion, and since the oxygen saturation (SaO2) can usually be
transfusion, and increasing cardiac output are shown. This maintained above 90% with supplemental oxygen (or if
emphasises that: (1) DO2 may be compromised by anaemia, necessary by intubation and mechanical ventilation), cardiac
oxygen desaturation, and a low cardiac output, either singly or output is the variable that is most often manipulated to
in combination; (2) global DO2 depends on oxygen saturation achieve the desired global DO2 levels.
rather than partial pressure and there is therefore little extra
benefit in increasing PaO2 above 9 kPa since, due to the OXYGEN CONSUMPTION
sigmoid shape of the oxyhaemoglobin dissociation curve, over Global oxygen consumption (VO2) measures the total amount
90% of haemoglobin (Hb) is already saturated with oxygen at of oxygen consumed by the tissues per minute. It can be
that level. This does not apply to the diffusive component of measured directly from inspired and mixed expired oxygen
oxygen transport that does depend on the gradient of oxygen concentrations and expired minute volume, or derived from
partial pressure. the cardiac output (Qt) and arterial and venous oxygen
Although blood transfusion to polycythaemic levels might contents:
seem an appropriate way to increase DO2, blood viscosity VO2 = Qt (CaO2 CvO2)
Table 1 Relative effects of changes in PaO2, haemoglobin (Hb), and cardiac output (Qt) on oxygen delivery (DO2)
Dissolved O2
FIO2 PaO2 (kPa) SaO2 (%) Hb (g/l) (ml/l) CaO2 (ml/l) Qt (l/min) DO2 (ml/min) DO2 (% change)
DO2 = CaO2 Qt ml/min, CaO2 = (Hb SaO2 1.34) + (PaO2 0.23) ml/l where FIO2 = fractional inspired oxygen concentration; PaO2, SaO2, CaO2 =
partial pressure, saturation and content of oxygen in arterial blood; Qt = cardiac output. 1.34 ml is the volume of oxygen carried by 1 g of 100%
saturated Hb. PaO2 (kPa) 0.23 is the amount of oxygen in physical solution in 1 l of blood, which is less than <3% of total CaO2 for normal PaO2 (ie
<14 kPa). *Normal 75 kg subject at rest. Patient with hypoxaemia, anaemia, reduced cardiac output, and evidence of global tissue hypoxia. Change
in DO2 expressed as a percentage of the preceding value.
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172 Leach, Treacher
D
which increases to 7080% during maximal exercise in the
well trained athlete. The oxygen not extracted by the tissues
400 800 1200
returns to the lungs and the mixed venous saturation (SvO2)
Oxygen delivery (DO2) (ml/min)
measured in the pulmonary artery represents the pooled
venous saturation from all organs. It is influenced by changes
Figure 2 Relationship between oxygen delivery and consumption.
in both global DO2 and VO2 and, provided the microcirculation
and the mechanisms for cellular oxygen uptake are intact, a
value above 70% indicates that global DO2 is adequate. had prognostic implications such that patients with higher
A mixed venous sample is necessary because the saturation values had an improved survival.7 A subsequent randomised
of venous blood from different organs varies considerably. For placebo controlled trial in a similar group of patients showed
example, the hepatic venous saturation is usually 4050% but improved survival if the values for DO2 (>600 ml/min/m2) and
the renal venous saturation may exceed 80%, reflecting the SvO2 (>70%) that had been achieved by the survivors in the
considerable difference in the balance between the metabolic earlier study were set as therapeutic targets (goal directed
requirements of these organs and their individual oxygen therapy).8
deliveries. This evidence encouraged the use of goal directed therapy
in patients with established (late) septic shock and organ
CLINICAL FACTORS AFFECTING METABOLIC RATE dysfunction in the belief that this strategy would increase VO2
AND OXYGEN CONSUMPTION and prevent multiple organ failure. DO2 was increased using
The cellular metabolic rate determines VO2. The metabolic rate vigorous intravenous fluid loading and inotropes, usually dob-
increases during physical activity, with shivering, hyperther- utamine. The mathematical linkage caused by calculating
mia and raised sympathetic drive (pain, anxiety). Similarly, both VO2 and DO2 using common measurements of Qt and
certain drugs such as adrenaline4 and feeding regimens CaO23 and the physiological linkage resulting from the meta-
containing excessive glucose increase VO2. Mechanical ventila- bolic effects of inotropes increasing both VO2 and DO2 were
tion eliminates the metabolic cost of breathing which, confounding factors in many of these studies.9 This approach
although normally less than 5% of the total VO2, may rise to was also responsible for a considerable increase in the use of
30% in the catabolic critically ill patient with respiratory pulmonary artery catheters to direct treatment. However, after
distress. It allows the patient to be sedated, given analgesia a decade of conflicting evidence from numerous small, often
and, if necessary, paralysed, further reducing VO2. methodologically flawed studies, two major randomised
controlled studies finally showed that there was no benefit
RELATIONSHIP BETWEEN OXYGEN CONSUMPTION and possibly harm from applying this approach in patients
AND DELIVERY with established shock.10 11 Interestingly, these studies also
The normal relationship between VO2 and DO2 is illustrated by found that those patients who neither increased their DO2
line ABC in fig 2. As metabolic demand (VO2) increases or DO2 spontaneously nor in response to treatment had a particularly
diminishes (CB), OER rises to maintain aerobic metabolism poor outcome. This suggested that patients with late shock
and consumption remains independent of delivery. However, had poor physiological reserve with myocardial and other
at point Bcalled critical DO2 (cDO2)the maximum OER is organ failure caused by fundamental cellular dysfunction.
reached. This is believed to be 6070% and beyond this point These changes would be unresponsive to Shoemakers goals
any further increase in VO2 or decline in DO2 must lead to tis- that had been successful in early shock. Indeed, one might
sue hypoxia.5 In reality there is a family of such VO2/DO2 rela- predict that, in patients with the increased endothelial
tionships with each tissue/organ having a unique VO2/DO2 rela- permeability and myocardial dysfunction that typifies late
tionship and value for maximum OER that may vary with shock, aggressive fluid loading would produce widespread
stress and disease states. Although the technology currently tissue oedema impairing both pulmonary gas exchange and
available makes it impracticable to determine these organ tissue oxygen diffusion. The reported increase in mortality
specific relationships in the critically ill patient, it is important associated with the use of pulmonary artery catheters12 may
to realise that conclusions drawn about the genesis of reflect the adverse effects of their use in attempting to achieve
individual organ failure from the global diagram are poten- supranormal levels of DO2.
tially flawed.
In critical illness, particularly in sepsis, an altered global SHOULD GOAL DIRECTED THERAPY BE
relationship is believed to exist (broken line DEF in fig 2). The ABANDONED?
slope of maximum OER falls (DE v AB), reflecting the reduced Recent studies examining perioperative optimisation in
ability of tissues to extract oxygen, and the relationship does patients, many of whom also had significant pre-existing car-
not plateau as in the normal relationship. Hence consumption diopulmonary dysfunction, have confirmed that identifying
continues to increase (EF) to supranormal levels of DO2, and treating volume depletion and poor myocardial perform-
demonstrating so called supply dependency and the ance at an early stage is beneficial.1316 This was the message
presence of a covert oxygen debt that would be relieved by from Shoemakers studies 20 years ago, but unfortunately it
further increasing DO2.6 was overinterpreted and applied to inappropriate patient
The relationship between global DO2 and VO2 in critically ill populations causing the confusion that has only recently been
patients has received considerable attention over the past two resolved. Thus, adequate volume replacement in relatively vol-
decades. Shoemaker and colleagues demonstrated a relation- ume depleted perioperative patients is entirely appropriate.
ship between DO2 and VO2 in the early postoperative phase that However, the strategy of using aggressive fluid replacement
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Oxygen delivery and consumption in the critically ill 173
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174 Leach, Treacher
Slow Rapid
diffusion diffusion
PaO2
PaO2
5.3 kPa PaO2
7 kPa
13 kPa
Pressure gradient
5.3 1.3 = 4.0 kPa
Diffusion distance
Pressure gradient
Intracellular
Intracellular Mitochondrial
Mitochondrial
PO2 1.3 kPa PaO2 <0.7 kPa
PaO2 0.71.3 kPa
Figure 4 Diagram showing the importance of local capillary oxygen tension and diffusion distance in determining the rate of oxygen delivery
and the intracellular PO2. On the left there is a low capillary PO2 and pressure gradient for oxygen diffusion with an increased diffusion distance
resulting in low intracellular and mitochondrial PO2. On the right the higher PO2 pressure gradient and the shorter diffusion distance result in
significantly higher intracellular PO2 values.
dobutamine may reduce splanchnic perfusion, dopexamine OXYGEN DELIVERY AT THE TISSUE LEVEL
hydrochloride has dopaminergic and -adrenergic but no Individual organs and cells vary considerably in their sensitiv-
-adrenergic effects and may selectively increase renal and ity to hypoxia.28 Neurons, cardiomyocytes, and renal tubular
splanchnic blood flow.25 cells are exquisitely sensitive to a sudden reduction in oxygen
supply and are unable to survive sustained periods of hypoxia,
OXYGEN TRANSPORT FROM CAPILLARY BLOOD TO although ischaemic preconditioning does increase tolerance to
INDIVIDUAL CELLS hypoxia. Following complete cessation of cerebral perfusion,
The delivery of oxygen from capillary blood to the cell depends nuclear magnetic resonance (NMR) measurements show a
on: 50% decrease in cellular adenosine triphosphate (ATP) within
factors that influence diffusion (fig 4); 30 seconds and irreversible damage occurs within 3 minutes.
Mechanisms have developed in other tissues to survive longer
the rate of oxygen delivery to the capillary (DO2);
without oxygen: the kidneys and liver can tolerate 1520 min-
the position of the oxygen-haemoglobin dissociation utes of total hypoxia, skeletal muscle 6090 minutes, and vas-
relationship (P50); cular smooth muscle 2472 hours. The most extreme example
the rate of cellular oxygen utilisation and uptake (VO2). of hypoxic tolerance is that of hair and nails which continue to
The sigmoid oxygen-haemoglobin dissociation relationship grow for several days after death.
is influenced by various physicochemical factors and its posi- Variation in tissue tolerance to hypoxia has important clini-
tion is defined by the PaO2 at which 50% of the Hb is saturated cal implications. In an emergency, maintenance of blood flow
(P50), normally 3.5 kPa. An increase in P50 or rightward shift in to the most hypoxia sensitive organs should be the primary
this relationship reduces the Hb saturation (SaO2) for any goal. Hypoxic brain damage after cardiorespiratory collapse
given PaO2, thereby increasing tissue oxygen availability. This is will leave a patient incapable of independent life even if the
caused by pyrexia, acidosis, and an increase in intracellular other organ systems survive. Although tissue death may not
phosphate, notably 2,3-diphosphoglycerate (2,3-DPG). The occur as rapidly in less oxygen sensitive tissues, prolonged
importance of correcting hypophosphataemia, often found in failure to make the diagnosis has equally serious conse-
diabetic ketoacidosis and sepsis, is frequently overlooked.26 quences. For example, skeletal muscle may survive severe
Mathematical models of tissue hypoxia show that the fall in ischaemia for several hours but failure to remove the causative
cellular oxygen resulting from an increase in intercapillary arterial embolus will result in muscle necrosis with the release
distance is more severe if the reduction in tissue DO2 is caused into the circulation of myoglobin and other toxins and activa-
by hypoxic hypoxia (a fall in PaO2) rather than stagnant (a tion of the inflammatory response.
fall in flow) or anaemic hypoxia (fig 5).27 Studies in patients Tolerance to hypoxia differs in health and disease. In a sep-
with hypoxaemic respiratory failure have also shown that it is tic patient inhibition of enzyme systems and oxygen
PaO2 rather than DO2that is, diffusion rather than utilisation reduces hypoxic tolerance.29 Methods aimed at
convectionthat has the major influence on outcome.9 enhancing metabolic performance including the use of
Thus, tissue oedema due to increased vascular permeability alternative substrates, techniques to inhibit endotoxin in-
or excessive fluid loading may result in impaired oxygen duced cellular damage, and drugs to reduce oxidant induced
diffusion and cellular hypoxia, particularly in clinical situa- intracellular damage are currently under investigation. Ischae-
tions associated with arterial hypoxaemia. In these situations, mic preconditioning of the heart and skeletal muscle is recog-
avoiding tissue oedema may improve tissue oxygenation. nised both in vivo and in experimental models. Progressive or
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Oxygen delivery and consumption in the critically ill 175
distance = 80 m
4
80 m 3
Hypoxia
80m
2
80 m Anaemia
0
INTERSTITIAL 0 5 10 15 20
OEDEMA
Oxygen delivery (ml/min/kg)
Intercapillary
distance = 160 m 6
160 m
3
Hypoxia
160 m
2
Anaemia
160 m 0
0 5 10 15 20
Figure 5 Influence of intercapillary distance on the effects of hypoxia, anaemia, and low flow on the oxygen delivery-consumption
relationship. With a normal intercapillary distance illustrated in the top panels the DO2/VO2 relationship is the same for all interventions.
However, in the lower panels an increased intercapillary distance, as would occur with tissue oedema, reducing DO2 by progressive falls in
arterial oxygen tension results in a change in the DO2/VO2 relationship with VO2 falling at much higher levels of global DO2. This altered
relationship is not seen when DO2 is reduced by anaemia or low blood flow.
repeated exposure to hypoxia enhances tissue tolerance to result in a high lactate concentration, whereas compensatory
oxygen deprivation in much the same way as altitude reductions in energy state [ATP]/[ADP][Pi] or [NAD+]/
acclimatisation. An acclimatised mountaineer at the peak of [NADH] may be associated with a low lactate concentration
Mount Everest can tolerate a PaO2 of 44.5 kPa for several during hypoxia.33 Thus, the value of a single lactate measure-
hours, which would result in loss of consciousness within a ment in the assessment of tissue hypoxia is limited.34 The sug-
few minutes in a normal subject at sea level. gestion that pathological supply dependency occurs only
What is the critical level of tissue oxygenation below which when blood lactate concentrations are raised is incorrect as the
cellular damage will occur? The answer mainly depends on the same relationship may be found in patients with normal lac-
patients circumstances, comorbid factors, and the duration of tate concentrations.35 Serial lactate measurements, particu-
hypoxia. For example, young previously healthy patients with larly if corrected for pyruvate, may be of greater value.
the acute respiratory distress syndrome tolerate prolonged Measurement of individual organ and tissue oxygenation is
hypoxaemia with saturations as low as 85% and can recover an important goal for the future. These measurements are dif-
completely. In the older patient with widespread atheroma, ficult, require specialised techniques, and are not widely avail-
however, prolonged hypoxaemia at such levels would be unac- able. At present only near infrared spectroscopy and gastric
ceptable. tonometry have clinical applications in the detection of organ
hypoxia.24 In the future NMR spectroscopy may allow direct
RECOGNITION OF INADEQUATE TISSUE OXYGEN non-invasive measurement of tissue energy status and oxygen
DELIVERY utilisation.36
The blood lactate concentration is an unreliable indicator of
tissue hypoxia. It represents a balance between tissue produc- CELLULAR OXYGEN UTILISATION
tion and consumption by hepatic and, to a lesser extent, by In general, eukaryotic cells are dependent on aerobic metabo-
cardiac and skeletal muscle.30 It may be raised or normal dur- lism as mitochondrial respiration offers greater efficiency for
ing hypoxia because the metabolic pathways utilising glucose extraction of energy from glucose than anaerobic glycolysis.
during aerobic metabolism may be blocked at several points.31 The maintenance of oxidative metabolism is dependent on
Inhibition of phosphofructokinase blocks glucose utilisation complex but poorly understood mechanisms for microvascular
without an increase in lactate concentration. In contrast, oxygen distribution and cellular oxygen uptake. Teleologically,
endotoxin and sepsis may inactivate pyruvate dehydrogenase, the response to reduced blood flow in a tissue is likely to have
preventing pyruvate utilisation in the Krebs cycle resulting in evolved as an energy conserving mechanism when substrates,
lactate production in the absence of hypoxia.32 Similarly, a particularly molecular oxygen, are scarce. Pathways that use
normal DO2 with an unfavourable cellular redox state may ATP are suppressed and alternative anaerobic pathways for
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176 Leach, Treacher
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Oxygen delivery and consumption in the critically ill 177
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